腹腔镜辅助全结肠系膜切除的右半结肠根治术

手术路径采用由内向外、自下而上的中间入路。右侧全结肠系膜切除(CME)手术强调间隙的分离和淋巴结的清扫。首先以回结肠血管解剖投影为起点切开腹膜,游离回结肠血管,显露肠系膜上静脉(SMV)远端并进入血管鞘,沿SMV向头侧解剖至胰腺颈部下缘,可逐个定位回结肠血管、右结肠血管和中结肠血管。在SMV前部行整体淋巴结清扫,再进入并由内向外拓展右侧Toldt间隙,显露十二指肠、胰腺头部、SMV的右侧及胃结肠干,最后由外侧分离将右半结肠完全游离,注意保护腹膜后结构。研究表明,CME理论指导下的右半结肠癌根治术可以彻底完成D3淋巴结清扫,并且降低局部复发和远处转移风险,延长总生存期。     

腹腔镜辅助中央入路根治性右半结肠切除术

患者全身麻醉后,5孔法建立气腹,术者左侧站位。探查腹腔未见转移,行腹腔镜辅助中央入路根治性右半结肠切除术。手术步骤：充分显露右半结肠系膜,辨认回结肠血管,沿肠系膜上静脉投影切开右半结肠系膜根部,进入Toldt’s间隙。分离显露回结肠血管并清扫淋巴结,进而显露肠系膜上静脉。向头侧拓展显露肠系膜上静脉并清扫血管根部淋巴结。显露右结肠、中结肠血管,清扫其根部淋巴结。结扎离断回结肠血管、右结肠血管及中结肠血管右支。向头侧及外侧拓展Toldt’s间隙,分离回肠系膜根部,最后从外侧游离升结肠与内侧贯通,完成右半结肠游离。修整回肠,距回盲部10 cm离断血管弓。采用5 cm上腹正中辅助切口,完成回肠-横结肠端侧吻合并移除标本。     

腹腔镜根治性(扩大)右半结肠切除术

手术采取经典的中间入路:沿肠系膜上静脉(SMV)表面切开,于其左侧清扫回结肠动脉、右结肠动脉及中结肠动脉根部淋巴结并切断;在回结肠血管下方2 cm自然皱褶处切开进入小肠系膜根部,清扫SMV右侧淋巴组织,根部切断回结肠静脉;沿十二指肠水平部与胰头表面间隙分离,显示胃结肠静脉干,于根部切断;胃大弯中部血管弓下方进入网膜囊,在距幽门10 cm处横断胃网膜右血管,沿胃大弯侧分离至显露胃网膜右动脉根部;沿胰颈下缘切开横结肠系膜前叶,向右分离至胃网膜右动脉根部,清扫并将其切断,向右清扫胰头与十二指肠降部前方横结肠系膜;从上至下、从内向外完整切除右半结肠系膜后叶。于右侧经腹直肌切口切开腹壁,长约6 cm,将右半结肠拖出体外。在肿瘤远端10~15 cm横断横结肠,在回盲部近端切断15 cm回肠后行回肠横结肠吻合术。     

腹腔镜右半结肠癌CME切除术——尾侧中间联合入路

手术遵循完整结肠系膜切除原则。手术过程包括：探查腹腔;自尾侧从末端回肠系膜根部黄白交界线打开系膜,进入右结肠后间隙,向头侧,外侧拓展该间隙,至十二指肠水平;回到传统中间入路,回结肠血管下方打开结肠系膜,与尾侧方向打开的间隙会师;解剖并高位结扎切断回结肠血管、打开肠系膜上静脉血管鞘,清扫外科干,高位结扎切断右结肠血管、中结肠血管右支,继续拓展分离右结肠后间隙、横结肠后间隙,直至胰腺下缘并进入小网膜囊;打开胃结肠韧带,游离结肠肝曲;打开右侧腹膜,完成肠段游离,体外切除标本、重建消化道。     

全腹腔镜根治性右半结肠切除术

术中切开回结肠血管蒂下缘系膜进入正确层面,处理回结肠血管并清扫203组淋巴结;继续扩展右结肠后间隙,处理右结肠血管并清扫213组淋巴结,处理中结肠血管并清扫223组淋巴结;裁剪右侧半大网膜及横结肠系膜,游离结肠肝曲,向下游离整个右半结肠;全腔镜下行回肠横结肠侧侧吻合,标本装袋后取出。     

尾侧入路腹腔镜右半结肠癌CME术

主要步骤包括:(1)腹腔探查;(2)右结肠后间隙(RRCS)拓展:进入Told筋膜与结肠系膜间的天然外科平面。至结肠肝曲水平,同时向内侧暴露十二指肠,此为进入横结肠后间隙(TRCS)的标志。(3)中间入路结扎肠系膜血管:以回结肠血管(ICV,ICA)在肠系膜表面投影为解剖标志打开结肠系膜,可轻易与其后方已打开的RRCS间隙相汇合。以肠系膜上静脉(SMV)为主线,清扫外科干,进一步解剖Henle’s干及其分支。(4)幽门下淋巴结清扫;(5)消化道重建。本文对由外周入路和中间入路发展而来的尾侧联合中间入路进行了简要介绍,该术式技术上可行,术者操作相对简便,手术安全性高,可供结直肠外科医生参考。     

