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。     

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。     

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.     

Laparoscopic resection of sigmoid colon cancer with intestinal malrotation: A case report

IntroductionIntestinal malrotation is a congenital abnormality which occurs due to a failure of the normal 270° rotation of the midgut. The non-rotation type is usually asymptomatic and discovered incidentally on imaging studies. Intestinal malrotation accompanied by colon cancer is extremely rare.Presentation of caseA 53-year-old male presented with postprandial abdominal discomfort. Colonoscopy showed a 14 mm polyp in the sigmoid colon and endoscopic polypectomy was performed. Pathological evaluation revealed an adenocarcinoma invading the submucosa more than 1000 μm with positive vertical and horizontal margins. A contrast enhanced computed tomography scan showed an anatomic variant of the ileocolic and inferior mesenteric arteries originating from a common channel branching from the abdominal aorta. Laparoscopic sigmoid colon resection was performed. The patient did well post operatively.DiscussionThe usual trocar placement for laparoscopic left side colectomy was used, and we found no difficulties intraoperatively. To secure safe ligation, the divisions of the common channel branching from the abdominal aorta were exposed as in a usual D3 dissection, and the inferior mesenteric artery was ligated after confirmation of the bifurcation of the ileocolic and inferior mesenteric artery.ConclusionTo the best of our knowledge, this is the first report of laparoscopic resection of a sigmoid colon cancer with intestinal malrotation. It was performed without difficulty using the usual trocar placement, with appropriate attention to the variant in vascular anatomy.     

A colovesical fistula with a persistent descending mesocolon due to partial situs inversus: A case report

IntroductionSitus inversus viscerum, a congenital condition in which the visceral organs are a mirror image of their normal physiological positions, could be total or partial. Persistent descending mesocolon (PDM) is a congenital anomaly that is asymptomatic because of its short length. PDM causing intestinal obstruction is a known clinical complication.Presentation of caseA 74-year-old woman presented with pneumaturia and enteruria for two months, and recurrent cystitis for a month. An enhanced computed tomography (CT) showed air in the bladder along with sigmoid colonic diverticula adherent to it, suspecting a fistula. The CT also showed partial situs inversus with the common hepatic artery, and left colic artery arising abnormally from the superior mesenteric artery (SMA). Minimally invasive endoscopic closure using the over-the-scope clipping system was difficult because of thickening and scar tissue due to chronic inflammation from diverticulitis. Thus, a sigmoidectomy was performed to close the fistula. Intraoperatively, we noted an abnormally fixed descending mesocolon. An emergency reoperation was performed on the sixth postoperative day owing to an anastomotic leak. Suture failure was attributed to these congenital abnormalities due to insufficient blood flow from an absent marginal vessel and a high endocolonic pressure by adhesions. Sigmoid colon re-resection and maturation of an ileostomy was performed. The patient had no specific postoperative complications, and the ileostomy was closed after three months.ConclusionWe report an extremely rare case of colovesical fistula due to a PDM in a patient having partial situs inversus with abnormal branches originating from the SMA.     

根部结扎肠系膜下血管在乙状结肠癌根治术中的意义

目的探讨乙状结肠癌根治术中于根部结扎肠系膜下血管的合理性。方法回顾性分析2005年12月~2006年12月间30例行乙状结肠癌根治术病例资料,手术时于根部切断结扎肠系膜下血管,注意保护内脏神经的腹主动脉丛和上腹下丛,分析肠系膜淋巴结转移和手术并发症情况。结果本组淋巴结转移者8例(26.7%),其中肠系膜根部有转移者3例(10.0%)。合并梗阻者一期切除吻合后有2例发生吻合口瘘,经引流等非手术治疗治愈,无手术死亡病例。结论乙状结肠癌根治术从根部处理肠系膜下血管合理可行。     

Elective laparoscopic surgery for sigmoid colon carcinoma incarcerated within an inguinal hernia: report of a case

Primary colon carcinoma within an inguinal hernia sac is very rare and most reported cases were found at emergency open surgery for an incarcerated hernia. We report a case of incarcerated sigmoid colon carcinoma diagnosed preoperatively and treated with elective laparoscopic surgery. A 67-year-old man with a 2-year history of swelling of the scrotum and a breast lump was referred to us for surgical treatment of an irreducible left inguinal hernia and a right breast tumor. Blood examination results showed severe anemia. Computed tomography scan and endoscopic biopsy confirmed sigmoid colon carcinoma incarcerated in the left inguinal hernia. Thus, we performed definitive laparoscopic sigmoidectomy and conventional hernia repair for preoperatively diagnosed sigmoid colon carcinoma within an inguinal hernia.     

