Application value of the anatomically oriented "six steps with six windows" approach in laparoscopic radical total gastrectomy
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摘要:目的
探讨以层面为导向“六步六窗口法”在腹腔镜根治性全胃切除术中的应用价值。
方法采用回顾性队列研究方法。收集2019年1月至2022年2月河南省人民医院收治的121例行腹腔镜根治性全胃切除术患者的临床病理资料；男53例,女68例；年龄为（68±12）岁。121例患者中,72例行常规手术入路设为对照组,49例行“六步六窗口法”手术入路设为试验组。观察指标：（1）手术情况。（2）术后情况。正态分布的计量资料以x±s表示,组间比较采用t检验。计数资料以绝对数或百分比表示,组间比较采用χ²检验。
结果（1）手术情况。121例患者均完成腹腔镜根治性全胃切除术,无中转开腹。对照组和试验组患者手术时间、术中出血量、清扫淋巴结数目分别为（250±50）min、（150±34）mL、（41±6）枚和（180±16）min、（55±13）mL、（51±5）枚,两者上述指标比较,差异均有统计学意义（t=11.04,21.47,9.42,P<0.05）。（2）术后情况。对照组和试验组患者术后使用镇痛药次数,术后首次肛门排气时间,术后住院时间,术后病理学分期（Ⅰ期、Ⅱ期、Ⅲ期）,术后并发症发生率分别为（3.4±1.6）次,（4.0±1.4）d,（13.1±2.0）d,9、32、31例,15.3%（11/72）和（3.5±1.7）次,（4.1±1.5）d,（13.1±1.7）d,6、25、18例,16.3%（8/49）,两者上述指标比较,差异均无统计学意义（t=0.35、0.18、0.03,Z=0.55,χ²=0.02,P>0.05）。两组患者均无围手术期死亡。
结论以层面为导向“六步六窗口法”应用于腹腔镜根治性全胃切除术安全、可行。
Abstract:ObjectiveTo investigate the application value of the anatomically oriented "six steps with six windows" approach in laparoscopic radical total gastrectomy.
MethodsThe retros-pective cohort study was conducted. The clinicopathological data of 121 patients who underwent laparoscopic radical total gastrectomy in Henan Provincial People′s Hospital from January 2019 to February 2022 were collected. There were 53 males and 68 females, aged (68±12)years. Of the 121 patients, 72 patients using the traditional approach in the surgery were divided into the control group, and 49 patients using the "six steps with six windows" approach in the surgery were divided into the experiment group. Observation indicators: (1) surgical situations; (2) postoperative situations. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the t test. Count data were described as absolute numbers or percen-tages, and comparison between groups was conducted using the chi‑square test.
Results(1) Surgical situations. All 121 patients underwent laparoscopic radical total gastrectomy successfully, without laparotomy conversion. The operation time, volume of intraoperative blood loss, number of lymph nodes dissected were (250±50)minutes, (150±34)mL, 41±6 in the control group, versus (180±16)minutes, (55±13)mL, 51±5 in the experiment group, showing significant differences in the above indicators between the two groups (t=11.04, 21.47, 9.42, P<0.05). (2) Postoperative situations. The times of postoperative analgesic injection, time to postoperative first flatus, duration of postoperative hospital stay, postoperative pathological staging (stage Ⅰ, stage Ⅱ, stage Ⅲ), incidence of postoperative complication were 3.4±1.6, (4.0±1.4)days, (13.1±2.0)days, 9, 32, 31, 15.3%(11/72) in the control group, versus 3.5±1.7, (4.1±1.5)days, (13.1±1.7)days, 6, 25, 18, 16.3%(8/49), showing no significant difference in the above indicators between the two groups (t=0.35, 0.18, 0.03, Z=0.55,χ²=0.02, P>0.05). There was no perioperative death in both groups of patients.
ConclusionAppli-cation of the anatomically oriented "six steps with six windows" approach in laparoscopic radical total gastrectomy is safe and feasible.
