王科医生的科普号

Quill线连续缝合法在后腹腔镜肾部分切除术中应用 ---糖尿病肾癌患者病肾重获新生糖尿病患者中30%的人最终会发展为糖尿病肾病 研究证明，糖尿病患者中接近30%的人最终会发展为糖尿病肾病，部分人进而发展成尿毒症。糖尿病引起的终末期肾脏病患者所占比例呈逐渐增加，在一些发达国家糖尿病肾病已经成为终末期肾脏病最主要的病因，在我国居第二位。 对于糖尿病患者，一侧肾根治性切除如雪上加霜，肾功能不全的发生率明显提高，需要透析治疗或肾移植可能性增加。肾癌并非都需要根治性肾切除 肾癌又称肾细胞癌，是成人肾脏最常见的恶性肿瘤，其发病率约占成人恶性肿瘤的2%—3%，是泌尿系统发病率第二位的恶性肿瘤，仅次于膀胱癌。据统计全世界肾细胞癌的发病率以每年2%的速度增长，发病率增长的原因尚不清楚。随着肿瘤影像学的快速发展，特别随着多层螺旋CT的不断发展，肾癌的早期诊断率有了很大提高。目前，手术切除仍是治疗局限性肾细胞癌最有效手段。对于T1期肾癌（直径≤7cm），保留肾单位手术(NSS)是治疗肾癌的一种合理手术方式，能够最大限度的保留肾功能。肾部分切除术已经取得与根治性肾切除术相同的治疗效果，且总生存率优于根治术。根治术后发生肾功能不全是肾部分切除的2倍(22.4%vs.11.6%)。研究显示选择性肾部分切除术5年肿瘤特异生存率94.4%～100%,10年肿瘤特异生存率92%～96.7%。我院一位糖尿病肾癌患者病肾重获新生 我院一位多年糖尿病患者查体发现右肾上极一4.5cm 大小肿瘤，按照传统治疗理念，患肾应该切除，但对于糖尿病患者无疑雪上加霜，两个肾脏不一定能够保证患者肾功能，一个肾脏更是难以保证。经过我院泌尿外科全体医生讨论，决定给予腹腔镜肾部分切除术。 2013年11月29日，高振利副院长、王科和于胜强博士顺利完成了腹腔镜肾部份切除术，全部手术时间65分钟，选用带双向倒刺的Quill缝合线，采用我院首创的肾盏、肾实质连续缝合法，这种缝合方法在国内外已得到广泛应用，收到良好的效果，手术时间和缝合时间明显缩短，手术安全性明显提高。 王科博士介绍说，腹腔镜肾部分切除的难点在于缝合，传统缝合线张力大，对合肾脏难度较大，牵拉时容易撕裂肾脏，带倒刺的缝合线受力均匀，收线方便、缝合牢固，不容易撕裂肾脏，还可以连续缝合肾盏和肾实质，明显缩短缝合时间。我院在国际上首先应用这种缝合方法，相继在解放军总医院、北大第一医院等医得到应用，都收到明显效果。我们目前随访100余例患者，无一例尿漏发生和结石形成。

全国首例3D腹腔镜肾部分切除术在烟台毓璜顶医院成功完成在电影影院里体会了3D电影的真实和震撼感觉，在手术室里带上3D眼镜做手术还是比较陌生。传统腹腔镜手术，三维的目标转换成二维图像展示在手术者面前，手术者需要克服较多困难，完成三维手术操作。曲华护士长介绍，这是我院第二例3D腹腔镜手术，我院腹腔镜手术基础较好，适应3D 腹腔镜手术的能力比较强，不需要培训，就能胜任3D腹腔镜手术。11月15日上午，我们在烟台毓璜顶医院手术中心见证了全国首例3D腹腔镜肾部分切除术。患者为一32岁女性，肿瘤位于肾脏中极，约3.5*3.5cm大小。术前全科讨论分析：保留肾脏难度较大，但考虑到患者比较年轻，仍决定行腹腔镜肾部份切除术尽力保留患侧肾脏。高振利副院长、王科副主任医师和于胜强主治医师戴上3D眼镜，像是在“3D 电影院”玩游戏，腹膜外脂肪清理、肾周筋膜打开等一系列手术操作轻松进行，肿瘤完整切除，肾脏得以保留。高振利院长说：3D腹腔镜下，血管、神经等组织完全是三维构造，符合正常人体结构，容易辨认，方便手术操作。3D 腹腔镜手术将是腹腔镜手术的又一巨大进步，术者和患者都会从中获益。

36岁小伙不幸一肾长两瘤--我院成功实施腹腔镜切瘤保肾手术 年富力强的36岁蓬莱小伙查体发现右肾长了两个肿瘤，这个“飞来横祸”给他的家庭带来的痛苦难以言喻，他是家庭的顶梁柱，绝不能倒下。于是他带着片子碾转到北京各大医院就诊，最后听说烟台毓璜顶医院泌尿外科腹腔镜水平位于全国领先水平，随后全家决定来我们医院就诊。 入院后，泌尿外科王科副主任医师和于胜强博士后以及全科人员对病人进行细致的化验检查，通过CT和核磁共振等影像学检查进行准确定位，并确定肿瘤大小。 传统的肾脏肿瘤手术需切除患侧肾脏，考虑患者比较年轻，保留肾脏对他意义重大，泌尿外科专家组决定对其实施腹腔镜肾部份切除术。腹腔镜肾部份切除术属于泌尿外科难度较大的腹腔镜手术，因为肾脏组织对缺血缺氧特别敏感，如果缺血时间超过30分钟，肾功能丧失的风险明显增加；肾脏组织脆性大，缝合困难。因此保留肾脏切除肿瘤手术对术者的手术技巧和缝合技术要求特别高。所以大部分医院还是多选择肾脏根治切除，但是对于病人来说却失去了一个肾脏。我们医院腹腔镜肾部份切除术虽然处于国际领先水平，但对于一肾两瘤腹腔镜肾部份切除术，还是第一次。 经过全科讨论和慎重考虑，决定对其实施腹腔镜肾部份切除术，可以考虑两次肾动脉阻断，必要行开放手术。 通过严密术前准备，王科副主任医师和林春华主治医师于2013年11月7日对其实施腹腔镜肾部份切除术。 11：40，手术准时开始，后腹腔建立、腹膜外脂肪组织清除、肾周筋膜切口、肾动脉游离、肾脏游离等一系列解剖程序化步骤一丝不苟，在肾脏的上极和下极各发现一个肿瘤。 12：10 ，肾动脉阻断，开始记录肾动脉阻断时间，时间就是生命，大家几乎屏住呼吸，目光都盯着腹腔镜显示器，王科副主任医师迅速准确地切除上极肿瘤，腹腔镜下熟练缝合，第一个肿瘤顺利完成，阻断时间12分钟。 12：23 紧接着王科副主任医师对第二个肿瘤进行切除，随后进行熟练的缝合，12：34缝合结束。同时器械护士准备好缝线，以备修补缝合。 12:35 解除肾动脉阻断，肾脏充盈良好，颜色恢复正常，无活动性出血。 取出标本，检查两个肿瘤完整，无肿瘤残余。 12：45 手术结束。 两个肿瘤的切除和缝合共用25分钟，为患者肾脏功能的保留争取了时间，同时也改写了我院腹腔镜肾部份切除术的记录。 与开放性肾部分切除术类似，目前学界公认的腹腔镜肾部分切除术的主要适应症是早期肾细胞癌（肿瘤局限于肾脏内，直径小于4cm）和肾血管平滑肌脂肪瘤（俗称肾错构瘤）。大量研究证实，肾部分切除术与根治性肾切除术治疗早期肾癌的效果相当，5年和10年生存率分别达到98%和92%，复发率极低。另外，近期的大规模临床研究证明，对于局限于肾脏内、直径在4-7cm的肾癌，同样可以选用腹腔镜肾部分切除术。目前为止，其远期预后与根治性手术还没有明显差别。 范围较小、部位靠近肾脏外周的肿瘤最适于施行腹腔镜肾部分切除术。如果肿瘤条件较复杂，术者的经验和技术将起到关键作用。该手术的成功标志着我院肾脏腹腔镜手术技术达到了较高的高度。

肾部分切除术有开放的肾部分切除术（open partial nephrectomy, OPN）、腹腔镜肾部分切除术（laparoscopic partial nephrectomy, LPN）和机器人辅助的肾部分切除术等术式。LPN达到与OPN相同的病理和功能结果，而且具有术后镇痛治疗减少、住院时间缩短、术后恢复快等优点。LPN 有经腹和经腹膜后两种手术路径，Gill于1994年完成第一例后腹腔镜肾部分切除术， Winfield于1993完成第一例经腹腹腔镜肾部分切除术。经腹途径具有操作空间大、解剖标志明确等优点，但有内脏干扰、可能肠管并发症等缺点；后腹腔途径具有肾蒂血管控制容易、腹腔脏器干扰小等方面的优势，但存在操作空间小、缺乏解剖标识等缺点；解剖、程序化和规范化手术操作能够尽可能弥补后腹腔途径在手术操作空间相对小、解剖标志欠明确等方面的不足。

因B超、CT和MRI等影像学技术的广泛应用，偶发肾癌逐步增加，而这些肿瘤具有体积较小、分期较低、增长速度慢和转移潜能低等特点，预后好于症状性肾癌，手术是局限性肾癌治疗的金标准。尽管如此，并不是所有患者都应切除患侧肾脏！肾部分切除术（partialnephrectomy, PN）近年来成为治疗T1a（肿瘤小于4cm，且局限于肾包膜内）肾细胞癌（renal cell carcinoma, RCC）的新术式。对于这些患者，肾部分切除在肿瘤复发和肿瘤切除效果等方面能达到肾脏全切一样效果。越来越多的研究证明慢性肾脏疾病和心血管疾病的关系，而且当GFR降低<60mL/min时，死亡和住院治疗的风险增加，肾脏全切被认为CKD发生和发展的危险因子，而肾脏部分切除带来的肾单位的保留能够减轻这些影响。肾脏部分切除在肾功能和心血管功能长期维持方面具有一定优势[。 因此，对于肾癌患者，要根据具体情况决定是否行患肾全切。

因B超、CT和MRI等影像学技术的广泛应用，偶发肾癌逐步增加，而这些肿瘤具有体积较小、分期较低、增长速度慢和转移潜能低等特点，预后好于症状性肾癌，手术是局限性肾癌治疗的金标准。肾部分切除术（partialnephrectomy, PN）近年来成为治疗T1a肾细胞癌（renal cell carcinoma, RCC）的新术式。事实上，肿瘤<4 cm 病人中，26％的病人在术前基础 GFR<60 mL/min；根治性肾切除(redical nephrectomy,RN)手术标本周围大多数非肿瘤肾组织有一定程度的组织病理异常。越来越多的研究证明慢性肾脏疾病和心血管疾病的关系，而且当GFR降低<60mL/min时，死亡和住院治疗的风险增加，RN被认为CKD发生和发展的危险因子，而PN带来的肾单位的保留能够减轻这些影响。RN对于慢性肾脏疾病的发生和恶化是一个危险因素，研究表明：RN能增加T1 RCC患者死亡率和肾衰竭发生率；PN 能达到RN同样的病理结果，而且在肾功能和心血管功能长期维持方面具有一定优势。

[摘要] 目的 探讨双向倒刺可吸收线在后腹腔镜肾部分切除术应用的安全性及可行性。 方法 2012年2月-2012年7月，我院共实施21例后腹腔镜肾部分切除手术，均采用双向到此可吸收线缝合肾脏。其中男13例，女8例。年龄25～74岁，平均51.2岁。肿瘤直径1.2～5.8cm，平均2.9cm。肿瘤位于肾上极8例，中部2例，下极11例，均为单发病例。术前按AJCC肾癌TNM肿瘤分期均为T1N0M0。结果 21例后腹腔镜肾部分切除手术全部顺利完成，无一例中转开放，未出现重要术中并发症。本组手术时间68～105min，平均78.5min。术中出血量30～140ml，平均60.5ml，术中均未输血。肾动脉阻断（热缺血）时间12～21min，平均15.2min。缝合时间5~17min,平均10.4min。术后住院5～7d，平均5.9d。术后病理报告肾透明细胞癌17例，乳头状细胞癌2例，切缘均为阴性；血管平滑肌脂肪瘤2例。结论 双向倒刺可吸收线在后腹腔镜肾部分切除术中应用能够明显缩短缝合时间和热缺血时间，减少手术并发症，具有很好的安全性和可行性，值得临床广泛推广。[关键词] 双向倒刺可吸收线 后腹腔镜；肾部分切除术; 肾细胞癌Application of Bidirectional BarbedAbsorbable Suture Line in Retroperitoneoscopic Partial Nephrectomy WANG Ke1, LIN Chun-hua，, MEN Chang-ping1 , LIU Dong-fu1，Wang Jian-ming1, WAN Feng-chun1, Wang Hui1, XIE Mao1, GAO Zhen-li11. Urology Department of Yantai Yuhuangding Hospital , Yantai 264000, ChinaCorresponding author：LIN Chun-hua , Urology Department of Yantai Yuhuangding Hospital , Yantai 264000, email: linchunhua2006@sina.com[Abstract] Objective To investigate the safety and feasibility of bidirectional barbed absorbable suture line application in retroperitoneoscopic partial nephrectomy. Methods Between Feb 2012 and July 2012, 21 cases of retroperitoneoscopic partial nephrectomy was performed in our hospital, bidirectional barbed absorbable suture line was used in all cases. With 31 males and 8 females, age 25-74 years; mean 51.2 years. The tumor size was 1.2 ~ 5.8 cm, mean 2.9cm.The tumor was located on upper pole of kidney in 8 cases, the middle part 2 cases and the lower pole 11 cases, all cases with single tumor, all cases were in stage T1N0M0 according to AJCC. Results All 21 cases of retroperitoneoscopic partial nephrectomy were successfully performed, without conversion to open surgery and important intraoperative complications. The operative time was 68 ~ 105min, mean 78.5min, the blood loss was 30 ~ 140ml, mean 60.5ml, without operative blood transfusion, warm ischemia time was 12~21 min, mean 15.2min, suture time was 5~17 min, mean 10.4, hospital stay was 5~7 d, mean 5.9 d. Postoperative pathology reported: 17 cases with renal clear cell carcinoma, 2 cases with papillary carcinoma, with negative surgical margin, 2 cases with angioleiomyoma. Conclusions The application of bidirectional barbed absorbable suture line in retroperitoneoscopic partial nephrectomy could shorten suture time and warm ischemia time, with good safety and feasibility, worthy of being applicated generally in clinic.