腹腔镜肿瘤切除术后的穿刺孔转移探讨

自从1987年第一例腹腔镜胆囊切除术(laparoscopiccholecystectomy,LC)成功以后,腹腔镜不仅普遍应用于胆囊切除术中.而且在其它胃肠道外科疾病中也得到了较多的应用,如对胃肠道恶性肿瘤的外科处理,现已运用诊断、分期、早期癌症治疗及缓解晚期疾病等方面.近年来,又新发展起内镜下超声、无气腹腹腔镜及微型腔镜手术等新技术.不仅保留了腹腔镜手术具有的微创、恢复快、痛苦小、对全身免疫系统的干扰较少及术后粘连发生少等优点,又克服了其本身存在的一些缺陷,使之应用范围更广泛,操作更为安全有效.然而,在处理恶性肿瘤的过程中,却出现了穿刺孔种植转移这一术后并发症,本文就近年有关穿刺孔种植转移方面的文献作一综述.     

腹腔镜妇科恶性肿瘤手术的腹壁穿刺孔转移

随着腹腔镜系统、手术器械的不断进步及术者技术水平的提高,腹腔镜等微创技术已广泛应用于妇科恶性肿瘤的诊断与治疗。对于子宫内膜癌、宫颈癌、卵巢癌甚至外阴癌、阴道癌等疾病而言,腹腔镜技术在具备微创优势的同时,各种相关并发症如血管并发症、肠道并发症等也逐渐受到重视。     

腹腔镜胆囊切除术穿刺孔并发症防治

目的 探讨腹腔镜胆囊切除术穿刺孔并发症防治。方法 回顾分析1996年以来腹腔镜胆囊切除术患者2955例临床资料。结果 本组2955例穿刺孔并发症包括感染16例，脂肪液化46例，出血7例，穿刺孔疝2例，线结排异反应25例，断针1例，结石残留6例，切口皮肤边缘部分坏死10例，胆囊癌种植1例。结论 腹腔镜胆囊切除术腹壁穿刺孔应遵循外科基本原则恢复原有的解剖层次，消灭死腔，爱惜组织，注意无菌观念和操作，减少穿刺孔并发症发生。     

术中肝穿刺胆道引流术治疗高位恶性胆道梗阻

术中肝穿刺胆道引流术治疗高位恶性胆道梗阻上海医科大学华山医院外科（２０００４０）倪泉兴，曹国海，张延龄我们自１９９０年６月起对手术证实癌肿无法切除的高位恶性胆道梗阻患者即时作术中肝穿刺胆道引流（ＩＴＣＤ），取得较同期施行的ＰＴＣＤ满意的结果。现将初步...     

缝针穿刺切开胆管法在腹腔镜胆道探查术中的应用

目的：探讨在腹腔镜胆道探查术（laparoscopic common duct exploration, LCDE）中应用缝针穿刺切开胆管法的有效性和安全性。方法：回顾性分析腹腔镜胆道探查手术中应用缝针穿刺切开胆管者75例临床资料。结果：所有患者均采用此法成功切开及探查胆总管,无邻近脏器损伤,无胆瘘及术后出血,无死亡病例;其中腹腔镜中转开腹2例,中转开腹原因1例为胆总管十二指肠内瘘,1例胆总管下段“铸型”结石嵌顿胆道镜无法取出。术后所有患者获4个月至2年随访,均未见胆道狭窄。结论：缝针穿刺切开胆管法是一种在腹腔镜下简单、有效和安全的解剖及切开胆总管的方法。     

腹腔镜术后穿刺孔疝的临床治疗及分析

探讨腹腔镜术后穿刺孔疝的临床特点、诊断、预后及治疗,以提高对此并发症的认识。通过分析本院三例腹腔镜术后穿刺孔疝的临床资料,并进行相关文献复习来总结其治疗效果。腹腔镜术后穿刺孔疝患者均有腹痛或腹胀、恶心及呕吐表现。腹部CT或B超均显示肠梗阻或穿刺孔疝表现。3例患者均治愈。腹腔镜穿刺孔疝虽然发生率较低,但后果严重,对该并发症的危险因素进行预防,早期诊断及治疗可望减少此类并发症及其造成的后果     

