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。     

Traumatic right paraesophageal hernia after Belsey Mark IV fundoplication

We report the case of a 70-year-old woman with a long history of achalasia and gastroesophageal reflux disease who presented with an acute right-sided paraesophageal hernia after a motor vehicle accident. Six months before the accident, she underwent an elective Belsey Mark IV fundoplication to reduce a hiatal hernia. The traumatic paraesophageal hernia traversed the diaphragm at a weakness opposite the fundoplication. The clinical presentation, surgical management, and previous literature are discussed.     

不断提高腹腔镜右半结肠癌根治术规范化水平

腹腔镜技术已广泛应用于结肠癌的手术治疗,并逐步得到普及。由于右半结肠复杂的血管解剖变异,导致术中易于出血,特别是实施完整全结肠系膜切除和彻底D3淋巴结清扫的难度较大,为此,我们需要从患者的合理选择、规范的术前分期、规范化的手术操作、手术质量及病理标本质量控制等方面加深认识,以不断提高腹腔镜右半结肠癌根治术的规范化水平。     

带蒂末端回肠瓣修补右半结肠癌切除术后的十二指肠缺损

目的 探讨右半结肠癌切除术所致十二指肠缺损的修补方法.方法 对5例右半结肠癌根治术后遗留的十二指肠巨大缺损采用了带蒂末端回肠瓣修补,附加减压、引流术.结果 5例均一期恢复,无围手术期死亡,术后未发生十二指肠瘘和十二指肠狭窄,术后上消化道造影显示十二指肠蠕动和排空正常.结论 带蒂末端回肠瓣修补右半结肠癌术后的十二指肠巨大缺损安全可靠.     

Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer

Background

Fast-track (FT) recovery protocols have demonstrated advantages over historical recovery routines after open colectomy; however, their impact in recovery after laparoscopic colectomy is not clearly defined. This study was designed to determine whether patients who recover on FT protocol after laparoscopic colectomy have a shorter length of stay (LOS) and fewer complications compared with patients who recover on standard (non-FT) protocol.

Methods

A cohort of consecutive patients with colon cancer who underwent completed laparoscopic-assisted right hemicolectomy from 2005–2007 was identified. Univariate and multivariate logistic analyses were performed to identify risk factors for increased LOS and postoperative complications with recovery protocol as the primary predictor.

Results

A total of 197 patients were included: 115 (58%) patients recovered on a non-FT protocol, and 82 (42%) patients on FT protocol. Univariate analysis showed no differences with respect to age, gender, body mass index, or American Society of Anesthesiologists (ASA) class between groups. The median (interquartile range) LOS was 4 (range, 3–6) days and 3 (range, 3–4) days for the non-FT and FT recovery patients, respectively (p < 0.001). On multivariate analysis, independent risk factors for increased LOS were complications (p < 0.001) and non-FT recovery (p = 0.007). Non-FT recovery also was associated with increased complications (56 vs. 29%, p = 0.0002); this remained significant on multivariate analysis (p < 0.001). Readmissions were similar (p = 1.0) between recovery groups. No mortalities were observed at 30 days.

Conclusions

Fast-track recovery is independently associated with a shorter LOS and decreased morbidity after laparoscopic right hemicolectomy.     

达芬奇机器人系统辅助右半结肠切除术

目的 探讨达芬奇机器人系统辅助右半结肠切除术的安全性与可行性.方法 总结2010年5-11月完成的5例达芬奇辅助右半结肠切除术的方法 及术后恢复情况.结果 5例患者行右半结肠切除,其中1例同时行胆囊切除.手术均顺利完成,无中转开腹.手术时间140～200 min,术中失血量30～80 ml.术后无并发症发生.结论 达芬奇机器人系统应用于右半结肠癌手术是安全可行的.

Abstract：

Objective To investigate the safety and feasibility of robot-assisted laparoscopic right hemicolectomy for colonic cancer. Methods These 5 patients with ascending colonic cancer received robot-assisted laparoscopic right hemicolectomy. Results All operations were performed successfully. There was no postoperative complications. Da Vinci surgical system was found to be associated with fewer hemorrhage, rapid postoperative intestinal recovery, and therefore a shorter hospital stay. Conclusions Robot-assisted laparoscopic right hemicolectomy can be applied safely and with feasibility for colonic cancer.     

腹腔镜右半结肠癌根治术的难点与争议

腹腔镜右半结肠癌根治术的手术技术已经非常成熟。但在淋巴清扫和手术入路方面,仍存在一些细节问题,成为当前争论的焦点。如淋巴清扫的内侧界,结肠肝曲癌常规清扫No.6淋巴结,手术入路除了经典的中间入路之外,头侧入路和尾侧入路是否更有优势,以及手术中的对Henle’s干解剖变异的认识等。     

Strangulated intestinal hernia through a drain site

IntroductionIntra-abdominal drains have been widely used in order to prevent intra-abdominal fluid accumulation and detection of anastomotic leakage.Presentation of caseWe herein report a case of small bowel herniation followed by strangulation in an 82 year old woman who had undergone sigmoidectomy for colorectal cancer.DiscussionAlthough several complications related to drain usage such as drainsite infection, hemorrhage and intestinal perforation may occur, intestinal incarceration through drain site is rarely reported.ConclusionDrains must be used with caution and only if indicated. Careful insertion, regular post-operative or post-removal inspection is strongly recommended.     

Impact of laparoscopic right hemicolectomy for colon cancer

INTRODUCTION

This study specifically examined right colonic cancer resection, a common operation for colorectal surgeons starting laparoscopic resection, to assess the impact of commencing laparoscopy.

PATIENTS AND METHODS

A total of 56 patients undergoing open (n = 34) and attempted laparoscopic (n = 22) elective right hemicolectomy for colorectal cancer between November 2003 and March 2007 were compared. Postoperative stay was the primary outcome. Secondary outcomes included analgesic requirements, bowel recovery, morbidity and mortality. Frequency of laparoscopic versus open surgery over time was also examined.

RESULTS

Resections attempted laparoscopically increased from 9.1% to 75% in the first and last quarters of the study period, respectively (P = 0.0002). Uptake of ‘enhanced recovery’ was mainly in the laparoscopic group. Conversion was required in two of 22 patients. Attempted laparoscopic cases had a shorter median postoperative stay (6 vs 10 days; P < 0.0001), duration of parenteral or epidural analgesia (48 vs 72 h; P < 0.0001) and time to first bowel action (3 vs 4 days; P = 0.001) compared with open cases. Demography, tumour characteristics, morbidity and mortality were comparable between groups. Multivariate analysis identified decreased age, attempted laparoscopic surgery, use of enhanced recovery and absence of complications as independently shortening postoperative stay.

CONCLUSIONS

Advantages of laparoscopic surgery and enhanced recovery, even early in a surgeon''s experience, suggest this is the preferred mode for elective right colon cancer resection.