[Key words] bidirectional barbed absorbable line; retroperitoneoscopy; partial nephrectomy，renal carcinoma随着腹腔镜技术的飞速发展，腹腔镜肾部分切除术成为治疗T1a肾细胞癌（renal cell carcinoma, RCC）的新术式[1]。与开放的肾部分切除术相比，腹腔镜肾部分切除术具有术后镇痛治疗少、住院时间缩短、术后恢复快等优点[2-6]；但亦有手术并发症较高和热缺血时间较长等缺点[7,8]。Quill线（双向倒刺可吸收线）具有无需打结、缝合时间缩短等优点，其在腹腔镜肾部分切除术应用能够缩短缝合时间和热缺血时间。2012年2月-2012年7月，我院共实施应用Quill线的后腹腔镜肾部分切除手术21例，效果良好，进行回顾分析如下。资料与方法一、病例资料本组21例,其中男13例，女8例。年龄25～74岁，平均51.2岁。肿瘤直径1.2～5.8cm，平均2.9cm。肿瘤位于肾上极8例，中部2例，下极11例，均为单发病例。所有病例均经B超、肾脏CT或核磁共振成像检查确诊肾脏肿瘤且未侵及周围淋巴结、肾脏血管。术前按AJCC肾癌TNM肿瘤分期均为T1N0M0。二、手术方法气管插管全麻成功后，患者取90°健侧卧位，升高腰桥。取腋后线肋缘下2cm(A点)切开皮肤，长血管钳钝性分离肌层和腰背筋膜，示指进入触及肋骨内侧面，证实进入后腹腔并分离后腹膜，置入自制乳胶气囊，充气500～800ml，保留3min后取出。在手指引导下分别于腋中线髂嵴上2cm（B点）、腋前线肋缘下2cm(C 点)穿刺，A、B、C三点分别植入12mm、10mm、5mm Trocar。缝合密闭切口后经Trocar B置入0°或30°观察镜，Trocar A置入主操作器械。建立CO2气腹并维持气腹压12～15mmHg。进入后腹腔后，用超声刀自上而下、由前至后锐性分离腹膜和Gerota筋膜外脂肪组织，之后可清晰辨认腹膜返折及Gerota筋膜。靠近腹膜返折打开Gerota筋膜，上方超过肾上极，下方达肾下极2-3cm。于肾脏于脂肪层之间充分游离肾脏，前后两面以及上下两端均充分游离。向腹侧牵拉肾脏，沿腰大肌向前游离肾后筋膜，显露肾蒂，打开肾动脉鞘，游离肾动脉。以血管阻断夹（哈巴狗钳，bulldog clamp）阻断并记录阻断时间。距瘤体边缘0.5～1.0cm用剪刀切除肿瘤及其周围组织。选用1号14×14cm 1/2园双向倒刺可吸收线（见图1），如存在肾盂、肾盏裂口，直接从肾脏表面进针，连续缝合肾盂或肾盏裂口（见图2），无需打结，针穿出肾脏表面，继续连续缝合肾脏创面（见图3），收紧缝线至不能拉动为止，收紧每一针缝线，两端尾线打结（见图4），或分别用Hem-o-lock夹夹闭（见图5），或两端直接剪掉缝针。松开血管阻断钳，确认无明显出血后。瘤体标本经扩大的A切口取出，送病检。留置后腹腔引流管，拔除各Trocar，关闭切口。 图1. a:双向双向倒刺可吸收线（Quill线）; b: 局部放大 图2. 缝合肾盏 图3. 连续缝合肾脏创面 图4. 两端尾线打结 图 5. 尾线Hem-o-lock夹夹闭 三、统计分析统计手术时间，术中失血量，肾动脉阻断（热缺血）时间，术后住院时间及随访情况。和2011年3月-2012年1月同期进行的26例后腹腔镜肾部分切除术（对照组）进行比较。结果21例后腹腔镜肾部分切除手术全部顺利完成，无一例中转开放，未出现大血管或邻近脏器损伤等术中并发症。本组手术时间68～105min，平均78.5min。术中出血量30～140ml，平均60.5ml，术中均未输血。肾动脉阻断（热缺血）时间12～21min，平均15.2min。缝合时间5－17min,平均10.4min。无大出血、继发性出血、尿漏等手术相关并发症。术后住院5～7d，平均5.9d。术后病理报告肾透明细胞癌17例，乳头状细胞癌2例，切缘均为阴性；血管平滑肌脂肪瘤2例。随访1-6月，无肿瘤局部复发和远处转移。缝合时间、热缺血时间和术中出血量明显短于对照组，手术时间和住院时间短于对照组，血尿发生率少于对对照组。见表1。表1. 本组和对照组手术基本情况和术后结果对比项目Quill线组(n=21)对照组(n=26)P 值年龄(y)51.2±10.150.8±11.20.899性别（m/f）13/816/100.980肿瘤大小（X±s）cm左/右(n)位置（上极、中部、下极）(n)2.9±1.210/118/2/112.8±1.412/149/3/130.7970.9200.962缝合时间（X±s）min10.4±3.219.4±6.7﹤0.001热缺血时间（X±s）min15.2±4.223.1±5.6﹤0.01手术时间（X±s）min78.5±15.490.3±18.10.022术中出血量（X±s）ml60.5±21.2110.4±21.1﹤0.001尿漏(n)00血尿(n)140.362住院时间（X±s）(d)5.9±2.16.8±2.30.173讨论因B超、CT和MRI等影像学技术的广泛应用，偶发肾癌逐步增加，而这些肿瘤具有体积较小、分期较低、增长速度慢和转移潜能低等特点，预后好于症状性肾癌[9,10]，手术是局限性肾癌治疗的金标准[11]。肾部分切除术（partial nephrectomy, PN）近年来成为治疗T1a肾细胞癌（renal cell carcinoma, RCC）的新术式。事实上，肿瘤<4 cm 病人中，26％的病人在术前基础 GFR<60 mL/min[12]；根治性肾切除(redical nephrectomy, RN)手术标本周围大多数非肿瘤肾组织有一定程度的组织病理异常[13]。越来越多的研究证明慢性肾脏疾病和心血管疾病的关系[14]，而且当GFR降低<60mL/min时，死亡和住院治疗的风险增加[15]，RN被认为CKD发生和发展的危险因子，而PN带来的肾单位的保留能够减轻这些影响[16,17]。RN对于慢性肾脏疾病的发生和恶化是一个危险因素，研究表明：RN能增加T1 RCC患者死亡率和肾衰竭发生率[18, 19]；PN 能达到RN同样的病理结果，而且在肾功能和心血管功能长期维持方面具有一定优势[17,20]。PN有开放的肾部分切除术（open partial nephrectomy, OPN）、腹腔镜肾部分切除术（laparoscopic partial nephrectomy, LPN）和机器人辅助的肾部分切除术等术式。LPN达到与OPN相同的病理和功能结果，而且具有术后镇痛治疗减少、住院时间缩短、术后恢复快等优点[2-6]。LPN 有经腹和经腹膜后两种手术路径，Gill于1994年完成第一例后腹腔镜肾部分切除术[21]， Winfield于1993完成第一例经腹腹腔镜肾部分切除术[22]。经腹途径具有操作空间大、解剖标志明确等优点，但有内脏干扰、可能肠管并发症等缺点；后腹腔途径具有肾蒂血管控制容易、腹腔脏器干扰小等方面的优势，但存在操作空间小、缺乏解剖标识等缺点；解剖、程序化和规范化手术操作能够尽可能弥补后腹腔途径在手术操作空间相对小、解剖标志欠明确等方面的不足[1]。尽管LPN有各种优点，LPN技术仍然具有一定挑战性，同时伴有术中并发症(出血和尿漏等)较多和热缺血时间相对较长等问题 [7,8]；热缺血时间和肾功能丢失密切相关，热缺血时间超过30min，热缺血对肾功能的影响超过3－5倍[23,24]。缝合是保持肾脏稳定和防止尿漏最有效的方法，然而它是具有挑战性，相对费时、费力[25, 26]，缝合技巧的提高可以降低并发症发生率和缩短缝合时间[3]。Hem-o-lok夹的使用代替打结是有效和安全的[26,27]，能够缩短缝合和热缺血时间，但仍然存在缝合不够严密、费时、费力等缺点。Quill线又称双向倒刺可吸收线，表面有均匀分布的三维微小倒钩，在缝线正中约1cm没有倒钩，具有无需打结、缝合时间缩短、可以多层缝合、术中出血少等优点[28]。我们应用Quill线明显提高了肾部分切除术的缝合效率，收线相对自如，省时省力，明显缩短了缝合时间和热缺血时间，而且尿漏和术后出血发生率明显降低。双向倒刺可吸收线在后腹腔镜肾部分切除术中应用能够明显缩短缝合时间和热缺血时间，减少手术并发症，具有很好的安全性和可行性，值得临床广泛推广。

Abstract Objectives Evaluate the advantages of inguinal incisionin extracting the kidney during retroperitoneal laparoscopic live-donornephrectomy(LDN). Methods From May2008 to June 2011, 58 cases of retroperitoneal LDN were performed at ourhospital, all data were analyzed retrospectively. All donors were grouped as atest group (n=32, inguinal incision) anda control group (n=26, lumbar incision) according to graft retrieval incisionselection. Donors were compared with regard to operative time and warm ischemiatime, operative blood loss, hospital stay and cosmetic satisfaction andincision complications. Results All 58cases of retroperitoneal LDN were successfully accomplished, without donordeath, serious complications, and conversion to open surgery. There were nodifferences in mean operation time, mean blood loss, mean warm ischemic time,graft function, and 1-year graft survival rate between the groups. But in atest group, the mean hospital stay was shorter, P < 0.01; and cosmeticsatisfaction was higher P < 0.01, the incidence rates of abdomen asymmetry(9/28),incision hernia(4/28), wound infection(5/28) and wound faulty union(6/28) ofthe control group was higher than that of the test group. The inguinal incisionis a safe and practical graft retrieval incision in retroperitoneallaparoscopic donor nephrectomy and can be generally applied.Key words: Laparoscopic live-donornephrectomy; Renal transplantation; Inguinal incision; retroperitonealIntroductionSince the first laparoscopic donor nephrectomy (LDN)was performed by Ratner in 1995, LDN has been gradually accepted as a safeprocedure in recent years, and has increased the potential number of livingkidney donors. Compared with open-donor nephrectomy(ODN), LDN results in fewerpostoperative complications, less pain, shorter hospital stay, earlier recovery,and ideal cosmesis without differences in renal function or allograftsurvival.2-4 LDN can be performed transperitoneally or retroperitoneally oneither side, the risk of bowel injury and intestinal obstruction is higher intransperitoneal LDN, retroperitoneal LDN has the advantages of limiting therisk of damage to intra-abdominal organs and providing direct access to therenal artery and vein, it has been performed in many countries, especially inchina. Graft