腹腔镜低位直肠癌根治术

松解乙状结肠与侧腹膜间的粘连。沿直肠系膜根部内侧打开浆膜,钝、锐性向上分离至肠系膜下动脉根部。分离打开Toldt’s筋膜下间隙,解剖肠系膜下动静脉,清扫血管根部周围的淋巴脂肪组织。提起乙状结肠,向上继续分离Toldt’s间隙至结肠脾曲,向下分离结直肠后间隙至盆腔,进入盆腔脏、壁筋膜间隙直至骶前间隙,离断两侧直肠侧韧带。分离直肠前侧,沿腹膜反折打开,沿直肠系膜间隙分离完整切除直肠系膜(TME)。术中于肿瘤下方约2 cm处离断直肠。取6 cm长左旁正中切口,将游离的直肠移至腹腔外,在肿瘤上方约10 cm处离断,移去标本,残端置入吻合器抵针座后,荷包缝合固定,将肠管回纳腹腔后逐层关腹。经肛门置入28 mm吻合器,行乙状结肠-直肠端端吻合。     

腹腔镜直肠癌根治术(Dixon)

在结肠系膜与后腹膜移行处切开后腹膜,分离系膜至肠系膜下动脉根部,清扫253组淋巴结,在距腹主动脉根部1 cm处夹闭并切断血管,切断肠系膜下静脉。由内侧向外侧分离结肠系膜至结肠旁沟,切开其左侧后腹膜,将降结肠及乙状结肠系膜从后腹壁游离。沿直肠固有筋膜与盆壁筋膜的间隙按照TME原则锐性分离直肠系膜,先游离后壁,再游离两侧壁及前壁,直至盆底。在肿瘤下方2 cm处用阻断夹夹闭肠管,冲洗远端直肠,用切割缝合器切断直肠。取脐部弧形切口。提出近端肠管,于肿瘤近端15 cm处离断肠管。近端置入管型吻合器抵钉座,还纳腹腔,重建气腹。经肛置入管型吻合器,在腹腔镜直视下作乙状结肠－直肠端端吻合,冲洗腹腔,置引流管,手术结束。     

腹腔镜直肠癌低位前切除术

腹腔镜直肠癌低位前切除术。术中首先经中间入路打开乙状结肠系膜内侧浆膜,循Toldt’s间隙向头侧游离至肠系膜下动脉根部,夹闭离断肠系膜下动脉,并清扫253组淋巴结;继续向外侧、尾侧游离左侧Toldt’s间隙,并向下延续至直肠后间隙,分离过程中注意保护左侧输尿管、左侧生殖血管。沿左结肠旁沟打开结肠系膜与侧腹壁的融合筋膜,向上游离左侧结肠至脾曲。向下继续沿直肠后间隙分离,并向两侧拓展;前方在腹膜返折略上水平打开腹膜,在邓氏筋膜前间隙向下游离,从前、后及两侧交替游离并完整切除直肠系膜;双吻合器法切除直肠肿瘤及重建肠道。     

机器人直肠癌根治术

术中自肠系膜下动脉下方切开乙状结肠系膜,游离Toldts间隙,暴露并保护左侧输尿管及生殖血管。切断肠系膜下动脉根部,清扫253组淋巴结。切开乙状结肠侧腹膜,游离乙状结肠下段。提起肠系膜下动脉血管蒂(已切断),沿Toldts层面分离直肠系膜与骶前间隙,环形完整游离直肠系膜,于肿瘤标记处远端约5cm处以直线切割闭合期切断直肠肠管。肠管断端提出体外,距离肿瘤近端约10cm,切断乙状结肠肠管,并包埋吻合器钉座。行乙状结肠-直肠端端吻合(Dixon手术)     

腹腔镜辅助直肠癌根治术

于2020-04-24全身麻醉下行腹腔镜辅助直肠癌根治术(低位直肠前切除术)。探查腹腔无远处转移后提起乙状结肠系膜,超声刀游离出肠系膜下动脉。肠系膜下静脉,分别结扎切断。继续游离乙状结肠以及直肠,游离直肠后间隙,于肿瘤下方使用腔镜下直线切割吻合器切断直肠。再切断肿瘤上方乙状结肠。使用管型吻合器作直肠-乙状结肠端端吻合。切除直肠上段以及部分乙状结肠。     

