肠系膜上静脉-门静脉序贯式径路在腹腔镜胰十二指肠切除术中的应用

目的 探讨腹腔镜胰十二指肠切除术安全快捷的手术入路。方法 回顾总结我院6例腹腔镜胰十二指肠切除术的手术方法和临床资料,分析肠系膜上静脉-门静脉序贯式径路在腹腔镜胰十二指肠切除术中的应用。结果 6例患者均顺利完成手术。手术时间390～630min,术中出血量150～800mL。术后病理：所有标本切缘均阴性;肿瘤直径1.8～3.0 cm;清扫淋巴结7～30枚,平均16.7枚。结论 肠系膜上静脉-门静脉序贯式径路能有效地进行探查、分离及淋巴结的清扫,可作为腹腔镜胰十二指肠切除术中安全快捷的手术入路。     

左肾旁前间隙入路在保留脾动静脉腹腔镜胰体尾切除术中的应用

目的 探讨保留脾动静脉腹腔镜胰体尾切除术安全快捷的手术入路.方法 回顾总结我院12 例保留脾动静脉腹腔镜胰体尾切除术的手术过程及结果,分析左肾前间隙入路在保留脾动静脉腹腔镜胰体尾切除术中的应用.结果 12 例手术顺利完成,平均手术时间(55±18)min,术中出血量(80±46)mL,术后平均住院时间7.6 d,术后未发生胰漏等并发症.结论 左肾前间隙入路是脾动静脉腹腔镜胰体尾切除术中安全快捷的手术入路.     

腹腔镜胰十二指肠切除术的手术入路的研究进展

腹腔镜胰十二指肠切除术的手术方式具有“管中窥豹”术式特点,手术中要通过多个筋膜间隙到达靶区,根据肿瘤的位置、大小及肿瘤与血管的关系,选择相应的手术入路。本综述结合目前国内外最新资料,介绍了腹腔镜胰十二指肠切除术手术的各种入路及不同手术入路的优缺点,为此手术入路的选择提供方向。     

腹腔镜胰十二指肠切除术手术入路选择及评价

在腹腔镜胰十二指肠切除术中,手术入路的选择对手术安全性及根治性显得尤为重要。通过术前综合评估肿瘤位置、钩突大小、血管侵犯、解剖变异、病人BMI等因素,个体化选择最优入路方式,有助于完成高质量的腹腔镜胰十二指肠切除术。     

困难腹腔镜胰十二指肠切除手术入路选择

腹腔镜胰十二指肠切除术具有操作复杂、学习周期长、手术风险高等特点。目前对于困难胰十二指肠切除术仍缺乏准确定义，建议可分为肿瘤切除困难和消化道重建困难。针对肿瘤切除困难，术前应结合病人的病情进行综合评估，术中应结合术者经验合理选择手术入路；对于消化道重建困难，应根据手术方式、胰腺残端质地及主胰管内径选择合理的胰肠吻合方式进行消化道重建。     

腹腔镜前入路静脉优先与右后入路动脉优先联合切除钩突的优势

随着腹腔镜胰腺手术技术水平的快速提高,腹腔镜胰十二指肠切除术在国内部分胰腺中心已逐渐开展。钩突切除是腹腔镜胰十二指肠切除术的关键步骤之一,影响着手术时间、术中出血量、肿瘤的R0切除等,如何较好处理钩突切除仍是腹腔镜胰十二指肠切除术的难点之一。目前,腹腔镜胰十二指肠切除术钩突切除的方法众多,各有利弊。笔者结合自身经验,总结了在腹腔镜胰十二指肠切除术中采用前入路静脉优先联合右后入路动脉优先的方法切除钩突,可大大缩短手术时间,减少术中出血量,提高肿瘤的R0切除率。在临床实践中该入路优势明显,安全可行。     