retrieval incision also plays an important role in encouragingkidney donation and ensuring better cosmetics, especially for young ladies whointend to donate a kidney.From May 2008 to June 2011, we performed 32 cases ofretroperitoneal LDNs with inguinal incision as graft retrieval incision. Weretrospectively compared the differences of inguinal incision and lumbarincision for retroperitoneal LDN. Materials and MethodsDonors and recipientsFrom May 2008 to June 2011, 58 cases of retroperitonealLDN s were performed at our center. Obese donors, donors with an lumbaroperation history of the same side as the donor kidney were excluded. Alldonors were informed about our study and signed the informed consent form.Prior to the study, the protocol was approved by our local institutional ethicscommittee, and conforms with the ethical guidelines of the 1975 HelsinkiDeclaration. Written, informed consent was obtained from all of the subjects.Among the donors, there were 17 men and 41 women (age range, 23-67 years, meanage, 38.6 years) and a kinship relationship developed between donor andrecipient. Before the operation, all donors underwent a completeexamination, including isotope nephrography and kidney arteriography with3-dimensional reconstruction. All donors were grouped as a test group (n=32)and a control group (n=26). According to graft retrieval incision, inguinalincision was used in test group, lumbar incision was used in control group.Among the 58 recipients, 37 men, 21 women (age range16-68 years; mean age, 37.5 years), no renal transplant contradictions werefound.Live-donor nephrectomiesprocedure(left) The patient was placed in a right lateral position.The port A(posterior axillary line maintained under the 12th rib) was created,2 cm incision was made by knife, them long forceps was used to dissociatesubcutaneous tissue, muscle, and lumbar fascia, finger could feel inner face ofthe rib, self-made gasbag was inserted, 500-800ml gas was incharged, kept for3-5minutes(Figure 1). Port B(anterior axillary line maintained under the 12thrib) was created by finger guidance，port C(middleaxillary line maintained above the iliac crest) was created, 10 trocar wasinserted(Figure 1). 12 cm trocar was inserted on the port A, lumbar fascia wassutured first, muscle and skin were sutured then. Entering retroperitoneal cavity, extraperitoneal andperirenal fasica adipose tissue was separated sharply with ultrasonic knifefrom superior to interior, from anterior to posterior, then peritonealreflection and Gerota fascia was identified clearly. Gerota fascia wasdissected near to peritoneal reflection, exceeding upper pole of kidney, lower3-4cm inferior to lower pole of kidney. The perirenal fat tissue was dissectedfrom lateral border near to renal hilum on the front of kidney first, then thereal part. On the level of inferior pole of kidney, dissection must beperformed carefully, ureter could be recognized and was mobilized. Renal vesselsheath was opened，then renal artery and vein were mobilizedcompletely. Adrenal gland was detached from kidney finally. The ureter wassectioned close to the crossover with the iliac vessels.For the test group, kidney was pulled out frominguinal incision, a 5-cm to 7-cm skin incision was made 2 cm apart from theinguinal ligament (Figure 2), skin, subcutaneous tissue, oblique externus abdominismuscle membrane were cut open, endoabdominal fascia and obliquus internusabdominis were left intact. For 12 cases, extract bags was placed intoretroperitoneal cavity from 12cm trocar which was inserted by inguinalincision, then kidney body was loaded in bag. The renal artery and vein wereligated, endoabdominal fascia and obliquus internus abdominis were slitted,extract bag with kidney was pulled out from inguinal incision. For 20 cases,inguinal incision was about 6-7cm long, kidney was pulled out by operator hand.For the contrast group, lumbar incision was createdfrom A to B, about 7-9cm long, external oblique muscle and internal obliquemuscle were cut, transverse abdominal muscle back fascia was left intact. Afterthe renal artery and vein were ligated, transverse abdominal muscle fascia wasslitted, kidney was pulled out by operator hand from lumbar incision. Clinical dataAlllive-donor nephrectomies’ operative time, operation blood loss, ischemia time,hospital stay and incision complications were recorded and compared. Incisioncomplications included abdomen asymmetry, incision hernia, wound infection and wound faultyunion. All donors andrecipients were followed-up for at least 12 months. Donors were asked tocomplete a questionnaire about incision satisfaction on 1 month and 3 monthspostoperatively. Incision satisfaction included not satisfactory(1),satisfactory(2), and very satisfactory (3). StatisticalAnalyses Statistical analyses were performed with SPSS softwarefor Windows (Statistical Product and Service Solutions, version 10.0, SSPS Inc,Chicago, IL, USA).Categorical variables were compared with the chi-square test; continuousvariables were compared with the Mann-Whitney U test. A value for P < .05was considered statistically significant.ResultsAll 58 cases of retroperitoneal LDN were successfullyaccomplished, without donor death, serious complications, or conversion to opensurgery. Demographics, operative time, blood loss, and warm ischemia time,1-year graft survival rate and incision complications were reported in Table 1.There were no differences in mean operation time, mean blood loss, mean warmischemic time, graft function, and 1-year graft survival rate between thegroups. But in the test group, mean hospital stay was shorter, P < 0.01; andcosmetic satisfaction was higher P < 0.01.In the control group, the incidence rates of abdomen asymmetry(9/28),incision hernia(4/28), wound infection(5/28) and wound faulty union(6/28) washigher than that of the test group.DiscussionSince the first laparoscopic donor nephrectomy (LDN)was performed by Ratner in 1995, LDN has been gradually accepted as a safeprocedure in recent years, and has increased the potential number of livingkidney donors.1,5 Since May 2004, all live-donor nephrectomies