超低位直肠癌保肛术

5孔法,仰卧,取头低足高30°的右侧倾斜膀胱截石位。1探查腹腔。2内侧入路从乙状结肠系膜与盆底腹膜交界处切开,自内向外分离Toldt's间隙。3距腹主动脉0.5 cm处Hem-o-lock断结扎肠系膜下动脉,在近屈氏韧带下方分离出肠系膜下静脉,切断,保护肠系膜下神经丛。4乙状结肠系膜裁剪及游离。5直肠后间隙分离:保护腹下神经丛。6直肠前壁及侧方分离:腹膜返折上0.5~1.0 cm切开,沿邓氏筋膜前分离直肠前壁,精囊腺底部切开邓氏筋膜,侧方分离全程以盆神经作为指引。7直肠末端系膜分离:将直肠系膜从肛提肌裂孔边缘切断,进入括约肌间隙,顺直肠壁向肛侧分离,距肿瘤2 cm切割闭合直肠。切除近端肠管行直肠乙状结肠端端吻合,回肠末端预防性造口。     

腹腔镜扩大左半结肠切除术

采用5孔法,经典中间入路。在右侧输尿管内侧2 cm切开,进入左侧Toldt间隙,自尾侧向头侧锐性分离,清扫肠系膜下动脉根部的淋巴脂肪组织。解剖降结肠及乙状结肠动脉,根部离断。十二指肠空肠曲左侧离断肠系膜下静脉根部,向外侧拓展降结肠后间隙、乙状结肠后间隙和直肠上段后间隙,确认左输尿管及生殖血管以防止损伤。切开并游离横结肠系膜,在胰颈下缘显露中结肠动静脉,于根部离断。沿降结肠沟剪开左侧腹膜,上至脾曲,下至直肠上段,与之前已拓展完成的左结肠后间隙汇合。自胃大弯侧血管弓内离断血管分支,直至根部切断胃网膜左血管,并切断脾结肠韧带,完全游离脾曲。于左侧经腹直肌切口切开腹壁,长约5 cm,将左半结肠拖出体外。在肿瘤近远端10～15 cm横断结肠,行端端吻合术。     

直肠局部解剖特点在腹腔镜直肠癌全直肠系膜切除术中的指导意义

本研究通过分析直肠的局部解剖学特点,总结腹腔镜直肠癌全直肠系膜切除术（TME）中的关键步骤、解剖层次及操作技巧.收集32例行腹腔镜TME的患者资料,对术中Toldt间隙及肠系膜下动脉根部游离,骶前间隙、直肠侧韧带及直肠前方间隙分离等术中关键步骤、解剖平面及操作技巧进行观察和描述.Toldt线是进入侧后方解剖平面的标志线,Toldt间隙是起始解剖的标准外科平面,直肠后壁为天然的外科平面,Toldt间隙和骶前间隙为相互延续的筋膜间隙,Denonvilliers筋膜是直肠前分离的标志平面.这些直肠局部解剖学特点对根治性直肠癌手术具有重要指导意义.     

腹腔镜辅助直肠癌根治术

中央入路于乙状结肠系膜内侧切开后腹膜,解剖Toldt’s间隙,分别向左、向尾侧、向头侧进一步游离、扩大该间隙,显露并注意保护左侧输尿管、左侧生殖血管。充分游离Toldt’s间隙后,放入小纱布以作标记。提起肠系膜下血管根部系膜组织,彻底分离清扫肠系膜下动脉根部淋巴脂肪组织。夹闭、切断肠系膜下动脉,注意保护生殖神经。向下游离,首先游离后方的直肠后间隙和前方的邓氏间隙,然后离断直肠侧韧带。最后按腹腔镜下全直肠系膜切除法+双吻合器法切除直肠肿瘤及重建肠道。     

腹腔镜辅助下低位直肠癌D3根治术(Dixon手术)

手术步骤包括:(1)中央入路法从乙状结肠系膜根部切开进入左Toldt间隙;(2)清扫肠系膜下动脉淋巴结,根部切断IMA;(3)继续分离左Toldt间隙;(4)裁剪乙状结肠系膜及切断IMV;(5)分离直肠后间隙直至骶尾韧带水平;(6)切断右侧直肠侧韧带及左结肠旁沟;(7)切断左侧直肠侧韧带及前壁邓氏筋膜,裸化肠管;(8)直肠切断与吻合。此手术以手控电刀操作为主,其主要优势有:(1)操作精细、快速、安全;(2)烟雾小,利于盆腔深部术野显露;(3)成本低,适合基层医院开展。     

腹腔镜直肠悬吊固定术治疗直肠重度脱垂

目的探讨腹腔镜直肠悬吊固定术治疗直肠脱垂的临床应用价值。方法1998年3月至2007年2月,对4例完全性直肠脱垂患者进行了腹腔镜直肠悬吊固定术。1例采用缝合固定法,将直肠后壁分离、提高,用丝线缝闭直肠前陷凹,并将直肠后壁悬吊固定于骶骨岬前筋膜上,再将乙状结肠缝合固定在左侧腰大肌筋膜。3例采用网片固定法,将直肠游离到肛提肌水平,用1张6cm×9cm的T字型聚丙烯网片置于直肠后方,网片下缘在肛提肌水平环绕直肠,在直肠前方用丝线缝合网片和直肠浆肌层,再将网片上端在直肠后用疝修补钉夹固定于骶骨岬前筋膜,缝合关闭盆底腹膜。再将乙状结肠缝合固定在左侧腰大肌筋膜。结果4例患者手术均顺利,无中转开腹者。手术时间92.5(80-100)min,出血量6.5(5～10)ml。无并发症发生。术后尿失禁和肛门失禁的症状缓解,术后随访2个月至3年均未见复发与便秘出现。结论腹腔镜下行腹腔镜直肠悬吊固定术创伤小、恢复快和安全有效。     

