256层螺旋CT对腹腔镜结直肠癌手术前肠系膜血管解剖结构评估的价值

目的探讨CT三维血管重建技术对结直肠癌患者术前进行肿瘤血管评估的临床价值．为腹腔镜结直肠癌手术提供参考。方法2010年2月至2010年12月间,对11例准备行腹腔镜结直肠癌根治术的患者术前进行256层螺旋CT扫描．通过三维血管重建技术观察其肠系膜血管解剖及变异情况．并将结果与腹腔镜术中所见进行对照。结果256层螺旋CT三维血管重建均清晰地显示出肠系膜血管解剖及变异情况．并与腹腔镜手术中所见吻合。3例右半结肠切除术患者中,1例回结肠动脉走行于肠系膜上静脉的腹侧．2例回结肠动脉走行于肠系膜上静脉的背侧：2例右结肠动脉和回结肠动脉分别直接起源于肠系膜上动脉．另1例未见右结肠动脉而由结肠中动脉右支参与供血。1例横结肠切除患者的结肠中动脉发自肠系膜上动脉。3例乙状结肠切除患者中,2例乙状结肠动脉与左结肠动脉共干起源于肠系膜下动脉．另1例乙状结肠动脉直接起源于肠系膜下动脉。4例直肠癌患者均由肠系膜下动脉延续的直肠上动脉供血。结论256层螺旋CT血管重建技术可以满足腹腔镜结直肠癌根治术前对肠系膜血管解剖及变异情况的观察．为手术提供重要参考。     

腹腔镜结直肠癌手术中术中意外出血的原因及对策

目的探讨腹腔镜结直肠癌手术术中意外出血的原因及应对措施。方法回顾性分析我院普外科腹腔镜专业组自2007年7月至2009年6月,2年间完成的270例腹腔镜结直肠癌手术。结果一次出血量超过100ml的术中意外出血有13例,发生率为4.8%,中转开腹2例,其余11例术中出血均在腹腔镜下止血。结论腹腔镜手术中的意外出血应根据具体出血原因具体处理。     

腹腔镜直肠乙状结肠手术中近端肠管的保护

结合首都医科大学附属朝阳医院普通外科行腹腔镜直肠乙状结肠手术中出现的11例近端肠管血运障碍的情况,对术中近端肠管的保护进行探讨。分析认为,腹腔镜直肠乙状结肠手术中近端肠管血运改变与结肠系膜血管的解剖学因素及手术操作有关。对于中低位直肠癌手术,术中保留左结肠动脉并于低位处理肠系膜下动脉,有利于降低血管解剖变异所引起的近端肠管出现血运障碍的风险。     

3D-CT导航的腹腔镜大肠癌手术

目的 探讨腹腔镜结直肠癌手术前血管构建及术中处理方法。方法 2003年1月～2004年12月，行腹腔镜结直肠癌手术48例，术前采用NSCr的血管分析(AVA)软件进行肿瘤段供应血管三维重建，其中，回结肠动脉12例；右结肠动脉2例；结肠中动脉10例；左结肠动脉3例；乙状结肠动脉，1支型2例；2支型9例；3支型10例。术中应用超声刀仔细游离血管的方法，离断血管。结果 腹腔镜结直肠癌手术无一例因血管损伤中转开腹。结论 术前肿瘤段肠管供应血管三维重建，术中超声刀仔细游离是腔镜结直肠癌手术血管处理的安全、可靠方法。     

腹腔镜结直肠手术术中意外情况20例处置分析

目的 探讨腹腔镜辅助结直肠手术中出现较严重意外情况的原因及处置方法。方法 回顾性分析首都医科大学附属北京朝阳医院普通外科2010年1月至2015年1月完成腹腔镜结直肠手术并出现较严重术中意外的20例病人资料。结果 20 例术中意外情况均得到妥善处理,未引起严重后果。其中术中大出血11例,分别为右结肠动脉2例、左侧阴部内静脉大出血5例、骶前静脉丛出血4例。女性直肠子宫陷凹处直肠壁炎性狭窄5例。直肠癌吻合后乙状结肠系膜360?扭转1例。直肠癌及乙状结肠癌术中近端肠管血运障碍3例。结论 腹腔镜结直肠手术操作越来越精细,对于各种术中意外情况采取相应的防范与处置对策,可以降低手术风险。     