have beenperformed by laparoscopy at our hospital. LDN seem to be at least as safe andefficacious as open-donor nephrectomies(ODN).6-9 Compared with ODN, LDN hasshown superior results in postoperative pain, less complications, satisfactory cosmesis,and fast recovery.9-13 There are nosignificant differences in cost-effectiveness and graft function between LDN and ODN.14-16 In addition, the longer warmischemia time during live-donor nephrectomies shows no significant deleteriouseffect on graft survival.17-20 LDN can be performed transperitoneally orretroperitoneally on either side. Due to adequate working space and easydissection, LDN was done transperitoneally at many centers. However, the riskof bowel injury and intestinal obstruction is higher in transperitoneal LDN. RetroperitonealLDN was performed firstly by Yang et al in 1995,21 because it has theadvantages of limiting the risk of damage to intra-abdominal organs andproviding direct access to the renal artery and vein, it has been performed inmany countries, especially in china.21-24 Many studies showed that RetroperitonealLDN was safe and feasible as transperitoneal LDN, was less invasive than transperitonealLDN. 25-27 The aim of LDN is to decrease operative trauma on thedonor and guarantee graft quality as much as possible. The incision trauma alsoplays an important role for the donor to decide donation at some degree,especially for young women. From a cosmetic standpoint, the midline orsubcostal scar is often prominent, and can not be concealed by lingerie orswimwear.28 Compared with lumbar incision and upper abdomen incision, theinguinal incision has the advantages of thinner muscle, less trauma, lessdehiscence, quick recovery, better cosmesis and less complications.28 Our studyshowed that inguinal incision did not increase operative time, blood loss, but decreasedhospital stay, incision complication rate of abdomen asymmetry, incisionhernia, wound infection and wound faulty union.The inguinal incision is a safe and practical graftretrieval incision in retroperitoneal LDN and can be generally applied.References1.RatnerLE, Ciseck LJ, Moore RG, et al. Laparoscopic live-donor nephrectomy.Transplantation. 1995; 60(9): 1047-1049.2.NicholsonML, Kaushik M, Lewis GR, et al. Randomized clinical trial of laparoscopicversus open-donor nephrectomy. Br J Surg. 2010; 97(1): 21-28.3.AntcliffeD, Nanidis TG, Darzi AW, Tekkis PP, Papalois VE. A meta-analysis of mini-openversus standard open and laparoscopic living donor nephrectomy. Transpl Int.2009; 22(4): 463-474.4.Nanidis TG, Antcliffe D, Kokkinos C, et al. Laparoscopic versus openlive-donor nephrectomy in renal transplantation: a meta-analysis. Ann Surg.2008; 247(1): 58-70.5.Gill IS, Carbone JM, Clayman RV, et al . Laparoscopiclive donor nephrectomy. J Endourol 1994; 8: 143-148. 6.SimforooshN, Basiri A, Tabibi A, et al. Comparison of laparoscopic and open-donornephrectomy: a randomized controlled trial. BJU Int. 2005; 95(6): 851-855. 7.ShokeirAA. Open versus laparoscopic live-donor nephrectomy: a focus on the safety ofdonors and the need for a donor registry. J Urol. 2007; 178(5): 1860-1866.8.Kok NF, Weimar W, Alwayn IP, etal. The current practice of live-donor nephrectomy in Europe.Transplantation. 2006; 82(7): 892-897.9.KokNF, Dols LF, Hunink MG, et al. 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Mini-incisions by lombotomy orsubcostal access in living kidney donors: a randomized trial comparing pain,safety, and quality of life. Clin Transplant. 2007; 21(2): 269-276.16.MjenG, yen O, Holdaas H,et al. Morbidity and mortality in 1022 consecutive livingdonor nephrectomies: benefits of a living donor registry. Transplantation.2009; 88(11): 1273-1279.17.PatelS, Cassuto J, Orloff M, et al. Minimizing morbidity of organ donation: analysisof factors for perioperative complications after living-donor nephrectomy inthe United States. Transplantation. 2008; 85(4): 561-565.18.Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidneydonation. N Engl J Med. 2009; 360(5): 459-469. 19.Andersen MH, Mathisen L, Veenstra M, et al. Quality of life afterrandomization to laparoscopic versus open living donor nephrectomy: long-termfollow-up. Transplantation. 2007; 84(1): 64-69.20.Kok NF, Adang EM, Hansson BM, et al.Cost effectiveness of laparoscopic versus mini-incision open-donor nephrectomy:a randomized study. Transplantation. 2007; 83(12): 1582-1587.21.Yang SC, Park DS, Lee DH, et al.Retroperitoneal endoscopic live donor nephrectomy: report of 3 cases. J Urol1995; 153: 1884-1886. 22. Jacobs SC, Flowers JL, Dunkin B,et al. Living donor nephrectomy. Curr Opin Urol. 1999; 2: 115–120. 23. Ishikawa A, Suzuki K, Saisu K, etal. Endoscopy-assisted live donor nephrectomy: comparison between laparoscopicand retroperitoneoscopic procedures. Transplant Proc 1998; 30: 165–167. 24. Hemal AK, Singh I. Minimallyinvasive retroperitoneoscopic live donor nephrectomy: Point of technique. SurgLap Endos Tech 2001; 11: 341-343.25.DongJ, Lu J, Zu Q,et al. Retroperitoneal laparoscopic live donor nephrectomy: report of 105cases. J Huazhong Univ Sci Technolog Med Sci. 2011; 31(1): 100-102.26.KoheiN, Kazuya O, Hirai T, et al. Retroperitoneoscopic living donor nephrectomy:experience of 425 cases at a single center. J Endourol. 2010; 24(11): 1783-1787.27.Dimitri Liapis, Alexandre De La Taille, GuillaumePloussard, et al. Analysisof complications from 600 retroperitoneoscopic procedures of the upper urinarytract during the last 10 years. World J Urol. 2008; 26(6): 523–530.28.Wang K, Wan FC, Gao ZL, et al. Inguinal Oblique Incisionas an Alternative Route To Extract the Kidney During Laparoscopic DonorNephrectomy. Experimental and Clinical transplantation. 2011; 9(5)：315-318Figurelegends Figure 1. Patient position and port andgraft retrieval incision for live-donor nephrectomiesA: 12-mm trocar for laparoscope; B: 5-mmtrocar for work port; C: 10-mm trocar for work port. Incision, inguinal incision for extraction ofdonor kidney. Figure 2. Inguinaloblique incision was created before renal artery obstructi