腹腔镜穿刺孔大出血的预防和处理(附五例报告)

目的探讨腹腔镜手术后穿刺孔大出血的预防和处理。方法回顾性分析我院2000年5月至2013年8月间5例腹腔镜手术后穿刺孔大出血的病例资料。结果5例病人术后出血量500~1200 ml,均经再次腹腔镜探查手术,最后确诊为腹壁穿刺孔出血,除1例肝硬化门脉高压病人为脐部交通静脉损伤出血外,其余4例均为腹壁肌层或腹膜外动脉损伤出血;并在腹腔镜直视下穿刺孔部位重新缝合止血,均治愈。结论腹腔镜手术中重视穿刺孔出血是防止术后腹腔大出血的重要原因。     

缝针穿刺胆管切开法在腹腔镜再次胆道手术中的应用

目的探讨一种腹腔镜再次胆道术胆总管处理技巧——缝针穿刺切开胆管法的有效性和安全性。方法回顾性分析和总结我科自2006年8月至2009年6月期间完成的56例既往行胆道手术的患者再次行腹腔镜胆道探查术中应用缝针穿刺切开胆管法的临床资料。结果所有患者均采用此法成功切开及探查胆总管,无邻近脏器损伤,无胆漏及术后出血,无死亡病例,其中腹腔镜中转开腹3例,术后所有患者获3个月至3年的随访,均未见胆管狭窄。结论缝针穿刺切开胆管法是一种对既往有胆道手术史患者行腹腔镜下简单、有效和安全的解剖及切开胆总管的方法。     

腹腔镜术穿刺孔出血的原因分析及其对策

目的探讨腹腔镜术穿刺孔出血的原因及其对策。方法对自1992年5月至2006年8月间腹腔镜穿刺孔出血21例病例进行回顾性分析。结果21例穿刺孔出血均发生在1.1cm穿刺孔,其中腹膜层出血5例,肌层出血7例,皮下层出血9例;术中发现并处理8例,术后发现并处理13例,均治愈出院。结论术前准备不充分,穿刺部位选择不当,穿刺操作不规范及标本取出时盲目扩张等是穿刺孔出血的根本原因;术中应对各穿刺孔仔细观察从而及时发现穿刺孔出血;术中应对穿刺孔出血彻底止血;术后出现穿刺孔出血,应根据不同原因合理选择治疗方式。     

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目的　研究腹腔镜结直肠癌手术对肿瘤切口种植及脏器转移的影响。方法　选用人结肠癌细胞 (Lo Vo细胞 )悬液 (1× 10 7/L) ,OT针注入雌性Balb/C裸鼠盲肠浆膜下 (0 1mL) ,建立人结肠癌细胞裸鼠原位种植模型。 2周后 ,实验裸鼠随机分为 3组 :CO2 人工气腹术组 (31只 )、剖腹术组 (31只 )、和未行手术组 (30只 )。 10周后 ,3组裸鼠均脱颈法处死 ,探查肿瘤细胞原位种植及致瘤鼠肿瘤细胞切口种植及各脏器转移情况。结果　 (1) 3组裸鼠的致瘤率为 :CO2 人工气腹组 2 3/ 31例 ,开腹术组 2 2 / 31例 ,未手术组 2 1/ 30例 ,差异无显著意义。 (2 )CO2 人工气腹术组的 2 3只致瘤鼠中 ,有 2只发生切口种植 ,12只发生脏器转移 ;开腹术组的 2 2只致瘤鼠中 ,有 4只发生切口种植 ,13只发生脏器转移 ;未手术组 2 1只致瘤鼠中 ,有 10只发生脏器转移 ,致瘤裸鼠的切口种植及脏器转移率差异无显著意义。结论　CO2 人工气腹没有促进人结肠癌细胞裸鼠原位种植模型切口种植及脏器转移的发生 ,腹腔镜结直肠癌手术具有一定的安全性与可行性。     