腹腔镜下右半结肠癌根治术血管解剖技巧:附45例报告

目的总结腹腔镜下右半结肠癌根治术血管解剖的经验。方法 2011年2月～2018年3月我科行中间入路腹腔镜右半结肠癌D3根治术45例,采用中间入路由尾侧向头侧解剖肠系膜上血管,先定位肠系膜上静脉,解剖回结肠血管,然后自下而上解剖肠系膜上血管,显露右结肠动脉,最后于横结肠系膜根部下方的胰头前方找到胃结肠静脉干,并游离各分支。结果 45例均存在肠系膜上动、静脉和回结肠动脉及结肠中动脉。右结肠动脉出现率44. 4%(20/45),胃结肠静脉干出现率73. 3%(33/45)。因术中出血和腹腔广泛粘连中转开腹2例。手术时间115～215(平均145) min,术中出血量48～400ml,平均105 ml。淋巴结清扫13～24枚(平均18枚)。45例随访3～80个月,中位随访时间49个月。无trocar处癌转移,6例死亡,其中4例Ⅲ期死于远处脏器转移,2例因心脑血管意外死亡; 4例局部复发。结论腹腔镜右半结肠癌D3根治术中需处理的血管复杂多变,熟悉和掌握右半结肠血管的正常解剖和变异,是进行腹腔镜下右半结肠癌根治术的基础和保障。采用合理的手术入路和运用娴熟的手术技巧,是顺利完成其手术的关键。     

左半结直肠癌合并降结肠系膜旋转不良的解剖学分型和腹腔镜手术

目的初步探讨左半结直肠癌合并降结肠系膜旋转不良(PDM)的解剖形态与分型, 并探究应用腹腔镜根治手术的安全性。方法本研究为描述性病例系列研究。回顾性分析2021年7月至2022年9月间, 福建医科大学附属协和医院结直肠外科数据库中实施腹腔镜根治手术的995例左半结肠和直肠癌患者的临床资料, 对其中24例(2.4%)合并PDM者回顾影像学资料和手术录像, 观察降结肠及系膜分布形态, 评估腹腔镜根治手术的可行性和并发症。根据解剖学形态特点, 将PDM分型如下:0型为PDM合并中肠旋转不良或升结肠系膜旋转不良;1型为横结肠与降结肠移行处系膜未固定;2型为PDM降结肠在肠系膜下动脉水平附近明显内移, 其中不越过腹主动脉者为2A型, 越过腹主动脉者为2B型;3型为降乙交界结肠系膜未固定, 在肠系膜下动脉水平以下明显内移。结果 24例术中诊断左半结直肠癌合并PDM患者中, 仅有9例(37.5%)术前影像被部分外科医师阅片时发现并诊断。全组患者男性22例, 女性2例;年龄为(63±9)岁。24例PDM分型如下:0型占4.2%(1/24);1型占8.3%(2/24);2A型和2B型分别占37.5%(9...     

腹腔镜下右半结肠血管解剖及血管并发症分析

目的探讨腹腔镜下右半结肠的血管解剖关系及血管相关并发症。方法收集2008年9月至2011年10月间南方医科大学南方医院普通外科实施的55例腹腔镜扩大右半结肠癌D3根治术的手术录像．研究右半结肠血管的解剖关系及术中明确出血的血管。结果55例患者均存在肠系膜上动、静脉和回结肠动脉及中结肠动脉。右结肠动脉出现率为45．5％（25／55）,胃结肠静脉干的出现率为74．5％（41／55）。腹腔镜扩大右半结肠癌根治术中,血管出血的总概率为43．6％（24／55）,胰头前区域血管（包括胃网膜右动脉、胃结肠静脉干及其属支）术中出血概率（16．4％,9／55）略高于中结肠血管（14．5％．8／55）,术中出现血管并发症可明显延长术中淋巴结清扫时间（P=0．014）和腹腔镜手术时间（P=0．042）。亚组分析显示,胰头前区域血管的出血不会明显延长术中淋巴结清扫和手术时间（P〉0．05）：而中结肠血管出血可明显延长术中淋巴结清扫时间（P=0．011）和手术时间（P=0．004）。结论腹腔镜扩大右半结肠癌D3根治术中需处理的血管复杂多变,术中血管出血概率较高。清楚了解腹腔镜下右半结肠血管的解剖关系,有利于降低术中血管并发症的发生率。     

