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A Comparative Study of Laparoscopic and Open Radical Nephrectomy

Author: ZhangXiao
Tutor: YuDaMin
School: Zhejiang University
Course: Surgery
Keywords: Laparoscopic Surgery Kidney Cancer Nephrectomy
CLC: R737.11
Type: Master's thesis
Year: 2007
Downloads: 135
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Abstract


Background and purpose of the traditional open kidney cancer radical mastectomy (Open radical nephrectomy, ORN) the use of up to about 20cm incision surgery need to cut off the layers of the abdomen or waist muscularis damage in patients with trauma patients slow recovery. Gradually since 1993, has successfully completed laparoscopic radical nephrectomy surgery (Laparoscopic radical nephrectomy, LRN) reported. Laparoscopic radical nephrectomy with less trauma, recover fast, postoperative analgesic use less, to some extent, make up for the shortcomings of open radical nephrectomy. Meanwhile, with the improvement of living standards, minimally invasive surgery is increasingly to be welcomed, and and outside scientific development trend. After 10 years of development, up to 2005, reported worldwide force LRN has more than 6000 cases, LRN has replaced the ORN become the gold standard for surgical treatment of localized renal tumors. The LRN indications on T1-T3a renal cell carcinoma. This study was designed to compare the efficacy of radical surgery with open radical nephrectomy, laparoscopic kidney cancer in our department from January 2004 to December 2006, and to evaluate its clinical value, to explore appropriate surgical approach channels. Clinical data and research methods. 1.1 LRN group of 53 patients with clinical data (which were converted to open surgery patients in the statistics), the success of the 51 cases, 36 men, 15 women. Age 32-74 years old, with an average of 54.71 ± 12.90 years. 27 cases, the left and right side in 24 cases. Maximum tumor diameter 3-9cm, with an average of 5 ± 1.43cm. Pathologically confirmed clear cell carcinoma 46 cases, two cases addicted chromophobe RCC, chromophobe renal cell carcinoma in 2 cases, one cases of cystic renal cell carcinoma. 1.2 ORN group of 42 patients, 26 men and 16 women, aged 33-74 years old, with an average of 54.64 ± 11.73 years. 15 cases, the left and right side in 27 cases. Maximum tumor diameter of 3-13cm, and an average of 5.79 ± 2.66cm. Pathologically confirmed clear cell carcinoma in 38 cases, 2 cases of chromophobe cell carcinoma, collecting duct type 2 cases. 2. Cases of inclusion and exclusion criteria included 2.1 standard: the renal masses disease, B ultrasound, CT or / and MRI imaging in preoperative examination, diagnostic considerations renal cell carcinoma line radical nephrectomy, pathologically confirmed for various types of renal cell carcinoma, TNM stage T1-3a. 2.2 Exclusion criteria: ① exclude other surgery such as cholecystectomy, gynecological surgery cases in the same period; ② exclude pathologically confirmed cases of kidney benign and non-renal pelvis cancer cell carcinoma; ③ exclude the the tumor thrombus violation of vena cava or T3b renal cell carcinoma of the renal vein; ④ distant metastases and palliative resection not included in the statistics. 3. Collection of cases collected hospital from January 2004 to December 2006, we made a total of 53 cases of laparoscopic radical nephrectomy and 42 cases of open radical nephrectomy complete clinical data, detailed record of the patient's name, medical record number , gender, age, contact address and telephone number, pathological diagnosis, comorbidities, complications, clinical manifestations, ultrasound (Bus) and CT or MRI results, date of surgery, operative time, blood loss, tumor size, postoperative analgesics (sent on behalf of pyridine) the frequency of use, eating time, pull out the drainage tube time, pulling the catheter time, days of intravenous antibiotics, postoperative hospital days. 4. Surgical methods 4.1 laparoscopic radical nephrectomy: preoperative conventional water fasting, cleansing enema the night before surgery and surgery on the morning of each day of surgery, preoperative herein are intravenous antibiotics to prevent infection. Using static suction composite intubation under general anesthesia. Surgery are intraperitoneal pathways, generally the contralateral semi-recumbent or 70-90 degrees lateral position. Umbilicus or umbilical level the rectus abdominis next at 1cm skin incision, the Veress the pneumoperitoneum needle aspiration, CO2 inflatable establishment of artificial pneumoperitoneum the pressure 2.0KPa (15mmHg) puncture placement of the first sleeve of laparoscopic 10mm (due to at more than \Under surveillance in the anterior axillary line flat umbilical axillary line subcostal midclavicular line subcostal placed 5 mm in diameter, 12mm and 5mm casing. In the paracolic gutter at the cut side of the peritoneum, colon retractor the exposure retroperitoneal space. Kidney fat extracapsular free exposure and treatment of renal pedicle separation of upper ureteral and titanium clips Close amputation, the free kidney placed in a specimen bag, connected to the original two trocar holes for a 5-10cm incision to remove the kidney. Observed obvious signs of lymph node metastasis, preoperative imaging or surgery is not routinely do the dissection. 