保留十二指肠、胆总管、Oddi’氏括约肌的胰头整块全切除术

保留十二指肠、胆总管、Oddi’氏括约肌的胰头整块全切除术(DCOPPHTR)。这个术式是基于我们对慢性胰腺炎病理改变的新发现和对胰腺解剖结构的深刻理解。因此这个术式打破了Beger术式的原理,是一个新的手术方式。要点如下:(1)采用Kocher手术从后腹膜游离胰头直到看见肠系膜下静脉。(2)沿肠系膜上静脉解剖,结扎Henle干。(3)解剖胃十二指肠动脉,暴露门静脉主干。(4)切断胰颈前缝合胰腺上下缘、结扎切除线的近端以减少出血。(5)在胰腺勾突注水,沿胰腺实质解剖,确保不损伤胰腺后被膜。(6)沿着十二指肠和胰头之间的疏松结缔组织解剖,结扎到胰头的小动脉分支。(7)沿胰腺实质和胆总管之间解剖,切断主胰管,用5-0普理灵线连续缝合其残端。(8)胰腺吻合采用胰管对黏膜的吻合方式。     

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。     

保留十二指肠、胆管和乳头并胰管端端吻合的胰头完全切除

由于放射学的发展，胰腺疾病已能精确定义，这对其治疗有很大影响。许多外科医生正逐渐进行较小范围的操作如保留幽门腔的胰十二指肠切除、保留十二指肠的陵头切除、胰体中部切除、腹侧胰切除。本文作者对两例胰头粘液囊肿患者进行了新的手术，即切除腹头保留十二指肠、胆管及乳头，在胰管与胆总管汇合前smm切断胰管并端端吻合，所有结果均显示良好。手术方法：开腹后，切断胃结肠、十二指肠结肠系膜暴露胰腺，结扎切断胃网膜右动脉，解剖胃十二指肠动脉根部至胰腺上缘分为胰十二指肠上动脉前后立分又处，结扎切断十二指肠上前动脉，保留后…     

保留十二指肠、胆管和乳头的胰头切除胰管端端吻合术

对2例胰头粘液囊肿患者施行了切除胰头并保留十二指肠、胆管和乳头，同时行胰管端端吻合术，效果良好。进腹后，分离胃、结肠韧带，暴后胰腺前面。不游离十二指肠，结扎、切断督网膜右血管，在胰腺上端分离鲁十二指肠动脉根部，显露胰十H指肠上动脉前支（ASPD）和后支（PSPD）的分叉部，结扎、切断ASPD，保留PSOD。在门静脉前方切断胰腺，分离结扎胰腺与门静脉之间的一些小血管直至能如及肠系膜上动脉（SMA）。确定胆总管前壁位置，并向乳头方向分离，剥离胰腺实质，使之与十二指肠分离，然后找出胆胰管汇合部，将一手指插入胰腺后…     

扩大胰十二指肠切除术

1.沿着自然的解剖间隙进行分离。2.所有大血管直接套线结扎,避免钳夹,以免形成假性动脉瘤,导致术后迟发性的大出血。3.横断胆总管后立即引流胆管,可避免胆汁进入手术野,让手术野清爽干净。4.切断胰颈前在胰腺上下缘各缝1针,将胰头端结扎,可减少切断胰颈时的出血。5.清扫范围:上至肝门,下至肠系膜下动脉起始部,右至右肾门,左至腹主动脉左侧缘。肠系膜上动脉要360°骨骼化。6.胰管空肠粘膜对粘膜吻合是最接近生理状态的吻合方式,容易操作,胰漏发生率也不高。     

游离右侧结肠和肠系膜根部可以避免重建门静脉时使用静脉移植血管

在胰十二指肠切除术常需切除受侵的门静脉 ,如切除长度 4～ 5 cm时则不需静脉移植血管以完成重建 ,可直接行端端吻合。如切除长度较长 ,常需自体静脉或人造血管修复。作者介绍一简易手术方法以直接修复切除 6～ 10 cm的门静脉段。作一长正中切口 ,按常规游离胰头 ,在其颈部切断 ,备作胰十二指肠切除。先结扎脾静脉 ,不需再建脾静脉。如作全胰切除 ,不切断胰颈部 ,在肠系膜上和门静脉旁游离全胰。在连接肠系膜上和门静脉处切断脾静脉。如估计静脉两切端不能拉拢时 ,作下列手术。完全游离右侧结肠、结肠系膜和肠系膜根 ,从十二指肠和胰腺处游…     

