Objective: To investigate the feasibility and safety of the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure. Methods: A retrospective cohort study was performed. Clinical data of 157 colorectal cancer patients undergoing the medial approach "four-step method" in the laparoscopic mobilization of splenic flexure at Gastrointestinal Surgical Department of Guangdong Provincial People's Hospital from July 2015 to June 2018 were retrospectively analyzed. Of 157 cases, 17 were transverse colon cancer, 94 were descending colon cancer, 25 were sigmoid cancer and 21 were rectal cancer; 89 were male and 68 were female; mean age was (61.8±10.3) years and mean body mass index was (23.2±3.7) kg/m(2). The medial approach "four-step method" in the laparoscopic mobilization of splenic flexure was performed as follows: (1) The root vessels were treated with the "provocation" technique to expand the Toldt's gap. This expansion was extended from the lateral side to the peritoneum reflex of left colonic sulcus, from the caudal side to the posterior rectal space, and from the cephalad side to the lower edge of pancreas. (2) The left colonic sulcus was mobilized, converging with the posterior Toldt's gap. Mobilization was carried out from cephalad side to descending colon flexure, freeing and cutting phrenicocolic ligament and splenocolic ligament, and from caudal side to peritoneal reflex. (3) Gastrocolic ligament was moblized. Whether to enter the great curvature of stomach omentum arch when the gastrocolic ligament was cut, that was, whether to clean the fourth group of lymph nodes, should be according to the tumor site and whether serosal layer was invaded. (4) Transverse mesocolon was moblized and transected at the lower edge of the pancreatic surface, merging with the posterior Toldt's gap, and from lateral side to lower edge of the pancreatic body, merging with the lateral left paracolonic sulcus. Safety and short-term clinical efficacy of this surgical procedure was summarized. Results: All the patients completed this procedure. During operation, 3 cases were complicated with organ injury, including 1 case of colon injury, 1 case of spleen injury and 1 case of pancreas injury. No operative death and conversion to open surgery was found. The average operation time was (147.5±35.1) minutes, the average intra-operative blood loss was (40.8±32.7) ml and the average number of harvested lymph node was (16.1±5.8), including (4.0±2.3) of positive lymph nodes. The first exhaust time after surgery was (41.3±20.6) hours, the fluid intake time was (1.5±1.3) days, the postoperative hospital stay was (5.2±2.3) days. Eight (5.1%) cases developed postoperative complications, and all were improved and discharged after conservative treatments. According to the TNM classification system, postoperative pathology revealed that 31 patients were stage I, 51 were stage II, 53 were stage III, 22 were stage IV. Conclusion: The medial approach "four-step method" is safe and feasible, which can effectively decrease the operation difficulty of the laparoscopic mobilization of the splenic flexure.
目的： 探讨腹腔镜结直肠癌手术中采用中间入路"四步法"技术游离结肠脾曲的可行性和安全性。 方法： 采用回顾性描述性病例系列研究方法，分析2015年7月至2018年6月期间，广东省人民医院普通外科胃肠专业组在腹腔镜下按中间入路"四步法"游离结肠脾曲的157例结直肠癌患者的临床资料，包括横结肠癌17例，降结肠癌94例，乙状结肠癌25例，直肠癌21例。全组男性89例，女性68例，年龄（61.8±10.3）岁，体质指数（23.2±3.7）kg/m(2)。中间入路"四步法"游离结肠脾曲操作如下：（1）处理根部血管，采用"挑拨离间"的手术技巧，拓展Toldt间隙。向外侧一直拓展至左结肠旁沟腹膜反折，向尾侧一直拓展至直肠后间隙，向头侧一直拓展至胰腺胰腺下缘。（2）游离左结肠旁沟，与后方拓展的Toldt间隙汇合。向头侧游离至降结肠脾曲，离断膈结肠韧带及脾结肠韧带，向尾侧游离至腹膜反折处。（3）游离胃结肠韧带。离断胃结肠韧带时是否进入胃大弯网膜弓内，即是否清扫第4组淋巴结，根据肿瘤部位及是否侵犯浆膜层决定。（4）游离横结肠系膜。于胰腺表面下缘切断横结肠系膜，与后方拓展的Toldt间隙汇合，外侧至胰体尾下缘与外侧左结肠旁沟游离间隙汇合。对游离结肠脾曲手术的安全性和临床短期疗效进行总结。 结果： 157例患者均在腹腔镜下按中间入路"四步法"完成结肠脾曲的游离，术中并发脏器损伤3例，为结肠损伤、脾损伤及胰腺损伤各1例，无中转开腹病例，无手术死亡病例。手术时间为（147.5±35.1）min，术中出血量为（40.8±32.7）ml，淋巴结清扫数目为（16.1±5.8）枚，其中阳性淋巴结数目为（4.0±2.3）枚，术后首次排气时间为（41.3±20.6）h，恢复流质饮食时间为（1.5±1.3）d，术后住院时间为（5.2±2.3）d。术后出现并发症8例（5.1%），均经保守治疗后好转出院。术后肿瘤病理TNM分期：Ⅰ期31例，Ⅱ期51例，Ⅲ期53例，Ⅳ期22例。 结论： 腹腔镜下中间入路"四步法"游离结肠脾曲安全可行。.
Keywords: Colorectal neoplasms; Feasibility; Laparoscopy surgery; Safety; Splenic flexure.