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Keywords:
- Stomach neoplasms /
- Radical resection /
- Surgical approach /
- Six steps with six windows /
- Laparoscopy
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随着腹腔镜技术的发展,越来越多的胃肠外科医师已能够熟练完成腹腔镜结直肠癌根治术,但由于胃癌手术的复杂性,腹腔镜胃癌根治术仍只能在较大的医学中心开展。如何在腹腔镜下选择合适的手术入路,分离正确的手术间隙层面,寻找手术标志安全完成血管游离和淋巴结清扫,是临床上关注的焦点。本研究回顾性分析2019年1月至2022年2月河南省人民医院收治的121例行腹腔镜根治性全胃切除术患者的临床病理资料,探讨以层面为导向“六步六窗口法”在腹腔镜根治性全胃切除术中的应用价值。
资料与方法
一、一般资料
采用回顾性队列研究方法。收集121例行腹腔镜根治性全胃切除术患者的临床病理资料；男53例,女68例；年龄为（68±12）岁。121例患者中,72例行常规手术入路设为对照组,49例行“六步六窗口法”手术入路设为试验组。两组患者性别、年龄、BMI、ASA分级、肿瘤长径、肿瘤位置、合并症、新辅助化疗比较,差异均无统计学意义（P>0.05）,具有可比性,见表1。本研究通过我院医学伦理委员会审批,批号为2023⁃08。患者及家属均签署知情同意书。
表 1 对照组和试验组胃癌患者术前一般资料比较Table 1. Comparison of preoperative general data of patients with gastric cancer in the control group and the experiment group组别 例数 性别（例） 年龄（x±s,岁） 体质量指数（x±s,kg/m2） 美国麻醉医师协会分级（例） 肿瘤长径（x±s,cm） 肿瘤位置（例） 合并症（例） 新辅助化疗（例） 男 女 Ⅰ级 Ⅱ级 Ⅲ级 胃上部 胃中部 对照组 72 30 42 63±10 25±3 59 11 2 6.4±2.8 28 44 60 14 试验组 49 23 26 60±10 25±3 41 7 1 6.8±3.4 21 28 50 8 统计量值 χ²=0.33 t=1.58 t=0.35 Z=0.02 t=0.35 χ²=0.19 χ²=0.02 χ²=0.19 P值 0.566 0.117 0.729 0.981 0.729 0.662 0.876 0.662 注： 对照组行常规手术入路；试验组行“六步六窗口法”手术入路二、纳入标准和排除标准
纳入标准：（1）进展期贲门癌或胃体癌。（2）术前胃镜病理学检查证实为腺癌。（3）无远处器官转移。
排除标准：（1）早期贲门癌行近端胃切除术。（2）急诊手术。（3）有腹部手术史。（4）心、肺及肝脏严重功能不全。
三、手术方法
主刀医师均为高年资医师,常规开展腹腔镜胃肠道手术,已度过腹腔镜胃癌根治及食管裂孔疝修补手术学习曲线。患者全身麻醉后行头高足低位,术者站立于患者左侧,助手站立于患者右侧,扶镜者站立于患者两腿之间。脐下置10 mm Trocar,腹腔镜经此孔置入并行全腹腔探查,主刀和助手医师布孔位置同常规腹腔镜胃癌手术。
