3D腹腔镜手术系统在胃肠肿瘤根治术中的应用

目的 探讨3D腹腔镜系统在胃肠肿瘤根治术中的应用价值.方法 回顾性分析自2013年10月-2014年10月在上海市微创外科临床医学中心收治的53例通过3D腹腔镜系统进行的腹腔镜胃肠肿瘤根治术患者的临床资料.其中14例行腹腔镜右半结肠癌根治术（其中2例同时行胆囊切除术）,17例行腹腔镜经腹直肠前切除术（其中1例同时行胆囊切除术）,3例行腹腔镜腹会阴联合直肠癌根治术,3例行腹腔镜乙结肠癌根治术（其中1例同时行胆囊切除术）,2例行腹腔镜左半结肠癌根治术,1例行腹腔镜横结肠癌根治术,8例行腹腔镜胃癌根治术（其中1例同时行胆囊切除术）,1例行腹腔镜下胃癌＋乙结肠癌根治术和4例行腹腔镜胃间质瘤切除术.结果 全组53例患者均在3D腹腔镜下成功完成手术,无中转开腹,无术中并发症,无手术相关死亡患者.手术中位时间为180 （70～370） min,术中中位失血为40 （10～300） mL.术后平均排气时间2（1～5）d,手术后平均住院天数8（2～46）d.术后1例直肠前切除术患者出现吻合口瘘;1例腹会阴联合直肠癌根治患者术后出现会阴切口感染;1例远端胃癌根治术患者术后出现十二指肠残端瘘.均以保守治疗方法治愈.结论 3D腹腔镜其手术操作与传统2D腹腔镜相似,能达到与传统腹腔镜手术相当的临床疗效.进一步的临床研究将有助于对其更加全面的评价.     

3D与2D腹腔镜系统在结直肠癌手术应用的随机对照研究

目的研究3D腹腔镜系统在结直肠癌根治术中手术操作技术、术后短期疗效、可行性、安全性及肿瘤根治性。方法采用前瞻性分析法,收入2013年11月至2015年6月在上海市微创外科临床医学中心进行腹腔镜结直肠癌根治术的74例病人,按照随机数字表法分为2D(高清)腹腔镜组及3D腹腔镜组。2D腹腔镜组共38例,其中男性20例、女性18例,中位年龄为60.5岁(46~83岁);3D腹腔镜组共36例,其中男性16例、女性20例,中位年龄为62岁(37~84岁)。38例2D腹腔镜组病人中,腔镜右半结肠癌根治术12例,腹腔镜左半结肠癌根治术4例,腹腔镜横结肠癌根治术1例,腹腔镜乙状结肠癌根治术2例,腹腔镜根治性直肠前切除术17例(其中3例行末端回肠造口术),腹腔镜腹会阴联合直肠癌根治术2例。36例3D腹腔镜病人中,腹腔镜右半结肠癌根治术15例,腹腔镜左半结肠癌根治术3例,腹腔镜横结肠癌根治术1例,腹腔镜乙状结肠癌根治术3例,腹腔镜根治性直肠前切除术10例(其中5例行末端回肠造口术),腹腔镜腹会阴联合直肠癌根治术4例。结果所有病例均成功接受手术,无术中严重并发症和手术死亡发生,无中转开腹手术。2D腹腔镜组平均手术时间为(153.3±54.9)min,平均术中出血为(117.9±102.5)ml,平均排气时间为(2.3±0.9)d,平均住院天数为(9.6±7.8)d。3D腹腔镜组平均手术时间为(152.9±48.3)min,与2D腹腔镜组比较P=0.973;平均术中出血为(100.3±66.3)ml,与2D腹腔镜组比较P=0.386;平均排气时间为(2.1±0.8)d,与2D腹腔镜组比较P=0.228;平均住院天数为(8.1±3.2)d,与2D腹腔镜组比较P=0.289。术后2D腹腔镜组有1例腹腔镜根治性直肠前切除术及1例腹腔镜右半结肠癌根治术出现吻合口漏;3D腹腔镜组有1例腹腔镜腹会阴联合直肠癌根治术出现会阴切口感染。以上病人予对症治疗后均好转,无行二次手术病人。结论 2D腹腔镜系统与3D腹腔镜系统在手术操作上相似,两者手术后临床短期疗效、肿瘤根治程度相当。进一步研究尚需病例的积累与远期疗效的观察。     