Effect analysis of one-year posttransplant body mass index on chronic allograft nephropathy of renal recipientsTransplant Proc. 2011 Sep;43(7):2592-5WANG Ke, LIU Qing-zuo,Organ Transplantation Center of Yantai Yuhuangding Hospital , Yantai 264000, ChinaCorresponding author：LIU Qing-zuo，ythuianliu@sina.com[Abstract] objective: Evaluate the effect of Body mass index (BMI) at 1 year after transplantation on chronic allograft nephropathy( CAN). Methods: 564 Patients receiving kidney transplants between June 1997 and March 2005 were grouped according to their body mass index (BMI) at 1 year after transplantation into group I, BMI more than 18.5 and less than equal to 25 (normal weight); group II, BMI greater than 25 and less than or equal to 30 (overweight); and group III, BMI greater than 30 (obese), all selected patients were retrospectively studied. All donors were live donors, no prisoners were used in our study. Results: One-year posttransplant BMI was more than that of preoperation, which of group II、III was more significantly than preoperation( respectively P < 0.05 and P < 0.01. The CAN incidence rate in 3 groups was 34.9%（128/367）、38.4%（48/125） and 43.1%（31/72）respectively，there was a statistically significant difference between group I and III（P<0.05）. With the increase of one-year posttransplant BMI, hypertension, diabetes mellitus and hyperlipidemia incidence rate increased, there was no difference in acute rejection rate between three groups. Multivariate analysis showed that BMI of first post-operative year had significant influence on CAN. Conclusions: 1 year BMI after kidney transplantation has a strong association with CAN, controlling diet, suitable exercises and decrease of immunosuppressive agent and so on could control BMI, then decrease the CAN incidence rate.[key words] renal transplantation; body mass index; chronic allograft nephropathyINTRODUCTIONWith the wide use of immunosuppressive agents, one year survival rate of renal allograft has been increased markedly. Unfortunately, five year survival rate has not been improved greatly, and chronic allograft nephropathy (CAN) was considered to be the major cause for the loss of graft function [1, 2]. Because there are controversies about the relationship between obesity and CAN, we retrospectively analyzed the data of 564 consecutive cases of renal allograft recipients from our center during June 1997 to March 2005, in order to investigate the relationship between BMI and the development of CAN in the first post-operative year of the renal allograft recipients.MATERIALS AND METHODSCLINICAL DATAA total of 564 patients with mean age of 39.2 years were enrolled in this study, 307 were male and 257 were female. Patients with age≤18, BMI<18.5, loss of functional renal graft within 18 months after transplantation, impaired renal function induced by surgical complications, and episodes of cardio-cerebrovascular diseases and diabetes mellitus before transplantation were excluded from this study. All the patients were divided into three groups according to their BMI in the first post-operative year, that is, group I, 18.5 ≤ BMI ≤ 25（normal）, group II, 25 < BMI ≤ 30（overweight）, and group III, BMI >30（obesity）. BMI was defined by WHO as weight in kilograms (kg) divided by height in meters squared (m2). All the patients were followed up to at least 18 months. All donors were live donors, no prisoners were used in our study.IMMUNOSUPPRESIVE REGIMENSCyclosporine A (CsA) was given at 8am and 8pm, with an initial dose of 6 ~ 7 mg/kg·d, and then adjusted to maintain serum CsA levels at 250 ~ 350 ng/ml in the first post-operative month, 200 ~ 300 ng/ml in the first post-operative year, 120 ~ 220 ng/ml in the second to the third year, 80 ~ 200 ng/ml in the fourth year and later. Tacrolimus (FK506) was given 1 hour before meal or 2 hours after meal, namely 6am/pm or 9am/pm, with an initial dose of 0.1 ~ 0.15 mg/kg·d, and adjusted to maintain serum FK506 levels at 8 ~ 10 ng/ml in the first post-operative month, 6 ~ 9 ng/ml in the first post-operative year, 5 ~ 7 ng/ml in the second to the third year, 3 ~ 6 ng/ml in the fourth year and later. A draught of Mycophenolate Mofetil (MMF) and Mizoribine（Bred）or Azathioprine （Aza）were given at a dose of 1g, 100mg or 100mg before transplantation, 1 ~ 1.5g/d, 100 ~ 150mg/d or 100mg/d in first post-operative half year, and 0.5 ~ 1g/d, 50 ~ 100mg/d or 50 ~ 100mg/d half a year later respectively. Methylprednisolone（MP）was administrated at a dose of 1g during the operation, and 0.5g at each of the first three post-operative days. Prednisolone acetate（Pred） was administrated from the fourth post-operative day at an initial dose of 40 ~ 50mg/d, and tapered to 10mg/d within the first 30 post-operative days and 5 ~ 10mg/d for half a year later as a maintenance dose. As for the dose of immunosuppressive agents, no significant difference was shown among the three groups.DIAGNOSTIC CRITIRIA FOR CAN AND CASES SELECTIONFrom patients with increased serum creatinine (>124μmol/L), CAN was diagnosed according to the criteria as follows: ① clinical manifestations such as abnormal increase of SCr at least 6 months after transplantation, and continuous dysfunction of the renal allograft despite of the administration of the MP anti-rejection therapy and regulation of the immunosuppressive regime. ② auxiliary examinations, such as ultrasonographic examination of the renal allograft, serum concentration determination of CsA or FK506 for excluding of diseases leading to chronic renal damage such as acute allograft rejection, acute toxicity of CsA, ureteral obstruction or vesico ureteral reflux, renal vascular stenosis, or infections. ③ renal allograft biopsy for identifying of non-specific pathological alterations such as renal interstitial fibrosis and renal tubular atrophy from those specific pathological alterations such as acute renal allograft rejection, acute poisoning with CsA, or recurrent glomerulonephritis.In this study, CAN in all patients were found within the first post-operative year, those who developed within 1 year were excluded.ANALYTICAL INDEXElectronic archives for all the renal transplantation recipients were