腹腔镜辅助根治性右半结肠切除术

右半结肠切除术的中间入路:回结肠血管被拉伸并且在所产生的腹膜皱褶的基部开始腹膜切开。腹膜前叶的解剖沿着SMA左边缘进行;在SMV前部行整体淋巴结清扫术,沿着肾前筋膜平面从内侧到外侧和从底部到顶部。Toldt筋膜的解剖胚胎平面被锐性分离:内测分离通常沿肝曲的结肠系膜与胰十二指肠前筋膜之间的平面解剖;外侧通过切开结肠肝曲外侧腹膜返折进入上述平面,在这个水平的结肠筋膜囊相互衔接,可以容易的分离。分离过程中确保右半结肠系膜完整性及保护腹膜后结构,如右输尿管和性腺血管。右侧腹膜返折和回盲部腹膜返折逐渐分离后使右半结肠标本完全游离。     

腹腔镜下往复式右半结肠D3/CME根治术

步骤包括:1先切开腹膜显露肠系膜上静脉(SMV)。并于中结肠血管左侧辨认胰颈下缘,进入小网膜囊;2沿SMV左侧缘纵向反复多次切开薄层脂肪组织,以显露可能的结肠动脉分支(回结肠动脉或右结肠动脉及中结肠动脉),并结扎处理,充分显露SMV的全长;3结扎处理中结肠静脉汇入SMV的属支后,与SMV右侧处理回结肠静脉;4沿SMV右侧向胰颈分离,显露胃结肠干的各个分支,单独切断右结肠静脉/或胃网膜右静脉;5分离胰十二指肠前间隙和Toldt间隙,游离结肠,脐周切口完成吻合。特点:1纵向显露SMV左侧缘全长后再处理各静脉属支,简化各静脉属支的显露;2以胰腺颈部为标示,处理静脉属支更加安全。腹腔镜下往复式右半结肠D3/CME根治术简单、安全、可行。     

腹腔镜辅助根治性右半结肠切除术(D3)

手术摘要：患者男性,72岁,因间断腹胀2个月入院。既往开腹阑尾切除手术史。辅助检查肠镜：距肛门70 cm环周肿物;活检：结肠腺癌。结肠增强CT：结肠肝曲处肠壁增厚,考虑结肠癌,符合T4aN1M0。诊断：结肠癌(cT4aN1M0)。手术：腹腔镜辅助根治性右半结肠切除术(D3),右腹大网膜、腹壁、右半结肠粘连,首先采用外侧入路分离粘连及右半结肠系膜外侧达结肠肝曲;再采用内侧入路沿肠系膜上静脉由回结肠血管向头侧游离清扫,最后上腹辅助切口完成回结肠端侧吻合。     

优先清扫No.206和No.204组淋巴结的全程无结扎结肠肝曲癌根治术

本文首次报道以头侧入路优先清扫No.206和No.204组淋巴结的结肠肝曲癌根治术。首先,使用LigaSure（LF1937）将胃网膜右系膜连同右结肠及其系膜向尾侧剥离,显露十二指肠降部外侧的Toldt筋膜平面,以及胰十二指肠前筋膜平面和Henle干汇入肠系膜上静脉处;其次,沿着回结肠血管蒂下窝切开回结肠系膜表面的膜桥,在右结肠系膜背侧叶与Toldt筋膜之间向头侧拓展筋膜间隙并与头侧间隙会师;最后,在肠系膜上动脉右侧缘剥离右结肠系膜,运用LigaSure（LF1937）防波堤技术,凝闭并切断回结肠动静脉、右结肠动静脉及中结肠动静脉,清扫No.203、No.213和No.223组淋巴结。     

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.     

腹腔镜辅助右半结肠癌根治切除术

采用中间入路五孔法。沿肠系膜上静脉(SMV)表面用超声刀切开后腹膜,暴露SMV。紧贴SMV主干离断回结肠动静脉,在右结肠动脉根部将其结扎切断。游离出结肠中动静脉脉主干、Henle’干、副右结肠静脉(SRCV)和胃网膜右静脉(RGEV)。结扎切断结肠中动静脉右支,解剖出胃网膜右动脉(RGEA),胰头前切开横结肠系膜前叶进入小网膜囊。依次在根部结扎切断SRCV、RGEV及RGEA。沿Todlt’间隙将右半结肠系膜掀向右侧腹,切断部分回肠系膜,沿右结肠旁沟切开侧腹膜。切断胃结肠韧带,清除第6组淋巴结。切断肝结肠韧带,完全游离右半结肠,在右中腹做小切口行标本切除及吻合。     

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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.     

