腹腔镜远端胃癌切除胃空肠Uncut Roux-en-Y吻合术

远端胃切除和淋巴结清扫结束后,进行腹腔镜消化道重建。首先提起横结肠,寻及Treiz韧带,提起距之约25 cm处的空肠,经系膜无血管区带线标记并待提出。沿观察孔切口绕脐向上延切口长约3~4 cm,自此切口取出标本。将标记小肠牵引线连同近端空肠自切口拖出,确认远近端后,距牵引线标记近端8 cm与远端40 cm处空肠行侧侧吻合,于标记线处用闭合器(无刀片)闭合肠管但不予以切断。最后将肠管还入腹腔,关闭腹部切口后,重新建立气腹。在闭合处远端2 cm使用直线切割缝合器行空肠残胃侧侧吻合,并关闭共同开口。     

全机器人下远端胃大部切除、毕Ⅱ＋Braun’s吻合术

全机器人下远端胃大部切除术,术中依次解剖胃右血管,胃小弯前壁,胃网膜右血管,胃网膜左血管,胃左血管后,分别离断胃周血管并完成D2清扫,用直线切割闭合器离断十二指肠,然后保留部分近侧胃并于胃上部以直线切割闭合器离断胃壁;然后用直线切割闭合器分别进行毕Ⅱ+Braun’s吻合。穿过winsiow孔于吻合口周围预防性留置腹腔引流管;适当延长脐下Trocar孔切口取出标本。     

完全腹腔镜远端胃癌根治术

患者全身麻醉,5孔法建立气腹。探查:无腹水,胃壁未见肿瘤外侵,胃周淋巴结稍肿大,未见腹盆腔种植转移,行完全腹腔镜下根治性远端胃大部分切除术(D2淋巴结清扫,毕II式+Braun吻合)。手术路线:切开肝胃韧带,沿右侧膈角表面打开,显露贲门右侧;打开胃结肠韧带,进入胃、结肠系膜融合间隙,游离并离断胃网膜右血管,清扫No.6组淋巴结;离断十二指肠;清扫胰腺上区淋巴结,顺序是:No.5、12a、8a、11p、7、9;随后清扫No.1、3、4sb、4d组淋巴结;离断远端胃,标本于脐周约3.5 cm小切口取出;取屈氏韧带以远40 cm处空肠,与残胃行侧侧吻合(毕II式吻合),距胃肠吻合口25 cm处,行输入袢、输出袢侧侧吻合(Braun吻合)。所有操作均在腹腔镜下完成。     

一种新型的完全腹腔镜下胃癌D2根治术后消化道重建方式

目的探讨一种新型的完全腹腔镜下食管．空肠消化道重建方式在胃癌根治术中的应用。方法常规腹腔镜下淋巴结清扫并完全游离食管后,于远端食管近食管胃交界处用超声刀打开一长约2．5cm的小孔,置入一次性吻合器底钉座,用切割缝合型闭合器切断并闭合食管。在距离Treitz韧带15cm处分离并离断空肠,远端空肠提至食管底钉座处,在空肠远端食管置入吻合器,行食管空肠吻合。再用直线切割闭合器闭合远端空肠断端,并加强缝合食管与空肠之间的吻合口。最后,空肠近端断端与距离食管-空肠吻合口处以下55cm处的空肠行空肠-空肠端侧吻合。结果患者成功实施完全腹腔下胃癌根治术,术后未发生并发症或中转开腹,手术时间230min,出血150ml,术后无反流、吻合口漏、吻合口狭窄等严重并发症发生,患者恢复良好。结论完全腹腔镜下新型的消化道重建方式安全可行。     

全腔镜全胃切除术

切开胃结肠韧带,游离至脾脏下极,于根部离断胃网膜左血管,清扫第4组淋巴结,离断胃短血管直至脾上极。游离胃窦部,于胰腺上缘离断胃网膜右静脉,显露胃十二指肠动脉后,于根部离断胃网膜右动脉,并完成第六组淋巴结的清扫。显露胃窦后壁,离断胃右血管,清扫肝门部淋巴结。距幽门2 cm离断十二指肠。沿胰腺上缘解剖脾动脉根部,于根部离断胃左静脉。显露腹腔干及胃左动脉,向右侧清扫第8组淋巴结,于根部离断胃左动脉后,向头侧清扫第1,2组淋巴结。游离食管腹段,解剖出迷走神经左右支后离断。悬吊肝左叶后,距贲门2 cm离断食管,取上腹正中辅助切口3 cm,移除胃标本及大网膜。重建气腹后,距TREIZ韧带20 cm离断空肠,行食管左后壁与近端空肠侧侧吻合(OVERLAP法),手工缝合共同开口。距此吻合口40 cm,借助辅助切口完成小肠侧侧吻合(ROUX－Y)吻合。     

