楊小光 程鑫 趙建亭

458000河南省鶴壁市人民醫(yī)院山城院區(qū)胸外科

全胸腔鏡肺葉切除治療早期肺癌的手術(shù)體會(huì)

楊小光 程鑫 趙建亭

458000河南省鶴壁市人民醫(yī)院山城院區(qū)胸外科

目的：探討全胸腔鏡肺葉切除治療早期肺癌的臨床療效。方法：2013年5月-2014年9月收治早期肺癌患者80例，隨機(jī)分成觀察組和對(duì)照組，各40例，所有患者均行常規(guī)術(shù)前準(zhǔn)備和護(hù)理，對(duì)照組采取傳統(tǒng)的開(kāi)胸肺葉切除術(shù)，麻醉方法采取全身麻醉雙腔氣管插管，術(shù)中單肺通氣，切斷第6肋后于第5肋間進(jìn)胸，常規(guī)清掃縱膈及肺門淋巴結(jié)，若患者病變發(fā)生在右肺，則清掃第2、4及7～9組淋巴結(jié)，若患者病變發(fā)生在左肺，要清掃第5～9組淋巴結(jié)。觀察組行全胸腔鏡肺葉切除術(shù)，于第7肋間切口置入胸腔鏡，麻醉方法及淋巴結(jié)的清掃措施與對(duì)照組相同。結(jié)果：觀察組手術(shù)時(shí)間(121.2±15.1)min，術(shù)中出血量(198.2±32.5)mL，術(shù)后疼痛水平(72.6±3.9)，術(shù)后住院時(shí)間(5.1±0.4)d，發(fā)生并發(fā)癥1例，并發(fā)癥發(fā)生率2.5%。對(duì)照組手術(shù)時(shí)間(141.2±22.8)min，術(shù)中出血量(285.6±44.2)mL，術(shù)后疼痛水平(81.5±6.1)，術(shù)后住院時(shí)間(6.8±0.6)d，發(fā)生并發(fā)癥8例，并發(fā)癥發(fā)生率20.0%。兩組比較差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。結(jié)論：全胸腔鏡肺葉切除治療早期肺癌術(shù)中出血少，患者痛苦小，恢復(fù)快，值得臨床推廣。

全胸腔鏡肺葉切除術(shù)；肺癌；早期

肺癌是我國(guó)常見(jiàn)的呼吸道惡性腫瘤[1]，目前其發(fā)病率明顯升高[2]，對(duì)于癌癥的防治要做到早發(fā)現(xiàn)、早治療[3]，手術(shù)治療具有較好的臨床效果，特別是早期患者。隨著全胸腔鏡外科的迅速發(fā)展，全胸腔鏡肺葉切除術(shù)得到廣泛應(yīng)用。為探討全胸腔鏡肺葉切除治療早期肺癌的臨床療效，2013年5月-2014年9月收治早期肺癌患者80例，對(duì)其進(jìn)行總結(jié)和分析。

資料與方法

2013年5月-2014年9月收治早期肺癌患者80例，所有患者均無(wú)遠(yuǎn)端轉(zhuǎn)移，診斷為早期肺癌。隨機(jī)分成觀察組和對(duì)照組，各40例。觀察組男26例，女14例，年齡47～79歲，平均62.5歲。病變位置：發(fā)生在右肺33例，其中右肺上葉11例，右肺下葉5例，右肺中葉10例，右肺中下葉7例，發(fā)生在左肺7例，其中左肺上葉5例，左肺下葉2例。病理分型：大細(xì)胞癌5例，腺癌19例，鱗癌16例。對(duì)照組男27例，女13例，年齡47～78歲，平均年齡62.7歲。病變位置：發(fā)生在右肺32例，其中右肺上葉12例，右肺下葉5例，右肺中葉10例，右肺中下葉5例，發(fā)生在左肺8例，其中左肺上葉5例，左肺下葉3例。病理分型：大細(xì)胞癌6例，腺癌18例，鱗癌16例。兩組患者一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。