established and data for weight, SCr, BUN, blood glucose, serum lipid, acute renal allograft rejection, and CAN were documented in details. The diagnostic criteria of 140/90mmHg (1mmHg=0.133kPa) was adopted because of the fact of relative hypertension seen in most of the renal transplantation recipients. According to 1997 diagnostic standards of American Diabetes Association (ADA), diabetes mellitus could be diagnosed if the patients’ blood glucose levels reached any of the following 2 criteria: fasting blood glucose > 7.0mmol/L, or postprandial blood glucose > 11.1mmol/L. And for hyperlipidemia, fasting total serum cholesterol > 572umol/L，and serum triglyceride > 1.70 μmol/L.Diagnostic criteria for acute renal allograft rejection are as follows: ① decreased urine volume, elevated blood pressure, fever, gaining body weight, distending pain in the allograft region; ② elevated levels of SCr to 15% more than before, increased urinary proteins, and increased renal vascular resistance index; ③ pathological alterations in renal allograft biopsies; and ④ clinical improvements after immunosuppressive treatments. Confirmed diagnoses were made upon a comprehensive analysis of the above findings.STATISTICAL ANALYSIST-test was applied to the comparison between each paired BMI, and Chi-square test was used for testing the differences of baseline characters among the groups, and binary logistic regression was used for the multiple analysis to adjusting the confounding factors. P<=0.05 was considered statistically significant, and all the analysis was conducted with SAS software, version 6.12.RESULTSBefore transplantation, no difference of BMI was found between group II and group III though minor differences among the three groups (p>0.05). After transplantation, BMI of each group increased in the first post-operative year, and significant differences were found in group II and III respectively, when compared with that before transplantation (P <0.05, P <0.01). With the increasing of BMI in the first post-operative year, incidences of CAN increased in each group by 34.9% (128/367), 38.4% (48/125), and 43.1% (31/72) respectively，and significant difference was found between group III and group I ( P<0.05). Incidences of hypertension, diabetes mellitus and hyperlipidemia in each group increased with BMI, and significant difference was found between group III and group I [30.6% (22/72) versus 21.0% (77/367), 26.4% (19/72) versus 15.8% (58/367), 29.2% (21/72) versus 18.1% (66/367), p all <0.05]. Incidences of acute allograft rejection in each group was 26.4% (97/367), 25.6% (32/125), and 22.2% (16/72) respectively, and no significant difference was found among the three groups ( p>0.05) . See Table 1.Multivariate analysis showed that BMI of first post-operative year had significant influence on CAN, CAN risk of group III was 2.046 times of group I. See Table 2.DISCUSSIONWith the wide use and the progressing research of immunosuppressive agents, 1 year survival rate of the renal allograft has significantly improved; however, it is not the same with the 5-year graft survival rate. CAN, which has been verified by renal allograft biopsy, is considered to be the main reason [1-2] and accounts for about 60% ~ 70% the loss of function of the renal allograft [3]. Immunological and non-immunological factors, such as acute allograft rejection, HLA mismatch, and obesity, hypertension, hyperlipidemia, calmodulin inhibitors, cytomegalovirus infection, the quality of the donor kidney, are all responsible for the pathogenesis of CAN[4]. Non-specific pathological changes, including extracellular matrix deposition, renal interstitial fibrosis, tubular atrophy and arteriosclerosis, represent the histopathological characteristics of CAN [5]. Weight gain after transplantation is a popular phenomenon among the renal transplantation recipients, and about 25% ~ 35% recipients were found to be obese in the first post-operative year. In this study, we found a significant BMI increase after renal transplantation in the recipients, especially for those in the overweight and obese groups. Redistribution of fat and fluid retention elicited by immunosuppressive agents, elimination of dietary restrictions, good postoperative cares, and increased appetite induced by steroid hormone contribute to the increase of body mass index [6].Obesity is a very important risk factor for increased morbidity and mortality in general population [7], and has close relationships with the increasing incidences of hypertension, hyperlipidemia, type 2 diabetes, proteinuria and glomerularnephropathy [8]. In general population, BMI >25 kg/m2 is considered to be a risk factor for type 2 diabetes. By studying this group of renal transplant patients, we found that the incidences of hypertension, diabetes and hyperlipidemia in the obesity group was significantly higher than that in other groups (p<0.01), thus showing a positive relationship for these diseases to the body mass index. Based on a research of The United States Renal Data System (USRDS), Kasiske et al. found that new-developed diabetes, especially for those emerged in the first post-operative year after renal transplantation, was a major complication seen in 2.5%~ 25% of the renal transplantation recipients. Obesity is considered to be an independent risk factor for the new-developed diabetes after renal transplantation.It is not clear about the influence of obesity on the renal allograft, and some researchers believe that obesity increased only slightly or even not increase the incidence of complications of the renal allograft [10]. However, some others believe that obesity can significantly increase the incidences of post-transplantation complications and eventually lead to the loss of the renal allograft [11]. Our data has shown that, in the first post-operative year after renal transplantation, the incidence of CAN had a close relationship to BMI and elevated with the increase of BMI. However, it is not the fact for acute renal allograft rejection. Through a research of 2165 renal transplantation cases, Aalten et al [12] found that 1-year and 