腹腔镜辅助直肠癌根治术

于2020-04-24全身麻醉下行腹腔镜辅助直肠癌根治术(低位直肠前切除术)。探查腹腔无远处转移后提起乙状结肠系膜,超声刀游离出肠系膜下动脉。肠系膜下静脉,分别结扎切断。继续游离乙状结肠以及直肠,游离直肠后间隙,于肿瘤下方使用腔镜下直线切割吻合器切断直肠。再切断肿瘤上方乙状结肠。使用管型吻合器作直肠-乙状结肠端端吻合。切除直肠上段以及部分乙状结肠。     

机器人直肠癌根治术

术中自肠系膜下动脉下方切开乙状结肠系膜,游离Toldts间隙,暴露并保护左侧输尿管及生殖血管。切断肠系膜下动脉根部,清扫253组淋巴结。切开乙状结肠侧腹膜,游离乙状结肠下段。提起肠系膜下动脉血管蒂(已切断),沿Toldts层面分离直肠系膜与骶前间隙,环形完整游离直肠系膜,于肿瘤标记处远端约5cm处以直线切割闭合期切断直肠肠管。肠管断端提出体外,距离肿瘤近端约10cm,切断乙状结肠肠管,并包埋吻合器钉座。行乙状结肠-直肠端端吻合(Dixon手术)     

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。     

肠系膜下动脉高位结扎后顽固性便秘21例临床分析

目的分析进展期乙状结肠癌或直肠上段癌行根治性切除术后顽固性便秘的致病因素,并总结其治疗经验。方法对江汉大学附属医院胃肠外科2004年1月至2014年12月收治的共21例顽固性便秘病人临床资料进行回顾性分析。结果所有病例既往均为进展期乙状结肠癌或直肠上段癌于外院行根治性手术,原手术均明确记录为肠系膜下动脉高位结扎。术后2~4年(平均3.4年)逐渐出现顽固性便秘,以腹痛、腹胀、大便次数减少及排便困难为主要临床表现。所有病例术前行X线钡剂灌肠造影均显示一共同特征,即结肠脾曲未游离,降结肠未切除,降结肠结肠袋消失,犹如小肠;结肠传输试验均提示为慢传输型,排粪造影均未见出口梗阻。12例再次接受手术,余9例因个人因素放弃手术,仍选择保守治疗(灌肠或口服泻药通便)。所有病人均随访至今,随访时间24~168个月,平均87.8个月,手术组术后效果显著,1年内均恢复正常排便(1~2次/d);而保守治疗组便秘症状无改善。结论乙状结肠癌或直肠上段癌根治术中行肠系膜下动脉高位结扎,而未游离结肠脾曲行包括降结肠、乙状结肠和直肠腹膜返折以上部分肠切除。其后果是部分病人降结肠慢性缺血,结肠形态及生理功能退化,导致顽固性便秘发生(慢传输型便秘)。其有效治疗为再手术行降结肠切除,横结肠-直肠吻合。     

A case of sigmoidectomy for sigmoid colon cancer with severe pulmonary arterial hypertension associated with mixed tissue connected disease: A case report