“结肠后入路-钩突先行”在腹腔镜胰十二指肠切除术中应用研究

目的 探讨“结肠后入路-钩突先行”在腹腔镜胰十二指肠切除术中应用的价值。方法 回顾性分析自2015年4月至2018年10月在吉林大学第一医院肝胆胰外科二科行腹腔镜胰十二指肠切除术的200例病例资料，在标本切除阶段均采用“结肠后入路-钩突先行”。结果 200例病人均成功完成腹腔镜胰十二指肠切除术，其中1例行腹腔镜胰十二指肠切除联合右半结肠切除术，2例行腹腔镜胰十二指肠切联合胰体尾切除术，2例行腹腔镜胰十二指肠切除联合门静脉重建（端端吻合）。平均手术时间（281±49）min，其中标本切除时间（91±15）min，术中出血量50～850 mL，平均（122±53）mL；术后平均住院时间（16±9） d；术后B级胰瘘18例（9.0%），C级胰瘘3例（1.5%）；术后吻合口出血2例（1.0%）；腹腔内出血14例（7.0%）；胃排空延迟9例（4.5%）；胆瘘11例（5.5%）；死亡2例（1.0%）。术后病理学诊断：胰头导管腺癌33例（16.5%），胰腺导管内乳头状黏液肿瘤15例（7.5%），胰头神经内分泌肿瘤6例（3.0%），胰腺导管上皮异型增生1例（0.5%），胰头实性假乳头状瘤9例（4.5%），胰头囊腺瘤5例（2.5%），慢性胰腺炎1例（0.5%），十二指肠腺癌4例（2.0%），十二指肠间质瘤2例（1.0%），十二指肠良性占位性病变11例（5.5%），非胰头来源的壶腹周围癌105例（52.5%），壶腹周围良性肿瘤9例（4.5%）。结论“结肠后入路-钩突先行”在腹腔镜胰十二指肠切除术中具有安全、快速、有效的特点，值得临床进一步推广和应用。     

困难腹腔镜胰十二指肠切除术精准评估及对策

腹腔镜胰十二指肠切除术技术要求较高,困难胰十二指肠切除术可分为肿瘤切除困难和消化道重建困难两类。应结合术前影像学和术中探查,充分评估病人全身情况、肿瘤大小、肿瘤位置、肿瘤与血管关系、区域粘连、血管变异、胰腺质地、胰管和胆管直径等因素,制定个体化的切除策略,灵活运用多种手术入路,以安全、根治为核心,结合术中自身经验和技术特点制定手术策略。     

腹腔镜胰十二指肠切除术R0切除技巧

正随着腹腔镜胰十二指肠切除术(laparoscopic pancreatoduodenectomy,LPD)技术的成熟,很多开腹胰十二指肠切除术(OPD)中的R0切除技巧逐渐应用至LPD中,例如动脉优先入路和联合门静脉-肠系膜上静脉(PV-SMV)切除重建技术等~([1])。本文就腹腔镜下胰腺癌R0切除的相关技巧进行论述。1腹腔镜下动脉优先的视觉角度及入路优势腹腔镜下动脉血管的显露,与开放手术相比,具有明显     

腹腔镜胰十二指肠切除术kocher切口的临床解剖学研究

【摘要】 目的 探讨腹腔镜胰十二指肠切除术(LPD)中相关血管和筋膜的解剖学特点,为腹腔镜下解剖定位和操作入路提供解剖学依据。方法 本研究选取南方医科大学遗体捐献接收中心提供的5具成人新鲜尸体腹部标本,对胰十二指肠切除术的Kocher切口手术入路及相关的安全外科平面进行解剖,对相关外科平面、解剖标志及筋膜间隙进行观察分析。结果〓胰前间隙和胰后间隙及其延伸是手术的两个主要的宏观外科平面,胰腺后融合筋膜及筋膜间隙是腹腔镜下外科手术操作的天然平面,一旦偏离则会导致邻近血管和脏器的损伤。LPD手术中沿着适宜的外科平面进行游离,特别是Kocher切口手术入路的运用,能充分体现手术无损伤原则和肿瘤根治原则。供应胰十二指肠的重要血管均位于筋膜和胰腺实质之间,LPD中注意保护好胰十二肠区域相关的血管,保留筋膜的完整性即可保护后动脉弓。结论 掌握LPD相关血管和筋膜的解剖学特点可为腹腔镜手术的设计和规范提供形态学依据,从而提高腹腔镜下操作的安全性和根治的彻底性。     

腹腔镜与开腹胰十二指肠切除术:系统回顾及RCT研究的meta分析

目的:评价腹腔镜胰十二指肠切除术的安全性及可行性。方法:全面检索PubMed、Embase、Cochrane数据库、中国期刊全文数据库(CNKI)、万方数据库及ClinicalTrials.gov数据库,检索时间限定为建库至2019年3月16日。纳入文献类型定为随机对照实验(RCTS)。本研究采用术后90 d内死亡率、术后胰瘘发生率、手术时间、失血量、住院时间、R0切除率、淋巴结清扫数量等指标评价LPD的安全性及可行性。结果:本研究纳入3篇RCTS共计224例患者,其中实验组114例,对照组110例。两组手术时间(WMD 97.93,95%CI 19.93,175.94,P=0.01,I2=93%)、术中失血量(WMD-184.04,95%CI-288.89,-79.19,P=0.0006,I2=54%),手术部位感染率(RR 0.40,95%CI 0.16,0.96,P=0.04,I2=0)差异有统计学意义;两组术后90 d内死亡率、术后胰瘘发生率、住院时间、胃排空延迟发生率差异无统计学意义(P>0.05)。结论:考虑到LPD的死亡率、术后胰瘘风险与OPD无明显差异,可认为LPD的安全性与OPD相当。在安全性相当的条件下,LPD需要更长的手术时间,不明显缩短住院时间,且具有高达16.7%的中转开腹率,可认为LPD相较OPD无明显优越性。     