新荷包技术联合经肛门外翻切除在全腹腔镜下低位直肠癌根治术中的应用

目的:讨论应用新荷包技术在全腹腔镜下低位直肠癌根治术中的可行性及近期疗效。方法:分析6例应用新荷包技术行全腹腔镜下低位直肠癌根治术患者资料。患者在全腹腔镜下完成全直肠系膜切除术后,将带有缝针的钉座通过靠近上切缘处乙状结肠肠壁切口置入乙状结肠肠腔内,然后将缝针从肠壁穿出,引导钉座杆穿出肠壁,靠近钉座处用直线切闭器切断结肠;远端肠壁连同肿瘤经肛门外翻拉出体外,在直视下行肿瘤下切缘的切割闭合,完成吻合。结果:6例患者手术均顺利完成,无中转开腹;手术时间为(165±21)min,出血(55±12)m L;无吻合口瘘;术后随访未发现肿瘤局部复发及远处转移。结论:新荷包技术应用于全腔镜下直肠癌根治术具有较高的安全性及良好的短期效果,远期疗效有待进一步观察。     

3D腹腔镜NOSES直肠癌根治术

五孔法,按TME及神经功能保护原则手术,骶岬前方切开后腹膜,打开血管鞘,分离直肠上动脉、肠系膜上动脉及左结肠动脉,清扫腹主动脉(253)淋巴结,结扎切断肠系膜下动静脉,沿Denonvilliers筋膜分离,注意保护腹下神经丛。游离乙状结肠及降结肠系膜,向下沿盆筋膜脏层和壁层之间游离至肛提肌平面,注意保护盆自主神经。切断直肠侧韧带游离直肠侧方,前方打开腹膜返折部及Denonvilliers筋膜向下游离至肿瘤下方5 cm。切断乙状结肠,3-0抗菌微乔线荷包缝合一圈,切断直肠,经肛门置入吻合器枪身,激发完成吻合。     

腹腔镜保留直肠上动脉的D3淋巴结清扫术在降结肠、近段乙状结肠癌根治术中的临床应用

目的:探讨降结肠及近段乙状结肠癌行腹腔镜辅助左半结肠D3淋巴结清扫术中保留直肠上动脉的安全性与可行性。方法:回顾分析2013年12月至2015年12月为13例患者行保留直肠上动脉的腹腔镜辅助左半结肠D3淋巴结清扫术的临床资料,其中近段乙状结肠癌8例,降结肠癌5例,2例合并完全性梗阻,经内镜支架置入缓解并充分肠道准备一周后手术。术中应用超声刀全程裸化肠系膜下动脉根部,沿血管鞘向远端分离、结扎左结肠动脉及若干支乙状结肠动脉,保留直肠上动脉;肠系膜下静脉于脾静脉汇合点前结扎切断。结果:术中发现左结肠动脉缺失1例;左结肠动脉发自乙状结肠动脉1例;Riolan弓缺失2例。手术均顺利完成,无一例中转开腹,手术时间平均(148.1±15.5)min,实际淋巴结清扫时间(自系膜切开至D3淋巴结清扫完成)平均(44.9±11.8)min,术中失血量平均(40.0±17.3)ml,淋巴结清扫数量平均(21.9±4.5)枚;吻合口均位于乙状结肠中下段,无吻合口瘘发生。无一例发生与淋巴清扫相关的副损伤、意外出血及死亡。1例患者于术后1周出现高位小肠梗阻,经禁食、胃肠减压后缓解;1例乳糜漏,经保守治疗后痊愈。结论:腹腔镜下保留直肠上动脉的肠系膜下动脉根部D3淋巴结清扫术治疗降结肠、近段乙状结肠癌是安全、可行的,可避免不必要的远端乙状结肠的过多切除。     

Total mesorectal excision of initially unresectable locally advanced rectal cancer infiltrating the pelvic wall after treatment with FOLFOX4 plus bevacizumab and preoperative chemoradiation: report of a case