Modified standard (D1 + α) pancreaticoduodenectomy for pancreatic cancer

Summary We believe that the effect of extended dissection, especially dissection of the nerve plexi around the celiac trunk, superior mesenteric vessels, and middle colic vessels, is impairment of intestinal motility that results in severe diarrhea postoperatively. Long term this results in a negative nutritional and possibly immunologic effect, which may have a long-term effect on outcome and patient survival. The best way to prevent severe diarrhea is to avoid complete resection of the nerve plexus around the SMA. To avoid diarrhea, we have been especially careful not to dissect the nerve plexus around the SMA in patients undergoing D 1 + α resection. The most important consideration is to avoid stripping the SMA bare. Dissection of the superior mesenteric lymph nodes with preservation of the superior mesenteric nerve plexus is theoretically possible because 95 % of the lymph nodes are located outside the nerve plexus. 2 From survival studies we concluded that D 1 + α dissection for pancreatic cancer is an adequate lymph node dissection in terms of the postoperative quality of life and survival rate for patients with pancreatic cancer.     

中间入路法腹腔镜右半结肠癌根治术55例临床体会

目的:探讨腹腔镜中间入路法右半结肠癌根治术的手术要点及临床疗效。方法:回顾分析2008年1月至2013年1月55例行腹腔镜下右半结肠癌根治术患者的临床资料,术中以回结肠血管为起始入路标志,以肠系膜上静脉为解剖学标志,建立正确的外科平面进行系膜血管的解剖及淋巴结清扫。结果:54例患者均顺利完成腹腔镜辅助根治性右半结肠切除术,1例(1.82%)中转开腹,手术时间平均(113.5±13.8)min,术中出血量平均(75.2±16.5)ml,切除标本长度平均(15.4±5.26)cm,淋巴结清扫数量平均(16±3)枚,术后排气时间平均(3.5±1.8)d,恢复流质饮食时间平均(3.2±0.85)d,平均住院(9.75±1.5)d。术中无肠系膜上静脉、十二指肠、输尿管、生殖血管损伤,术后无切口感染、吻合口漏、腹腔脓肿等并发症发生。55例患者随访10~40个月,平均(25.5±2.3)个月,未发现吻合口复发、穿刺孔或辅助切口种植转移、远处转移等。结论:以回结肠血管为标志的中间入路法能快速准确地进入Toldt间隙及胰腺十二指肠前筋膜间隙,既能保证肿瘤的根治性,又能保证手术的安全性,具有较高的临床应用价值。     

腹腔镜右半结肠切除术中血管解剖辨识及意义研究

目的 探讨腹腔镜右半结肠切除术中肠系膜上血管主干及对应分支与属支的解剖规律、变异类型及临床意义。方法 回顾性分析2017年3月至2021年1月中国医科大学附属盛京医院结直肠肿瘤外科200例腹腔镜右半结肠切除术病人资料,通过影像学读片、手术记录查阅、术后视频回放方式观察肠系膜上血管主干、回结肠血管、右结肠血管、结肠中血管、Henle干的出现概率、走行特点、毗邻关系以及变异情况。结果 肠系膜上血管主干变异按肠系膜上静脉（SMV）数量分为单支型与双支型,按SMV与肠系膜上动脉（SMA）的空间位置关系分为右位、左位、交叉3种类型。回结肠动脉（ICA）与回结肠静脉（ICV）出现率均为100.0%,2例ICV直接汇入Henle干,62.0%病人ICA走行于SMV背侧。术中解剖出右结肠动脉（RCA）73例（36.5%）,右结肠静脉（RCV）195例（97.5%）,单支型、双支型、三支型RCV分别占48.2%、43.6%和8.2%,RCA走行于SMV腹侧者62例（84.9%）,RCA走行与SMV背侧者11例（15.1%）。解剖出结肠中动脉（MCA）192例（96.0%）,结肠中静脉（MCV）196例（98.0%）,单支型、双支型与三支型MCV分别占63.8%、33.2%与3.0%,MCV有4种汇入情况：汇入SMV、Henle干、脾静脉（SV）和第一支空肠静脉（FJV）,其中汇入到SMV最常见占95.4%,当MCV汇入FJV时,FJV均走行于SMA前方,当MCV为多支型时,RCV多支型占比更高。按胰十二指肠上前静脉（ASPDV）与胃网膜右静脉（RGEV）是否共干以及结肠支的数量将Henle干分为基本型（0~Ⅲ型）和特殊型,其中基本Ⅰ型最为常见（43.6%）。结论 肠系膜上血管主干变异情况较少,分支与属支变异常见。术中操作应始终遵循精细解剖的原则,避免辨识不清晰的情况下导致出血及副损伤。