全腹腔镜根治性全胃切除术

34岁女性胃体腺癌患者,拟行全腹腔镜根治性全胃切除术。患者取平仰卧位,主刀位于患者左侧。腹腔镜下探查肿瘤位于胃体,无腹腔种植转移。游离大网膜及横结肠系膜前叶,向左达脾下极,向右达结肠肝曲。继续游离、夹闭、离断胃左右动静脉、胃网膜左右动静脉、胃短动脉、胃后动脉,清扫NO.1～NO.11,NO.12a,NO.12p,NO.14v组淋巴结。幽门远端3 cm离断十二指肠。腔镜下游离小肠系膜,距屈氏韧带20cm处切割闭合离断空肠,远端上提,使用overlap技术完成食道空肠的侧侧吻合,连续缝合关闭共同开口。据此吻合口远端40 cm处行近端空肠远端空肠的侧侧吻合,连续缝合关闭共同开口。检查吻合口对合良好。冲洗术野,腹腔镜下放置腹腔引流管。     

腹腔镜下扩大淋巴结清扫的胰十二指肠切除术

行传统Kocher切口行腹膜后淋巴结清扫,距屈氏韧带5～10 cm离断空肠,离断远端2/3胃体,肝十二指肠韧带骨骼化清扫,离断GDA,离断胰颈,清扫肝总动脉及腹腔干周围淋巴结,解剖SMA-CT系统,行SMA左右侧360°清扫,完成钩突全系膜切除,切除胆囊,最后离断肝总管。标准清扫+8P、9、12a、12P、14c-d、16a2、16b1的扩大淋巴结清扫。胰肠吻合采用创新的"两点法"胰管导管-黏膜吻合,胆肠吻合采取连续缝合,直线切割闭合器行胃后壁与空肠侧侧吻合。     

完全腹腔镜进展期远端胃癌根治术并改良Roux－en－Y吻合

常规5孔法操作,根据D2淋巴结清扫原则进行胃周淋巴结清扫并解剖离断相应血管。直线切割缝合器离断十二指肠,预切除线处离断胃体。标本装入自制标本保护套。距Treitz韧带15 cm处直线切割闭合器离断空肠,将远端小肠与残胃大弯侧行胃空肠侧侧吻合。沿脐旁做弧形绕脐切口约2～3 cm,将标本取出,并提起近端空肠与远端小肠体外完成端侧吻合。术中失血30 ml,手术时间150 min。     

全腔镜全胃切除术

切开胃结肠韧带,游离至脾脏下极,于根部离断胃网膜左血管,清扫第4组淋巴结,离断胃短血管直至脾上极。游离胃窦部,于胰腺上缘离断胃网膜右静脉,显露胃十二指肠动脉后,于根部离断胃网膜右动脉,并完成第六组淋巴结的清扫。显露胃窦后壁,离断胃右血管,清扫肝门部淋巴结。距幽门2 cm离断十二指肠。沿胰腺上缘解剖脾动脉根部,于根部离断胃左静脉。显露腹腔干及胃左动脉,向右侧清扫第8组淋巴结,于根部离断胃左动脉后,向头侧清扫第1,2组淋巴结。游离食管腹段,解剖出迷走神经左右支后离断。悬吊肝左叶后,距贲门2 cm离断食管,取上腹正中辅助切口3 cm,移除胃标本及大网膜。重建气腹后,距TREIZ韧带20 cm离断空肠,行食管左后壁与近端空肠侧侧吻合(OVERLAP法),手工缝合共同开口。距此吻合口40 cm,借助辅助切口完成小肠侧侧吻合(ROUX－Y)吻合。     

一种新型的完全腹腔镜下胃癌D2根治术后消化道重建方式

目的探讨一种新型的完全腹腔镜下食管．空肠消化道重建方式在胃癌根治术中的应用。方法常规腹腔镜下淋巴结清扫并完全游离食管后,于远端食管近食管胃交界处用超声刀打开一长约2．5cm的小孔,置入一次性吻合器底钉座,用切割缝合型闭合器切断并闭合食管。在距离Treitz韧带15cm处分离并离断空肠,远端空肠提至食管底钉座处,在空肠远端食管置入吻合器,行食管空肠吻合。再用直线切割闭合器闭合远端空肠断端,并加强缝合食管与空肠之间的吻合口。最后,空肠近端断端与距离食管-空肠吻合口处以下55cm处的空肠行空肠-空肠端侧吻合。结果患者成功实施完全腹腔下胃癌根治术,术后未发生并发症或中转开腹,手术时间230min,出血150ml,术后无反流、吻合口漏、吻合口狭窄等严重并发症发生,患者恢复良好。结论完全腹腔镜下新型的消化道重建方式安全可行。     