腹腔镜保留直肠上动脉的D3淋巴结清扫术在降结肠、近段乙状结肠癌根治术中的临床应用

目的:探讨降结肠及近段乙状结肠癌行腹腔镜辅助左半结肠D3淋巴结清扫术中保留直肠上动脉的安全性与可行性。方法:回顾分析2013年12月至2015年12月为13例患者行保留直肠上动脉的腹腔镜辅助左半结肠D3淋巴结清扫术的临床资料,其中近段乙状结肠癌8例,降结肠癌5例,2例合并完全性梗阻,经内镜支架置入缓解并充分肠道准备一周后手术。术中应用超声刀全程裸化肠系膜下动脉根部,沿血管鞘向远端分离、结扎左结肠动脉及若干支乙状结肠动脉,保留直肠上动脉;肠系膜下静脉于脾静脉汇合点前结扎切断。结果:术中发现左结肠动脉缺失1例;左结肠动脉发自乙状结肠动脉1例;Riolan弓缺失2例。手术均顺利完成,无一例中转开腹,手术时间平均(148.1±15.5)min,实际淋巴结清扫时间(自系膜切开至D3淋巴结清扫完成)平均(44.9±11.8)min,术中失血量平均(40.0±17.3)ml,淋巴结清扫数量平均(21.9±4.5)枚;吻合口均位于乙状结肠中下段,无吻合口瘘发生。无一例发生与淋巴清扫相关的副损伤、意外出血及死亡。1例患者于术后1周出现高位小肠梗阻,经禁食、胃肠减压后缓解;1例乳糜漏,经保守治疗后痊愈。结论:腹腔镜下保留直肠上动脉的肠系膜下动脉根部D3淋巴结清扫术治疗降结肠、近段乙状结肠癌是安全、可行的,可避免不必要的远端乙状结肠的过多切除。     

结肠系膜作屏障在腹腔镜下游离结肠脾曲中的应用

目的探讨利用结肠系膜形成屏障在直肠癌保肛术中腹腔镜下游离脾曲时的应用价值。方法 2016年6月～2017年7月,在23例低位直肠癌保肛术中,利用结肠系膜作屏障,形成操作空间,在腹腔镜下游离结肠脾曲。结果手术均顺利完成,游离脾曲时间(40±15)min,术中出血(50±10)ml。均未发生肠管损伤、脾出血等并发症,术后排气时间(3±1)d。结论结肠系膜形成屏障应用于腹腔镜下游离结肠脾曲安全有效。     

Medially approached radical lymph node dissection along the surgical trunk for advanced right-sided colon cancers

Although laparoscopic surgery is one of the treatment options for colorectal cancer, certain technical problems remain unresolved for the radical dissection of regional lymph nodes (LNs), which is essential to improve treatment outcome. We present a safe procedure for laparoscopic right hemicolectomy to dissect the regional LNs along the superior mesenteric vein (SMV). The key characteristic of our procedure is that all right and middle colic vessels are cut along the surgical trunk using only a medial approach. First, the pedicle of ileocolic vessels is identified and the mesocolon is dissected between the pedicle and the periphery of the SMV to expose the second portion of the duodenum. The ileocolic vessels are then cut at their roots. The ascending mesocolon is separated from the retroperitoneal tissues, duodenum, and pancreatic head up to the hepatocolic ligament cranially. The important detail in this procedure is the wide separation between the pancreatic head and the transverse mesocolon. This procedure uncovers the course of the right colic artery, veins, and the gastrocolic trunk [1]. The right colic artery and veins can then be safely cut at their roots. For an extended right hemicolectomy, the middle colic vessels can easily be identified below the lower edge of the pancreas and cut at their roots [2]. We performed curative resections in this manner for 16 consecutive patients with advanced right-sided colon cancer without any serious intraoperative complications. The median number of retrieved lymph nodes was 31 (range = 9–57). The median operative time and intraoperative blood loss were 274 min (range = 147–431 min) and 45 g (range = 0–120 g), respectively. The postoperative course of all patients was uneventful. Four of 16 patients had node-positive disease. With a median follow-up period of 272 days, all patients are alive without recurrence. We consider this a safe method for radical LN dissection during laparoscopic right hemicolectomy. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