腹腔镜下扩大淋巴结清扫的胰十二指肠切除术

行传统Kocher切口行腹膜后淋巴结清扫,距屈氏韧带5～10 cm离断空肠,离断远端2/3胃体,肝十二指肠韧带骨骼化清扫,离断GDA,离断胰颈,清扫肝总动脉及腹腔干周围淋巴结,解剖SMA-CT系统,行SMA左右侧360°清扫,完成钩突全系膜切除,切除胆囊,最后离断肝总管。标准清扫+8P、9、12a、12P、14c-d、16a2、16b1的扩大淋巴结清扫。胰肠吻合采用创新的"两点法"胰管导管-黏膜吻合,胆肠吻合采取连续缝合,直线切割闭合器行胃后壁与空肠侧侧吻合。     

全腹腔镜根治性全胃切除术

34岁女性胃体腺癌患者,拟行全腹腔镜根治性全胃切除术。患者取平仰卧位,主刀位于患者左侧。腹腔镜下探查肿瘤位于胃体,无腹腔种植转移。游离大网膜及横结肠系膜前叶,向左达脾下极,向右达结肠肝曲。继续游离、夹闭、离断胃左右动静脉、胃网膜左右动静脉、胃短动脉、胃后动脉,清扫NO.1～NO.11,NO.12a,NO.12p,NO.14v组淋巴结。幽门远端3 cm离断十二指肠。腔镜下游离小肠系膜,距屈氏韧带20cm处切割闭合离断空肠,远端上提,使用overlap技术完成食道空肠的侧侧吻合,连续缝合关闭共同开口。据此吻合口远端40 cm处行近端空肠远端空肠的侧侧吻合,连续缝合关闭共同开口。检查吻合口对合良好。冲洗术野,腹腔镜下放置腹腔引流管。     

保留贲门空肠双口端侧吻合术

胃癌根治术后消化道代胃重建方法很多,但都各有其利弊。笔者近年来对5例胃癌病人采用保留贲门的超亚全胃切除,空肠双口端侧吻合代胃术,切除胃体约95%以上,取得满意效果。操作方法1.上腹正中切口,为有利于胃底贲门的操作,必要时将剑突切除。2.扩大游离胃体,彻底清扫淋巴结。3.距贲门2～4cm 切除全部胃体,缝闭十二指肠残端。4.距屈氏韧带8cm 切断空肠,肠系膜做适当游离。空肠远端自身做双口端侧,侧侧吻合,侧侧吻合口2～3cm 即可,胃与空肠做断端吻合;胃肠吻合口与空肠自身断侧吻合口均距侧侧吻合5～7cm。十二指肠远端与空肠做断侧吻合,该吻合口距空肠自身断侧吻合口8～10cm。手术完成及切除范围见图示。     

机器人胰十二指肠切除术

解剖胰颈下缘肠系膜上静脉，离断胃结肠干，游离十二指肠及胰头，解剖下腔静脉、左肾静脉、肠系膜上动脉并清扫淋巴结。离断空肠、胰十二指肠下动静脉及钩突；解剖变异肝总动脉(起源于肠系膜上动脉)。解剖胰颈上缘门静脉及胆管、离断胃右和胃十二指肠动脉并清扫淋巴结；离断远端胃、胰颈、胆管、切除胆囊。消化道重建：胰管内置硅胶管行内引流；4－0普理灵缝扎胰腺断端，4－0普理灵连续缝合胰腺断端与空肠浆肌层。4－0普理灵行胆肠吻合。胃后壁与空肠用3－0普理灵行连续侧侧吻合。文氏孔及胰肠吻合前置引流管。病理：中分化腺癌，T₂N₁M₀。     