腹腔镜远端胃癌根治术D2淋巴结清扫—四角吻合

探查胃窦肿物,见浆膜层受累,第6组淋巴结转移可能性大,建议进行14v组淋巴结清扫。过程包括打开胃结肠韧带,解剖胃结肠静脉干、肝十二指肠韧带、小网膜、胃胰皱襞,分别于根部离断胃网膜左血管、胃网膜右血管、胃右血管、胃左血管,清扫第1、3、4、5、6、7、8、9、11p、12a、12p、14v组淋巴洁,完成D2腹腔淋巴结清扫。腔镜下离断十二指肠及部分远端胃,标本取出后行胃十二指肠毕I式吻合(四角吻合)。     

腹腔镜根治性全胃切除重建术

患者,59岁男性,术前诊断：胃体腺癌(cT3N1＋M0)。拟行腹腔镜根治性全胃切除术。手术思路：1.打开胃结肠韧带,游离横结肠系膜前叶2.显露并离断胃网膜右静脉根部,清扫14V组淋巴结,显露胃十二指肠动脉,于根部离断胃网膜右动脉,清扫6组淋巴结。3.游离胰腺被膜,清扫7、8、9组淋巴结。沿肝总动脉后方显露门静脉,清扫12a组淋巴结。显露胃十二指肠动脉、肝固有动脉,离断胃右动脉,清扫5组淋巴结。游离肝胃韧带至贲门右侧,清扫1组淋巴结。4.沿脾动脉游离,显露脾门血管,清扫10、11组淋巴结。游离贲门左侧,清扫2组淋巴结。5.采取腹部辅助小切口完成胃肠Roux－en－Y重建。     

近端胃癌D2根治术淋巴结清扫技巧（LN 7、8、9、10、11）（文字介绍）

一、胃癌的部分淋巴结分组 NO.7-胃左动脉淋巴结：N0.8a-肝总动脉前淋巴结;N0.8p-肝总动脉后淋巴结;N0.9-腹腔干淋巴结;N0.10-脾门淋巴结;N0.11p-脾动脉近端淋巴结;N0.11d-脾动脉远端淋巴结。二、具体步骤1.清扫肝总动脉旁淋巴结。2.定位腹腔干的任何一支具名分支（包括胃左动脉）,紧贴血管外膜沿血管走行解剖其周围结缔组织即可实现腹腔干、肝总动脉、胃左动脉及脾动脉起始段的＂脉络化＂从而完成No.7、No.8a和No.9组淋巴结清扫。3.离断胃左静脉。4.离断胃左动脉。5.离断脾周围韧带。6.游离胃大弯及贲门左侧并清扫相应淋巴结。7.游离食管腹段。     

腹腔镜远端胃癌切除胃空肠Uncut Roux-en-Y吻合术

远端胃切除和淋巴结清扫结束后,进行腹腔镜消化道重建。首先提起横结肠,寻及Treiz韧带,提起距之约25 cm处的空肠,经系膜无血管区带线标记并待提出。沿观察孔切口绕脐向上延切口长约3~4 cm,自此切口取出标本。将标记小肠牵引线连同近端空肠自切口拖出,确认远近端后,距牵引线标记近端8 cm与远端40 cm处空肠行侧侧吻合,于标记线处用闭合器(无刀片)闭合肠管但不予以切断。最后将肠管还入腹腔,关闭腹部切口后,重新建立气腹。在闭合处远端2 cm使用直线切割缝合器行空肠残胃侧侧吻合,并关闭共同开口。     

全腹腔镜远端胃癌根治术(Uncut Roux-en-Y吻合)