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??Surgical anatomy of superior mesenteric vessels and its distributaries XIAO Yi??LU Jun-yang??XU Lai. Department of General Surgery??Peking Union Medical College Hospital??Peking Union Medical College??Chinese Academy of Medical Sciences??Beijing 100730??China
Corresponding author: XIAO Yi??E-mail: xiaoy@pumch.cn
Abstract Objective To study the surgical anatomy of superior mesenteric vessels and its distributaries in the pancreaticoduodenal area. Methods The prospective observational trial included 27 patients performed laparoscopic complete mesocolic excision (CME) procedure in order to study the anatomical artery-vein relationships of the ileocolic vessels??right colic vessels??middle colic vessels??and the configurationally relationship of the distributaries to Henle’s trunk. Results Ileocolic vessels were found in each patient. The probability of right colic artery and vein were 33.3% and 11.1% respectively. The middle colic artery and vein were found at a rate of 88.9% and 92.6% respectively. The length of middle colic artery was 1.9??0 to 7.2??cm. The probability of Henle’s trunk was 92.6%??with the length of 0.8 ??0.2 to 2.4??cm. There were 2 to 5 branches drained into Henle’s trunk. Conclusion Laparoscopic CME procedure should start at dissecting ileocolic vessles??because of its constant location. Getting familiar with the complicated anatomic configuration of pancreaticoduodenal area would be helpful to precisional surgery.     

A rare anomaly of left renal vein drainage into the left common iliac vein: A case report

IntroductionHerein, we describe a case of sigmoid colon cancer with a rare anomaly of the left renal vein located between the inferior mesenteric artery (IMA) and the left common iliac artery.Case presentationA 57-year-old woman with sigmoid colon cancer underwent three-dimensional computed tomography angiography for a preoperative assessment; the results revealed a rare variant of the left renal vein. There were two left renal veins: one retroaortically drained into the inferior vena cava, and the other was located between the IMA and the left common iliac artery and drained into the left common iliac vein. Laparoscopic sigmoid colectomy was performed safely while carefully avoiding any injury to the left renal vein located posterior to the IMA.DiscussionSeveral variations of the left renal vein have been reported, such as retroaortic or circumaortic left renal veins. The variants of renal vessels, which are frequently overlooked in the preoperative assessment, is rarely affected in colorectal surgery. However, if the surgeon is unaware of such renal vessel anomalies, an injury can occur, resulting in severe bleeding.ConclusionIt is important that surgeons identify retroperitoneal vessel variants before performing colorectal surgery.     

腹腔镜D2胃癌根治术术中出血原因与防治

目的探讨腹腔镜下胃癌根治术术中出血并发症的原因分析及防治。方法回顾性分析2013年4月至2014年12月施行腹腔镜下胃癌根治性切除手术146例,对术中出血情况进行统计分类,处理方法归类并分析出血原因,总结防治措施。结果本组146例中,平均出血量(88±72.1)ml,7例(4.79%)发生术中大出血(出血量大于300 ml),其中3例因为超声刀误伤导致胃右动静脉或胃十二指肠动脉出血,2例患者因为肥胖、暴力牵拉导致胃网膜左动静脉或胃周实质性脏器损伤出血,1例患者因为肥胖、肿瘤侵犯导致脾动静脉出血达500 ml,为本研究最大出血量,所有出血均在腹腔镜下采用夹闭、电凝、缝扎等止血方法成功止血,无1例中转开腹。结论出血是腹腔镜下胃癌根治术术中的常见的并发症之一,患者和术者两方面因素共同决定手术中的出血量,术中一旦发生出血,在助手充分暴露术野的前提下,执行"5P"原则止血。     