4.2 open radical nephrectomy: preoperative preparation and anesthetic methods processing with LRN group. In this group use more abdominal incision or lower back oblique incision, the incision total length of about 16 to 30cm. ① abdominal incision: Often the middle of the abdomen or paramedian incision into the abdominal cavity, cut side peritoneal push to gut the inside exposed perirenal fascia along the vena cava, and other signs to find the renal pedicle. ② lower back incision: often do rib 11 or 12 subcostal incision, cut the skin and subcutaneous tissue in turn, pay attention not to damage the pleura find renal pedicle. Renal pedicle after separation option in conjunction renal pedicle ligation or first ligation of the renal artery ligation of the renal vein on three long forceps, the proximal end of the 10th silk double ligation after suture a block of free and remove the kidney specimens. 5. Data processing 5.1 comparing laparoscopic group and the open surgery group (sent on behalf of pyridine), patient gender, age, ipsilateral, surgery time (min), blood loss amount (ml), postoperative analgesic use the number of patients after eating time (d), postoperative indwelling drainage tube time (d), postoperative indwelling catheter Time (d), postoperative intravenous antibiotic use (d), postoperative hospital stay (d), intraoperative and postoperative indicators such as the incidence of complications, research laparoscopic group surgery can achieve the same effect as in open surgery and whether they can achieve the effect of minimally invasive. 5.2 LRN group of bulky tumors (diameter ≥ 5cm) with small-volume tumors (diameter <5cm) patients age, operative time (min), blood loss (ml), postoperative analgesics (sent on behalf of pyridine) frequency of use after eating time (d), postoperative drainage tube Time (d), the indwelling catheter Time (d), postoperative intravenous antibiotic use (d), postoperative hospital stay (d), indicators of postoperative complications incidence study bulky tumors whether we can achieve the same minimally invasive efficacy of small volume tumors. 5.3 All data by SPSS13.0 for Windows Professional statistical software, T-test test depending on the data, the statistical methods to analyze non-parametric test, P <0.05 for the difference was statistically significant results 1. The of the LRN group of 53 cases switch to open surgery in two cases, the huge kidney tumors and adhesions close separation difficulties turn open surgery, 1 patient with renal pedicle poorly controlled hemorrhage turn open surgery, 3.8% of the rate of conversion to open. Average surgery time for this group of patients 127.55 ± 50.26min (55-240min), the average intraoperative blood loss 252.94 ± 236.52ml (50-1000ml); postoperative average eating time 2.12 ± 0.77d (1-4d), postoperative complications cases, the incidence rate of 5.88%. 2. ORN group (42 cases), the average operation time was 132.86 ± 22.36min (95-175min), the average intraoperative blood loss 310.71 ± 248.05ml (100-1100ml); postoperative average eating time 2.79 ± 1.09d (1-5d), postoperative concurrent of 3 cases, the incidence of 7.14%. 3. Comparing LRN group and the ORN group and two groups no statistically significant differences in the patients' gender, age, tumor ipsilateral tumor size. LRN group to reduce the length of the incision to reduce postoperative analgesic use, eating early, shorter hospital stay and other Japanese better than the ORN group, and a statistically significant difference. In the time of surgery, blood loss, postoperative indwelling catheter, indwelling abdominal lead pipe, postoperative intravenous antibiotics and postoperative complication rate is better than the ORN group, but the difference was not statistically significant. 4. Laparoscopic radical surgery patients divided into two groups, the large volume Oncology Group (diameter ≥ 5cm) and small size tumor group (<5cm in diameter), found that the average small volume, volume group surgery a long time, more than the average amount of bleeding, but both are not statistically significant. It also found that the two groups in postoperative pain, eating time, drainage pipe, postoperative intravenous antibiotic use, postoperative hospital stay and complication rate, the difference was not statistically significant. Conclusion 1. Laparoscopic radical nephrectomy as a minimally invasive method for the treatment of renal cell carcinoma, a safe, effective, minimally invasive, by celiac pathways of LRN is the preferred method of treatment of T1-3a of kidney cancer. Laparoscopic surgery compared with open radical nephrectomy, incision length, number of postoperative analgesic use, eating time, postoperative antibiotic Time, postoperative hospital days, etc., statistically significant differences between the two groups, are superior to open surgery. 2. Have of certain laparoscopic radical nephrectomy experience of skilled surgeon, bulky tumors (diameter ≥ 5cm) resection obtain the same effect with a small volume of tumor resection, both in blood loss and surgical time no significant statistically significant.

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CLC: > Medicine, health > Oncology > Genitourinary tumors > Urinary tumors > Kidney,renal pelvis tumor
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