Uncut-Roux-en-Y吻合方式顺序为:在距Treitz韧带约20 cm处的空肠对系膜缘侧打开0.5 cm切口,在残胃大弯侧残端打开0.5 cm切口,切口分别置入切割闭合器"分支"行侧侧吻合,共同开口再行切割闭合器闭合(胃肠吻合);距胃肠吻合口近端7~8 cm处及远端约30 cm处空肠对系膜缘处分别打开0.5 cm切口,分别置入切割闭合器"分支"行侧侧吻合,共同开口再行切割闭合器闭合(空肠侧侧吻合-Braun吻合);最后在距胃肠吻合口近端2~3 cm空肠处用no cut闭合器闭合的方法闭合输入袢空肠(输入袢阻断)。     

机器人胃癌根治术

Troca采用“W型”5孔法布局。探查完毕后,辅助臂提起横结肠系膜,助手于对侧牵拉横结肠,超声刀沿横结肠切断大网膜,分离横结肠系膜前叶,清扫N0.4淋巴结。接着剥离胰腺前背膜,游离部分脾静脉,根部切断胃网膜左动、静脉及两支胃短血管。解剖胃结肠静脉干及胃网膜右血管,根部切断胃网膜右动、静脉,清扫N0.6淋巴结。沿肝脏侧切开肝胃韧带,幽门上方清扫N0.5淋巴结。辅助臂提起胃,清扫N0.8,9淋巴结,根部结扎并切断胃左动脉、静脉,清扫N0.7淋巴结。向上切除肝胃韧带并游离至贲门部,清扫N0.1,3淋巴结,左侧切断脾胃韧带。幽门下2cm处用切割闭合器横断十二指肠。     

毕Ⅱ+Braun吻合与毕Ⅱ式吻合在腹腔镜远端胃癌根治术中的疗效对比研究

目的:对比分析毕Ⅱ式+Braun吻合与单纯毕Ⅱ式吻合在腹腔镜远端胃癌根治术中的安全性及有效性,探讨毕Ⅱ+Braun吻合在胃癌根治术中的优势.方法:回顾分析2015年12月至2018年12月74例行腹腔镜远端胃癌根治术患者的临床资料,其中35例行毕Ⅱ+Braun吻合(毕Ⅱ+Braun组),39例行毕Ⅱ式吻合(毕Ⅱ组).对...     

Laparoscopy-assisted D2 subtotal gastrectomy in early gastric cancer

The purpose of this study is to prove the safety and efficacy of laparoscopy-assisted subtotal gastrectomy and D2 lymph node dissection using 4 ports and an EEA stapler with a Billroth I anastomosis. From 1999 to 2001, 20 patients with EGC located in the distal stomach underwent laparoscopy-assisted Billroth I gastrectomy (LABIG). A 4-port-technique was performed for omentectomy, vascular ligation, and D2 lymph node dissection. A mini-incision was created between the two ports in the epigastric area and a gastroduodenal anastomosis with an EEA stapler and a distal resection was performed. The mean operating time was 261.8 (170-410) minutes. There was one postoperative complication without any intraoperative transfusions or perioperative mortality. The number of harvested nodes was 31.9 +/- 11.4. Mean distance from the lesion to the margin of resection was 5.3 +/- 2.2 cm proximally and 4.0 +/- 2.0 cm distally. On average, oral liquids were started at the 4.7th (3rd-8th) postoperative day. LABIG is a safe and effective way of performing D2 gastrectomy in terms of morbidity and oncological principles. A randomized controlled clinical study to compare long-term survival and quality of life is warranted.     

The contribution of laparoscopy to the treatment of gastric cancer

BACKGROUND: Laparoscopy plays a role in the preoperative diagnosis of gastric cancer, particularly in determining the location and extent of the neoplasia. In addition to its use in staging, laparoscopy is indicated for the gastric resection of T1-T2, and its middle- and long-term results are comparable to those obtainable with open surgery. Herein we describe our experience with the laparoscopic resection of gastric carcinomas, including the dissection of lymph nodes and the Billroth II reconstruction of digestive continuity with gastrojejunostomia. METHODS: We carried out laparoscopic gastric resections in 25 patients with adenocarcinomas. Our method involved installing five trocars, tying the left and right gastric vessels and the right gastro-epiploic vessels, sectioning the duodenum 3 cm from the pylorus, sectioning the remaining portion of the stomach obliquely 3 cm from the cardias, and performing Billroth II reconstruction. RESULTS: The average duration of the operation was 4 h 45 min. The average number of removed lymph nodes was 30.5 (range, 22-41). Five patients were converted to laparotomy. Significant complications were observed in four cases (16%). Hospitalization ranged from 5 to 16 days. The average follow-up was 38 months (range, 7-63), without evidence of relapse. CONCLUSION: In terms of morbidity, our results were similar to those obtained with open surgery. Lymphectomy according to the extent and number of lymph nodes is acceptable in the treatment of tumors of the lower third of the stomach. More case studies are needed to provide further indications of the applicability of the technique (which is currently used only in a few centers) and long-term results.     

