选择体外吻合还是体内吻合
国内学者多支持体外吻合，我国2006 版和2008 版《腹腔镜结直肠癌根治手术操作指南》推荐腹腔镜右半结肠行体外吻合[8，9]。欧美多选择体内吻合，近年来体内吻合在国内也逐渐推广普及。随着腹腔镜技术的开展，术者手术技巧越来越纯熟，越来越多的文献支持体内吻合。
Jorge[10]回顾性分析了60 名行腹腔镜右半结肠癌根治术的患者的临床资料发现，体内吻合并不会增加手术时间及手术患者失血情况，这已经得到了目前大部分结直肠外科医生的认可[11，12]。研究发现行体内吻合术式有助于清除病灶周围的淋巴结。体外吻合需要将肠管提出腹壁，大大限制了肠管的切除术范围。Gabriele Anania，等[13]的研究也验证了这一结论，他们认为体外吻合会减少病灶周围淋巴结的清扫情况，并且体外吻合过度牵拉肠管会造成肠功能性麻痹，影响肠道功能恢复的时间。
一篇纳入了14 项临床研究包含1717 名患者的meta 分析[14]结果显示：体内吻合及体外吻合在安全性上并未发现差异，同时行体内吻合有助于患者肠道功能的恢复、患者可以更早地进行经口进食，因此明显地缩短了患者的住院时间。J.Abrisqueta[15]等人认为体内吻合术者可以在直视下观查吻合过程中系膜的情况，视野清楚，大大降低了系膜扭转的发生率。
Massimiliano Fabozzi[16]等的研究发现体内吻合的切口更小、美观性更好，同时位置更灵活，因此其切口的近期及远期并发症概率更小。在同样止疼治疗情况下，行体外吻合的病人自述其切口疼痛更严重。这可能是因为体内吻合选择耻骨上位置的无肌肉覆着，术后疼痛更轻。此外，因为体外吻合的右上腹切口受呼吸活动的影响，其张力更大，同时将肠管提出体外吻合会挤压切口造成组织缺氧状态[17]，更加容易发生切口感染。
Vergis[18]等的研究中甚至存在因为右上腹切口疼痛，影响患者术后肺复张及呼吸情况的病例。远期研究发现，体外吻合的切口疝率明显高于体内吻合的患者。
Minia Hellan[19]等的研究也证实了这一结论。一项RCT 研究[20]将60 例病人随机分为两组，分别行体内吻合及体外吻合，对比术后白细胞、C反应蛋白及白细胞介素6 等指标，发现体内吻合组术后的手术应激反应明显更低，更有利于患者的恢复。在操作难度上，肥胖患者体内吻合的优势更加明显[21，22]。
但是R.Bergamaschi[23]认为体内吻合同样存在弊端：①体内吻合是外翻缝合，与手工内翻缝合相比并发症发生率更高；②使用切割闭合器进行侧侧吻合，吻合口长度不易控制，可能会造成吻合口过窄；③可能需要增加一个腹壁戳卡口以便于操作；④可能需要使用多次切割闭合器，增加了患者的经济负担。
Mark H.Hanna[24]等人发现术者在行腹腔镜右半结肠的初期，行体内吻合较体外吻合的二级并发症（例如：肠梗阻，切口感染）的发生率更高。但随着术者腹腔镜技术的提高，二者之间并无差异，似乎行体内吻合患者的并发症更少。对于腹腔镜手术经验较少的术者，体外吻合更加安全，而随着技术的熟练，体内吻合的优势更加明显。
腹腔镜右半结肠手术吻合方式是选择体外吻合还是体内吻合，目前还没有明确结论，现有的临床研究结果似乎体内吻合效果更佳。
（周建平）
参考文献
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