腹腔镜主动脉旁淋巴结清扫术的改进与挑战：新型“帐篷式”前向入路及腹主动脉区域血管解剖变异

本研究介绍并比较了一种新型腹腔镜主动脉旁淋巴结清扫术，旨在达到肾静脉水平的清扫效果，称为“帐篷式”前向入路，与传统逆行入路在手术成功率、并发症发生率及淋巴结切除数量方面的差异，重点评估其可行性、安全性和有效性。同时，报告在腹主动脉区域发现的血管解剖变异，以提高手术安全性。本为一项回顾性队列研究，纳入2020年1月至2023年12月在单一中心接受腹腔镜主动脉旁淋巴结清扫术的患者，主要针对高危子宫内膜癌和早期卵巢癌患者。通过回顾患者资料，分析手术方式、围手术期并发症、手术细节和组织病理。患者根据手术模式分为前向组和逆行组，比较两组在肾静脉水平淋巴结清扫成功率、围手术期并发症及切除淋巴结数量。采用t检验分析定量资料，非参数检验分析非正态分布资料，Fisher精确检验和卡方检验分析分类变量，统计学意义设定为P<0.05。在173例患者中，前向组手术成功率更高（97.5%对68.82%），切除淋巴结数更多（中位数14比7），失血量更少。手术时间也更短。术后并发症如淋巴囊肿和静脉血栓发生率较低。血管异常在28.9%的患者中发现，最常见的是腰椎附加静脉路径异常和肾动脉变异。前向入路具有可行、安全且有效的优点，能改善手术暴露，操作难度降低，无需额外器械或穿刺点，减少器官损伤风险。它在获得更好的肾静脉通路和切除更多腹主动脉旁淋巴结方面优于逆行入路。识别并妥善处理包括肾动脉、静脉及下腔静脉在内的多样血管变异，对减少术中出血及避免转换为开腹手术具有重要意义。

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety.This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05.Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common.The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.