A 60-year-old man underwent sigmoid loop colostomy for obstructive rectal cancer. Computed tomography (CT) showed a circumferential thickening of the lower rectal wall caused by a tumor invading the posterior and side pelvic wall. As we considered R0 resection too difficult, we gave the patient bevacizumab plus FOLFOX4 (oxaliplatin, leucovorin, and 5-fluorouracil). After eight courses, CT showed improvement in the rectal wall thickening but linear thickening of the mesorectal fascia remained. We therefore gave the patient chemoradiotherapy (CRT), and then 10 weeks later performed Hartmann's operation laparoscopically. Microscopic examination revealed that the tumor had been almost replaced by fibrous tissue, with only a few cancer cells left in the subserosa. The circumferential resection margin was free of cancer cells. The patient is doing well after 27 months of follow-up. This case suggests that systemic chemotherapy with FOLFOX4 plus bevacizumab prior to conventional preoperative CRT is a promising strategy for patients with initially unresectable locally advanced rectal cancer.     

Gastroenterological options in faecal incontinence.

Faecal incontinence may be due to a trauma, a rectal prolapse, or a neurological disorder. Obstetric trauma: If the sphincter has been severed, direct repair is indicated. In the case of neurological damage, plication of the levators can provide significant improvement; while the post-anal repair has become popular, anterior sphincter plication and levatorplasty, provide equivalent results. Rectal prolapse: Full thickness rectal prolapse is frequently associated with incontinence. Two categories of operations have been described: local operative procedures (Delorme's plicature, perineal resection) provide poor results in term of restoration of continence and should be reserved to unfit and elderly patients; abdominal operations combine an extensive rectal mobilisation and they differ by the type of fixation. The Ripstein operation (fixation to the promontory by an encircling sling of non absorbable mesh) has long been popular in the United States, but is followed by severe constipation. In the simple suture rectopexy, the rectum is fixed to the pelvic floor and the presacral fascia by non absorbable procedures. In the Ivalon sponge rectoprexy, a polyvinyl alcohol mesh in secured between the sacrum and the rectum, and provides a dense fibrous reaction. In the antero-posterior Marlex rectopexy, a sheet of Marlex mesh is fixed posteriorly to the rectum, and a sling is interposed anteriorly in order to support the anterior wall. In the resection rectopexy, a sigmoid resection in added to the rectal fixation in order to suppress the redundant sigmoid which is responsible for the constipation frequently following rectopexy. Results of abdominal rectopexy are satisfactory in terms of recurrence and restoration of continence.(ABSTRACT TRUNCATED AT 250 WORDS)     

Modified Hartmann procedure in emergency sigmoid colectomy

A new technique has been added to the Hartmann procedure to suture the rectal stump to the presacral fascia using black silk sutures at the time of the initial resection and closure of rectal stump. This will prevent contraction of the rectal stump behind the bladder or vagina deep in the pelvis and makes reanastomosis of the proximal colon to the rectal stump very easy. Also discussed are the advantages of the modified Hartmann procedure in cases of emergency sigmoid colectomy as opposed to the conventional three stage procedure.     

纳米碳淋巴示踪剂在乙状结肠癌及高位直肠癌腹腔镜根治术中的应用

目的:探讨纳米碳淋巴示踪剂在乙状结肠癌及高位直肠癌腹腔镜根治术中的临床应用价值。方法:回顾分析2010年5月至2016年12月为153例乙状结肠癌及高位直肠癌患者行腹腔镜根治术的临床资料,59例患者术前1 d肠镜下于肿瘤周围注射纳米碳(观察组),94例患者直接手术(对照组);分析比较两组大体标本情况及淋巴结检出情况。结果:与对照组相比,观察组标本长度较短[(17.8±5.3)cm vs.(19.7±4.2)cm,P=0.020],近切缘距肿瘤距离较短[(7.3±3.7)cm vs.(8.6±3.3)cm,P=0.028)],远切缘距肿瘤距离较短[(4.7±1.8)cm vs.(5.7±2.6)cm,P=0.014)],淋巴结检出数量较多[(16.9±6.5)vs.(11.2±5.9),P<0.001],淋巴结<12枚比例较低(13.6%vs.59.6%,P<0.001)。结论:腹腔镜乙状结肠癌及高位直肠癌腹腔镜根治术中应用纳米碳淋巴示踪技术有助于指导合理选择手术切除范围,提高淋巴结检出率,具有较高的临床应用价值。     

Robotic rectal cancer surgery: technique of abdomino-perineal resection

Rectal cancer surgery using a minimally invasive technique has been regarded as a challenging procedure. Since the introduction of the robotic surgical system into the operating theater, totally robotic rectal surgery has been attempted with several techniques. Abdomino-perineal resection might be a more reliable indication for totally robotic surgery than low anterior resection. Because the range of dissection is confined to the pelvic cavity and mobilization of the sigmoid colon, problems during totally robotic surgery can be minimized. With our technique, totally robotic surgery can be performed successfully. Technical advantages of the current robotic system can be reflected in patient benefits after totally robotic abdomino-perineal resection.