膈下静脉在后腹腔镜下左肾上腺切除术中的应用

Clinical value of inferior phrenic vein in retroperitoneal laparoscopic left adrenalectomy

摘要:

目的 探讨以左膈下静脉为解剖标志，优先解剖肾上腺中央静脉，在后腹腔镜左肾上腺切除术（RLLA）中的可行性。方法 回顾性分析2021年1月－2023年12月于该院行RLLA的116例患者的临床资料，根据手术方式的不同，将患者分为实验组（以左膈下静脉为解剖标志，并优先解剖肾上腺中央静脉的RLLA）和对照组［传统“三层面法”解剖性后腹腔镜肾上腺切除术（RLA）］，各58例。比较两组患者术中及术后24 h临床指标、应激指标、免疫功能和并发症。结果 两组患者顺利完成RLLA，且无1例中转开放手术。实验组手术时间、找到中央静脉时间、引流管留置时间和术后住院时间明显短于对照组，术中出血量和术后引流量明显少于对照组，差异均有统计学意义（P < 0.05）；两组患者术后胃肠功能恢复时间比较，差异无统计学意义（P > 0.05）。两组患者术前炎症因子、应激指标和免疫功能指标比较，差异均无统计学意义（P > 0.05）；两组患者术后24 h的白细胞（WBC）、C反应蛋白（CRP）和白细胞介素-6（IL-6）明显高于术前，且实验组明显低于对照组，差异均有统计学意义（P < 0.05）。两组患者术后24 h的丙二醛（MDA）明显高于术前，超氧化物歧化酶（SOD）和谷胱甘肽过氧化物酶（GSH-Px）明显低于术前，且实验组MDA明显低于对照组，SOD和GSH-Px明显高于对照组（P < 0.05）。实验组术后24 h的CD4⁺和CD4⁺/CD8⁺明显低于术前，且实验组术后24 h的CD3⁺、CD4⁺和CD4⁺/CD8⁺明显高于对照组，差异均有统计学意义（P < 0.05）；两组患者术后24 h的CD8⁺比较，差异无统计学意义（P > 0.05）。实验组发生术中血压波动率明显低于对照组，差异有统计学意义（P < 0.05）；两组患者均未发生腹膜损伤、肾蒂血管损伤和腹膜后血肿。结论 RLLA中以左膈下静脉作为解剖标志，优先解剖肾上腺中央静脉是可行的，可以改善手术指标，减轻应激反应和免疫应答，具有临床推广应用价值。

Abstract:

Objective To explore the feasibility of using the left inferior phrenic vein as an anatomical landmark and prioritizing the dissection of the central adrenal vein in retroperitoneal laparoscopic left adrenalectomy (RLLA).Methods 116 patients who had RLLA carried out in our hospital between January 2021 and December 2023 were chosen. They were separated into the experimental group (RLLA with the left inferior phrenic vein as an anatomical landmark and prioritizing the dissection of the central adrenal vein) and the control group [conventional three-layer method anatomic retroperitoneal laparoscopic adrenalectomy (RLA)], with 58 cases in each group. The clinical data of the two groups were compared, and the intraoperative and postoperative 24 h clinical indicators, stress indicators, immune function, and complications were evaluated.Results RLLA was successfully completed in two groups, and no cases were converted to open surgery. The operation time, time for searching the central vein, retention time of the drainage tube and postoperative hospital stay in the experimental group were significantly shorter than those in the control group. The intraoperative blood loss and postoperative drainage volume were significantly less than those in the control group, the differences were all statistically significant (P < 0.05); There was no statistically significant difference in the recovery time of gastrointestinal function between the two groups of patients after surgery (P > 0.05). There were no statistically significant differences in preoperative inflammatory factors, stress indicators and immune function indicators between the two groups of patients (P > 0.05). The white blood cell (WBC), C-reaction protein (CRP) and interleukin-6 (IL-6) of the two groups of patients 24 hours after the operation were significantly higher than those before the operation, but the experimental group was significantly lower than the control group, the differences were statistically significant (P < 0.05). The malondialdehyde (MDA) of the two groups of patients 24 hours after the operation was significantly higher than that before the operation, while the superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) were significantly lower than those before the operation, and the MDA in the experimental group was significantly lower than that in the control group, and the SOD and GSH-Px were significantly higher than those in the control group (P < 0.05). The levels of CD4⁺ and CD4⁺/CD8⁺ in experimental groups of patients 24 hours after the operation were significantly decreased than those before the operation, and the levels of CD3⁺, CD4⁺ and CD4⁺/CD8⁺ in the experimental group were significantly higher than those in the control group. The differences were statistically significant (P < 0.05). There was no statistically significant difference in CD8⁺ between the two groups of patients 24 hours after surgery (P > 0.05). The number of cases with intraoperative blood pressure fluctuations in the experimental group was significantly lower than that in the control group, the difference was statistically significant (P < 0.05). Neither peritoneal injury, renal pedicle vascular injury or retroperitoneal hematoma occurred during or after the operation in the two groups of patients.Conclusion In RLLA, using the left inferior phrenic vein as an anatomical landmark and prioritizing the dissection of the central adrenal vein is feasible, which can improve surgical indicators, reduce stress response and immune response, and have clinical application value.