Port-site metastasis after CO<Subscript>2</Subscript> pneumoperitoneum

Background Port-site metastasis is a continuing problem in laparoscopic cancer surgery. To clarify the role of adhesion molecules in the development of port-site metastasis, particularly with regard to prevention, we performed experiments in which port-site metastasis was inhibited using antibodies against extracellular matrix proteins or the active Arg–Gly–Asp (RGD) peptide after CO₂ pneumoperitoneum in a murine model.Methods We examined the development of port-site metastasis under the following conditions: (1) CO₂ pneumoperitoneum with or without hyaluronic acid and anti-integrin or anti-CD44 antibody and (2) CO₂ pneumoperitoneum and a RGD peptide or pseudo-RGD sequence peptide (FC-336). BALB/c mice (n = 130) were injected with 5 × 10⁵ human gastric cancer cells (MKN45) and either antibody or peptide, treated with CO₂ pneumoperitoneum, and injected intraperitoneally with antibody or peptide for 5 days. Three weeks after CO₂ pneumoperitoneum, the frequency and weight of port-site metastatic tumors were determined.Results Anti-integrin antibody significantly decreased the weight of port-site metastatic tumors without hyaluronic acid (control vs anti-integrin: 8.2 ± 7.1 vs 3.6 ± 4.5 mg; p < 0.05) but not the frequency of port-site metastases. With hyaluronic acid, the frequency of port-site metastasis and the weight of port-site metastatic tumors were significantly decreased both by anti-integrin and by anti-CD44 antibody (control vs anti-integrin and anti-CD44; 95% and 8.5 ± 7.2 mg vs 50% and 3.1 ± 4.3 mg and 55% and 3.3 ± 5.1 mg, respectively; p < 0.05). RGD peptide and FC-336 also inhibited port-site metastasis in a dose-dependent manner.Conclusion Cell adhesion molecules integrin and CD44 play an important role in the development of port-site metastasis after laparoscopic cancer surgery. Intraperitoneal injection of RGD peptide or pseudo-RGD sequence peptide (FC-336) can prevent port-site metastasis.     

Port-site metastases of adenocarcinoma of the fallopian tube after laparoscopically assisted vaginal hysterectomy and salpingo-oophorectomy

Port-site metastases following laparoscopic surgery for cancer constitute an emerging problem. We report a case of cutaneous metastasis at a port site following laparoscopically assisted vaginal hysterectomy and salpingo-oophorectomy for unsuspected adenocarcinoma of the fallopian tube. This complication occurred 7 months postoperatively and was treated with resection. A single site was involved. Possible etiologies are implantation from ``contaminated' instruments or dissemination of tumor cells by the positive-pressure pneumoperitoneum. Preventive measures include precise and clean surgical technique, the use of a nonporous bag, postoperative trocar-site excision or irradiation, and conversion to laparotomy either intra- or postoperatively.     

Port-site recurrence reproduced in the VX-2 rabbit carcinoma model: an in vivo model comparing laparoscopic port sites and open incisions.

