腹腔镜全结肠切除术

自1990年Jacobs进行第一例腹腔镜结直肠手术以来，经过10余年的发展，目前开展的腹腔镜结直肠手术类型越来越多，主要包括右半结肠切除术、左半结肠切除术、乙状结肠切除术、直肠切除术(Miles手术、Dixon手术)和全结肠切除术等。其中腹腔镜全结肠切除术技术难度大、开展的数量最少，国内尚未见献报道，现根据我们的经验，结合献就有关原则和方法介绍如下。     

腹腔镜全结肠切除术

腹腔镜全结肠切除手术在文献报道中并不多见,究其原因,与手术操作复杂,难度较大,手术用时较长有关,另外也受适应证的限制。自1991年Jacobs首先报道腹腔镜乙状结肠切除以来,腹腔镜全结肠切除术在发展中逐步成熟。1腹腔镜全结肠切除术的适应证与禁忌证(1)适应证:暴发性结肠炎(包括溃疡性结肠炎、克罗恩病和感染性肠炎)、结肠慢传输障碍、家族性腺瘤性息肉     

腹腔镜全结肠切除术的护理体会

2004年2月至2006年4月,我院开展腹腔镜全结肠切除术9例,现将其围手术期护理体会报道如下。1资料与方法1.1临床资料9例患者中男5例,女4例,14~68岁,平均40.5岁。其中结、直肠多发性息肉7例(有明显家族史1例,伴恶变2例),溃疡性结肠炎1例,结肠多发血管瘤1例,9例患者均行钡灌肠、结肠镜检查并取病理,以确定病变的部位和性质。1.2手术方法患者在全身麻醉下取截石位,在脐孔穿刺建立气腹,在脐部、左下腹、左上腹、右上腹、右下腹分别做5个切口,建立操作通道,置入腹腔镜、超声刀等器械,手术操作顺序应根据疾病不同选择。2护理2.1术前护理本组患者病史…     

腹腔镜全结肠切除术的临床应用

经过10余年的发展，经腹腔镜已能进行右半结肠切除、左半结肠切除、乙状结肠切除、直肠切除(Miles手术、Dixon手术)等结直肠手术，但腹腔镜全结肠切除术开展数量仍较少，国内多限于个案报道，原因主要是其技术难度大和适应证窄等，本就腹腔镜全结肠切除术的有关原则和方法做一概述。     

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。     

腹腔镜结肠切除术

腹腔镜结肠切除始于1991年[1]，由于此种手术集合了腹腔镜外科的微创、恢复快、痛苦少、美容效果好等优点，发展很快。但因手术操作复杂、费用高、手术时间长，加之腹腔镜手术对癌肿治疗的效果尚有争议，使该手术的普及推广受到限制。较早期的腹腔镜结肠切除术多用于良性肿瘤切除[2]，而后开始试用于早期或晚期癌肿切除，Monson等还将此手术用于各种结肠疾病而需特别的选择[3]。现手术范围已包括全段结肠及直肠上段病变的切除和癌肿清扫、根治。手术采用全麻。操作步骤与传统手术类似。因结扎不易，分离时尽量采用电凝锐性分离，遇血管以钛…     

腹腔镜右半结肠切除术

术中纤维结肠镜业甲蓝染色定位,肿瘤位于结肠肝区,将大网膜和横结肠推向头侧,小肠推向左侧腹腔,暴露肠系膜根部,提起回盲部,沿肠系膜上静脉方向超声刀剪开后腹膜,分别于根部结扎回结肠动静脉和右结肠动静脉,同时清扫血管根部淋巴结.于结扎血管处进入Toldt间隙,暴露并切断胃网膜右血管,清扫幽门下方淋巴结.沿结肠外侧自髂窝至结肠肝曲,切开后腹膜,将升结肠从腹后壁游离,右下腹取7 cm切口,保护切口.体外切除右半结肠包括肿瘤、结肠系膜和足够的肠段（回肠末段、盲肠、升结肠和右半横结肠）.回肠横结肠端侧吻合.缝合横结肠系膜与回肠系膜的系膜裂口 放置引流,查无出血后,关腹.     

单切口腹腔镜全结肠切除术二例

单切口腹腔镜手术是近年出现的新技术[1-3].中国医科大学附属盛京医院普通外科于2010年7月首次尝试开展了2例单切口腹腔镜全结肠切除,现将体会总结如下.     

