腹腔镜保脾胰体尾切除术治疗体会

目的 探讨Kimura法腹腔镜保脾胰体尾切除术的经验和体会。方法 回顾性研究我院肝胆外科2013年4月至2021年4月开展的20例Kimura法腹腔镜保脾胰体尾切除术的患者资料。结果 患者平均手术时间（188.2±47.2）min,平均术中出血量（97.4±71.1）mL,术后平均住院时间（12.3±4.0）d。术后均无严重并发症,6例出现术后生化漏,经保守治疗后治愈。结论 Kimura法腹腔镜保脾胰体尾切除术是安全可行的。应重视术前影像学检查评估,术中应注意保护胃网膜左血管,可采用悬吊提拉胃体的方法协助视野的显露,并熟练掌握脾动静脉分支的离断技巧。     

一种标准化腹腔镜左半肝切除术模式探讨：“隧道法”腹腔镜解剖性左半肝切除术

目的 探讨“隧道法”腹腔镜解剖性左半肝切除术的安全性及可行性。方法 回顾性分析2018年8月至2021年4月西南医科大学附属简阳市人民医院肝胆外科接受腹腔镜左半肝切除术患者的临床资料,根据不同的手术操作方式分为两组：“隧道法”腹腔镜解剖性左半肝切除术组（隧道法组）19例、经前入路腹腔镜解剖性左半肝切除术组（前入路组）20例,比较两组的手术时间、术中出血量、断肝时间、断肝出血量、术后住院时间、术后并发症等。结果 隧道法组在手术时间、术中出血量、断肝时间、断肝出血量方面均低于前入路组[（185.53± 59.84）min vs （232.50±62.92）min, （244.74±88.03）mL vs （327.50±154.30）mL, （15.11±5.53）min vs （41.25±21.21）min, （65.26±23.66）mL vs （156.50±69.46）mL],差异均具有统计学意义（均P<0.05）。两组在术后住院时间、术后并发症方面差异无统计学意义（均P>0.05）。结论 “隧道法”腹腔镜解剖性左半肝切除术安全、可行,且手术时间短、出血少,有望成为腹腔镜左半肝切除的一种标准术式。     

胰体尾部肿瘤12例手术治疗体会

目的 探讨如何提高胰体尾切除术成功率和手术效果.方法 对我院2004年以来收治的12例胰体尾肿瘤手术患者进行回顾性分析.结果 本组12例胰体尾切除术均获得成功,平均手术时间为130 min,平均住院天数16 d;术中输血4例,平均输血360 mL;胰漏2例,无手术死亡及严重的手术并发症.结论 术前正确评估影像资料、术中积极主动的手术理念、选择合理的手术入路、正确的围手术期管理是保证胰体尾切除术成功的重要因素.     

腹腔镜肝尾状叶切除术五例临床体会

目的 探讨腹腔镜肝切除术在尾状叶疾病中的应用价值,总结手术技巧和经验。方法 回顾性分析2021年1月至2022年3月南京医科大学附属淮安第一医院肝胆胰外科行腹腔镜尾状叶切除术治疗的3例肝细胞癌和2例肝良性肿物患者的临床资料。术前均行三维重建,准确评估肿瘤的位置和直径。术中均采用左侧入路,3例肝细胞癌术中联合应用ICG荧光显像。围手术期管理应用加速康复理念。3例放置引流管,术后3 d内拔除.术后第1天均拔除导尿管并下床活动。结果 患者平均手术时间（158.2±27.6）min,平均出血量（166.4±81.5）mL。术后天冬氨酸转氨酶（AST）、丙氨酸转氨酶（ALT）较术前升高,行保肝治疗后基本恢复正常。3例肝细胞癌患者手术切缘均为阴性。平均住院时间（7.6±0.9）d。结论 腹腔镜下尾状叶切除术安全有效,但需要术前精准评估,选择恰当的入路,实现解剖性肝切除。围手术期管理采用加速康复理念可以促进术后恢复,但是否需要常规放置引流管目前仍有争议。     

手助法在腹腔镜巨脾切除术中的应用

目的 通过总结手助法在腹腔镜巨脾切除术中的应用经验,探讨手助法在腹腔镜脾切除术中的价值.方法 总结我科2007年3月至2012年4月施行的15例手助式腹腔镜巨脾切除术.结果 15例中,男6例,女9例,年龄21~46岁;其中1例采用Endo-GIA行一级脾蒂离断术,其余均通过超声刀及血管夹行二级脾蒂离断术,2例同时行贲门周围血管离断术.手术时间80~180min,平均(117.4±30.3) min,出血量20~450 mL,平均(178.0±137.7) mL,术后引流管于2~5 d拔出,住院时间8~10 d,无并发症发生.结论 手助法能够明显降低腹腔镜巨脾切除术的手术难度及术中出血的危险,缩短手术时间,减少出血量,值得推广.     