腹腔镜与开腹结肠癌根治术的对比研究

比较结肠癌的腹腔镜手术与传统开腹手术的治疗效果。67例结肠癌患者中,42例行腹腔镜结肠癌根治术,25例行开腹结肠癌根治术。与开腹组比较,腹腔镜组手术时间和术后卧床时间明显缩短,术中出血量明显减少。腹腔镜结肠癌根治术在根治肿瘤方面与传统开腹手术没有明显差异,在患者恢复、手术创伤、手术时间等方面显示较好效果。     

腹腔镜下横结肠癌全结肠系膜切除术的临床应用

目的:探讨腹腔镜下横结肠癌全结肠系膜切除术的临床处理技巧,以提高手术安全性及短期疗效。方法:回顾分析2009年6月至2013年12月行腹腔镜横结肠癌全结肠系膜切除术的31例患者的临床资料。结果:2例患者中转开腹,29例在腹腔镜下完成手术。手术时间85~290 min,平均(140.0±28.6)min;术中出血量25~550 ml,平均(80.0±33.0)ml;术后排气时间2~7 d,平均(2.5±1.3)d;引流量55~450 ml,平均(83.0±24.6)ml;术后开始进食时间2~6 d,平均(2.5±1.2)d;淋巴结清扫数量9~33枚,平均(14.6±3.5)枚;术后住院7~21 d,平均(9.0±3.6)d。术后并发肠梗阻、肺部感染、切口感染各1例,均经保守治疗后治愈,无吻合口漏发生。结论:腹腔镜下横结肠癌全结肠系膜切除术中精细操作注意层面,熟悉常见解剖及变异,具有一定的腹腔镜操作技巧,是安全、有效的,在发挥微创手术优势的同时不增加手术相关风险。     

腹腔镜右半结肠癌根治术解剖学基础与规范化手术

腹腔镜手术现已广泛应用于结肠癌的手术治疗,其中的腹腔镜右半结肠癌根治术是难度较大的术式,术中需结扎处理的血管较多,且相关血管存在较多变异。完成规范化的腹腔镜右半结肠切除术,还需对淋巴结清扫范围及完整结肠系膜切除术有充分认识。本文结合国内外文献及我科腹腔镜右半结肠癌根治术的多年经验,对腹腔镜右半结肠癌根治术所需掌握的相关外科解剖做简要综述,探讨淋巴结清扫范围,并介绍我科规范化的腹腔镜右半结肠切除术操作流程供同道参考。     

腹腔镜右半结肠癌根治术中间入路手术体会

探讨腹腔镜中间入路法右半结肠癌根治术的手术要点、安全性及临床应用。回顾分析2015年1月—2018年4月行右半结肠癌根治术66例患者,其中开腹33例,腹腔镜中间入路33例。腹腔镜手术以回结肠血管为起始入路标志,以肠系膜上静脉为解剖学标志,建立正确的外科平面进行系膜血管的解剖及淋巴结清扫。比较两组患者的手术时间、术中出血量、术后肛门首次排气时间、术后住院时间、淋巴结清扫数目及并发症情况。结果显示,腹腔镜中间入路与开腹侧方入路比较,其在术后肛门首次排气时间、术后住院时间、淋巴结清扫数目有优势,并发症和术中出血量减少,但手术时间延长。结果表明,腹腔镜右半结肠癌中间入路完整肠系膜切除,手术安全,创伤小,可行性高。     