对照组：从胃大弯侧游离进入小网膜囊,完成幽门下区血管离断和淋巴结清扫后,上挑胃幽门,经幽门后入路显露胃右血管并离断。胃左血管‑脾血管角暴露出脾血管起始部,沿脾血管走行清扫第11组淋巴结,沿肝动脉走行清扫第8组淋巴结,离断胃左血管,清扫第7、9组淋巴结,完成胰腺上区淋巴结清扫。在脾门区依照黄氏三步法,从脾下极入路完成脾门区淋巴结清扫。
试验组：（1）处理贲门区。先切开小网膜,悬吊肝脏,分离贲门右缘与膈肌右脚的膜性粘连,进入食管裂孔,分离腹段食管与腹主动脉的粘连,暴露膈肌左脚,继续沿此贲门后方间隙向左分离至暴露胃底及脾上极。打开食管膈肌脚窗口（图1）。（2）处理幽门区。助手医师于幽门上缘上提胃右血管,主刀医师分离其与幽门的粘连,打开胃右血管胃窦窗口（图2）。转至胃大弯侧,切断大网膜与结肠的附着,切开胃结肠韧带进入小网膜囊,助手医师左手抓持并上提胃窦后壁,分离胃系膜与结肠系膜的粘连,向右分离暴露十二指肠降部,分离胃幽门与胰腺的粘连,暴露胃十二指肠动脉,沿结肠中血管走行于胰腺下缘暴露肠系膜上静脉,清扫第14v组淋巴结,于胰头表面暴露并离断胃网膜右动、静脉,清扫第6组淋巴结（图3）,裸化十二指肠球部,使用切割闭合器离断十二指肠。（3）处理肝十二指肠韧带。助手医师左手抓持胃右血管束并向左季肋区牵拉,主刀医师沿肝固有动脉左缘清扫第12组淋巴结并显露肝十二指肠韧带内的门静脉。离断胃右血管完成此部位的清扫（图4）。（4）处理胰上左后间隙。助手医师左手抓持并上提胃胰皱襞,主刀医师沿胃左血管‑脾动脉角分离进入胰上左后间隙（图5）,拓展此间隙向右侧打开胃胰皱襞膈肌脚窗口（图6）,显露出肝尾状叶,向左上方打开胃底膈肌窗口（图7）,显露脾上极。继续向上拓展左右侧窗口,并与膈肌脚窗口会师。向下方暴露脾动静脉,清扫第11d组淋巴结至显露脾血管第一分支（图8）。（5）处理胰上右后间隙。胃胰皱襞及肝总动脉上方,裸化并离断胃左动静脉,清扫第7、9组淋巴结。沿肝总动脉与胰腺间隙分离,打开肝总动脉胰腺窗口（图9）,显露后方门静脉,清扫第8组淋巴结。（6）处理脾门区。转移至左季肋区,助手医师左手抓持并上提胃底后壁,主刀医师沿脾下极显露出胃网膜左血管及脾血管下极分支,离断胃网膜左血管后（图10）,向上显露脾血管脾门分支,打开脾血管第一分支下方窗口（图11）,暴露脾上极,离断胃短血管。此时脾血管第一分支处于悬空状态。助手医师左手抓持上提脾血管上方分支血管束,沿此血管向远端游离,依据其走向,走向脾上极的血管,予以保留,走向胃底的胃后血管,予以离断（图12）。经过“六步六窗口法”的淋巴结清扫,可成功完成幽门下区、胰腺上区、脾门区血管暴露（图13~15）。完成全胃游离及淋巴结清扫后,行全腹腔镜下食管空肠Roux‑en‑Y重建术。
四、观察指标
（1）手术情况：手术完成情况、手术时间、术中出血量、清扫淋巴结数目、切口长度。（2）术后情况：术后使用镇痛药次数、术后首次肛门排气时间、术后住院时间、术后病理学分期、术后并发症发生率。
五、统计学分析
应用SPSS 13.0统计软件进行分析。正态分布的计量资料以x±s表示,组间比较采用t检验。计数资料以绝对数或百分比表示,组间比较采用χ²检验。P<0.05为差异有统计学意义。
结果
一、手术情况
121例患者均完成腹腔镜根治性全胃切除术,无中转开腹。对照组和试验组患者手术时间、术中出血量、清扫淋巴结数目分别为（250±50）min、（150±34）mL、（41±6）枚和（180±16）min、（55±13）mL、（51±5）枚,两者上述指标比较,差异均有统计学意义（t=11.04,21.47,9.42,P=0.001,0.001,0.001）；切口长度分别为（6.0±1.4）cm和（6.0±1.3）cm,两者比较,差异无统计学意义（t=0.11,P=0.915）。
二、术后情况