胰腺残端处理方式对胰体尾切除术后胰瘘的影响

目的探讨预防胰体尾切除术后胰瘘的胰腺残端处理方式。方法回顾性分析我院1996至2008年186例因胰腺或胰外病变行胰体尾切除术患者的临床资料,胰腺残端处理方法分别为：结扎主胰管、残端结扎、间断缝合、Prolene线连续缝合、胰腺空肠吻合及闭合器钉合六种方式,比较上述六种方式对术后胰瘘的影响并行统计学分析。结果186例患者中围手术期死亡5例（2．7％）,术后总并发症发生率34．9％（65／186）,胰瘘发生率21．0％（39／186）。8例胰腺残端结扎术后4例发生胰瘘,11例胰腺空肠吻合患者无胰瘘发生;17例Endo—GIA关闭胰腺残端者有胰瘘4例;结扎主胰管组、连续缝合组、间断缝合组胰瘘发生率分别为13．9％（5／36）、15．6％（10／64）、32．0％（16／50）,前两者与后者差别具有统计学意义（P〈0．05）。结论胰体尾切除术中残端结扎和间断缝合容易发生胰瘘,选择性缝扎主胰管或Prolene线连续缝合能降低胰瘘发生率,尤其后者更简单易行。近端胰管梗阻患者可选用胰肠吻合预防胰瘘;闭合器钉和胰腺残端要根据胰腺大小和质地选择性使用。     

捆绑式胰肠端侧吻合术

目的:介绍一种新型胰肠吻合术——捆绑式胰肠端侧吻合术,及其应用价值。方法:分析2009年3月至2011年3月间7例病人,其中5例行胰十二指肠切除,2例行胰腺中段切除,包括胰头癌3例、胰体癌2例、肿块型慢性胰腺炎2例。其中2例胰腺残端明显过大超过肠腔管径,2例行门静脉-肠系膜上静脉或脾静脉部分切除修补。操作包括3个主要步骤:胰腺残端游离,空肠系膜对侧肠壁切开及荷包缝线预置,胰肠端侧吻合(包括胰腺残端拖入空肠、吻合口两端肠壁固定于胰腺上、下缘后腹膜、浆肌层荷包缝线结扎捆绑)。结果:全组手术均顺利完成,无死亡。并发症包括:切口感染1例,切口疝1例,无胆漏和胰肠吻合口漏发生。结论:捆绑式胰肠端侧吻合术能有效地预防吻合口漏发生,特别是胰腺残端过大者,从而提高胰十二指肠切除术和胰腺中段切除术的安全性。     

胰腺癌十二指肠切除术

目的采用kocher手法，分离十二指肠降部与下腔静脉之间间隙；分离胃结肠韧带，不保留大网膜，进入小网膜囊，小网膜囊后壁下面即为胰腺前缘；分离横结肠系膜前叶及胰腺背膜，于胰腺下缘找到肠系膜上静脉，分离钳顺着肠系膜上静脉在胰腺后侧打洞分离，直至门静脉；解剖肝十二指肠韧带，游离肝门三管；分别于胃大弯和胃小弯游离韧带，于固定处用直线切割闭合器切断胃；于预定切除处断胰；仔细分离钩突与SMV之间的小静脉、以及可能出现的胃结肠干、胃网膜右静脉等血管；施行胰肠吻合、胆肠吻合、胃肠吻合。     

胰腺切除不伴胰瘘的形成

作者介绍一种胰腺切除不伴胰瘘形成的手术方法。在10例的胰十二指肠切除术后,胰腺的残端的处理方法是:(1)用可吸收的聚乙二醇酸000缝线缝扎胰管(作荷包缝合);(2)将胰腺残端套入空肠腔内,用000丝线作二层缝合,其内层缝合空肠壁和胰腺包膜及其包膜下实质,外层缝合使空肠呈袖套状固定在胰包膜上;(3)在此空肠上作一侧孔插入-18F 导管,以引流邻近胰空肠吻合处的胆汁和胰液。在15例远端胰大部切除术后胰腺残端的处理方法是:(1)结扎胰腺;(2)用褥式缝合和大网膜填塞,以闭合胰腺的切面。作者认为暂时结扎胰管可防止胰空肠吻合口愈合前激活的胰酶在空肠腔内的作用,这是防止胰瘘形     