腹腔镜结肠癌根治术对Ⅰ、Ⅱ期结肠癌患者近期复发的影响

目的:对比研究腹腔镜与开腹结肠癌根治术对患者术后近期结肠癌复发的影响,确定手术的安全性与有效性。方法:2010年1月至2012年10月的895例结肠癌患者,最终纳入62例腹腔镜结肠癌根治术与83例开腹结肠癌根治术作为队列研究,通过术后随访结局及GCC-mRNA、CEA分析,对比腹腔镜与开腹手术对结肠癌复发的影响。结果:两组患者入院时年龄、性别、BMI、肿瘤大小、分期、评分、病理类型及切除范围差异均无统计学意义。术后3年两组复发率差异无统计学意义,术后1年,腹腔镜组复发率明显低于开腹组(3.2%vs.14.5%,P=0.024);两组患者术后总生存率与死亡率差异亦无统计学意义,但术后1年,无瘤生存率腹腔镜组明显高于开腹组(93.5%vs.81.3%,P=0.040)。患者术后早期GCC-mRNA与CEA阳性率腹腔镜组显著低于开腹组。对患者术后1年的结肠癌复发进行单因素与多因素分析发现,与开腹手术相比,腹腔镜结肠癌根治术术后1年内可明显降低结肠癌的复发率。分期及有无氨基水杨酸类药物的应用都是术后复发的危险因素。结论:腹腔镜结肠癌根治术是安全的手术方式,较开腹手术可显著降低Ⅰ、Ⅱ期患者近期结肠癌复发率。     

腹腔镜结肠癌根治术对早期结肠癌术后近期复发的影响

目的:对比腹腔镜和开腹结肠癌根治术对早期结肠癌患者术后近期复发的影响,确定手术的安全性和有效性。方法:纳入2010年1月—2012年10月行腹腔镜结肠癌根治术患者62例和开腹结肠癌根治术患者83例作为队列研究,通过随访术后结局以及鸟苷酸环化酶C(GCC)-mRNA和癌胚抗原(CEA)水平进行分析,比较腹腔镜和开腹手术对结肠癌复发的影响。结果:腹腔镜组和开腹组患者入院时年龄、性别、体重指数、肿瘤大小、分期、评分、病理类型以及切除范围等差异均无统计学意义(P>0.05)。两组术后3年的复发率差异无统计学意义(P>0.05),但术后1年腹腔镜组较开腹组复发率明显低(3.2%比14.5%),差异有统计学意义(P<0.05);两组患者术后总生存率和死亡率差异无统计学意义(P>0.05),但术后1年无瘤生存率腹腔镜组明显高于开腹组(93.5%比81.3%),差异有统计学意义(P<0.05)。患者术后早期(术后6个月)GCC-mRNA和CEA阳性率腹腔镜组显著低于开腹组。对患者术后1年的结肠癌复发率进行单因素和多因素分析发现,腹腔镜结肠癌根治术较开腹手术在术后1年内能明显降低结肠癌的复发(P<0.05)。另外,分期及氨基水杨酸类药物的应用都是术后复发的危险因素(P<0.05)。结论:腹腔镜结肠癌根治术是一种安全的手术方式,较开腹手术能显著降低患者近期结肠癌复发率。     

完全中间入路腹腔镜左半结肠癌完整结肠系膜切除3例报告

正腹腔镜左半结肠癌根治术与右半结肠癌根治术相比,具有手术范围广、操作跨度大、解剖相对复杂等特点,对术者技术要求较高。其手术路径一直处于探索阶段。本文回顾性分析2016-04-01—30新疆医科大学第一附属医院胃肠肿瘤外科采用完全中间入路行腹腔镜左半结肠完整结肠系膜切除(CME)的3例左半结肠癌病人的临床资料,探讨完全中间入路腹腔镜左半结肠CME的可行性及技术要点。1资料与方法     