方法：所有患者均行常規(guī)術(shù)前準(zhǔn)備和護(hù)理。①對(duì)照組采取傳統(tǒng)的開(kāi)胸肺葉切除術(shù)，麻醉方法采取全身麻醉雙腔氣管插管，術(shù)中單肺通氣，切斷第6肋后于第5肋間進(jìn)胸，常規(guī)清掃縱膈及肺門淋巴結(jié)，若患者病變發(fā)生在右肺，則清掃第2、4及7～9組淋巴結(jié)，若患者病變發(fā)生在左肺，要清掃第5～9組淋巴結(jié)。②觀察組行全胸腔鏡肺葉切除術(shù)，于第7肋間切口置入胸腔鏡，麻醉方法及淋巴結(jié)的清掃措施與對(duì)照組相同。

統(tǒng)計(jì)學(xué)方法：所有數(shù)據(jù)采用SPSS 19.0進(jìn)行統(tǒng)計(jì)分析，計(jì)量資料用(±s)表示，采用t檢驗(yàn)；計(jì)數(shù)資料采用χ2檢驗(yàn)。P＜0.05為差異具有統(tǒng)計(jì)學(xué)意義。

結(jié)果

兩組患者手術(shù)時(shí)間、術(shù)中出血量、術(shù)后疼痛水平、住院時(shí)間及并發(fā)癥發(fā)生情況比較：觀察組手術(shù)時(shí)間(121.2±15.1) min，術(shù)中出血量(198.2±32.5)mL，術(shù)后疼痛水平(72.6±3.9)，術(shù)后住院時(shí)間(5.1±0.4)d，發(fā)生并發(fā)癥1例，并發(fā)癥發(fā)生率2.5%。對(duì)照組手術(shù)時(shí)間(141.2± 22.8)min，術(shù)中出血量(285.6±44.2)mL，術(shù)后疼痛水平(81.5±6.1)，術(shù)后住院時(shí)間(6.8±0.6)d，發(fā)生并發(fā)癥8例，并發(fā)癥發(fā)生率20.0%。兩組比較差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)，見(jiàn)表1。

表1 兩組手術(shù)時(shí)間、術(shù)中出血量、術(shù)后疼痛水平、住院時(shí)間及并發(fā)癥發(fā)生情況比較(±s)

表1 兩組手術(shù)時(shí)間、術(shù)中出血量、術(shù)后疼痛水平、住院時(shí)間及并發(fā)癥發(fā)生情況比較(±s)

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討論

全胸腔鏡肺葉切除術(shù)作為近年崛起的微創(chuàng)術(shù)式[4]，以其術(shù)野大、創(chuàng)傷小、痛苦少、恢復(fù)快以及并發(fā)癥少等優(yōu)點(diǎn)[5]，讓更多心肺功能處于臨界值不能耐受常規(guī)開(kāi)胸的患者獲得了手術(shù)機(jī)會(huì)，極大地改善了患者術(shù)后生活質(zhì)量。

全胸腔鏡肺葉切除術(shù)與傳統(tǒng)的開(kāi)胸切除術(shù)的區(qū)別在于：未將肺門根部的肺動(dòng)脈、肺靜脈和支氣管等組織逐個(gè)解剖出來(lái)結(jié)扎切斷，而是利用直線切割器一并釘合切割，這種術(shù)式風(fēng)險(xiǎn)高、并發(fā)癥多。全胸腔鏡與輔助小切口的區(qū)別就在于：①不需要開(kāi)胸器暴露術(shù)野，所有操作均通過(guò)內(nèi)鏡鉗、電凝鉤、直線切割縫合器等內(nèi)鏡手術(shù)設(shè)備完成；②術(shù)者在整個(gè)手術(shù)過(guò)程中不再通過(guò)手術(shù)切口直視術(shù)野，而是注視監(jiān)視器屏幕上放大的術(shù)野完成分離、切割、縫合等一系列復(fù)雜的手術(shù)操作。