颌后切口入路治疗髁突骨折

目的：探讨髁突中、低位骨折开放复位手术入路.方法：采用颌后切口入路解剖复位、小型接骨板坚强内固定治疗髁突中、低位骨折.结果：本组21例（23侧）经5～52个月随访,并发症发病率低,切口瘢痕不明显,功能恢复良好.结论：对治疗髁突中、低位骨折,颌后切口入路是一种安全有效的手术切口。     

Cost analysis of open and laparoscopic pancreaticoduodenectomy: a single institution comparison

Introduction

The laparoscopic approach to pancreaticoduodenectomy has been recently more frequently reported and is now being performed at multiple centers across the US. While laparoscopic pancreaticoduodenectomy (LPD) has been shown to be safe and feasible, comparing its cost in relation to open pancreaticoduodenectomy (OPD) has not been examined. The aim of this study is to examine the cost of LPD compared with OPD at a single institution over a 3-year time period.

Methods

An institutional database was analyzed to compare patients who underwent OPD and LPD (including Whipple resections and total pancreatectomy) between May 2009 and June 2012. A cost analysis was performed, which included the use the hospital billing database to assess surgical costs, hospital admission costs, and overall cost of the patient’s care during the index admission. The operative costs were further analyzed with respect to OR time and surgical supplies. Standard statistical analysis was performed to assess for significance.

Results

In the study time period, 123 patients underwent pancreaticoduodenectomy, including 48 OPD (39 %) and 75 LPD (61 %). The groups were similar with respect to age, gender, ASA, vein resection, and indication for surgery. In the LPD group, the use of hand assist or conversion to OPD occurred in 3 (4 %) and 10 (13 %) patients, respectively. Additionally, 10 % of the OPD group underwent total pancreatectomy (n = 5), compared to 21 % of the LPD (n = 16). Mean operative time for OPD and LPD was 355 min (range 199–681) and 551 min (range 390–819) respectively (p < 0.0001). Median hospital stay for OPD and LPD was 8 days (range 5–63), and 7 days (range 4–68) respectively (p = 0.5). Morbidity rates were equal at 31 % for the two groups. The LPD group was associated with significantly higher surgical cost due to both increased time and supply cost. However, mean hospital admission cost associated with OPD was greater in comparison to the LPD group, though not significant. The overall total cost of care was similar between the two groups.

Conclusions

LPD is associated with equivalent overall cost compared with OPD. While operating time and supply costs were higher for LPD, this was balanced by decreased cost of the postoperative admission.     

Defining the Learning Curve for Team-Based Laparoscopic Pancreaticoduodenectomy

Background

The purpose of this study was to define the learning curves for laparoscopic pancreaticoduodenectomy (LPD) with and without laparoscopic reconstruction, using paired surgical teams consisting of advanced laparoscopic-trained surgeons and advanced oncologic-trained surgeons.

Methods

All patients undergoing PD without vein resection at a single institution were retrospectively analyzed. LPD was introduced by initially focusing on laparoscopic resection followed by open reconstruction (hybrid) for 18 months prior to attempting a totally LPD (TLPD) approach. Cases were compared with Chi square, Fisher’s exact test, and Kruskal–Wallis analysis of variance (ANOVA).

Results

Between March 2010 and June 2013, 140 PDs were completed at our institution, of which 56 (40 %) were attempted laparoscopically. In 31/56 procedures we planned to perform only the resection laparoscopically (hybrid), of which 7 (23 %) required premature conversion before completion of resection. Following the first 23 of these hybrid cases, a total of 25 TLPDs have been performed, of which there were no conversions to open. For all LPD, a significant reduction in operative times was identified following the first 10 patients (median 478.5 vs. 430.5 min; p = 0.01), approaching open PD levels. After approximately 50 cases, operative times and estimated blood loss were consistently lower than those for open PD.

Conclusions

In our experience of building an LPD program, the initial ten cases represent the biggest hurdle with respect to operative times. For an experienced teaching center using a staged and team-based approach, LPD appears to offer meaningful reductions in operative time and blood loss within the first 50 cases.     