BACKGROUND: The use of advanced laparoscopy remains controversial in the field of surgical oncology because the potential for port-site recurrence may violate sound oncologic principles. Two mechanisms are theorized to be the cause of port-site recurrences: first, indirect contamination caused by pneumoperitoneum, aerosolization, or intraperitoneal spread, and second, direct contamination by physical trocar seeding. METHODS: A VX-2 carcinoma cell suspension was transferred under the left renal capsule of 31 rabbits with either an open flank incision (16) or laparoscopy (15). Animals were observed for tumor recurrence at the video port, the working port, and the open incision. Intraoperative findings and necropsy were used to document recurrence. RESULTS: The open incision technique resulted in local tumor recurrence in 1/16 animals with 16/16 viable intraabdominal tumors. The laparoscopic technique resulted in 0/15 video port-site recurrences and 9/15 working port-site recurrences, with 14/15 viable intraabdominal tumors. Recurrence at the laparoscopic working port occurred more frequently than in the open (P < 0.02) or laparoscopic video port groups (P < 0.007). No significant difference existed in recurrence between the open incision and the laparoscopic video port (P > 0.5). CONCLUSIONS: Laparoscopic port-site recurrences can be reproduced using the transplantable VX-2 rabbit carcinoma model. In the VX-2 model, trocar recurrence is the result of direct contamination via surgical instrumentation of viable tumor cells. The effect of the pneumoperitoneum or intraperitoneal cytological spillage (indirect contamination) does not have any effect on trocar recurrence. This model can be used to test and improve laparoscopic techniques to minimize the risk of port-site recurrence. Until technological advances have eliminated the risk of trocar recurrences, direct contact between malignant cells and laparoscopic instruments should be performed with caution.     

Hepatic metastasis after laparoscopic cholecystectomy for polypoid gallbladder cancer followed by radical surgery

While laparoscopic cholecystectomy is being increasingly performed on patients with gallbladder disease, this approach in cases of polypoid lesions in the gallbladder may not always be justified. We report here a case of early development of intrahepatic metastasis after laparoscopic cholecystectomy for polypoid gallbladder cancer; wedge resection of the gallbladder bed and dissection of regional lymph nodes had to be done. When a malignancy of the gallbladder is suspected during preoperative examinations, open cholecystectomy should be done.     

Hyaluronic acid secretion during carbon dioxide pneumoperitoneum and its association with port-site metastasis in a murine model

Background: The mechanism of port-site metastasis after laparoscopic cancer surgery is unclear. This study aimed to determine whether carbon dioxide (CO2) pneumoperitoneum caused an increase in hyaluronic acid, which is secreted from mesothelial cells of the peritoneal cavity, and to assess the risk for port-site metastasis using a murine pneumoperitoneal model. Methods: Sandwich-binding protein assay was used to measure the concentration of hyaluronic acid in the peritoneal cavity at 6, 12, 18, 24, 48, and 72 h after CO2 pneumoperitoneum or laparotomy for 30 min. The concentrations of hyaluronic acid during pneumoperitoneum were compared among different gases (CO2, helium, air), intervals (5, 30, 60 min), and pressures (0-2, 4-6, 8-10 mmHg). To investigate the effects of exogenous hyaluronic acid, the development of port-site metastasis was examined using mouse adenocarcinoma cell-line colon 26 cells. Results: The intraperitoneal concentration of hyaluronic acid after CO2 pneumoperitoneum had increased already at 6 h, had reached the maximum level at 24 h, and had begun to decrease at 72 h. The concentration of hyaluronic acid at 24 h and 48 h in the CO2 pneumoperitoneum group was higher than that in the laparotomy group. This increase in hyaluronic acid also was found during helium and air pneumoperitoneum, and the concentration of hyaluronic acid in the peritoneal cavity was at its maximum when CO2 pneumoperitoneum lasted 30 min at 4 to 6 mmHg. The frequency of port-site metastasis was the highest when hyaluronic acid was injected during CO2 pneumoperitoneum (100%). Conclusions: In a murine model, the intraperitoneal concentration of hyaluronic acid was significantly increased after CO2 pneumoperitoneum, and the increase was more evident than that after laparotomy. Increased hyaluronic acid during pneumoperitoneum may be associated with port-site metastasis after laparoscopic cancer surgery.     