腹腔镜与开腹手术治疗T4a期结肠癌的临床疗效比较

目的探讨T4a期非转移性结肠癌行腹腔镜结肠癌根治术与开放结肠癌根治术的临床疗效差异。方法回顾性分析2011年1月至2017年12月期间于北京协和医院行手术治疗且病理学结果明确为T4a期非转移性结肠癌患者的临床资料,根据手术类型分为腹腔镜组107例(行腹腔镜结肠癌根治术)和开放组52例(行开放结肠癌根治术),对2组患者的术中情况及术后疗效进行分析。结果腹腔镜组和开放组的手术时间、淋巴结获检数量、阳性淋巴结数量、30 d内并发症发生率及Clavien-Dindo分级比较差异均无统计学意义(P0.05),但腹腔镜组的术中出血量、术后排气时间及术后住院时间均少于(短于)开腹组(P0.05)。本组131例患者获访,随访时间为1～90个月,中位数为34个月。2组患者的无瘤生存情况和总体生存情况比较差异均无统计学意义(P0.05)。结论 T4a期非转移性结肠癌行腹腔镜结肠癌根治术安全可行,较之开放手术具有术中出血少、术后恢复快及住院时间短的优势。     

生物可降解吻合环在腹腔镜结肠癌根治术中的应用

目的探讨生物可降解吻合环在腹腔镜结肠癌根治术消化道重建中的应用价值。方法回顾性分析2007年1月-2010年10月31例腹腔镜结肠癌根治术应用Valtrac吻合环进行消化道重建的临床资料。其中升结肠13例,横结肠8例,降结肠6例,乙状结肠4例。腹腔镜下完成肠管及系膜游离、淋巴结清扫操作,经腹壁5-8 cm切口入腹,切除肿瘤后用生物可降解吻合环进行肠管端端吻合。结果 31例手术均获得成功,完成肠吻合时间12.5-17 m in,平均14.5 m in。术中出血20-100 m l,平均30 m l。13例行回肠-结肠吻合,吻合环直径28 mm、闭合间隙2.0 mm,18例行结肠-结肠吻合,吻合环直径31或33 mm、闭合间隙2.5 mm。未发生术后吻合口出血、吻合口漏。1例术后3个月结肠-结肠吻合口狭窄,直径约1.2cm,肠镜下扩张。术后肠功能恢复时间28-56 h,平均42.2 h。31例术后随访6-24个月,平均10个月,无肿瘤复发、远处转移及伤口种植转移。结论在腹腔镜结肠癌根治术中应用生物可降解吻合环进行消化道的重建是一种安全、微创、高效、可标准化的术式。     

Management of severe obstruction of the large bowel due to malignant disease

One hundred twenty-four patients with complete bowel obstruction from colorectal cancer requiring emergency surgery were treated between 1961 and 1970. Two thirds of the tumors were distal to the transverse colon. Curative resection was possible in 72 per cent and the over-all mortality was 15 per cent. Forty per cent survived five years after resection for cure. Primary resection was preferred for obstructions of the right side of the colon and the transverse colon, and staged procedures rather than primary resection were more satisfactory for lesions of the left side of the colon and rectum. The mortality rate was lower after transverse colostomy than after cecostomy. Combined perforation and obstruction (twenty-four patients) had a particularly high mortality (42 per cent) and a poor prognosis (14 per cent five year survival).     

Curative resection of transverse colon cancer via minilaparotomy

Minilaparotomy has been reported to be a minimally invasive alternative to laparoscopically assisted surgery. We retrospectively evaluated the usefulness of minilaparotomy for the resection of transverse colon cancer, which has generally been considered difficult to resect laparoscopically. Patients for whom curative resection was attempted for transverse colon cancer (n = 21) or sigmoid colon cancer (n = 81) via minilaparotomy (skin incision, < or = 7cm) were analyzed. The 2 groups did not significantly differ in terms of success rate of minilaparotomy (90.5% versus 97.5%), age, sex, pathologic stage, body mass index, operative time (mean, 133.5 minutes versus 122.5 minutes), blood loss (119.7 mL versus 92.4 mL), number of lymph nodes harvested, incidence of postoperative complications (9.5% versus 12.3%), postoperative length of stay, and 5-year disease-free survival rate (86.6% versus 79.6%). Minilaparotomy is feasible, safe, and favorable in terms of early oncologic outcome in patients with transverse colon cancer as well as those with sigmoid colon cancer.     