IntroductionPatients with mixed connective tissue disease (MCTD) have higher rates of pulmonary arterial hypertension (PAH) than the general population. PAH is a risk for perioperative respiratory and heart failure, and marked edema of colonic stoma after sigmoidectomy. We report a case of sigmoidectomy for sigmoid colon cancer in a patient with PAH associated with MCTD for whom perioperative treatment was planned to control pulmonary arterial pressure (PAP), and a surgical strategy to avoid complications attributable to PAH and MCTD was employed.Case presentationA 52-year-old woman with sigmoid cancer and severe PAH associated with MCTD underwent surgery. We controlled PAH by using intravenous epoprostenol. We selected open surgery without laparoscopy and Hartmann's operation. After surgery, severe perioperative complications were not detected, and the patient discharged from hospital 17 days after the operation.DiscussionDuring surgery under general anesthesia, the mortality rate of PAH is high because of heart and respiratory failure. We planned to switch the PAH treatment from an oral agent to intravenous epoprostenol only in the preoperative period, and selected open surgery. We ligated the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) below the branch of LCA to avoid marked edema of stoma. Consequently, we could avoid severe intraoperative and postoperative complications.ConclusionsControlling PAP using epoprostenol, open surgery, stoma and the ligation level for the IMA and IMV preventing are important to avoid perioperative complications of sigmoid colon cancer complicated by severe PAH.     

腹腔镜扩大左半结肠切除术

采用5孔法,经典中间入路。在右侧输尿管内侧2 cm切开,进入左侧Toldt间隙,自尾侧向头侧锐性分离,清扫肠系膜下动脉根部的淋巴脂肪组织。解剖降结肠及乙状结肠动脉,根部离断。十二指肠空肠曲左侧离断肠系膜下静脉根部,向外侧拓展降结肠后间隙、乙状结肠后间隙和直肠上段后间隙,确认左输尿管及生殖血管以防止损伤。切开并游离横结肠系膜,在胰颈下缘显露中结肠动静脉,于根部离断。沿降结肠沟剪开左侧腹膜,上至脾曲,下至直肠上段,与之前已拓展完成的左结肠后间隙汇合。自胃大弯侧血管弓内离断血管分支,直至根部切断胃网膜左血管,并切断脾结肠韧带,完全游离脾曲。于左侧经腹直肌切口切开腹壁,长约5 cm,将左半结肠拖出体外。在肿瘤近远端10～15 cm横断结肠,行端端吻合术。     

新式保护性肠造口在急诊结肠手术中的应用价值

目的 探讨新式保护性肠造口在急诊结肠手术中的应用价值.方法 回顾性分析16例急诊结肠一期切除吻合术中应用新式保护性肠造口患者的临床资料:回盲部癌合并阑尾穿孔2例;自发性乙状结肠穿孔3例;闭合性腹部外伤致降结肠、乙状结肠广泛挫裂4例;左半结肠癌、乙状结肠癌伴肠梗阻7例.造口方法:回盲部癌伴阑尾穿孔患者,切除末段回肠、部分...     

Assessment of colonic ischemia during aortic surgery by Doppler ultrasound.

Colonic ischemia, related to division of the inferior mesenteric artery during aortic surgery, can be a significant cause of postoperative mortality. Operative determination of collateral mesenteric blood flow during temporary occlusion of the inferior mesenteric artery by use of the Doppler ultrasound device was evaluated in 25 patients undergoing aortic reconstructive vascular procedures. In five patients, the evaluation confirmed arteriographic evidence of an occluded inferior mesenteric artery; however, collateral flow was audible at the base of the large bowel mesentery and serosal surface of the left colon. In the other 20 patients with patent inferior mesenteric arteries, temporary occlusion of the artery resulted in persistent audible collateral flow in eighteen. However, in the remaining two patients, temporary arterial occlusion resulted in loss of audible Doppler flow signals over the base of the mesentery and serosa of the left colon. Maintaining patency of the inferior mesenteric artery by proper placement of the aortic graft in one patient and reimplantation of the artery into the prosthesis in another resulted in a return of Doppler flow over the left colon. All patients did well post operatively. Our data suggest that the presence of audible Doppler flow over the base of the large bowel mesentery and serosal surface of the left colon may correlate with viability of the colon postoperatively. We recommend routine use of the Doppler ultrasound device to determine adequacy of collateral mesenteric blood flow in patients undergoing aortic reconstructive vascular procedures.     