5-year survival rate of the renal transplant recipients in the obesity and the non-obesity group were 94%, 97% and 81%, 89% respectively（p < 0.01）, 1-year and 5-year survival rate of the renal allograft in the two groups were 86%, 92% and 71% , 80%， respectively（p < 0.01）, and believed that BMI is an independent predictive factor for the death of the recipients and the loss of the renal allograft in transplantation. A Cox regression analysis on 51927 adult renal allograft recipients from USRDS by Meier-Kriesche et al. showed that BMI had a close relationship to the outcome of renal transplantation, those with relatively high or low BMI would have a low survival rate of the allograft and the recipients, and the incidences of CAN increased significantly. Increase of BMI is also a risk factor for DGF, while no obvious relationship was found between BMI and the acute allograft rejection.On the contrary, there are still some other researchers insisting that weight gain after renal transplantation will be a favorable factor to the renal allograft. After a retrospectively analyze of 165 renal transplantation recipients according to their weight gain 1 or 5 years after renal transplantation, Homa et al [12] found that the recipients who had weight gain kept relative satisfactory functions of the renal allograft. However, some other researchers did not support these findings[10，14-15]. Through a multivariate analysis of 27377 renal transplantation recipients, Gore et al [16] found that obesity was not only an influencing factor to the occurrence of DGF, prolonged hospitalization time and the onset of acute allograft rejection, but also a covariate affecting the outcomes of the allograft.Researches have demonstrated that obesity after transplantation is related to proteinuria [17], metabolic syndrome, shortened allograft survival [18-19] and C - reactive protein. These facts are in accordance with the speculation that obesity is a kind of inferior inflammatory factors and is involved in the pathogenesis of CAN and CVD. In recent years, metabolic syndrome, which is characteristic with obesity, lipid metabolism disorders, hypertension and insulin resistance, is considered to be a risk factor for the morbidity and mortality of CVD [20] and a non-immunological risk factor for CAN. Based on these data, we could rationalize that metabolism syndrome may lead to the loss of the allograft. A cross-sectional study of 606 renal transplant recipients has found that the presence of metabolic syndrome was associated with impaired renal allograft function beyond 1 year post-transplant, though multivariate analyses revealed that only systolic blood pressure and hypertriglyceridemia were found to be independently associated with impaired renal allograft function [21].How to control the body mass index of the renal transplant allograft recipients is directly related to the long-term survival of renal allograft. Through diet control, appropriate physical exercise, reduction of immunosuppressive agents, body mass index of the renal allograft recipients might be controlled appropriately, thereby the goal of a maximal reduced occurrence of CAN and a most prolonged survival rate of the renal allograft could be achieved.REFERENCES[1]. Ruggenenti P. Chronic allograft nephropathy: a multiple approach to target nonimmunological factors. Contrib Nephrol, 2005, 146: 87-94.[2]. Artzm A, Hilbrands L B, Borm G, et al. Blockade of the rennin-angiotensin system increases graft survival in patients with chronic allograft nephropathy. Nephrol Dial Transplant, 2004, 19: 2852-7.[3]. T Paul LC. Chronic allograft nephropathy: an update. Kidney Int. 1999, 56:783–793.[4]. Prommool S, Jhangri G S, Cockfield, et al. Time dependency of factors affecting renal allograft survival. J AmSoc Nephrol, 2000, 11: 565-573.[5]. Densem CG, Mutlak ASM, Pravica V, et al. A novel polymorphism of the gene encoding furin, a TGF-β1 activator, and the influence on cardiac allograft vasculopathy formation. Transplant Immunology, 2004, 37: 697- 702.[6]. Clunke JM, Lin CY, Curtis JJ, et al. Variables affecting weight gain in renal transplant recipients. Am J Kidney Dis, 2001, 38(2): 349–353.[7]. Byers T. Body weight and mortality. N Engl J Med, 1995, 383: 728–734.[8]. Adelman RD. Obesity and renal disease. Curr Opin Nephrol Hypertens, 2002, 11: 331–335.[9]. Kasiske BL, Snyder JJ, Gilbertson D, et al. Diabetes mellitus after kidney transplantation in the United States. Am J Transplant, 2003, 3:178–185.[10]. Johnson DW, Isbel NM, Brown AM, et al. The effect of obesity on renal transplant outcomes. Transplantation, 2002, 74: 675–681.[11]. Meier-Kriesche HU, Arndopfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: A significant independent risk factor for graft failure and patient death. Transplantation, 2002, 73:70–74.[12]. Aalten J, Christiaans MH, de Fijter H, Hené R, van der Heijde JH, Roodnat J, Surachno J, Hoitsma A. The influence of obesity on short- and long-term graft and patient survival after renal transplantation. Transpl Int, 2006, 19: 901 -907.[13]. Homa B, Grover VK, Shoker A. Prevalence of weight gain in patients with better renal transplant function.Clin Nephrol, 2006, 65: 408-414.[14]. Massarweh NN, Clayton JL, Mangum CA, et al. High body mass index and short- and long-term renal allograft survival in adults. Transplantation, 2005, 80: 1430– 1434.[15]. Yamamoto S, Hanley E, Hahn AB, et al. The impact of obesity in renal transplantation: an analysis of paired cadaver kidneys. Clin Transplan, 2002, 16:252–256.[16]. Gore JL, Pham PT, Danovitch GM, et al. Obesity and outcome following renal transplantation. Am J Transplant, 2006, 6:357–363.[17]. Armstrong KA, Campbell SB, Hawley CM, et al. Obesity is associated with worsening cardiovascular risk factor profiles and proteinuria progression in renal transplant recipients. Am J Transplant, 2005, 5:2710–2718.[18]. Ducloux D, Kazory A, Simula-Faivre D, et al. One-year posttransplant weight gain is a risk factor for graft loss. Am J Transplant, 2005,5:2922–2928.[19]. Raiss-Jalali GA, Mehdizadeh AR, Razmkon A, et al. Effect of body mass index at time of transplantation and weight gain after transplantation on allograft function in kidney transplant recipients in Shiraz. Transplant Proc, 2005, 37:2998–3000.[20]. Sarti C, Gallagher J. The metabolic syndrome: prevalence, CHD risk, and treatment. J Diabetes Complicat, 2006, 20:121–13[21]. De Vries APJ, Bakker SJL, Van Son WJ, et al. Metabolic syndrome is associated with impaired long-term renal allograft function: not all component criteria contribute equally. Am J Transplant, 2004, 4:1675–1683.