Surgical Treatment and Subsequent Outcome of Patients with Carcinoma of the Splenic Flexure

Extended resection, comprising extended right hemicolectomy, splenectomy, and distal pancreatectomy, has been advocated for carcinoma of the splenic flexure because the lymphatic drainage at this site is variable. The present study addresses the problems associated with selecting the most appropriate operative procedure to achieve cure of splenic flexure cancers. We conducted a retrospective review of 27 patients with splenic flexure cancer who under-went curative resection. Left partial colectomy was performed in 20 patients and partial resection of the transverse/descending colon was performed in 7 patients. The combined resection of adjacent organs due to tumor adherence was performed in three patients. The spleen and distal pancreas were the organs most frequently resected among a collective total of six adjacent organs. The median duration of follow-up was 60.9 months after resection for splenic flexure cancer. No patient developed local recurrence. There was no significant difference in 5-year survival between patients with splenic flexure cancers and those with colon cancers at other sites. In conclusion, splenic flexure cancer resected by left partial colectomy or partial resection of the transverse/descending colon without routine extended resection was not associated with a worse prognosis than colon cancers at other sites. Received: February 17, 2000 / Accepted: September 26, 2000     

腹腔镜结直肠手术55例报告

目的 探讨腹腔镜结直肠手术的优缺点、手术方法及应用价值。方法 经腹腔镜行结直肠手术55例,其中右半结肠切除15例,横结肠癌根治3例,Dixon手术20例,乙状结肠癌姑息切除4例(其中2例肝转移癌电凝固化),左半结肠切除1例,Miles手术6例,乙状结肠腺瘤切除2例,乙状结肠造瘘1例、直肠悬吊1例,先天性巨结肠切除2例。结果 54例成功完成手术,肿瘤侵犯十二指肠及胰头而中转开腹1例。手术时间平均148．8分钟。术后平均30．9小时胃肠功能恢复,且无并发症发生,术后平均住院7．6天。随访1～66月,1例横结肠癌术后23月出现肺转移,32月死亡;1例乙状结肠癌伴肝转移术后23月出现别处肝转移,开腹行右半肝切除。结论 腹腔镜结直肠手术技术上是可行的,具有手术创伤小、术后恢复快、胃肠道干扰小、术后疼痛轻、疤痕小等优点,值得进一步探索。     

Lymph Node Metastasis Patterns in Right-Sided Colon Cancers: Is Segmental Resection of These Tumors Oncologically Safe?

Purpose  The type of surgery and the extent of lymphadenectomy depend on the tumor location and should be based on the extent of lymphatic spread and the oncologic outcome. The aim was to analyze patterns of lymph node metastasis in patients with right-sided colon cancer. Methods  Between 1996 and 2007, a total of 419 patients underwent curative resection for right-sided colon cancer. Lymph nodes were grouped immediately after surgery on the basis of the location of the tumor. Results  There were 75, 208, 78, and 58 tumors in the cecum, ascending colon, at the hepatic flexure, and in the transverse colon, respectively. Of the 58 patients with transverse colon tumors, 43, 11, 3, and 1 underwent right hemicolectomies, transverse colectomies, left hemicolectomies, and a subtotal colectomy, respectively. Patients with cecal and ascending colon cancers most frequently had metastases in the ileocolic lymph nodes. Metastasis to the lymph nodes along the right branch of the middle colic artery occurred in 6.1% of patients with cecal cancer. In patients with hepatic flexure cancers, the epicolic lymph nodes along the right and middle colic arteries were most commonly metastatic lymph nodes. In transverse colon cancer, the middle colic node was the most commonly involved lymph node. Approximately 10% of patients had metastases to the right colic nodes. Conclusions  Metastasis to lymph nodes along the right colic artery occurred in approximately 10% of the patients with transverse cancer, indicating the need for great care in deciding the extent of segmental resection for these patients.     

