后腹腔镜胰腺手术微创解剖及临床手术优化性研究

At present, laparoscopic pancreatic surgery (LPS) has been widely accepted for the advantages of less trauma, simple manipulations, excellent postoperative recovery time, and cosmetic incision. However, the limitation of LPS should be recognized, such as long surgical path of traditional LPS, many para-pancreatic ligaments should be transected, insufficient exposure of some operative fields, influent transperitoneal drainage, and so on. Recently, we innovatively used retroperitoneal approach to perform the retroperitoneoscopic pancreatic surgery (RPS), early experience suggested that RPS had many potential advantages, such as direct and natural access, less damage, and fluent post-surgery drainage, however, the lack of comparative research and anatomic research seriously hinder the systematic development of RPS. This research aims to investigate the anatomy of para-pancreas under retroperionoeoscopy, try to identify the anatomic mark, modify the surgical procedures, and compare the RPS and LPS, modified RPS and the former one. Finally, We are trying to design a systematic optimizing strategy for RPS, and further improve the development of RPS.

腹腔镜胰腺手术(Laparoscopic pancreatic surgery, LPS)创伤小、恢复快、切口美容，现临床应用广泛，但传统LPS显露胰腺时路径长，韧带离断多，部分位置显露困难，术后引流难以保持通畅，手术安全性不高。申请人创新性地经腹膜后入路行后腹腔镜下胰腺手术 (Retroperitoneoscopic pancreatic surgery, RPS)，初步经验提示RPS潜在优势显著，手术入路直接，生理破坏少，术后引流通畅，安全性高，发展潜力巨大，但目前RPS适应证较局限和模糊，解剖学基础和临床对比研究缺乏，手术发展受到严重阻碍。本项目希望应用微创解剖学方法深入了解后腹腔镜下围胰腺解剖，确定解剖标识、改进手术操作，并将RPS与LPS、和术式改进前后对比，明确适应证，综合制定RPS优化方案，进一步完善RPS手术体系。

后腹腔镜胰腺手术符合胰腺解剖，已安全应用少量远端胰腺手术，但目前缺乏解剖学基础研究，临床手术操作待优化，与腹腔镜对比优势不明确，推广应用受限。本课题由此切入，通过对5例新鲜冰冻尸体解剖，明确后腹腔镜下胰周解剖，确定了腹膜内反折、左侧肾上腺、脾血管、肠系膜下静脉和肠系膜上动静脉为主的解剖标识，做出远端胰腺前上方和近段胰腺背侧病变为手术相对禁忌证的判断，优化了布孔、明确了操作禁忌，提出了Warshaw可行、胰头背侧肿瘤手术可行的临床假想；与腹腔镜手术对比，后腹腔镜手术时间短（72.35±28.51 VS 93.95±33.14, P = 0.033）、术中出血少（23.50±11.82 VS 42.50±28.45, P = 0.007），严重胰瘘发生率低（0% VS 15%, P = 0.230），结果提示在严格选择适应证的情况下，后腹腔镜远端胰腺手术优于腹腔镜手术，前者入路直接、操作简便，通畅的腹膜后引流可限制胰瘘发生严重程度，提高手术安全性。对比传统后腹腔镜手术，机器人后腹腔镜手术优势不明确（手术时间67.78±23.73 VS 72.35±28.51, P = 0.598；术中出血25.00±15.43 VS 23.50±11.82, P = 0.927；胰瘘发生率50% VS 35%, P = 0.350；术后住院天数5.50±2.04 VS 5.80±1.93, P = 0.372），且费用昂贵（76839.92±9545.20 VS 63119±15715.34, P = 0.002），但在狭小空间内机器人操作更为灵活，复杂远端胰腺手术时，可酌情考虑选择应用。本研究还从多个角度对后腹腔镜手术进行优化，如腔镜首选/机器人备选、选择性4孔法取代常规3孔法、后侧入路优先的手术路径、血管优先控制的远端胰腺切除技术等，证实了解剖学得出的手术相对禁忌证；临床探索性研究完成国际首例后腹腔镜近端胰腺手术、机器人后腹腔镜胰岛素瘤剜除、机器人远端胰腺切除术、机器人后腹腔下腰椎侧前入路显露操作、后腹腔镜下腰疝修补等手术，进一步拓展了后腹腔镜应用范围。. 本研究补充了后腹腔镜胰腺手术微创解剖学内容，明确了手术的优势和相对禁忌证，从多个角度优化了临床手术，完成部分临床探索性研究，研究结果进一步完善了后腹腔镜胰腺手术体系，以便更好地推广该术式。