同濟外科學之微創(chuàng)外科技術

1、微創(chuàng)外科技術MINI-INVASIVE SURGERY,不低于或高于傳統(tǒng)治療效果前提下盡可能減少病人的近期和遠期的痛苦,微創(chuàng)外科技術MINI-INVASIVE SURGERY,包括腔鏡外科內(nèi)鏡外科 各種影像學介導下的治療技術,外科腔鏡,LAPAROSCOPY,LAPAROSCOPY,腔鏡簡史,1901 KELLING膀胱鏡觀察狗腹腔1910 JACOBAEUS腹腔鏡觀察人腹腔1938 VERESS發(fā)明彈簧氣腹針1950

2、HOPKING 柱狀透鏡 圖像清晰1960 SEMM 婦科腹腔鏡手術1987 MOURET1988 DUBOIS腹腔鏡膽囊切除術,腹腔鏡設備器械,腹腔鏡 光學傳導作用微型攝像頭及數(shù)模轉(zhuǎn)換器顯示器冷光源錄像機及圖象存儲CO2氣腹系統(tǒng)手術設備器械,腹腔鏡設備器械,,基本技術,建立氣腹 1直接TROCAR穿刺法 2 氣腹針穿刺法 3開放法止血 電凝 鈦夾 超聲刀 縫合 紗布填塞,基本技術,組織分離切開

3、 電刀 剪刀 超聲刀 分離鉗撕剝腹腔鏡縫合標本取出 TROCAR孔 小切口 粉碎 標本袋,建立氣腹,腹腔鏡手術資質(zhì),傳統(tǒng)外科培訓腹腔鏡基礎知識培訓動物實驗非獨立完成一定數(shù)量腹腔鏡手術,腹腔鏡手術適應證,膽囊切除術 結(jié)腸良惡性疾病闌尾切除術 食管反流手術小腸切除術 疝修補術脾切除術 腎上腺切除術淋巴清掃術 肝楔形切除術婦科手術 腹腔鏡診斷術,腹

4、腔鏡診斷,單獨診斷應用較少有創(chuàng)檢查 需要麻醉 深部病變發(fā)現(xiàn)率低,腹腔鏡膽囊切除術LAPAROSCOPIC CHOLECYSTECTOMY,適應證 與開腹手術指證相同 膽囊息肉 膽囊結(jié)石 充滿型膽囊結(jié)石 急性膽囊炎膽總管探查 造影,,,,LAPAROSCOPIC CHOLECYSTECTOMY,禁忌證 嚴重肝硬化 凝血障礙 妊娠 病理性肥胖 嚴重心肺功能不全,LAPAROSCOPIC CHOLECYSTECTOMY,

5、相對禁忌證 上腹部手術史嚴重萎縮性膽囊炎,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,,,,,LAPAROSCOPIC CHOLECYSTECTOMY,,LAPAROSCOPIC CHOLECYSTECTOMY,,LAPAROSCOPIC CHOLECYSTECTOMY,,LAPAROSCOPIC CHOLECYSTECTOMY,,,LAPAROSCOPIC C

6、HOLECYSTECTOMY,Risks of surgery,Bleeding (needing transfusion) - 2%Infection - 2%Conversion to open surgery - 2%Bile leak - 2%,Risks of surgery,Retained stone in the common bile duct - variable depending on preoper

7、ative tests Injury to the common duct 0.2 %Injury to other structures in the abdomen including small intestines, liver, and blood vessels - <1% Hernia development at incision sites - < 1%,腹腔鏡膽囊切除術并發(fā)癥及處理,一血管損傷

8、 1大血管損傷 腹主動脈 門靜脈 腸系膜上動脈 下腔靜脈－－立即開腹止血 2手術區(qū)出血 膽囊動脈 膽囊床出血－－電凝 鈦夾 紗條填塞,腹腔鏡膽囊切除術并發(fā)癥及處理,二膽道損傷1膽管橫斷－－ 修復 T管引流 ROUX-Y盆式吻合,腹腔鏡膽囊切除術并發(fā)癥及處理,2肝管側(cè)面損傷－－T管引流 ENBD 3膽囊管漏－－腹腔引流 ENBD 4膽管損傷后狹窄－－ROUX-Y肝門盆式