Lymphatic flow of the remnant stomach

Aiming at establishing an appropriate lymph node dissection for carcinoma of the remnant stomach and of the lower esophageal carcinoma in the status post-gastrectomy, lymphatic flow was investigated clinically as well as experimentally. Nineteen cases of carcinoma of the remnant stomach and 8 cases of esophageal carcinoma after partial gastrectomy were studied. Lymph node metastasis of the remnant stomach carcinoma were more frequently seen at perigastrium, splenic hilum, and along splenic artery. Those further extended to para-aortic and diaphragmatic nodes. Three cases of lower esophageal carcinoma after gastrectomy had massive nodal involvement at perigastrium, as well as intra-thoracic lymph nodes. Experimentally 5-Fu emulsion was injected submucosally under endoscope in 25 dogs and subserosally in 6 rabbits. 5-Fu contents in lymph nodes were measured 30 minutes after injection. The most prominent difference in lymphatic flow from the remnant stomach was increase in ascending flow into intrathoracic lymph nodes through para-aorta. This increment was seen irrespective of Billroth I or II anastomosis. On the contrary, descending lymphatic flow from the lower esophagus into the intra-abdominal lymph nodes was not disturbed by gastrectomy. Cardiac lymph node dissection in rabbits accelerated ascending flow. Those results would indicate the necessity of complete block of ascending flow in cases of the remnant stomach carcinoma and of intra-abdominal lymph node dissection in those of the lower esophageal carcinoma after gastrectomy.     

A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect?

BACKGROUND: There have been no reports evaluating the completeness of systematic nodal dissection with video-assisted thoracic surgery (VATS). In order to elucidate the completeness of the dissection, we have conducted a prospective trial with patients having primary lung cancer. METHODS: Patients with clinical stage I lung cancer were the candidates for this study. Thoracotomy was performed with a small skin incision of 7 cm to 8 cm in length. Through these small wounds and two trocars, pulmonary resection was performed and then hilar and mediastinal lymph nodes were dissected. After that, a standard thoracotomy was carried out by another surgeon to complete systematic nodal dissection. RESULTS: Video-assisted thoracic surgery lobectomy with lymph node dissection was accomplished in 17 right lung cancer patients and 12 left lung cancer patients. On the right side, the average numbers of resected lymph nodes by VATS and remnant lymph nodes were 40.3 and 1.2, respectively. The average weights of dissected tissues by VATS and remnant tissues were 10.0 g and 0.2 g, respectively. On the left side, there were 37.1 and 1.2 lymph nodes and 8.3 g and 0.2 g of weight of dissected tissues. No nodal involvement was observed in the remnant lymph nodes. CONCLUSIONS: The lymph node dissection with VATS was technically feasible and the remnant ("missed" by VATS) lymph nodes and tissues were 2% to 3%, which seems acceptable for clinical stage I lung cancer.     

全腹腔镜下远端胃癌根治术三角吻合术

先确定肿瘤位置,沿横结肠边缘超声刀游离横结肠系膜前叶,向右游离至结肠肝曲,左至脾曲,离断网膜左血管,清扫4sb,4d淋巴结;沿结肠中动脉及其分支分离,向上暴露肠系膜上静脉、右结肠静脉、胃网膜右静脉,骨骼化胃网膜右动脉于根部切断;裸化十二指肠下缘,暴露胃十二指肠动脉,肝总动脉胃左脾动脉和腹腔干,切断胃左动脉清扫第7.8.9.11p组淋巴结;向下剥离裸化肝十二指肠韧带,清扫第12a组淋巴结,并向上彻底清扫第1,3,5组淋巴结,使用内镜下直线切割吻合器离断十二指肠球部,胃体。扩大脐部穿刺孔至取出标本,缝合切口。重建气腹,行胃大弯和十二指肠后壁三角吻合。