联合脏器切除应用于局部进展期右半结肠癌的疗效

目的探讨右半结肠联合周围脏器切除治疗局部进展期右半结肠癌的疗效。方法回顾性分析13例因局部进展期结肠癌并侵犯邻近组织器官而行联合脏器切除的右半结肠切除患者的临床资料。结果13例患者中男8例,女5例,年龄39-76（平均58．6）岁。原发肿瘤位于结肠肝曲6例。升结肠5例．横结肠2例。肿瘤仅侵犯十二指肠3例,同时侵犯十二指肠和其他组织器官9例,另1例侵犯胰腺和胃。手术均采用右半结肠联合胰十二指肠和（或）其他脏器切除术。13例患者术后1年、3年及5年生存率分别为69％、54％和30％。结论右半结肠联合脏器切除术对于局部进展期右半结肠癌具有积极的治疗意义。     

腹腔镜辅助右半结肠癌根治术的临床应用

目的:探讨腹腔镜辅助右半结肠癌根治术的方法及应用价值。方法:回顾分析2006年2月至2008年12月我院24例右半结肠癌患者的临床资料及手术方法。术中用超声刀切开右半结肠外侧腹膜,游离升结肠及右半横结肠,游离清除肠系膜上血管根部淋巴结,体外切除肿瘤,吻合肠管。结果:22例顺利完成腹腔镜手术,2例中转开腹。手术时间140～360min,平均202min,术中出血平均70ml,术后恢复肠蠕动平均32h,术后平均住院8d,术后2例切口感染,1例炎性肠梗阻,无出血、肠漏等严重并发症发生及死亡病例。结论:腹腔镜辅助右半结肠癌根治术安全有效,符合微创手术切口小、患者痛苦轻、康复快的优点及肿瘤根治原则。     

Hematogenous umbilical metastasis from colon cancer treated by palliative single-incision laparoscopic surgery

Sister Mary Joseph’s nodule (SMJN) is a rare umbilical nodule that develops secondary to metastatic cancer. Primary malignancies are located in the abdomen or pelvis. Patients with SMJN have a poor prognosis. An 83-year-old woman presented to our hospital with a 1-month history of a rapidly enlarging umbilical mass. Endoscopic findings revealed advanced transverse colon cancer. computer tomography and fluorodeoxyglucose-positron emission tomography revealed tumors of the transverse colon, umbilicus, right inguinal lymph nodes, and left lung. The feeding arteries and drainage veins for the SMJN were the inferior epigastric vessels. Imaging findings of the left lung tumor allowed for identification of the primary lung cancer, and a diagnosis of advanced transverse colon cancer with SMJN and primary lung cancer was made. The patient underwent local resection of the SMNJ and subsequent single-site laparoscopic surgery involving right hemicolectomy and paracolic lymph node dissection. Intra-abdominal dissemination to the mesocolon was confirmed during surgery. Histopathologically, the transverse colon cancer was confirmed to be moderately differentiated tubular adenocarcinoma. We suspect that SMJN may occur via a hematogenous pathway. Although chemotherapy for colon cancer and thoracoscopic surgery for the primary lung cancer were scheduled, the patient and her family desired home hospice. Seven months after surgery, she died of rapidly growing lung cancer.     

结肠冗长症外科治疗术式的探讨

目的　探讨结肠冗长症的外科治疗术式 ,以提高治疗效率 ,减少并发症。方法　结合国内外文献及我院 12例结肠冗长症外科治疗的体会 ,探讨结肠切除的合理范围。结果　结肠冗长症所致的顽固性便秘术后效果较为满意。随访 6个月～ 8年 ,以横结肠大部分切除 +左半结肠切除效果最佳 ,无腹泻并发症。结论　结肠冗长症外科治疗切除结肠的范围应尽可能的扩大。横结肠大部分切除 +左半结肠切除并不增加腹泻并发症。合理性的扩大切除是减少复发的关键。