对照组和试验组患者术后使用镇痛药次数,术后首次肛门排气时间,术后住院时间,术后病理学分期（Ⅰ期、Ⅱ期、Ⅲ期）,术后并发症发生率分别为（3.4±1.6）次,（4.0±1.4）d,（13.1±2.0）d,9、32、31例,15.3%（11/72）和（3.5±1.7）次,（4.1±1.5）d,（13.1±1.7）d,6、25、18例,16.3%（8/49）,两者上述指标比较,差异均无统计学意义（t=0.35、0.18、0.03,Z=0.55,χ²=0.02,P=0.725,0.859,0.979,0.581,0.876）。
72例对照组患者中,11例发生术后并发症,其中吻合口瘘3例,脾梗死液化、切口感染、肺部感染、粘连性肠梗阻各2例；3例吻合口瘘患者发生于术后5~8 d,无明显腹膜炎体征,因出现胸闷、发热症状,行CT造影检查证实2例吻合口瘘位于胸腔,行胸腔闭式引流术,1例吻合口瘘位于腹腔,经引流管置入双套管持续0.9%氯化钠溶液冲洗及负压吸引,再结合肠内肠外营养支持及抗感染治疗,均治愈,未行再次手术。4例将脾上极血管误认为胃后血管给予结扎,2例在胃网膜左血管与脾下极血管分叉近端结扎,导致局部脾缺血,2例术后脾上极梗死液化,患者间断高热（体温>39 ℃）,持续7 d,经脾周引流管给予持续冲洗吸引后,患者体温恢复正常。49例试验组患者中,8例发生术后并发症,其中肺部感染、切口感染各2例,吻合口出血、下肢深静脉血栓形成、粘连性肠梗阻、吻合口瘘各1例。并发症均经保守治疗,治愈出院。两组患者均无围手术期死亡。
讨论
D2淋巴结清扫是进展期胃癌根治术的金标准,涉及诸多血管,手术难度较大。为达到胃肿瘤的en‑block切除,有学者提出全胃系膜切除的概念[1‑6]。即在相应的系膜间隙内游离,完成胃周系膜的整块切除及相应血管的淋巴结清扫。如何便捷安全地寻找这些潜在的系膜间隙,并完成系膜间隙的连通会师,是临床医师需要思考的问题。笔者团队创新手术路径,达到较好手术效果,并将此手术路径命名为“六步六窗口法”,即将胃的游离分为处理贲门区、幽门区、肝十二指肠韧带、胰上左后间隙、胰上右后间隙、脾门区六步。在六步分离过程中,为完成安全的间隙游离,将食管膈肌脚窗口、胃右血管幽门窗口、胃胰皱襞膈肌脚窗口、胃底膈肌窗口、肝总动脉胰腺窗口、脾血管第一分支下方窗口作为游离的单点标志,并通过窗口的会师达到间隙平面完整分离,既降低术中出血率,又缩短手术时间。
笔者中心将游离贲门区作为操作的第一步,此步骤借鉴食管裂孔疝修补手术入路[7‑11]。完成贲门区游离后,手术视野转到幽门区,进行胃小弯侧操作,在胃幽门上方打开胃右血管胃窦窗口,继续转到胃大弯侧,进行胃系膜与结肠系膜的分离,十二指肠降部的暴露,胃网膜右血管的离断,胃十二指肠动脉及肠系膜上静脉的显露[12‑17]。此时可看到胃右血管‑胃窦窗,使用切割闭合器离断十二指肠球部。对于幽门上缘胃右血管的暴露,通常有2种方法,常规手术流程为上提幽门,从后方分离胃右血管‑胃窦窗的幽门后入路,另一种是在小弯侧上提胃右血管分离胃右血管‑胃窦窗的幽门上入路[18‑21]。我国外科专家采用后入路方法较多[22‑25]。该入路符合腹腔镜下胃癌根治术由胃大弯到胃小弯、由尾侧至头侧的淋巴结清扫特点,无需悬吊肝脏。同时,不离断十二指肠使助手医师易于通过对胃窦十二指肠的牵拉,形成对胰腺上缘淋巴结清扫的有效张力[26‑27]。但该入路存在胰腺上区显露空间小、门静脉显示困难等缺陷。而且在分离过程中,容易误伤胃右血管。为降低血管误伤率,常需要胃复位,采用幽门上入路定位胃右血管,难免会多次翻动胃幽门,这样既增加肿瘤种植概率,又降低手术流畅性,增加手术时间。而在“六步六窗口法”的手术流程中,先完成胃小弯侧的游离,直接从幽门上入路开窗分离胃右血管和胃幽门,降低误损伤血管的概率。