手助腹腔镜全结肠切除术治疗结肠无力症的临床研究

目的比较手助腹腔镜与开腹全结肠切除术的临床疗效,评价手助腹腔镜全结肠切除术在结肠无力症手术治疗中的应用价值。方法采用前瞻性随机对照研究的方法,将2001年1月至2006年6月收治的42例结肠无力症患者分为传统开腹手术（22例）和手助腹腔镜手术（20例）两组,比较两组患者的一般临床资料、手术情况（手术时间、出血量、切口长度）、术后情况（肛门排气时间、进流质时间、术后平均住院日、术后早期并发症以及费用）,并随访术后排便情况。结果开腹组与手助腹腔镜组一般临床资料无明显差别。42例均行全结肠切除术,无手术死亡。两组的手术时间、术中出血无明显差别;但两组的手术切口长度、术后肛门排气时间、进流质时间和术后平均住院天数差异有统计学意义（P〈0．05）,手助腹腔镜组优于传统开腹手术组;但平均住院费用手助腹腔镜组高于开腹组（P〈0．05）。开腹组1例发生切口感染,1例出现早期肠梗阻。手助腹腔镜组术后无明显并发症。术后随访2～14个月,两组平均排便（3．55±1．80）次／d。结论手助腹腔镜与开腹全结肠切除术均安全、简捷、有效,前者更有手术外观好、术后恢复快的优点。     

腹腔镜下全结肠切除术治疗顽固性结肠慢传输型便秘的临床疗效研究

目的评价腹腔镜下全结肠切除术治疗顽固性结肠慢传输型便秘（CSTC）的安全性、有效性与可行性。方法2002年6月至2010年12月对53例顽固性CSTC患者采用全结肠切除术,其中腹腔镜组24例,开腹组29例。结果腹腔镜组与开腹组患者在切口长度[（5．27±0．33）CITI比（15．83±0．68）cm]、术后止痛剂使用次数[（2．04．±0．46）比（6．28±0．65）]、术后肠道功能恢复时间[（2．25±0．68）h比（4．41±0．95）h]、术后住院及出院期间粘连性肠梗阻并发率（4．17％比24．14％）及住院时间[（9．50±0．98）d比（14．76±1．67）d]方面差异均有统计学意义（P〈0．05）。结论腹腔镜下全结肠切除术治疗CSTC是一种更加安全有效、创伤小、瘢痕小、恢复快、并发症少的手术方式,值得临床推广。     

腹腔镜与开腹全结肠切除术治疗家族性息肉病的疗效比较

目的:比较腹腔镜下全结肠切除术和传统开腹术在治疗家族性息肉病的安全性与有效性。方法:回顾性分析2003年1月—2011年1月间收治的家族性息肉病患者56例的临床资料,按术式将患者分为腹腔镜组(31例)和传统开腹组(25例),比较两组术前、术中及术后情况。结果:两组术前一般资料具有可比性(P>0.05);两组术中失血量无明显差异,均无输血(均P>0.05),腹腔镜组平均手术时间长于开腹组(330 min vs.160 min)(P<0.05);术后,两组除胃肠道恢复时间无统计学差异外(P>0.05),与开腹组比较,腹腔镜组术后并发症发生率(0 vs.24%),止痛药使用例数(0 vs.6),平均住院时间(8 d vs.14 d)及术后前3天平均引流量(30 mL vs.100 mL)均明显减少(均P<0.05);术后3个月,腹腔镜组未见复发,而开腹组3例复发(P<0.05)。结论:腹腔镜下全结肠切除术可以安全有效地治疗家族性息肉病,且较开腹术在生活质量和远期疗效方面存在优势。     

Laparoscopic total abdominal colectomy in the acute setting

We report results from a single surgeon’s 10-year team experience with laparoscopic total abdominal colectomy. We review our series, which includes a large subgroup of ill, high-risk patients with acute colitis requiring urgent surgery. From 1993 to 2003, we performed 65 laparoscopic total abdominal colectomies. All patients referred for total abdominal colectomy were offered the laparoscopic approach. We prospectively collected the following data on all patients: demographics, surgical indications, preoperative status, duration of surgery, intraoperative blood loss, operative complications, length of stay, subsequent operations, patient satisfaction, and lessons learned from our team experience. Preoperative diagnoses included ulcerative colitis (n = 55), Crohn’s colitis (n = 3), colonic inertia (n = 4), and familial adenomatous polyposis (n = 3). Among the patients with inflammatory bowel disease, 70% of cases were performed on ill patients, refractory to medical management, requiring urgent surgery. This subgroup was managed with laparoscopic total abdominal colectomy and Brooke ileostomy, with ileoanal pouch anastomosis deferred. Operative times were long, ranging from 6 to 11 hours. Mean intraoperative blood loss was 200 ml. Mean length of stay was 4.3 days and ranged from 2 to 13 days. There were no conversions to open surgery and there were no deaths. Complications occurred in 12% of patients and included intra-abdominal abscess (n = 2), wound infection (n = 3), stoma stenosis (n = 1), and incisional hernia (n = 2). Postoperative patient satisfaction was high. Subsequent operations, including restorative proctectomy, were also performed laparoscopically. Laparoscopic total abdominal colectomy is technically challenging and requires a team approach but offers patients significant benefit in length of stay and surgical recovery. This operation can be effectively used with minimal morbidity in difficult, ill patients requiring urgent surgery. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Uniformed Services University, the Department of the Air Force, or the Department of Defense.     

Laparoscopic total colectomy: hand-assisted vs standard technique

Background: Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures. Methods: We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique. Results: There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable. Conclusion: HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 13–15 March 2003.     