全胸腔鏡肺癌根治術(shù)的療效與傳統(tǒng)開(kāi)胸手術(shù)療效相同。我們認(rèn)為電視胸腔鏡可以近距離地觀察到胸腔內(nèi)每個(gè)角落放大的圖像，同時(shí)配合精巧的內(nèi)鏡器械清掃淋巴結(jié)，清掃比傳統(tǒng)開(kāi)胸手術(shù)更具徹底性和安全性，但術(shù)者必須具備嫻熟的腔鏡技術(shù)。全胸腔鏡肺葉切除術(shù)治療早期肺癌的優(yōu)勢(shì)：①術(shù)后疼痛明顯減輕；②縮短胸管放置時(shí)間和住院時(shí)間；③患者術(shù)后肺功能情況和活動(dòng)能力均優(yōu)于常規(guī)開(kāi)胸手術(shù)患者。

本組資料結(jié)果顯示，全胸腔鏡肺葉切除術(shù)在手術(shù)時(shí)間、術(shù)中出血量、術(shù)后疼痛水平、住院時(shí)間及并發(fā)癥發(fā)生情況方面均明顯優(yōu)于傳統(tǒng)的開(kāi)胸組。

綜上所述，全胸腔鏡肺葉切除治療早期肺癌術(shù)中出血少，患者痛苦小，恢復(fù)快，值得臨床推廣。

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[2]楊學(xué)寧,肖樸.早期非小細(xì)胞肺癌電視胸腔鏡輔助系統(tǒng)性淋巴結(jié)清掃的前瞻性研究[J].循證醫(yī)學(xué),2004,4(1):34-36.

[3]Congregado M,Merchan RJ,Gallardo G,et al. Video-assisted thoracic surgery (VATS) lobectomy:13 years' experience[J].Surg Endosc,2008,22(8):1852-1857.

[4]林敏,涂遠(yuǎn)榮,李旭,等.胸腔鏡輔助小切口肺癌根治術(shù)102例[J].中國(guó)癌癥雜志,2006, 16(5):388-393.

[5]Solaini F,Prusciano P,Bagioni F,et al.Video-assisted thoracic surgery(VATS)of the lung:analysis of intraoperative and postoperative complications over 15 years and review of the literature[J].Surg Endosc,2008,22(2): 298-310.

Operation experience of totally thoracoscopic lobectomy in the treatment of early lung cancer

Yang Xiaoguang,Cheng Xin,Zhao Jianting
Department of Thoracic Surgery,Mountain City District,the People's Hospital of Hebi City,Henan Province 458000

Objective:To investigate the clinical curative effect of complete video-assisted thoracoscopic lobectomy in the treatment of early lung cancer.Methods:80 patients with early stage lung cancer were selected from May 2013 to September 2014. They were randomly divided into the observation group and the control group with 40 cases in each.All of the patients were given the routine preoperative preparation and nursing care,while the control group adopted the traditional thoracotomy lobectomy. Anesthesia method adopts the general anesthesia double lumen endotracheal intubation,single pulmonary ventilation during the operation,we cuted the sixth rib from the fifth intercostal into chest.We cleaned the mediastinal and hilar lymph node regularly.If the patients lesions in the right lung,we cleaned up the second,fouth and seventh to ninth groups of lymph nodes.If the patients’lesions occurred in the left lung,we cleaned up the fifth to ninth group lymph nodes.The observation group underwent thoracoscopic lobectomy,from the seventh intercostal incision implantation thoracoscopy,the anesthesia measures and the lymph node sweeping methods were same as the control group.Results:The operation time of the observation group was(121.2±15.1)min; the amount of bleeding during operation was(198.2±32.5)mL;the level of pain after operation was(72.6±3.9);the time of hospitalization after operation was(5.1±0.4)d;1 case occurred complications,and the complication rate was 2.5%.The operation time of the control group was(141.2±22.8)min;the amount of bleeding during operation was(285.6±44.2)mL;the level of pain after operation was(81.5±6.1);the time of hospitalization after operation was(6.8±0.6)d;8 patients occurred complications after operation,and the complication rate was 20%.The two groups had statistical significance(P＜0.05).Conclusion:Totally thoracoscopic lobectomy in the treatment of early stage lung cancer has less bleeding during the operation,little pain,quick recovery,so it is worth the clinical promotion.

Thoracoscopic lobectomy;Lung cancer;Early

10.3969/j.issn.1007-614x.2015.6.19