腹腔镜直肠癌前切除术术中保留左结肠动脉的临床价值探讨

目的探讨腹腔镜直肠癌前切除术术中处理肠系膜下动脉时保留左结肠动脉(left colic artery,LCA)的临床价值。 方法回顾性分析昆明医科大学附属延安医院2014年1月至2015年6月间71例行腹腔镜直肠癌前切除术患者的临床资料,按照术中是否保留左结肠动脉进行分组,其中保留LCA组36例,不保留LCA组35例,比较两组的术中出血量、手术时间、肠系膜淋巴结清扫数目、术后是否发生吻合口瘘、术后1年复查有无肿瘤转移等方面的差异。 结果两组的术中出血量相当[(81.7 ± 19.5)ml vs (72.9 ± 21.9)ml,t＝1.769,P＝0.081];手术时间,保留LCA组较不保留LCA组稍长[(135.6 ± 27.2)min vs(124.9 ± 38.3)min,t＝1.354 ,P＝0.181];清扫淋巴结数量[(12.0 ± 2.8)枚 vs ( 12.5 ± 2.6)枚,t＝－0.803,P＝0.425],两组比较,差异无统计学意义(P<0.05)。保留LCA组术后无吻合口瘘患者,不保留LCA组4例发生吻合口瘘,发生率11.4%,高于保留LCA组,两组比较,差异有统计学意义(P＝0.037)。术后1年复查腹部CT,保留LCA组2例发生肝转移,不保留LCA组3例发生肝转移,两组比较,差异无统计学意义(P＝0.620)。 结论腹腔镜直肠癌前切除术术中处理肠系膜下动脉时保留LCA可以有效保障近端肠管血运,减少吻合口瘘的发生,并不影响第3站淋巴结的清扫及患者预后。     

Laparoscopic colectomy for persistent descending mesocolon in sigmoid colon cancer: A case report

A 55-year-old-man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Preoperative barium enema showed a slightly medial displacement of the descending colon, and the sigmoid colon was quite long. The operative findings showed that the descending colon was not fused with the retroperitoneum and shifted to the midline and the left colon adhered to the small mesentery and right pelvic wall. Thus, a diagnosis of persistent descending mesocolon (PDM) was made. The left colon, sigmoid colon, and superior rectal arteries often branch radially from the inferior mesenteric artery. The sigmoid mesentery shortens, and the inferior mesenteric vein is often close to the marginal vessels. By understanding the anatomical feature of PDM and devising surgical techniques, laparoscopic sigmoidectomy for sigmoid colon cancer with PDM could be performed without compromising its curative effect and safety.     

左半结肠癌行No.223、No.253淋巴结清扫意义及争议

淋巴结转移是结直肠癌的主要转移方式,NCCN、日本大肠癌研究会（JSCCR）和我国结直肠癌诊疗相关规范都规定了结肠癌根治术需要行区域淋巴结清扫,No.223、No.253淋巴结属于左半结肠癌的区域淋巴结。结肠脾曲癌由结肠中动脉左支和左结肠动脉双重供血,推荐行No.223、No.253淋巴结清扫,降结肠癌和乙状结肠癌主要由肠系膜下动脉供血,只须行No.253淋巴结清扫。目前,部分研究认为血管低位结扎（血管根部淋巴结清扫）与血管高位结扎对于淋巴结清扫数量及肿瘤学效果一致,部分研究提示血管高位结扎可能影响肠管血供,增加吻合口漏的发生。因此,推荐清扫No.223、No.253淋巴结时可以保留结肠中动脉和肠系膜下动脉。由于左半结肠癌发病率较低,目前缺乏有说服力的证据,期待临床进行高级别循证医学研究进一步明确淋巴结清扫范围。     

Laparoscopic D3 lymph node dissection with preservation of the superior rectal artery for the treatment of proximal sigmoid and descending colon cancer

In this paper we report a technique for laparoscopic lymph node (LN) dissection for descending and proximal sigmoid colon cancer with the preservation of the superior rectal artery (SRA) to maintain the blood supply to the distal sigmoid colon. Five (5) cases were included from November 2004 to March 2005. For D3 LN dissection, the root of inferior mesenteric artery was exposed with ultrasonic cutting and coagulating surgical device to avoid bleeding. The arterial wall was then exposed with a spatula-type electric cautery down to the left colic artery (LCA). The LCA was then clipped and cut while preserving the SRA. The inferior mesenteric vein was divided at the caudal side of the LCA and prior to joining to the splenic vein. All cases underwent a LN dissection laparoscopically. There were no cases of complications originating from the LN dissection. Although long-term outcomes should be investigated, our results indicate that this is a safe, applicable method.