全腹腔镜全胃切除＋D2淋巴结清扫＋Orvil辅助食管空肠Roux－en－Y吻合术

食管空肠吻合采用OrVil腔内行食管空肠Roux－en－Y吻合,巡回护士将OrVil装置经口放入,引导胃管缓慢送到食道下端并到达食道切缘,主刀用超声刀锐性切开食道切缘正中暴露OrVil的引导胃管,用肠钳将OrVil引导胃管从食道残端的小孔内拉出,直到食道切缘的小孔卡住钉砧头,然后剪断OrVil与引导胃管之间的连接线,确定屈氏韧带,远端25 cm处直线切割闭合器离断空肠,残端包埋,结肠前上提远端。取上腹正中切口,长约4 cm,放置切口保护器,外套装7号手套,于手套拇指剪切口进管状吻合器,重新建立气腹行腹腔镜下食管空场吻合。     

完全腹腔镜Roux-en-Y吻合术治疗先天性胆总管囊肿

目的探讨完全腹腔镜下Roux-en-Y吻合术治疗先天性胆总管囊肿的可行性。方法 2011年3～9月,对6例先天性胆总管囊肿行完全腹腔镜下Roux-en-Y吻合术。术中常规切除胆囊,游离囊肿壁,于正常肝总管交界处离断。距十二指肠悬韧带15～20 cm处切断空肠,于断端远端下方约50 cm处用腔镜直线切割吻合器行肠肠吻合,镜下用3-0可吸收线行肝总管-空肠端侧吻合。结果手术均获成功。术后随访3～9个月,平均5.5月,无出血、胆漏、吻合口狭窄、肠漏、腹腔脓肿、逆行感染等并发症发生。结论完全腹腔镜Roux-en-Y吻合术治疗先天性胆总管囊肿是可行的,并且具有切口小、术后腹壁瘢痕小、创伤轻、美观等微创特点。     

全腹腔镜远端胃癌根治术(Uncut Roux-en-Y吻合)

Uncut-Roux-en-Y吻合方式顺序为:在距Treitz韧带约20 cm处的空肠对系膜缘侧打开0.5 cm切口,在残胃大弯侧残端打开0.5 cm切口,切口分别置入切割闭合器"分支"行侧侧吻合,共同开口再行切割闭合器闭合(胃肠吻合);距胃肠吻合口近端7~8 cm处及远端约30 cm处空肠对系膜缘处分别打开0.5 cm切口,分别置入切割闭合器"分支"行侧侧吻合,共同开口再行切割闭合器闭合(空肠侧侧吻合-Braun吻合);最后在距胃肠吻合口近端2~3 cm空肠处用no cut闭合器闭合的方法闭合输入袢空肠(输入袢阻断)。     

腹腔镜直肠癌根治术(Dixon)

在结肠系膜与后腹膜移行处切开后腹膜,分离系膜至肠系膜下动脉根部,清扫253组淋巴结,在距腹主动脉根部1 cm处夹闭并切断血管,切断肠系膜下静脉。由内侧向外侧分离结肠系膜至结肠旁沟,切开其左侧后腹膜,将降结肠及乙状结肠系膜从后腹壁游离。沿直肠固有筋膜与盆壁筋膜的间隙按照TME原则锐性分离直肠系膜,先游离后壁,再游离两侧壁及前壁,直至盆底。在肿瘤下方2 cm处用阻断夹夹闭肠管,冲洗远端直肠,用切割缝合器切断直肠。取脐部弧形切口。提出近端肠管,于肿瘤近端15 cm处离断肠管。近端置入管型吻合器抵钉座,还纳腹腔,重建气腹。经肛置入管型吻合器,在腹腔镜直视下作乙状结肠－直肠端端吻合,冲洗腹腔,置引流管,手术结束。     

Reconstruction of the gastrointestinal tract by hemi-double stapling method for the esophagus and jejunum using EEA OrVil in laparoscopic total gastrectomy and proximal gastrectomy

We report the method of anastomosis based on a hemi-double stapling technique (hereinafter, HDST) using a trans-oral anvil delivery system (EEA OrVil) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection. As a basic technique, end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum. After the gastric lymph node dissection, the esophagus was cut off obliquely to the long axis using an automated stapler. EEA OrVil was orally, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, HDST-based anastomosis was completed. The method may safe laparoscopic anastomosis between the esophagus and reconstructed intestine.     