[摘要]目的：研究腹股沟斜切口在后腹腔镜肾癌根治术中应用。方法：选择我院 2009 年 4 月至 2011 年8月开展的后腹腔镜肾癌根治术 202 例，根据手术标本取出切口的不同分为试验组和对照组，试验组（n = 78）采用腹股沟斜切口取出标本，对照组（n=124）采用腰部斜切口。对其手术时间、术中出血量、患者住院时间、切口并发症以及美容满意度进行比较。结果：本组 202 例后腹腔镜肾癌根治术均全部成功，未出现死亡和重大并发症。实验组和对照组在手术时间、术中出血量差别无统计学意义；两组术后需镇痛治疗、切口感染、切口脂肪液化、切口疝、切口膨出、腰腹部不对称病例分别为 2 例和 23 例（P＜0.01）、1 例和 12 例（P＜0.01）、0 例和 6 例（P＜0.01）、0 例和 3 例（P＜0.05）、0 例和 2 例（P＜0.05）、0 例和 14 例（P＜0.01）；两组平均住院时间分别为（5.2±2.3）d和（6.8±3.4）d（P＜0.05）；切口美容满意度(I/II/III)分别为 2/12/64和 34/47/43（P＜0.01），实验组美容满意度明显高于对照。结论：对于后腹腔镜肾癌根治术，腹股沟斜切口用于手术标本的取出具有创伤小、切口并发症少、患者美容满意度高等优点，值得临床广泛推广。[关键词] 后腹腔镜；肾癌；腹股沟斜切口；切口并发症Application of Inguinal Oblique Incision in Retroperitoneal Laparoscopic Radical Nephrectomy Abstract Objectives Evaluate the advantages of inguinal oblique incision in retroperitoneal laparoscopic radical nephrectomy. Methods From April 2009 to August 2011, 202 cases of retroperitoneal laparoscopic radical nephrectomies were performed at our hospital. all data were analysed retrospectively. All cases were grouped as test group( n=87, inguinal oblique incision) and control group( n=124, lumbar incision) according to operation specimen retrieval incision selection. Operation time, operative blood loss, hospital stay, incision complications and cosmetic satisfaction were compared. Results All 202 cases of retroperitoneal laparoscopic radical nephrectomies were successfully accomplished, without death and serious complications. There were no differences in mean operation time and blood loss between test group and control group. The cases of postoperative analgesia therapy, incision infection, incision fat liquefaction, incision hernia, incision bulging and lumboabdominal unsymmetry in two groups were respectively 2 and 23(P＜0.01), 1 and 12(P＜0.01), 0 and 6(P＜0.01), 0 and 3(P＜0.05), 0 and 2(P＜0.05), 0 and 14(P＜0.01). Mean hospital stay were（5.2±2.3）d and (6.8±3.4）d(P＜0.05), cosmetic satisfaction (I/II/III) were 2/12/64和34/47/43(P＜0.01), cosmetic satisfaction of test group was higher than that of control group. Conclusions For retroperitoneal laparoscopic radical nephrectomy, the inguinal oblique incision as specimen retrieval approach offers advantage of less trauma, less complications and higher cosmetic satisfaction, can be thought to be he applied generally .Keywords retroperitoneal laparoscopy, renal carcinoma; inguinal oblique incision, incision complication随着腹腔镜技术的飞速发展，腹腔镜肾癌根治术已逐渐成为治疗局限性肾癌的标准术式[1]。腹腔镜肾癌根治术具有创伤小、术中出血少、术后恢复等优点。腹腔镜手术的目的就是尽可能减少手术的损伤，标本取出切口的选择是腹腔镜手术的考虑要素之一，亦是减少手术并发症、提高患者美容满意度的重要因素。腹股沟处腹部肌肉薄，腹股沟斜切口对患者肌肉的损伤以及对腹部脏器的影响均达到最小化，有利于患者的术后恢复；腹股沟斜切口位置低，亦有利于患者的美容。我院自 2009年 4 月至 2011 年 8 月进行了216例后腹腔肾癌根治术，其中78例切除标本经腹股沟切口取出，其余经腰部斜切口取出；本文对其手术时间、术中出血量、住院时间、美容满意度、切口并发症等方面进行比较，总结如下。资料与方法一、病例资料本组202例，其中男120例，女82例。年龄24～83岁，平均53.8岁。所有病例均经B超、肾脏CT平扫、增强或磁共振成像检查确诊肾脏肿瘤且无远处转移，无肾静脉、腔静脉瘤栓形成。肿瘤位于肾上极74例，中部69例，下极59例。左肾肿瘤114例，右肾肿瘤88例。肿瘤直径2.5～11.3cm，平均6.3cm。按AJCC肾癌TNM肿瘤分期T1N0M0 119例，T2N0M0 72例，T3N0M0 11例。根据标本取出切口的不同分为实验组和对照组，实验组自腹股沟切口取出标本（78例），对照组自腰部斜切口取出标本（124例）。剔除标准：因组织粘连、术中出血中转开放病例。二、手术方法（以左侧为例）气管插管全麻成功后，患者取90°健侧卧位，升高腰桥。取腋后线肋缘下2cm(A点，见图1)切开皮肤，长血管钳钝性分离肌层和腰背筋膜。进入示指，向上外触及肋弓，向前分离后腹膜，置入自制乳胶气囊，充气500～800ml，保留3-5min后取出。在手指引导下分别于腋中线髂嵴上2cm（C点）、腋前线肋缘下2cm(B 点)穿刺，A、B、C三点分别置入12mm、10mm、5mmTrocar。缝合密闭切口后经Trocar C置入0°或30°观察镜，Trocar A置入主操作器械。建立CO2气腹并维持气腹压12～15mmHg。图1. Trocar 和腹股沟斜切口位置进入后腹腔，首先寻找到腰大肌，其为肾脏背侧标志。用超声刀自上而下、由内至外锐性分离腰大肌旁、腹膜和Gerota筋膜外脂肪组织，之后可清晰地辨认腹膜返折及Gerota筋膜。在Gerota后筋膜与腰大肌筋膜之间、Gerota前筋膜与腹膜之间各有一无血管间隙，顺此间隙分离。背侧游离范围上至穹窿样的膈肌脚，下至Gerota筋膜后层的锥尖部；腹部游离范围上至肾上腺，下至Gerota筋膜前层的锥尖部，深部至肾蒂。向腹侧牵开肾脏显露肾蒂后，在肾门处寻找搏动的肾动脉及位于其前下方的肾静脉。用超声刀打开动脉外鞘，充分游离肾脏动脉，三重Hem-o-lock夹闭后切断。观察肾脏颜色、疲软度及肾静脉是否塌陷以确认无肾脏异位动脉存在。游离肾静脉，同法切断。于Gerota筋膜外侧游离整个肾脏，在髂嵴水平夹闭并切断输尿管。根据肿瘤位置及术前影像检查决定是否保留肾上腺。实验组：取腹股沟切口（见图1），长约4-6cm，切开腹外斜肌腱膜，在腹腔镜直视下置入10mmTrocar，置入取物袋，标本装入取物器，切开腹内斜肌、腹横肌和腹横筋膜，取出标本。对照组：切除标本装入标本袋，自A切口向前延长切口5-7cm，取出标本。三、统计指标观察指标包括手术时间、术中出血量、术后切口疼痛、住院时间、切口感染、切口脂肪液化、切口疝、切口局部膨出、腰腹部不对称以及美容满意度。切口美容满意度：分为不满意（I）、较满意（II）、满意（III）；四、统计学处理所有数据经SPSS 11.0软件分析处理。结果本组202例后腹腔镜肾癌根治术均全部成功完成，未出现死亡和重大并发症。实验组和对照组手术时间、术中出血量分别为（64.5±13.2）min和（67.2±14.6） min（P＞0.05）、（50.0±13.2）ml和（57.2±14.2）ml（P＞0.05），差别均无统计学意义。两组术后镇痛治疗、切口感染、切口脂肪液化、切口疝、切口膨出、腰腹部不对称病例分别为2例和23例（P＜0.01）、1例和12例（P＜0.01）、0例和6例（P＜0.01）、0例和3例（P＜0.05）、0例和2例（P＜0.05）、0例和14例（P＜0.01）。住院时间分别为（5.2±2.3）d和（6.8±3.4）d，P＜0.05，差别有统计学意义。切口美容满意度(I/II/III)分别为2/12/64和34/47/43，P＜0.01，实验组切口美容满意度明显高于对照组，见表1。表1. 实验组和对照组基本情况和术后结果对比项目实验组p(n=78)对照组(n=124)P 值年龄(岁)（X±s）53.3±6.754.1±8.5P>0.05性别(男/女)（n）47/3175/49P>0.05肿瘤(n 右/ 左)38/4161/73P>0.05手术时间(分)（X±s）64.5±13.267.2±14.6P>0.05术中出血量（ml）（X±s）50.0±13.250.0±13.2P>0.05术后镇痛治疗（n）223P＜0.01切口感染（n）112P＜0.01切口脂肪液化（n）06P＜0.01切口疝（n）03P＜0.05切口膨出（n）02P＜0.05腰腹部不对称（n）014P＜0.01者住院时间(d) （X±s）5.2±2.36.8±3.4P＜0.05术后3月切口美容满意度(I/II/III) （n）2/12/6434/47/43P＜0.01讨论随着腹腔镜技术的飞速发展，腹腔镜肾癌根治术已逐渐成为治疗局限性肾癌的标准术式，已被众多泌尿外科医生和患者的认可[1-4]。与开放手术相比，腹腔镜肾癌根治术具有创伤小、术中出血少、术后恢复等优点[5]。以往认为肿瘤直径＜5cm是行腹腔镜肾癌根治手术的适应症，当肿瘤直径较大，开放手术可能比腹腔镜手术更加安全和容易处理[6]。但随着腔镜操作技术的进展及操作水平的提高，现在的共识认为只要肿瘤局限于Gerota筋膜（T1、T2期），同时具备熟练的腔镜操作技巧，肾脏肿瘤的大小不是决定何种术式的标准。Jeon等[7]研究发现，对于直径＞7cm的肾脏肿瘤，尽管腹腔镜手术时间较长，但和开放手术相比，在手术并发症、疾病特定生存率上并无明显差异。腹腔镜肾癌根治术有经腹途径和经腹膜后途径。经腹途径的优点是：操作空间大、解剖标识明确，缺点是：干扰腹腔脏器；后腹腔途径优点是：腹腔脏器干扰小，术后肠功能恢复快，缺点是：操作空间小、解剖标识欠明确。因后腹腔镜途径在对腹腔脏器的影响方面明显优于经腹途径，越来越受到泌尿外科医生和患者的认同。腹腔镜手术的目的就是尽可能减少手术的损伤，同时保证手术质量。在一定程度上，标本取出切口的选择是腹腔镜手术的考虑要素之一，亦是减少手术并发症、提高患者美容满意度的重要因素[8]。腹股沟斜切口仅有腹内斜肌和腹横肌两层肌肉，而且腹内斜肌和腹横肌在此处的肌层相对较薄，切口对患者的损伤达到最小化，有利于供者的术后恢复；腰部切口肌肉层次多且肌肉层次较厚，切口对供者的损伤较大。相对于横切口，竖形切口包括正中切口、旁正中切口容易产生切口撕裂和切疝[10]。从美容角度考虑，腰部手术疤痕难以被内衣或泳衣隐藏，不容易被年轻女性接受；腹股沟斜切口隐蔽性较高，对患者的形体美破坏最小，患者更易于接受[9]。我们研究显示，腹股沟斜切口术式在手术时间、术中出血量、供肾热缺血时间等方面与其它术式无明显区别，在切口并发症方面明显优于腰部切口，住院时间缩短、患者美容满意度明显提高。对于后腹腔镜肾癌根治术，腹股沟斜切口用于手术标本的取出具有创伤小、切口并发症少、患者美容满意度高等优点，值得临床广泛推广。参考文献1. 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