Laparoscopic colectomy

The unique challenges of a laparoscopic approach to colorectal surgery have delayed its widespread adoption into clinical practice. Advances in instrumentation, modifications of technique, and an unequivocal demonstration of its safety undoubtedly will increase its popularity in the future.     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Laparoscopic total colectomy for colorectal cancers: a comparative study

Background No previous report could be found in the literature comparing laparoscopic and open total colectomy for colorectal cancers, especially synchronous colorectal cancers. This study aimed to compare the short-term clinical outcomes and oncologic results of laparoscopic and open total colectomy or proctocolectomy for colorectal cancers. Methods Between July 1997 and January 2005, six patients with colorectal cancers underwent elective laparoscopic total colectomy or proctocolectomy at the authors’ institution. Clinical data for 12 patients who underwent elective open total colectomy or proctocolectomy for colorectal cancers during the same period were prospectively collected and compared. Results The median follow-up periods were 43.9 months for the laparoscopic group and 48.2 months for the open group. Conversion to open procedure was required for one patient (16.7%) in the laparoscopic group because of bleeding. The median operative time was significantly longer in the laparoscopic group (427.5 min; range, 280–480 min vs 172.5 min; range, 90–260 min; p = 0.001). The patients in the laparoscopic group required a significantly shorter duration of parenteral analgesia (3 vs 5 days; p = 0.01), but there were no differences in time to first bowel motion, time to resumption of diet, time to full ambulation, and duration of hospital stay between the two groups. Perioperative morbidity rates were comparable between the two groups, and there was no operative mortality. The oncologic results, including number of lymph nodes removed, recurrence rates, and survival rates, were similar in the two groups. Conclusions Laparoscopic total colectomy has short-term clinical outcomes (postoperative recovery and perioperative morbidity and mortality rates) and oncologic results similar to those of open surgery for treating patients with colorectal cancers. Our study has shown that the only advantage of laparoscopic over open surgery is a shorter duration of analgesic requirement, but at the expense of a longer operative time.     

Laparoscopic vs open total colectomy: a case-matched comparative study

Background Open total colectomy and ileorectal anastomosis (OTC) is a major colorectal procedure which would preclude laparoscopy in many centers because of technical difficulty and the fact that laparoscopic total colectomy (LTC) takes much longer than standard laparoscopic proctosigmoidectomy (LPS). This study compares OTC with LTC and LPS.Methods In this study, 34 LTC patients (May 1999 to August 2003) were matched for age, diagnosis, operative period, and procedure with patients undergoing OTC. Patients with a previous major laparotomy were excluded from the open group. Groups were compared for gender, American Society of Anesthesiology (ASA) classification, operating time, estimated blood loss, length of hospital stay (LOS), complications including readmissions, and costs. The LPS cases were picked randomly from the laparoscopic database (every eighth patient), and the OT and LOS were noted.Results The LTC and OTC groups were matched for age (mean, 31 vs 34 years; p = 0.2), sex (14 vs 13 females; p = 0.8), ASA (8/23/3/0 vs 8/22/4/0, class 1/2/3/4). The body mass index was higher in the open group (23.8 vs 27.9; p = 0.04). The operating time was significantly longer (187 vs 126 min; p = 0.0001) and the median LOS shorter in the LTC group (3 days [IQR, 2.5-5 days] vs 6 days [IQR 4-8 days]; p = 0.0001). The estimated blood loss was significantly less in the LTC group (168 [50-700] ml) vs 238 [50-800] ml); p = 0.001, but there was no significant difference in the complication (26.5% vs 38.2%; p = 0.4) readmission (11.8% vs 14.7%; p = 1.0), reoperative rates (8.8% vs 11.8%; p = 1.0), or direct costs ($4,578 vs $4,562; p = 0.3). One LTC patient died expired on postoperative day 2 of a cardiac event. Four patients (11.8%) required conversion for obesity (n = 2), adhesions (n = 1), or intraoperative hemorrhage (n = 1). The operating times were 36 min longer in the LTC group than in the LPS group (151 vs 187 min; p = 0.02), but there was no significant difference in the LOS. (3 vs 3 days, p = 0.2).Conclusions The findings show that LTC provides a significant decrease in the LOS over OTC, with increased operating time, but without any change in other parameters. A laparoscopic approach to subtotal colectomy is recommended for suitable patients when an experienced team is available.     

Laparoscopic colectomy.

Fifty-one laparoscopic colectomies were attempted at two institutions. The clinical results and methods are presented. Seven cases (14%) were converted to facilitated procedures, and four cases (8%) were converted to "open." Cases of cancer, diverticulitis, endometriosis, regional enteritis, villous adenomas, and sessile polyps were operated. Right, transverse, left, low anterior, and abdominoperineal colectomies were performed. Colotomies and wedge resections were also performed. Laparoscopic suturing was required in five cases of incomplete anastomosis by circular stapler (18%). Suturing was required in all right, transverse colectomies and colotomies. Operative time averaged 2.3 hours. Hospitalization averaged 4.6 days. Four patients had complications (8%), and one 95-year-old died of pneumonia (2%). Laparoscopic colectomies can be performed safely, but require two-handed laparoscopic coordination, as well as suturing and knot-tying skills.