Laparoscopic assisted proctosigmoidectomy with extracorporeal transanal anastomosis

Summary Laparoscopic colon resections have often required an abdominal incision to remove the specimen and perform the anastomosis. Our aim was to mobilize the left colon and rectum using the laparoscope and perform a perineal proctosigmoidectomy with a primary end-to-end anastomosis. In eight pigs we used the operating laparoscope to mobilize the left colon, to ligate the inferior mesenteric artery at its origin, to ligate the inferior mesenteric vein as it crossed the left colic artery, and to fully mobilize the rectum. The rectum and sigmoid colon were then prolapsed through the anal canal, transected, and anastomosis was performed using an EEA stapler. The anastomosis was tested for structural and vascular integrity. Following the procedure, laparotomy was performed to estimate blood loss, to record visceral injury, and to examine the specimen for extent of resection. We were able to perform the resection and anastomosis in all animals with minimal blood loss and with high ligation of the vascular pedicle. There were no major visceral injuries. All anastomoses were perfused, patent, and intact. We concluded that when using the laparoscope in the porcine model, a low anterior resection and anastomosis can be performed safely with an adequate specimen without a laparotomy incision.     

三角吻合技术在全腹腔镜下胃远端癌根治术中的应用

目的 探讨三角吻合技术在全腹腔镜下胃远端癌根治术中的可行性和临床疗效.方法 回顾性分析2012年11-12月间福建医科大学附属协和医院实施的18例全腹腔镜胃远端癌根治术并残胃十二指肠吻合(三角吻合)病例的临床资料.三角吻合是完全在腹腔镜下应用直线切割闭合器完成残胃和十二指肠后壁的功能性端端吻合,再利用直线切割闭合器闭合共同开口后,吻合口内部的缝钉线呈现为三角形.结果 18例患者均成功施行全腹腔镜下胃远端癌淋巴结清扫(D1+或D2)及三角吻合.手术时间(156.3±38.5) min,三角吻合耗时(24.6±11.2) min.肿瘤距上切缘(5.8±2.4) cm,距下切缘(4.1±2.7) cm,上、下切缘病理结果均未见癌残留.术中出血量(70.7±43.8) ml,淋巴结清扫数目(32.4±12.0)枚/例.术后首次下床活动时间(1.8±0.9)d,肛门排气时间(3.1±1.2)d,进食流质时间(3.6±1.7)d,术后住院时间(9.6±2.5)d.术后1例患者出现乳糜瘘伴腹腔感染;全组均未出现吻合口出血、吻合口狭窄或吻合口瘘等吻合口相关并发症.结论 三角吻合技术应用于全腹腔镜下胃远端癌根治术是安全可行的,近期疗效满意.     

Laparoscopic oncologic proctosigmoidectomy with low colorectal anastomosis in a cadaver model

The purpose of this study was to demonstrate that a standardized approach to laparoscopic proctosigmoidectomy in a cadaver model with (1) initial proximal ligation of the inferior mesenteric (IM) vascular pedicle, (2) complete mobilization of the splenic flexure, and (3) intraperitoneal stapled colorectal anastomosis can be accomplished in complete accordance with oncologic surgical principles. Using nine cadavers in the fresh state, six abdominal wall cannulas were placed so as to allow good access to the left colon and rectum. After identifying the left ureter and gonadal vessel, the IM pedicle was divided close to the aorta and the left mesocolon was separated from the retroperitoneal structures. The sigmoid colon was transected at the proximal resection line with an endoscopic stapler; then the splenic flexure and descending colon were completely mobilized. The rectum was freed circumferentially, dissected first posteriorly, laterally, and anteriorly, and then transected in its middle portion with an endoscopic stapler. The specimen was removed through a widened left-lower-quadrant trocar incision and the anvil of a circular endoscopic stapler was placed into the proximal colon extraperitoneally. An intraperitoneal laparoscopic colorectal anastomosis was performed using a double-stapled technique. The median length of specimen was 53 cm (range 45–80 cm) and the median number of removed lymph nodes was 15 (range 11–20). A careful abdominal autopsy was carried out in all cadavers. Length of remaining inferior mesenteric artery was smaller than 1.5 cm in all cases and only one remaining lymph node (3 mm in diameter) was found adjacent to the IMA in one subject. No damage to either ureter occurred. All colorectal anastomoses were patent without signs of air leakage or defects on air insufflation and gross inspection. Using this standardized laparoscopic technique, it is possible to perform a proctosigmoidectomy with stapled intraperitoneal anastomosis according to oncologic surgical principles.