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。     

Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience

Background  Laparoscopic surgery demands mastery of a steep learning curve. Defining a learning curve in laparoscopic surgery is useful for planning training programs or clinical trials. This study aimed to define the learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer by evaluating early surgical outcome data from three colorectal surgeons. Methods  This study analyzed data from 138 consecutive patients undergoing laparoscopic sigmoidectomy for curable sigmoid colon cancer performed by three colorectal surgeons between May 2001 and November 2006. The learning curve for each surgeon were generated using the moving average method to assess changes in operation time and cumulative sum (CUSUM) analysis to assess changes in failure rates [(failure = conversion to open surgery, major perioperative complication, or failure to harvest an adequate number of lymph nodes (<12 nodes)]. Results  Learning curves generated with the moving average method indicated that the operation time reached a steady state after 42 cases for surgeon A, 35 cases for surgeon B, and 30 cases for surgeon C. The overall open conversion rate was 2.9%. There was only one laparoscopy-related perioperative major complication (0.7%). An inadequate number of lymph nodes was harvested in 10 cases (7.2%): 6 (10.5%) for surgeon A, 1 (2.4%) for surgeon B, and 3 (7.7%) for surgeon C. Learning curves generated using CUSUM analysis based on a 90% success rate showed that adequate learning occurred after 10 cases for surgeon A, 17 cases for surgeon B, and 5 cases for surgeon C. Conclusion  Pertinent learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer can be generated using the moving average method and CUSUM analysis. These results are likely to be useful in designing laparoscopic training programs and clinical trials aimed at investigating outcomes of laparoscopic colorectal cancer surgery. Presented at the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, Seoul, Korea, 20 October 2006     

CT虚拟内镜精准肿瘤定位在腹腔镜中高位直肠癌根治术手术方案制定中的应用

目的探讨CT虚拟内镜三维重建左半结直肠的影像对在腹腔镜中高位直肠癌根治术前制定详细精准的手术方案的预测作用。方法将2017年6月至2018年10月我科收治的40例中高位直肠癌患者,术前利用CT虚拟内镜结肠重建来制定降结肠游离范围及肿瘤远、近端切除范围,并通过肠系膜下动脉CTA提前预判肠系膜下血管走行及变异。对比术前、术中所得数据并进行统计学分析,评估术前CT三维重建的准确性。结果40例患者左半结肠-直肠平均长度预测值为(68.3±7.5)cm,实际长度(68.2±6.6)cm,经配对t检验差异无统计学意义(t=0.562,P=0.725)。肠系膜左动脉发出部位距肠系膜下动脉根部距离术前评估为(3.84±0.78)cm,术中测定为(3.81±0.72)cm,差异无统计学意义(t=0.795,P=0.453)。术前预测左结肠动脉分型准确率为97.5%(39/40)。结论左半结肠CT虚拟内镜三维重建在中高位直肠癌术前精准定位中的应用,可作为中高位直肠癌术前手术方案制定的重要环节,提高手术效率及促进术后康复。     

腹腔镜全直肠系膜切除术手术技巧与手术副损伤的预防

目的探讨如何合理运用手术技巧避免腹腔镜全直肠系膜切除术（laparoscopic total mesenteric excision,LTME）的手术副损伤的发生。方法对我院2005年1月～2008年6月182例LIME治疗低位直肠癌的临床资料进行回顾性分析,就手术过程中的手术入路、肠系膜下血管及降结肠系膜处理、直肠系膜游离等手术技巧进行总结,寻找避免手术副损伤发生的方法。结果182例均顺利完成LIME,无中转开腹。手术时间115～320min,平均150min。术中出血量15～75m1,平均25m1。术中直肠损伤发生率2.7%（5/182）,骶前静脉丛损伤发生率2.2%（4/182）,阴道损伤发生率1.1%（2/182）,精囊、输精管损伤发生率1.1%（2/182）,未发生输尿管损伤、前列腺损伤等。13例手术副损伤镜下缝合或压迫止血成功,术后无吻合口漏等并发症发生。术后病理：低分化腺癌56例,中分化腺癌98例,息肉恶变28例。Dukes分期：A期23例,B期67例,C期92例。182例术后随访6～32个月,平均18个月,均未发现吻合口肿瘤复发及远处转移。结论只要熟练地掌握乙状结肠、直肠毗邻结构的镜下解剖,运用合理的手术技巧和规范的操作可以防范LIME手术副损伤的发生。