腹腔镜结直肠癌根治术中结肠血管变异的应对措施

往腹腔镜结直肠癌根治术中．当切除肿瘤后进行消化道重建时，远近端肠管有时会出现血运改变，术中难以对肠管生机进行判断。术中肠管血运改变主要与结肠系膜皿管的解剖学因素和手术操作有关。结肠壁的直接血供来源是边缘血管弓，边缘血管弓的完整性、通畅性是决定肠管存活率的关键.然而，边缘向．管弓在不同区段直径大小不等，搏动强弱不一．有时甚至中断，对术中结肠的切除吻合造成影响。最常见的3处吻合不全区域有：（1）回结肠动脉与有结肠动脉之间：（2）中结肠动脉与左结肠动脉之间——睥曲的Griffiths关键点；（3）乙状结肠动脉最下支与直肠上动脉之间——Sudeck危险区．在腹腔镜结直肠癌根治手术中，应注重预防性保护残留肠管的血供，保护边缘血管弓，警惕上述3处的血管解剖变异．应在精准的解剖部位结扎血管，以保证残端的良好血供．从而确保结直肠吻合口的正常愈合。对于老年体弱或糖尿病等患者，尤其注意保护结肠血运，如埘吻合口有疑虑，应行保护性末端回肠造口。

Measures to anatomic variations of the colonic vessels in laparoscopic operations

In laparoscopic colorectal resection, the poor blood supply of the anastomosis after tumor excision is difficuh to be determined during the operations sometimes. The ehange ill blood supply of the bowel is mainly due to the mesenteric anatomy and the operative teehniques. The direct blood supply of colon is the marginal vessels in the mesentery. The integrity and patency of the marginal vessels determine tile vitality of the bowel. However, the marginal vessels al~ different ira diameter, pt, lsation or even discontinue in various areas, affecting the excision of the colon and following anastomosis. The most common three dangerous areas to anaslomosis include： （l）area between ileoeolie artery and right cohmie artery; （2）area between middle colonic m＇tery and left colonic artery-the Griffiths point. （3）area between the terminal branch of sigmoid colonic artery, and superior rectal artery- Sudeek dangerous area. In laparoscopic colureeial resection, one should pay attention to protect the blood supply of the bowel and the margi,ml blood vessels, and be vigilant to the three vascular variations above mentioned. The vessels should be ligated accurately to ensure sufficient blood supply to tire anastomosis and consequent normal healing of the rectal and colonic anastomosis. More attention shouht be paid to the elderly, morbid, and diabetic patients. If the safety of tire anastomosis is unsure, prophylactic ileostomy should be performed.