手术机器人系统和腹腔镜微创外科技术在胃癌治疗中的应用

腹腔镜外科在胃癌治疗中面临着两大困难,即D2淋巴结清扫及全腹腔镜下的消化道重建。而手术机器人系统具有图像立体三维、放大10倍、有7个自由度关节的器械和医生工作体位舒适等优点,有利于行胃癌D2淋巴结清扫及消化道吻合重建．增强微创手术的优势,拓展微创外科在胃癌治疗中的适应证。在加速康复外科理念下开展微创手术治疗胃癌,必将有利于促进患者的快速康复。     

Comparison of robotic reduced-port and laparoscopic approaches for left-sided colorectal cancer surgery

Background/objectiveThe reduced-port approach can overcome the limitations of single-incision laparoscopic surgery while maintaining its advantages. Here, we compared the effects of robotic reduced-port surgery and conventional laparoscopic approaches for left-sided colorectal cancer.MethodsBetween January 2015 and December 2016, the clinicopathological characteristics and treatment outcomes of 17 patients undergoing robotic reduced-port surgery and 49 patients undergoing laparoscopic surgery for left-sided colorectal cancer were compared.ResultsThe two groups were comparable in almost all outcome measures except for the distal resection margin, which was significantly longer in the laparoscopic group (P < 0.001). The between-group differences in reoperation, incisional hernia development, and overall and progression-free survival were nonsignificant; however, the total hospital cost was significantly higher in the robotic group than in the laparoscopic group (US$13779.6 ± US$3114.8 vs. US$8556.3 ± US$2056.7, P < 0.001).ConclusionRobotic reduced-port surgery for left-sided colorectal cancer is safe and effective but more expensive with no additional benefit compared with the conventional laparoscopic approach. This observation warrants further evaluation.     

急诊腹腔镜手术治疗急性胆源性胰腺炎

目的探讨急诊腹腔镜手术治疗急性胆源性胰腺炎（acute biliary pancreatitis，ABP）可行性及疗效。方法2001年5月～2005年12月对87例ABP行急诊腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）；对胆总管结石和（或）胆总管增宽者，行腹腔镜胆总管探查术（laparoscopic common bile duct exploration，LCBDE）并置T管引流。结果手术成功75例，其中单纯LC 20例，LC联合LCBDE 55例（49例同时行胰腺被膜切开、腹腔置管灌洗引流术）；中转开腹手术12例。87例随访3～58个月，平均28．2月，无手术并发症和（或）胰腺炎及胆总管结石复发。结论急诊腹腔镜手术治疗ABP安全可行，疗效明确。     

Postural ergonomics during robotic and laparoscopic gastric bypass surgery: a pilot project

We hypothesized that a laparoscopic technique for Roux-en-Y gastric bypass surgery is associated with more musculoskeletal discomfort and ergonomic strain than a robotic technique. This pilot project studied one surgeon while he performed four laparoscopic and four robotic (da Vinci system) Roux-en-Y gastric bypass procedures. We measured musculoskeletal discomfort with body part discomfort score (BPD) and ergonomic positioning with the rapid upper-limb assessment tool (RULA). At the end of the case, the robotic cases were associated with more discomfort in the neck (median BPD scores 2.5 versus 1.0, P = 0.028), while the laparoscopic cases were associated with more discomfort in the upper back (median BPD scores 2.0 versus 1.0, P = 0.028). Both the right and left shoulders demonstrated more discomfort with the laparoscopic group (median BPD scores 3.0 versus 1.5, P = 0.057). The RULA analysis demonstrated that the upper arm (1.0 versus 2.25), lower arm (1.125 versus 2.125), wrist (2.5 versus 3.5) and wrist twist (1.25 versus 2) were held in less ergonomically correct positioning (higher score) in the laparoscopic group compared to the robotic group (P = 0.029). In contrast, the trunk (1.5 versus 1.0) had a worse RULA score in the robotic group compared to the laparoscopic cases. These pilot data suggest that robotic Roux-en-Y gastric bypass surgery may result in less musculoskeletal stress to the upper extremities than standard laparoscopic technique. In contrast, robotic surgery seems to offer both postural advantages and disadvantages for the neck and back region. More-detailed studies are needed to fully assess the potential postural advantages of robotic surgical techniques over standard laparoscopy.