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中华普通外科学文献(电子版) ›› 2026, Vol. 20 ›› Issue (05) : 325 -329. doi: 10.3877/cma.j.issn.1674-0793.2026.05.007

综述

腹腔镜根治性右半结肠切除术手术入路文献回顾
易小江, 刘佳丽, 蒋天明, 梁超, 黄海鹏, 刁竞芳†()   
  1. 510120 广州,广州中医药大学第二附属医院(广东省中医院)结直肠外科
  • 收稿日期:2026-07-31 出版日期:2026-10-01
  • 通信作者: 刁竞芳
  • 基金资助:
    广东省医学科研基金项目(B2025709); 广州市科技局市院联合资助项目(2025A03J2486)

Advances in surgical approaches for laparoscopic radical right hemicolectomy: A literature review

Xiaojiang Yi, Jiali Liu, Tianming Jiang, Chao Liang, Haipeng Huang, Jingfang Diao†()   

  1. Department of Colorectal Surgery, Guangdong Provincial Hospital of Chinese Medicine, the Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510120, China
  • Received:2026-07-31 Published:2026-10-01
  • Corresponding author: Jingfang Diao
引用本文:

易小江, 刘佳丽, 蒋天明, 梁超, 黄海鹏, 刁竞芳. 腹腔镜根治性右半结肠切除术手术入路文献回顾[J/OL]. 中华普通外科学文献(电子版), 2026, 20(05): 325-329.

Xiaojiang Yi, Jiali Liu, Tianming Jiang, Chao Liang, Haipeng Huang, Jingfang Diao. Advances in surgical approaches for laparoscopic radical right hemicolectomy: A literature review[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2026, 20(05): 325-329.

目前,肿瘤位于右半结肠的患者常采用腹腔镜根治性右半结肠切除术进行治疗,尽管腹腔镜技术使得手术更加可视化和精细化,但由于右半结肠血管形态各异且走行位置多变,术者常面临挑战,术中操作不当可能造成不必要的损伤。因此,为更好地克服和解决血管变异问题并减少术中副损伤,本文对腹腔镜右半结肠切除术手术入路及手术解剖进行文献综述,以期寻找更合理、简化和个体化的手术入路方式。

Currently, patients with tumors located in the right colon are commonly treated with laparoscopic radical right hemicolectomy. Although laparoscopic techniques have made surgery more visual and precise, the varied morphology and variable course of the right colic vessels often pose challenges for surgeons, and improper manipulation may lead to unnecessary intraoperative injuries. Therefore, to better address and overcome the issues of vascular variations and reduce intraoperative injury, we conducted a literature review on the surgical approaches and anatomical guidance for laparoscopic right hemicolectomy, aiming to identify more reasonable, simplified, and individualized surgical approaches.

图1 手术入路示意图(绿色箭头所示) A. 头侧优先入路;B. 中间优先入路;C. 尾侧优先入路
表1 腹腔镜根治性右半结肠切除术不同手术路径技术要点、技术优势和劣势总结
手术路径 技术要点 技术优势 技术劣势
头侧优先入路 1. 基于胚胎学原理,优先打开网膜囊,以RGEV及ARCV为标志显露Henle干
2. 离断ARCV及MCV根部,沿SMV自头侧向尾侧清扫淋巴结
3. 早期游离横结肠系膜与胰头、十二指肠间隙
1. 早期显露胰腺及Henle干解剖结构,便于安全处理血管
2. 血管结扎前即完成结肠游离,早期可评估肿瘤可切除性
3. 有效避免在狭小空间内操作Henle干及中结肠血管,减少盲目损伤
1. 对术者解剖经验要求高,初学者学习曲线陡峭
2. ARCV及Henle干分支极易损伤,可能导致难以控制的出血
3. 止血过程中可能误伤SMV、MCV或MCA,影响淋巴结清扫彻底性4. 经头侧对MCA根部结扎操作困难,较中间入路无明显优势,尤其仅需结扎右支
中间优先入路 1. 在根部分离结扎回结肠血管、右结肠血管及中结肠血管,沿SMV自下而上清扫淋巴结
2. 再拓展游离升结肠系膜后间隙,最后打开胃结肠韧带及肝结肠韧带,游离结肠肝曲
1. 符合“无接触”原则,早期结扎血管根部,避免肿瘤播散 1. 肥胖或肠系膜肥厚患者SMV显露困难,易进入错误解剖层次
2. 存在“杠杆效应”或“隧道效应”,重要结构易被无意损伤
3. 对术野显露及解剖识别要求高,学习曲线较长,推广受限
尾侧优先入路 1. 以Toldt线为标志进入右半结肠后间隙,扩展Toldt间隙,显露胰头及十二指肠水平段
2. 以十二指肠为内侧引导,切开胰腺前被膜安全进入胰十二指肠前间隙
3. 沿SMV自尾侧向头侧解剖,依次结扎离断各结肠血管
4.最后游离胃结肠韧带进入网膜囊,贯通横结肠后间隙
1. 易于找到正确解剖层次,对肥胖及粘连水肿病例更具优势
2. 腹膜后间隙预先解剖,术中出血便于控制,中转率低
3. 学习曲线较短,对初学者友好,手术时间较中间入路短
1. T4b期肿瘤广泛侵犯输尿管或十二指肠时应用受限
2. 后方间隙游离后肠管偏离原位,牵拉回结肠血管存在SMV出血风险
3. 下腹部或盆腔手术史、持续性降结肠系膜患者存在致密粘连,显露困难,可能需中转其他入路4. 部分学者认为早期接触肿瘤,违反“无接触”原则(但高级别证据不足)
头尾联合入路 1. 首先游离头侧胃结肠系膜融合间隙及横结肠系膜与胰头、十二指肠的融合间隙,或是先从尾侧游离右结肠系膜与腹膜后的融合间隙
2. 将头尾两侧间隙贯通后,最后经中间入路处理血管及清扫淋巴结
1. 充分拓展系膜间隙后血管处理视野开阔,克服中间入路“隧道效应”
2. 头尾间隙贯通后解剖层次清晰,操作安全可控
3. 处理手术难点、提高手术安全性及质量控制方面优势明显
1. 手术步骤相对繁琐,要求术者对头尾两侧解剖均熟练掌握
2. 需助手配合良好,团队磨合要求高
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