原位二级脾蒂离断脾切除术的临床应用

目的 探讨原位二级脾蒂离断脾切除术在择期脾切除中的临床应用.方法 比较分析2000年6月至2008年5月问106例原位二级脾蒂离断脾切除术与118例传统睥切除术的手术时间、术中出血、术后住院时间以及术后并发症等临床资料.结果 与传统组比较,原位组的术中出血量、术后住院时间显著缩短[(310.4±55.2)ml vs(554.3±71.6)ml;(12.9±4.3)vs(15.7d±6.8)d,P<0.05)];门静脉血栓和胰漏的发生率显著降低[(0.9%vs 6.7%;O vs 7.6%,P<0.05)];手术时间虽有延长,但两组相比差异无统计学意义(P>0.05).结论 在择期病理脾切除时,原位二级脾蒂离断脾切除术是一种较好的备选术式方案.     

ERAS策略在腹腔镜保留脾脏的胰体尾切除术中的应用

目的 探讨腹腔镜保留脾脏的胰体尾切除术的安全性以及围术期加速康复外科（enhanced recovery after surgery,ERAS）实施的策略和方法。方法 回顾性收集2018年6月至2020年12月收治的38例胰体尾良性病变和低度恶性肿瘤行腹腔镜胰体尾切除术患者的临床资料,其中保脾组23例（实施Kimura法20例,Warshaw法3例）,切脾组15例;围术期均实施ERAS措施,并分析患者术前影像学资料、手术时间、失血量、具体术式、ERAS实施方法、术后腹腔引流管拔除时间、术后住院时间、术后并发症和随访资料。结果 保脾组和切脾组在肿瘤大小、手术时间、术中失血量、术后腹腔引流管拔除时间、术后住院时间及术后严重并发症方面,差异均无统计学意义（P>0.05）。全组中位引流管拔除时间为6（5~7）d,保脾组为7（4~7）d,切脾组为6（5~7）d;无死亡病例。随访时间3~18个月,无肿瘤复发转移。结论 胰体尾良性和低度恶性肿瘤实施腹腔镜保留脾脏的胰体尾切除术安全可行,围术期可按照ERAS策略实施。     

右侧卧位与仰卧位在急诊腹腔镜下治疗外伤性脾破裂的手术效果比较

目的 比较右侧卧位与仰卧位在急诊腹腔镜治疗外伤性脾破裂中的手术效果。方法 回顾性分析绍兴市中心医院2015年1月至2021年12月收治的81例外伤性脾破裂行腹腔镜手术的患者资料,手术中分别采用了右侧卧位（A组,n=35）和仰卧位（B组,n=46）,比较两组手术时间、术中出血及中转开腹、术后住院时间、术后并发症等情况。结果 与B组比较,A组手术时间更短[（145.5±24.4）min vs （169.0±15.3）min;t=5.308,P<0.001],术中出血更少[（75.3±35.3）mL vs （110.3±50.6）mL;t=3.490,P= 0.0008],中转开腹率更低（2.9% vs 19.6%,χ²=5.127,P=0.024）,术后胰漏并发症发生率更低（8.6% vs 28.3%,χ²=4.861,P=0.028）,差异均有统计学意义;两组在术后腹腔感染（2.9% vs 6.5%,χ²=0.569,P=0.451）、术后出血（2.9% vs 4.3%,χ²=0.124,P=0.725）、静脉血栓（5.7% vs 10.9%,χ²=0.669,P=0.413）等方面差异无统计学意义。结论 对外伤性脾破裂患者,手术中采取右侧卧位更有助于术者腹腔镜下脾切除术的实施,手术效果更好。     

腹腔镜巨脾切除术

目的: 探讨腹腔镜脾切除术治疗乙肝后肝硬化门静脉高压脾功能亢进的方法和疗效.方法: 对8例乙肝后肝硬化门静脉高压脾功能亢进患者采用腹腔镜脾切除术.在腹部放置3个套管,脾周韧带及脾门用超声刀解剖,脾门血管用Endo GIA夹闭离断.结果:8例病人均顺利完成腹腔镜脾切除术,无中转开腹,无术后并发症发生.术后血小板明显上升,从平均36×109/L[(17~56)×109/L]升至437×109/L[(316~624)×109/L],随访7~24个月血小板均大于100×109/L.结论: 超声刀、Endo GIA等先进技术的应用已使腹腔镜脾切除术成为治疗乙肝后肝硬化门静脉高压脾亢有效的手术方法.     