9、吻合,LC并發(fā)癥預防,根據(jù)自身能力嚴格掌握適應癥第一戳孔要小心將膽囊三角完全分離清晰后再斷膽囊管近膽管處慎用電凝,LC并發(fā)癥預防,出血時不盲目上鈦夾膽囊破裂者要用標本袋解剖不清 手術困難 出血不能控制及時開腹放置腹腔引流管便于發(fā)現(xiàn)并發(fā)癥,腹腔鏡在胃腸道手術中的應用現(xiàn)狀與展望,腹腔鏡直結(jié)腸手術,結(jié)直腸惡性腫瘤 是腹腔鏡消化道外科最成熟的手術 手助技術應用降低了中轉(zhuǎn)開腹率 直腸全系膜切除更方便盆腔

10、植物神經(jīng)識別保護 更確切 前瞻性多中心隨機對照研究表明生存率相當 長期存活率 衛(wèi)生經(jīng)濟學評價是今后關注焦點 執(zhí)業(yè)環(huán)境惡化價格昂貴是該技術推廣的最大障礙,,結(jié)直腸良性疾病,乙狀結(jié)腸息室有望成為標準手術潰瘍性結(jié)腸炎進展緩慢治療CROHN病近期效果得到認可,腹腔鏡胃手術,胃腫瘤手術 胃腫瘤局部切除 胃楔形切除 胃遠端切除 后者手術困難推廣有困難腹腔鏡胃減容術胃短路手術胃底折疊術 如NISSEN手術

11、小腸腫瘤手術,腹腔鏡在腹部實質(zhì)性臟器手術中的應用現(xiàn)狀及展望,,肝臟(LH),易出血為主要障礙 處于嘗試階段適應證 Ⅱ－ⅳ段 腫塊直徑≤10CM血管瘤 多發(fā)肝囊腫 肝內(nèi)膽管結(jié)石肝腺瘤有氣栓的危險缺乏理想的刀具（超聲刀螺旋高壓水刀 微波刀 LIGASURE ENDO-GIA）,,肝臟(LH),,,胰腺,Diagnostic and exploratory laparoscopy in patients with cancer of

12、the pancreaselaparoscopic distal pancreatectomy for endocrine and cystic tumors,急性壞死性胰腺炎假性胰腺囊腫內(nèi)引流胰島細胞瘤剜除術胰體胰尾切除胰十二指腸切除－－沒給病人帶來實質(zhì)性好處,,laparoscopic Whipple operation. chronic pancreatitis, and small cystic and endocr

13、ine tumors of the pancreas and patients who have ampullary cancerEnucleation of pancreatic islet cell tumorshttp pancreatic pseudocyst,脾臟 Laparoscopic Splenectomy,LS安全可靠手助法 全腹腔鏡法適應證 ITP 脾占位 脾亢 脾外傷脾蒂處理困難ENDO-GIA昂貴,L

14、aparoscopic Splenectomy,,,Laparoscopic Splenectomy,,,Laparoscopic Splenectomy,,,腹腔鏡在其它手術中的應用,甲狀腺,滿足美容要求并非微創(chuàng)局限良性疾病對甲狀腺癌的腔鏡手術存在疑慮手術時間長,,乳腺良性腫瘤切除腋窩淋巴清掃乳腺前哨淋巴結(jié)活檢疝修補術LIHR 有四種方法內(nèi)環(huán)關閉 IPOM腹腔內(nèi)補片植入法 TAPP經(jīng)腹腹膜前補片植入法 TEP全腹膜外補片