Invasive carcinoma of the pancreas derived from intraductal papillary adenocarcinoma without mucin hypersecretion but with changes in the pancreatic duct on pancreatography

We present a case of invasive carcinoma of the pancreas derived from intraductal papillary adenocarcinoma without mucin hypersecretion in a 65-year-old man with a 45-year history of alcohol abuse and a 2-year follow-up of chronic pancreatitis. Two years previously, in May 1998, he was admitted for investigation of abdominal pain. Computed tomography (CT) showed diffuse dilation of the main pancreatic duct with atrophy of the pancreatic parenchyma. Endoscopic retrograde pancreatography (ERP) showed a diffusely dilated main pancreatic duct with irregular side branches in the head of the pancreas. Chronic alcoholic pancreatitis was diagnosed on the basis of the pancreatography findings. The patient was readmitted for investigation of progressive weight loss in August 2000. Serum CA19-9 levels were markedly elevated (750 U/ml) and CT showed enlargement of the head and body of the pancreas. ERP showed irregularity of the main pancreatic duct in the head of the pancreas, and the distal main pancreatic duct (which was dilated on initial ERP examination) was interrupted in the body of the pancreas. Suspected pancreatic carcinoma was diagnosed, and pylorus-preserving pancreatoduodenectomy was performed. Frozen section examination of the cut end of the pancreas revealed ductal carcinoma, and total pancreatoduodenectomy with portal vein resection was performed. Histologically, the resected tumor was diagnosed as an invasive carcinoma derived from intraductal papillary adenocarcinoma without mucin hypersecretion. We recommend observing changes in the pancreatic duct on pancreatography to diagnose invasive carcinoma of the pancreas derived from intraductal papillary adenocarcinoma in a resectable state. Received: February 6, 2002 / Accepted: June 10, 2002 Offprint requests to: S. Ariizumi     

Simplified pancreatoduodenectomy for complex blunt pancreaticoduodenal injury

A 34-year-old man admitted to our de- partment with complex blunt pancreaticoduodenal injury af- ter a car accident. The wall of the first, second, and third portions of the duodenum was extensively lacerated, and the pancreas was longitudinally transected along the supe- rior mesenteric vein-portal vein trunk. The pancreatic head and the uncinate process were devitalized and the distal common bile duct and the proximal main pancreatic duct were completely detached from the Vater ampulla. The length of the stump of distal common bile located at the cut surface of remnant pancreas was approximately 0.6 cm. A simplified Kausch-Whipple＇s procedure was performed after debride- ment of the devitalized pancreatic head and resection of the damaged duodenum in which the stump of distal common bile duct and the pancreatic remnant were embedded into the jejunal loop. Postoperative wound abscess appeared that eventually recovered by conservative treatment. Dur- ing 16 months follow-up the patient has been stable and healthy. A simplified pancreaticoduodenectomy is a safe alternative for the Whipple procedure in managing complex pancreaticoduodenal injury in a hemodynamically stable patient.     

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。     

完全腹腔镜下右半肝切除

切除胆囊后,向左牵拉胆囊管,显露门静脉右支,分离,7号丝线结扎;分离出肝右动脉,结扎切断。显露左右半肝缺血线。游离肝结肠韧带,肝肾韧带,右侧冠状韧带,肝镰状韧带,右半肝充分游离。沿缺血线切开肝脏实质,结扎切断肝中静脉5段支,应用Endo GIA blue reload离断右肝蒂后沿下腔静脉前面结扎切段右侧肝短静脉,继续沿缺血面离断肝组织,结扎切断肝中静脉第8段支,显露肝右静脉,Endo GIA white reload离断。完整切除右肝。装入自制标本袋。取出!     

Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure?