循肝静脉入路腹腔镜肝切除术59例临床分析

目的 分析循肝静脉入路腹腔镜下肝切除术的安全性与临床效果。方法 回顾性分析2019年7月至2020年12月苏州大学附属第三医院肝胆胰外科59例循肝静脉入路腹腔镜肝切除术患者的临床资料。结果 本组35例行鞘内阻断,24例行鞘外阻断,其中51例联合Pringle阻断（15+5）min,最多阻断5次,累计75 min,22例解剖第二肝门联合肝静脉预阻断。手术时间为（155.8±71.3）min,术中出血50~600 mL,术中输血2例,无中转开腹病例。术中肝静脉修补5例,发生CO₂栓塞4例。术后胆漏4例,胸腹水7例,经保守治疗治愈,无出血、肝衰病例,无再次手术或死亡病例,术后住院时间为（7.9±5.4）d。结论 循肝静脉入路腹腔镜下肝切除技术安全可行,术中准确定位、暴露肝静脉走行是为关键,断肝过程应避免肝静脉损伤和气体栓塞。     

前后入路法行保留脾血管及脾脏的胰体尾切除术12例

目的探讨前后入路法行保留脾血管及脾脏的胰体尾切除术的可行性和安全性。方法回顾性分析2008年7月至2013年3月收治的12例胰体尾病变患者,采用前后入路法行保留脾血管及脾脏的胰体尾切除术。结果 12例患者均成功完成手术。手术时间180~280 min,平均（230±50）min。术中出血量240~360 ml,平均（300±60）ml,术中均未输血。术后平均住院时间（12±2）d。术后胰瘘1例,引流量20~60 ml/d,经引流后治愈,无其他并发症。术后随访6~30个月,无一例死亡。结论在掌握脾动静脉的解剖基础上,采用前后入路法耐心、细致分离脾动静脉,保留脾血管及脾脏的胰体尾切除术安全、简便,易于实施,值得推广。     

保留脾脏的胰体尾切除术的临床应用

目的 总结保留脾血管的保留脾脏胰体尾切除术的临床应用经验.方法 回顾性分析中山大学附属第一医院胃肠胰腺外科和广东省人民医院普通外科2002年5月至2009年4月间施行的26例胰体尾切除手术,其中选择保留脾脏组13例,切除脾脏组13例.比较两组的手术时间,术中出血量,术后感染与非感染并发症,术后血小板计数及术后住院时间等情况.结果 保留脾脏组和切除脾脏组在手术时间[(172±47)min比(157±52)min,P＞0.05],术中出血量[(183±68)ml比(160±51)ml,P＞0.05],术后并发症和术后住院时间等差异无统计学意义[(10.1±2.2)d比(12.1±4.6)d,P＞0.05];而术后血小板计数差异有统计学意义[(37.3±12.8)×109/L比(54.7±13.2)×109/L,P＜0.05].结论 保留脾脏的胰体尾切除手术治疗胰腺良性或低度恶性肿瘤是可行、安全的.     

Laparoscopic Spleen-Preserving Distal Pancreatectomy: The Technique Must Suit the Lesion

Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P?<?0.001) and longer operative times (256 vs 201 min, P?=?0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.     

Spleen-Preserving Distal Pancreatectomy Combined with Distal Gastrectomy for Distal Pancreatic Lesion and Gastric Cancer: Report of a Case

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein was recently devised as a feasible operation. We report the case of a patient who underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein, combined with distal gastrectomy, for gastric cancer and a distal pancreatic lesion. Thus, unnecessary total gastrectomy was avoided. The operative blood loss and operative time were 630 ml and 465 min, respectively. The patient's postoperative course was complicated by a minor pancreatic fistula, which required daily irrigation and drainage, but she recovered and was discharged from hospital. This case report demonstrates that spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein combined with distal gastrectomy can be performable synchronously and is a feasible alternative to avoid unnecessary total gastrectomy.     