第三步行肝十二指肠韧带裸化。《中国腹腔镜胃癌根治手术质量控制专家共识（2022版）》和韩国KLASS‑2研究的胃癌D2根治术标准均指出：进行第12a组淋巴结清扫时,门静脉的左侧壁必须显露,沿门静脉左侧壁的软组织必须清除[28‑29]。第四步处理胰上左后间隙,第五步处理胰上右后间隙,在常规手术流程中,通常将离断十二指肠放在淋巴结清扫完成后和胃肠吻合前,而在六步六窗口手术流程中,先离断十二指肠,将胃倒向左季肋区后胰腺上区手术视野开阔,同时配合肝脏悬吊,助手医师协助主刀医师更精准地清扫淋巴结,尤其是对肥胖症患者,该方法优势更明显[30‑32]。然后安全离断胃左血管并完成第7、9组淋巴结清扫,彻底清扫肝总动脉后方及其与门静脉之间淋巴结,保证门静脉和下腔静脉的安全[33‑36]。手术的第六步转移到脾门淋巴结清扫,通过前述手术步骤,胃底和脾血管上方分支均处于悬空状态,且脾上极作为重要解剖标志也已显露,即脾上极入路优先原则,这极大降低了脾上极血管误伤的概率[37‑39]。“六步六窗口法”通过对手术步骤优化,将胃大弯侧优先改为胃小弯侧优先,将食管膈肌脚分离,幽门上入路,十二指肠先离断,肝动脉下入路和脾上极入路作为优先处理手段,将血管导向改为层面导向,降低手术难度,增加手术流畅性,缩短手术时间,取得良好手术效果。
综上,以层面为导向“六步六窗口法”应用于腹腔镜根治性全胃切除术安全、可行。所得结论仍需高级别循证医学证据验证。
宋玉成、张广坛：起草文章；耿雯静：统计学分析；宋玉成、李闯、陈克、耿雯静、唐瑞雪、张广坛：采集数据；宋玉成、张广坛：实施手术,酝酿和设计试验,对文章的知识性内容作批评性审阅所有作者均声明不存在利益冲突宋玉成, 李闯, 陈克, 等. 以层面为导向“六步六窗口法”在腹腔镜根治性全胃切除术中的应用价值[J]. 中华消化外科杂志, 2023, 22(8): 1021-1027. DOI: 10.3760/cma.j.cn115610-20230524-00230.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20230524-23230
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表 1 对照组和试验组胃癌患者术前一般资料比较
Table 1 Comparison of preoperative general data of patients with gastric cancer in the control group and the experiment group
组别 例数 性别（例） 年龄（x±s,岁） 体质量指数（x±s,kg/m2） 美国麻醉医师协会分级（例） 肿瘤长径（x±s,cm） 肿瘤位置（例） 合并症（例） 新辅助化疗（例） 男 女 Ⅰ级 Ⅱ级 Ⅲ级 胃上部 胃中部 对照组 72 30 42 63±10 25±3 59 11 2 6.4±2.8 28 44 60 14 试验组 49 23 26 60±10 25±3 41 7 1 6.8±3.4 21 28 50 8 统计量值 χ²=0.33 t=1.58 t=0.35 Z=0.02 t=0.35 χ²=0.19 χ²=0.02 χ²=0.19 P值 0.566 0.117 0.729 0.981 0.729 0.662 0.876 0.662 注： 对照组行常规手术入路；试验组行“六步六窗口法”手术入路
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