腹腔镜直肠癌术后吻合口漏的临床分析及对策(附8例报告)

摘要

目的 探讨腹腔镜直肠癌术后吻合漏的原因及防治对策. 方法 2014年2月~2015年12月我科行腹腔镜直肠癌Dixon根治手术117例,常规五孔法穿刺置入器械,气腹压维持于12~15 mm Hg.解剖游离结直肠系膜,肠系膜下血管根部结扎切断,清扫淋巴脂肪组织.于骶前间隙锐性分离,切除范围包括肿瘤在内两端足够肠段及直肠系膜(近端距肿瘤≥15 cm,远端距肿瘤≥2 cm).左下腹取切口取出标本,近端结肠置入吻合器钉座,重建气腹,腹腔镜下完成经肛门吻合器端端吻合. 结果 8例术后发生吻合口漏:2例经吻合口旁双套管冲洗引流、抗感染、抑制消化液分泌、静脉营养等保守治疗14、22 d治愈;1例修补漏口、横结肠双襻造瘘,5例漏口远端肠管切断缝闭、近端结肠造瘘,10~15 d治愈.8例术后随访12~18个月,平均13个月,无局部复发或转移. 结论 术中确保吻合口血供良好且无张力,重视围手术期合并症的处理及肠道准备,能降低吻合口漏的风险.及时发现吻合口漏并制定个体化的保守或手术方案,能提高吻合口漏的治愈率.%Objective To explore the prevention and treatment of anastomotic leakage after laparoscopic rectal cancer Dixon surgery.Methods A total of 117 rectal cancer cases were performed by laparoscopic rectal cancer Dixon surgery.By using five trocars, the pneumoperitoneal pressure was set between 12-15 mm Hg.The colorectal mesenteries were dissected after cutting off the base of inferior mesenteric artery.The lymph tissue was dissected.Sharp dissection of the presacral space was performed.Resection of adequate colorectum and mesentery were conducted.Put the anastomat nail seat into the proximal colon, and resume the pneumoperitoneum to anastomose the colon and rectum through the anus.Results There were 8 cases with anastomotic leakage after surgery.Two cases had a good recovery by conservative treatments after 14 and 22 days, including washing and attraction by drainage tube, antibiotics, inhibition of the secretion of digestive juices by using somatostatin and parenteral nutrition support.Six cases had a good recovery after 10-15 days.One case was cured by colonic perforation repair surgery and double loop transverse colostomy, while the other 5 cases were cured by descending colon colostomy.All the 8 cases had no tumor recurrence or distant metastasis after 12-18 months of follow-ups.Conclusions Improvement of surgical skills to make anastomosis with sufficient blood supply and tensionless state and the treatment of preoperative complications and thorough bowel preparation could reduce the risk of anastomotic leakage after laparoscopic radical resection for rectal neoplasms.Early diagnosis and individualized therapy could increase the cure rate of anastomotic leakage.