浅论经脐单孔腹腔镜乳头式输尿管膀胱再植术初步体会

浅论经脐单孔腹腔镜乳头式输尿管膀胱再植术初步体会 浅论经脐单孔腹腔镜乳头式输尿管膀胱再植术初步体会 作者:韩金利 黄健 许可慰 林天歆 江春 黄海 尹心宝 张彩霞 谢文 练 姚友生【摘要】 【目的】 探讨采用自制多通道套管和常规器械 经脐行腹腔镜下乳头式输尿管膀胱再植术的可行性和疗效。【方法】 年4月至年月对9例输尿管末端狭窄或异位开口的患者行腹腔镜输尿 管膀胱再植术。气管内全麻下经脐部切口置入自制多通道套管(用手 套和两个弹性橡胶环制作而成)。从髂血管分叉处找到并游离异常输 尿管至膀胱壁段处切断，末端1 cm纵行切开外翻缝合形成乳头，输 尿管内置双J管，从膀胱后顶部切口插入膀胱约1 , 1.5 cm，4-0 可吸收线间断吻合6针，检查无渗漏后放置盆腔引流。【结果】 全部 手术均在单孔腹腔镜下成功完成，无需术中增加套管或开放手术。平 均手术时间为87 min，平均估计失血量小于30 mL，无术中并发症发 生，术后1 d可起床活动，引流管、尿管、双J管分别在2 d、7 d、 30 d拔除，内镜下可见输尿管乳头，术后2 , 3月静脉尿路造影(IVU) 及膀胱尿道造影未见吻合口狭窄和反流，脐部切口美观。【结论】 经 脐单孔腹腔镜下输尿管膀胱再植术具有创伤小、美观经济、恢复快的 优点。输尿管乳头式膀胱再植法狭窄率低、抗反流效果好，镜下操作 简便，值得推广应用。 【关键词】 腹腔镜; 单孔系统; 输尿管膀胱 再植术; 脐 Abstract: 【Objective】 To evaluate the feasibility and effect of laparoscopic surgery of ureterovesical reimplantation through transumbilical single-port access using homemade multichannel cannula with conventional laparoscopic instruments. 【Method】 Between April and December ， 9 patients with ureter end stricture or ectopic orifice were performed single-port laparoscopic surgery of ureterovesical reimplantation. The multichannel port made of glove and two elastic rubber rings was inserted transumbilically under general anesthesia. The abnormal ureter was mobilized from common iliac artery branches to the bladder. The 1 cm of ureter end was opened longitudinally and formed split nipple. Double J stent was inserted into the ureter. The ureteral split nipple was inserted into the bladder at the posterior vertex of the bladder and fixed by interrupted suture with 4-0 absorbable suture. The drainage tube was put into the pelvic after the ureterovesical anastomosis was watertight. 【Result】 All procedures were completed successfully without application of additional ports or conversion to open surgery. The mean operative time was 87 min. The mean estimated blood loss was less than 30 mL. None of complications occurred perioperatively. The patients were ambulant in 1 day after operation. Drainage tube， catheter and double J stent were removed in 2， 7， and 30 days postoperatively， respectively. Split nipple was observed under endoscopy one month postoperatively. Postoperative intravenous urography and cystourethrography in 2 or 3 months showed no stricture or reflux of ureterovesical anastomosis. Umbilical cosmetic results achieved. 【Conclusion】 Transumbilical single-port laparoscopic ureterovesical reimplantation is safe and feasible with minimal invasion， cosmetic benefits， less costs and rapid rehabilitation. Ureterovesical reimplantation with split nipple method have advantages with less stricture， antireflux effect， easy manipulation under laparoscope. 经 脐单套管腹腔镜手术具有创伤小、并发症少、术后恢复快、切口美观 等优点，近年来应用于多种泌尿生殖系统疾病，取得了良好的初步效 果[1]。该手术多采用特殊的操作器械和商业化的套管，费用昂贵， 操作复杂，应用于功能重建的较少。常用的输尿管膀胱抗反流式吻合 存在镜下操作复杂、术后再狭窄或反流率高等不足。我们在常规腹腔 镜输尿管膀胱再植术的基础上，采用自制的多通道单套管和常规腹腔 镜操作器械经脐部行腹腔镜下乳头式输尿管膀胱再植术，取得了良好 的初步效果。 1 材料与方法 1.1 临床资料 年4月至年月 中山大学孙逸仙纪念医院泌尿外科收治共9例患者，男4例，女5例， 年龄6月,13岁，中位年龄5.7岁;右输尿管下段狭窄2例，右重复肾输尿管畸形并异位开口1例，左重复肾输尿管畸形并异位开口2例，左输尿管下端狭窄4例;术前经静脉尿路造影(IVU)、计算机断层尿路成像(CTU)或磁共振尿路成像(MRU)明确诊断，患侧肾输尿管轻中度扩张积水，肝肾功能及尿常规检查均正常。 1.2 手术器械 一个自制的多通道套管、5 mm 30?腹腔镜和常规腹腔镜操作器械。多通道单套管采用手套和两个弹性橡胶环制作，直径6 cm的弹性环位于手套的袖口处，距袖口约5 cm处放置一个直径4 cm的弹性环，将4 cm的环和手套翻转形成内环，剪去手套拇指、中指和小指的尖端，中指固定5 mm的套管放置5 mm的腹腔镜，拇指固定5 mm的橡胶阀，小指固定5 mm的橡胶阀，常规腹腔镜操作器械通过拇指和小指的通道进行手术(图1)。 1.3 手术方法 气管内全麻下，头低脚高仰卧位，经脐切开约2.5 cm的切口进入腹腔，放置自制的多通道单套管，充气形成气腹，压力约10 , mmHg。将肠管向头侧推开，在患侧髂血管上方剪开后腹膜，在输尿管与髂血管交界处找到异常输尿管，向下游离至膀胱连接处，靠近膀胱壁处用Hem-o-lock 夹闭输尿管，近端切断输尿管，切开输尿管末端1 cm，4-0可吸收线外翻纵行缝合2-3针形成乳头，在导丝引导下输尿管内置入F6双J管作内引流，女性患者将输尿管穿过阔韧带底部与膀胱吻合。充盈膀胱，在膀胱后顶部切开膀胱壁约1 cm， 将输尿管乳头插入膀胱，膀胱壁全层与输尿管外膜肌层纵行吻合6针，充盈膀胱无渗漏后留置盆腔引流管。