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目的探讨弓状韧带的解剖及其在后腹腔镜解剖性肾切除手术中作为肾动脉定位标志的临床意义。方法回顾性分析2008年1月-2014年7月行后腹腔镜解剖性肾切除术297例的病例资料。其中,男176例,女121例,年龄26~82岁,平均54.6岁。左侧174例,右侧123例。肾癌186例,肾盂癌74例,输尿管癌37例。术中采用“用多少,开多少,宁少勿多”的原则按需打开部分肾后间隙,显露腰大肌、腰方肌及膈肌等后腹腔解剖标志。识别内外侧弓状韧带,以内侧弓状韧带为导向,寻找并显露肾动脉。Hem-o-lok处理切断后,于其内下深面稍做游离,即可显露肾静脉,同法处理,总结后腹腔镜下内侧弓状韧带与肾动脉的解剖定位关系。结果后腹腔镜下可清晰识别三个肌性标志,即腰大肌、腰方肌及膈肌;及二个韧带标志,即外侧弓状韧带及内侧弓状韧带。内外弓状韧带在腔镜下呈现“海鸥”样外观,内侧弓状韧带水平向中线方向走行,正对肾动脉。以内侧弓状韧带为定位标志,297例手术快速寻找肾血管,明显缩短手术时间,同时也减少了因损伤肾血管出血而中转开放的几率。结论遵循“用多少,开多少,宁少勿多”的原则游离肾后间隙能依托肾周自身的悬吊固定结构显露肾血管,减少操作通道的数量;内侧弓状韧带是后腹腔镜上尿路手术中肾动脉的重要定位标志,以之为导引寻找肾动脉,能缩短手术时间。
Objective To investigate the anatomy of the arcuate ligament and its clinical significance as a marker of renal artery in retroperitoneal laparoscopic anatomic nephrectomy. Methods A retrospective analysis of January 2008 - July 2014 post-laparoscopic anatomical nephrectomy in 297 cases of case data. Among them, 176 males and 121 females, aged 26 to 82 years old, with an average age of 54.6 years. 174 on the left and 123 on the right. 186 cases of kidney cancer, renal pelvis cancer in 74 cases, 37 cases of ureteral cancer. Intraoperative use of “how much, how much to open, rather less” principle according to need to open part of the kidney after the gap, reveal the psoas muscle, lumbar muscle and diaphragm and other retroperitoneal anatomical landmarks. Identify medial and lateral arcuate ligaments, medial arcuate ligament-oriented, to find and reveal the renal artery. Hem-o-lok treatment cut off, deep within its surface in a little free, you can reveal the renal vein, the same treatment, post-laparoscopic anatomical localization of the medial arcuate ligament and renal artery. Results After laparoscopy, the three muscular signs, namely the psoas muscle, the lumbar muscles and the diaphragm muscle, were clearly identified. The two ligaments, the lateral and medial arcuate ligaments, were identified. The medial and lateral arcuate ligaments show a “seagull” -like appearance under endoscopy, with the medial arcuate ligaments running horizontally toward the midline and facing the renal arteries. With the medial arcuate ligament as a landmark, 297 surgeries were performed rapidly to find the renal vessels, which significantly shortened the operation time and reduced the chance of transit to open due to renal vascular hemorrhage. Conclusions The principle of “how much to use, how much to open, and not to be more” should be followed. The free posterior renal space can expose the renal vessels by means of the renal peritoneal suspension structure and reduce the number of the operative channels. The medial arcuate ligament is a retroperitoneal laparoscopic Upper urinary tract surgery in the important positioning of renal artery signs, as the guide to find the renal artery, can shorten the operation time.