摘要如何降低直肠癌术后吻合口漏的发生是结直肠外科医师共同面临的难题.本文旨在与同道们分享一些临床中预防直肠癌术后吻合口漏的手术操作技巧,包括:(1)直肠癌全系膜切除术中低位结扎肠系膜下血管,可改善吻合口血供,减小吻合口张力,进而降低吻合口漏风险.而高位结扎肠系膜下动脉后吻合口血供差、张力高,会大大增加发生吻合口漏的风险.(2)对于术前行新辅助放化疗、或术中行超低位前切除术的直肠癌患者,应联合行保护性肠造口术,以降低吻合口漏的发生;而对于行低位前切除术及前切除术的直肠癌患者,若无其他合并危险因素,不建议行保护性肠造口术.(3)吻合口附近推荐常规留置腹(盆)腔引流管,不仅可以降低吻合口漏的发生率,还可早期识别吻合口漏,且通畅引流经吻合口漏出的盆腔积液可对吻合口漏进行保守治疗.(4)对于吻合口血供及张力欠佳的患者,可在腔内器械吻合后视情况行腔镜下加固缝合.可采用3-0或4-0可吸收缝线行连续缝合,或在吻合薄弱处至少行2针间断缝合.但这种加固缝合仅适用于具有丰富腔镜下缝合经验的外科医生,骨盆狭小的男性患者及低位直肠癌患者因操作空间有限,行加固缝合时应慎重.(5)对于存在可疑机械性不完全吻合患者,推荐术中行漏气试验检测吻合完整性.(6)由经验丰富的外科医师主刀手术能显著降低直肠癌术后吻合口漏的发生率.

abstractsFor colorectal surgeons, how to reduce anastomotic leakage after laparoscopic rectal cancer surgery remains to be challenging. We provide a brief discussion regarding the surgical skills required to prevent anastomotic leakage after rectal cancer surgery, such as the following: 1) Low ligation of inferior mesenteric vessel during laparoscopic total mesorectal excision can improve anastomotic tension and blood supply, thus reducing the risk of anastomotic leakage. While high ligation of inferior mesenteric artery resultsin poor blood supply and high tension in atastomotic site, thus increasing the risk of anastomotic leakage. 2)Protective enterostomy is recommended for patients with high risk of developing anastomotic leakage. 3)Use of abdominal/pelvic drains after colorectal anastomosis is recommended to decrease the incidence of anastomotic leakage, early detect anastomotic leakage, and conservativdy manage anastomotic leackage through drainage of pelvic effusion. 4)Laparoscopic reinforcing sutures should be used if anastomotic tension and blood supply are unsatisfactory, including continuous suture with 3-0 or 4-0 absorbable suture and 2-needle interrupted suture in the weak anastomosis. However, these sutures should be performed by experienced surgeons. For male patients with narrow pelvis and those with low rectal cancer, laparoscopic reinforcing sutures should be performed carefully due to the limited operative space. 5)Intraoperative air leak test is recommended to identify the anastomotic integrity for those with suspicious mechanically insufficient rectal anastomosis. 6)Experienced surgeon can reduce the incidence of anastomotic leakage after rectal cancer operation.