Novel approach to laparoscopic resection of tumours of the distal pancreas

Background: Laparoscopic resection for small lesions of the pancreas has recently gained popularity. We report our initial experience with a new approach to laparoscopic spleen‐preserving distal pancreatectomy so that the maximum amount of normal pancreas can be preserved while ensuring adequate resection margins and preservation of the spleen and splenic vessels. Methods: Three patients underwent laparoscopic distal pancreatectomy with spleen and splenic vessel preservation over a 2‐month period. Surgical techniques and patient outcomes were examined. Results: All three patients were females, with ages ranging from 31 to 47 years. Two patients underwent resection using the conventional medial‐to‐lateral dissection as the lesion was close to the body or proximal tail of the pancreas. The third patient had a lesion in the distal tail of the pancreas and surgery was carried out in a lateral‐to‐medial manner. This new approach minimized excessive sacrifice of normal pancreatic tissue for such distally located lesions. The splenic artery and vein were preserved in all cases and there was no significant difference in clinical outcome, operative time or intraoperative blood loss. Conclusion: Laparoscopic distal pancreatectomy with preservation of the spleen and splenic vessels is a feasible surgical technique with acceptable outcome. We have shown that a tailored approach to dissection and pancreatic transection based on the location of the lesion allows the maximum amount of normal pancreatic tissue to be preserved without additional morbidity. Although the conventional ‘medial‐to‐lateral’ approach is recommended for more proximal tumours of the pancreas, distal lesions can be safely addressed using the ‘lateral‐to‐medial’ approach.     

保留脾血管的腹腔镜胰体尾切除术安全性初探

目的 探讨保留脾血管腹腔镜胰体尾切除术（Kimura法）的安全性。方法 回顾性分析2015年1月至2019年6月内蒙古医科大学附属医院5例行保留脾血管腹腔镜胰体尾切除术患者的临床资料。结果 5例手术均顺利完成,无中转开腹,无围手术期死亡;病理证实均为良性或者低度恶性肿瘤;手术时间3.0～8.5 h,平均（5.7±1.82）h;出血量50～300 mL,平均（130±98.49）mL。术后第4～12 d拔管,第7～14 d出院,术后平均住院时间（9.52±2.21）d。术后随访,无肿瘤复发。A级胰瘘1例。结论 围手术期精心准备,初期尝试行保留脾血管的腹腔镜胰体尾切除术是安全可行的。     

Laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: Report of three cases

Between March 2003 and March 2007, three patients with benign pancreatic tumors underwent a planned laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. Four trocars were placed, and an endoscopic linear stapler was used to transect of the pancreas. The perioperative data and surgical outcomes were examined. This procedure was successfully completed in three patients. The mean operative time was 158.3 min, with mean blood loss of 14.7 ml. The postoperative pathological diagnoses included one insulinoma, one solid pseudopapillary tumor, and one intraductal papillary-mucinous adenoma. The mean size of the tumors was 29.3 mm. Oral intake was initiated on day 1.7, and the length of postoperative hospital stay was 8.7 days on average. No morbidity or mortality was observed. A laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is a safe and feasible treatment option without compromising the splenic function for benign or borderline malignant tumors in the distal pancreas.     

Distal pancreatectomy with splenic preservation: the anatomic basis for a meticulous operation

A case of distal pancreatectomy with splenic preservation is presented. In ten cadaver dissections of distal pancreas, an average of 22.1 tributaries of the splenic vein and 7.6 branches of the splenic artery were demonstrated. Anatomic considerations for splenic salvage during distal pancreatectomy are reviewed. Knowledge of the smaller pancreatic branches of the splenic vasculature is important in this surgical repair.     

Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

Herein, we report the successful performance of a laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for a patient with pancreatic cystadenoma, as a minimally invasive procedure with the preservation of function. The laparoscopy-assisted distal pancreatectomy procedure involved detaching the spleen and the distal pancreas from the retroperitoneum by a hand-assisted procedure, removing them from the peritoneal cavity through a small incision, and detaching the distal pancreas by ligating and transecting the short gastric artery and vein and the branches of the splenic artery and vein, while the spleen and main splenic artery and vein were preserved under direct view. The pancreatic parenchyma was transected with a stapling device (TL-30), and continuous suturing was added to the resected margin. The patients postoperative course was uneventful; the patient started to eat and walk on postoperative day 2 and was discharged on day 8. It is considered that the combination of hand-assisted and laparoscopy-assisted distal pancreatectomy, with conservation of the splenic artery and vein, is a minimally invasive and clinically useful technique for treating tumors of cystic disease of the pancreas with low-grade malignant potential, or benign solitary neuroendocrine tumors.     

Distal pancreatectomy with preservation of the spleen and splenic vessels

This article draws attention to the concept of distal pancreatectomy with splenic preservation including the splenic artery and vein.