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目的 探讨腹腔镜下膀胱全切除原位回肠代膀胱手术方法。 方法 浸润性膀胱癌患者 15例 ,年龄 39～ 71岁 ,平均 5 9岁 ,男 14例 ,女 1例。采用 5个套管针 ,腹腔镜由脐部上缘套管针进入 ,手术者经左侧 2个套管针操作 ,助手经右侧 2个套管针操作。清扫双侧盆腔淋巴结 ;游离输尿管下段在其末端切断 ;男性患者行膀胱前列腺全切除 ,紧贴前列腺尖端离断尿道 ;女性行膀胱全切除的同时作子宫及附件切除。在下腹正中线上作 4～ 5cm切口 ,取出标本。将回肠拉出切口外 ,隔离 5 0cm回肠剖开后M形折叠形成贮尿囊 ,将输尿管末段 1cm插入贮尿囊后顶部作吻合。贮尿囊最低位开口与尿道断端 6针吻合 ,前 4例直视下作吻合 ,后 11例在腹腔镜下行尿道吻合。 结果 手术时间 5～ 10h ,平均 6 .5h ;出血量 2 0 0～ 10 0 0ml,平均 387ml。术后 3周KUB、IVU及代膀胱造影检查显示 :双肾显影良好 ,无输尿管返流及梗阻 ,代膀胱充盈良好 ,容量约 30 0ml,术后 4～ 6周内患者均恢复控尿功能。无排尿困难及尿失禁。 结论 腹腔镜下行膀胱全切除视野清楚 ,可减少出血 ,避免尿道括约肌损伤 ,保留海绵体神经血管束 ;减少肠管暴露时间 ,有利于术后肠道功能恢复 ,减少肠粘连。小切口取出标本 ,体外构建贮尿囊 ,吻合输尿管 ,可缩减手术时间
Objective To investigate the method of laparoscopic total ileal bladder resection in situ ileal bladder surgery. Methods 15 patients with invasive bladder cancer, aged 39 to 71 years, mean 59 years, 14 males and 1 female. Using 5 trocars, laparoscopic access from the upper umbilical trocar, the operator by the left two trocar operation, the assistant by the right two trocar operation. Clearance of bilateral pelvic lymph nodes; lower ureter free at the end of the cut off; male patients with bladder resection of the prostate, close to the tip of the prostate off the urethra; female line resection of the hysterectomy for uterus and attachment resection. In the lower abdomen midline for 4 ~ 5cm incision, remove the specimen. The ileum was pulled out of the incision, isolated 50cm ileum cut open M-shaped formation of storage after the storage of urine, the last paragraph of the ureter inserted into the storage compartment after the top of 1cm for anastomosis. The lowest opening of the storage and urethra 6 stitches anastomosis, the first 4 cases under direct vision for anastomosis, after 11 cases of laparoscopic urethral anastomosis. Results The operation time was 5 to 10 hours, with an average of 6.5 hours. The amount of bleeding was 200 ~ 100ml, with an average of 387ml. Three weeks after operation, KUB, IVU and on behalf of the cystography examination showed: good development of both kidneys, no ureteral reflux and obstruction, on behalf of the bladder filling well, the capacity of about 30 0ml, 4 to 6 weeks after the patients were restored urine control function. No dysuria and urinary incontinence. Conclusions Laparoscopic total cystectomy with clear visual field can reduce the bleeding, avoid urethral sphincter injury and retain the cavernous nerve vascular bundle; reduce bowel exposure time, is conducive to postoperative recovery of intestinal function, reduce intestinal adhesion. Small incision to remove the specimen, in vitro storage of storage allantoic, anastomosis ureter, can reduce the operation time