BACKGROUND: Less extensive resection of the head of the pancreas has been the procedure of choice recently for low-grade malignant neoplasms. The anatomical detail of the head of the pancreas is currently insufficient for segmental resection along the embryological fusion plane. METHODS: The anatomy of the head of the pancreas was analyzed in 31 consecutive autopsy specimens. An anterior (n = 10) or posterior (n = 10) segmentectomy of the head of each pancreas was performed along the macroscopically found fusion plane. The pancreatic arteries, the portal vein, the bile duct, and the pancreatic duct were visualized by injecting 3 silicon dyes of different colors. Another 11 specimens were examined by pancreatography before and after anterior (n = 5) or posterior (n = 6) segmentectomy. Eight of these 11 specimens were stained immunohistochemically to reveal the distribution of pancreatic polypeptide cells after segmentectomy. RESULTS: The cleavage between the anterior and posterior segments was discovered at the anterior inferior edge or at the posterior superior edge of the head of the pancreas. Anterior segmentectomy was accomplished while preserving the anterior and posterior pancreaticoduodenal arcades and the lower bile duct in the posterior segment. Posterior segmentectomy involved the removal of the lower bile duct and the posterior pancreaticoduodenal arcades. Pancreatography after segmentectomy showed the division of the ducts of Wirsung and Santorini with the peripheral branches. The immunohistochemical boundary of pancreatic polypeptide cells coincided with the surgical plane. These results showed the anterior and posterior segments were originated from the embryologically dorsal and ventral primordia, respectively. CONCLUSIONS: The current anterior or posterior segmentectomy of the head of the pancreas corresponded to the resection of the embryologically dorsal or ventral primordium, respectively. Anterior segmentectomy of the head of the pancreas might be a clinically applicable procedure; however, posterior segmentectomy involving the resection of the lower bile duct may be impractical.     

胰管结石的外科分型及处理对策

目的 探讨胰管结石的外科分型并根据外科分型制定相应的有效处理对策。方法结合文献对33例胰管结石的诊断及处理进行回顾性分析。总结不同类型胰管结石治疗方法与结果,提出胰管结石的外科分型和处理对策。结果根据影像学(B超、ERCP、CT)检查结果和手术探查结果,将胰管结石分为四型：(1)I型：结石主要位于胰头部,主要处理方法是采用内镜取石,介入治疗失败或疗效不佳可行胰头十二指肠切除(Whipple手术);(2)Ⅱ型：结石主要位于胰体部,主要处理方法是采用胰管切开取石胰管空肠吻合(Puestow 手术);(3)Ⅲ型：结石主要位于胰尾部,主要处理方法是采用胰尾部加脾切除;(4)Ⅳ型：结石广泛分布于头、体和尾部主胰管,主要处理方法是采用Puestow．Gillesby和胰颈部离断,胰管探查取石加胰管两断端空肠Rous-en-Y吻合手术。结论正确的术前及术中诊断、分型,结合针对性的个体化处理对策在慢性胰腺炎导致的胰管结石治疗中具有重要意义。     

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目的 探讨胰腺损伤的诊断与治疗经验.方法 分析自2002年4月至2007年2月间中国医科大学.附属第一医院普通外科收治的15例胰腺损伤的临床资料情况.按美国创伤外科学会(AAST)以及术中探查所见胰腺损伤分级:Ⅰ级2例,Ⅱ7例,Ⅲ级3例.Ⅳ级2例和V级1例.5例行非手术治疗.10例病人经过手术治疗:胰头血肿清创止血、腹腔多管引流1例;胰头颈部破裂缝合修补、胰周引流术4例;胰头侧断端胰管结扎闲镇缝合、胰体尾部切除术3例;胰头侧断端胰管结扎闭锁缝合、体部断端胰空肠Roux-en-Y吻合术2例.结果 12例治愈.其中1例发生创伤性胰腺炎,2例发生胰漏,经引流、胰酶抑制剂、抗炎等治疗治愈.2例好转,腹痛症状较前减轻,血淀粉酶降至正常范围.1例因多发创伤死亡.结论 早期诊断、准确掌握手术时机、必要时果断开腹仔细探查是治疗胰腺损伤的关键.依据胰腺损伤类型选择合理的术式与充分引流,可以有效提高治愈率并减少术后并发症.