改良贯穿式胰肠连续吻合在腹腔镜胰十二指肠切除术中的应用

背景与目的:腹腔镜胰十二指肠切除术(LPD)是普通外科最为复杂手术之一,具有手术时间长、切除难度大、吻合口多和并发症发生率高等特点,尤其是LPD术后胰瘘(POPF)及其所导致的腹腔感染和出血,甚至死亡,严重制约了LPD技术的进一步推广和应用。因此,如何避免POPF的发生已成为当前亟待解决的难题之一。笔者前期将贯穿式胰肠连续吻合应用于LPD术中,取得了良好效果,但仍有不足之处,故本研究进一步探讨改良贯穿式胰肠连续吻合应用于LPD术中的临床效果。方法:将弋矶山医院2017年6月—2019年12月收治拟行LPD手术的患者25例随机分为两组,分别在LPD术中行贯穿式胰肠连续吻合(对照组,15例)和改良贯穿式胰肠连续吻合组(观察组,10例)。后者即在贯穿式胰肠连续吻合实施之前,对胰腺断面进行2针U型缝合,加固胰腺断面。比较两组患者的相关临床资料。结果:两组患者术前各项指标均无统计学差异(均P0.05)。25例患者均成功完成LPD,两组手术时间和术中出血量无统计学差异(均P0.05),观察组平均胰肠吻合时间明显长于对照组(23.50 min vs.20.20 min,P=0.003)。两组总胰瘘发生率无统计学差异(P0.05),观察组B级胰瘘发生率明显低于对照组(0 vs.40%,P=0.028);观察组术后其他并发症如腹腔感染和出血的总发生率低于对照组,但差异未达统计学意义(0 vs.33.3%,P=0.057);观察组胰肠吻合口旁引流管拔管时间(11.00 d vs.25.60 d,P0.001)与术后住院时间(12.20 d vs.18.53 d,P=0.045)均明显短于对照组。结论:改良贯穿式胰肠连续吻合是一种操作简便的胰肠吻合方法,在LPD术中的应用安全、可靠,不仅降低了B级胰瘘的发生率,而且加速了患者术后的康复,值得临床推广和应用。     

复杂性后尿道狭窄的手术径路探讨

目的：总结各种复杂性后尿道狭窄手术径路的应用经验,提高复杂性后尿道狭窄的治疗效果。方法：对72例复杂性后尿道狭窄患者的手术径路进行回顾性分析。结果：64例（89％）一次手术成功,经会阴径路中采用单纯经会阴径路34例中治愈31例（91％）,经会阴耻骨下缘径路14例中治愈13例（93％）,经耻骨径路中采用单纯经耻骨径路6例中治愈4例（67％）,经耻骨联合会阴径路18例中治愈16例（89％0,41例长段后尿道狭窄（＞3cm)者治愈35例（85％）,18例有合并症者治愈17例（94％例）。结论：复杂性后尿道狭窄的各种手术径路均存在一定的优缺点,选择合适的手术径路应综合多种因素考虑,经会阴径路因操作简单,创伤小,并发症少,仍是目前首选的手术径路。     

Use of the harmonic scalpel in thyroidectomy

Thyroidectomy is a surgical procedure that requires meticulous dissection, safe anatomical exposure and effective haemostasis. Use of the harmonic scalpel in thyroidectomy may assist in achieving these goals, particularly in respect to enabling efficient haemostatic coagulation and division of small vessels. This report demonstrates the results of utilizing the harmonic scalpel in a series of 88 prospective thyroidectomies in patients under the care of two surgeons over a 2‐year period recording a number of parameters, including operative times and post‐operative complications. These data were compared with a retrospective cohort of 57 patients who underwent thyroidectomies by the same two surgeons prior to the introduction of the harmonic scalpel. The results of this study show that the use of the harmonic scalpel decreased surgical operating time by 20 min (22.5%) for a hemithyroidectomy and 13.5 min (12%) for a total thyroidectomy. Harmonic scalpel use was not associated with an increased complication rate and has been demonstrated to be a very efficient and safe tool in assisting with the conduct of a thyroidectomy.     

腹腔镜胰十二指肠切除术中钩突处理技巧

腹腔镜胰十二指肠切除术（LPD）是腹部高难度手术之一,对手术技巧、团队配合等要求较高。其中,因胰腺钩突部位解剖深在、暴露困难,钩突的处理为LPD的难点;钩突及胰腺系膜的完整切除,成为LPD的关键。笔者团队通过探索、改进、优化LPD手术路径和技术细节,在开展多角度动脉入路的基础上,应用中间、左后组合入路,原位精准处理关键血管—胰十二指肠下动脉（IPDA）,实现钩突和胰腺系膜安全、完整切除。该技巧能适应不同难度的钩突切除,并且符合肿瘤手术学“No touch”理念。