15、植入法,內(nèi)鏡外科技術,內(nèi)鏡種類,胃鏡 十二指腸鏡結(jié)腸鏡小腸鏡膽道鏡胰管鏡乳管鏡腹腔鏡胸腔鏡,氣管鏡膀胱鏡輸尿管鏡腎盂鏡宮腔鏡關節(jié)鏡椎間盤鏡腦室鏡心鏡,gastroscope,,,十二指腸鏡duodenoscope,,,colonoscope,,colonoscope,,,colonoscope,,,choledochoscope,,,腹腔鏡laparoscope,,內(nèi)鏡配置,內(nèi)鏡系統(tǒng) 內(nèi)鏡 主機－光源 監(jiān)

16、視器手術設備 手術器械,內(nèi)鏡外科基本技術,注射術鉗夾術切除術導線置入術擴張術支架置放術引流術碎石術,,內(nèi)鏡外科基本技術,氬氣刀凝切術十二指腸乳頭切開術,內(nèi)鏡外科的臨床應用,消化道出血食管胃底曲張靜脈破裂出血潰瘍出血消化道腫瘤出血消化道息肉出血,內(nèi)鏡外科的臨床應用,消化道惡性腫瘤早期腫瘤拒絕手術或無法手術者晚期腫瘤止血 再通,,,.  內(nèi)鏡外科的臨床應用,Polypectomy can be d

17、efined as the endoscopic resection of polyps or tumors, obviating the need for open surgery. This is one of the most important scientific advances in the field of gastroenterology, since it enables us to treat many gastr

18、ic or colonic tumors, without the inconvenience associated with major surgery,,Endoscopic snare resection of a villous adenoma of the ampulla of Vater,,.,內(nèi)鏡外科的臨床應用,胃腸道息肉gastric and colonic polyps良性腫瘤,,內(nèi)鏡外科的臨床應用,良性狹窄食管瘺

19、胃石癥肝膽胰疾病,乳頭切開支架術,內(nèi)鏡外科的臨床應用,肝外膽管結(jié)石乳頭切開取石術碎石術electrohydraulic lithotripsy引流術,十二指腸乳頭切開術sphincterotomies,,ERCP取石,內(nèi)鏡外科的臨床應用,,,膽道梗阻 漏與炎癥 外引流術ENBD 內(nèi)引流術,內(nèi)鏡外科的臨床應用,肝內(nèi)膽管結(jié)石 PTCS+EHL急性胰腺炎sphincterotomies＋ ENBD,外科手術并發(fā)癥的內(nèi)鏡治療,食管

20、穿孔食管吻合口瘺吻合口狹窄膽道狹窄膽瘺肝移植術后膽道狹窄,肝移植術后膽道狹窄,,,,,,Fig. 1. A 57-year-old male with choledocho-choledochostomy after living donor liver transplantation. A. The cholangiography obtained after transhepatic insertion of a bil

21、iary drainage catheter shows a biliary anastomotic stricture, which divided the fifth and eighth segment ducts from the sixth and seventh segment ducts (white and black arrow). B. An 8 mm diameter balloon catheter was p

22、ositioned through the anastomotic stricture. C. Two internal-external biliary drainage catheters (12 and 14 F) were inserted after biloplasty. D. The cholangiogram after the large profile catheter maintenance method (3

23、 months) shows patent bile ducts (arrow), with excellent flow of contrast medium into the duodenal loop.,Fig. 2. A 56-year-old man with choledocho-choledochostomy after living donor liver transplantation. A. The cholang

24、iography obtained during transhepatic insertion of a biliary drainage catheter shows a biliary anastomotic stricture (arrow). B. An 8 mm diameter balloon catheters was positioned through the anastomotic stricture. C. A

25、 percutaneous transhepatic cholangiographic catheter (16 F) was inserted after biloplasty. D. The cholangiogram after the large profile catheter maintenance method (2 months) shows patent bile ducts (arrow), with excell

26、ent flow of contrast medium into the duodenal loop.,超聲內(nèi)鏡外科技術,診斷 活檢 治療（有限） 顯示食管曲張靜脈 顯示早期胃癌 顯示巨脾壓迫胃,,介入治療技術 interventional therapy,通過現(xiàn)代影像學技術和導管對遠處外科疾病實施治療的技術,血管內(nèi)途徑介入,藥物灌注術,血管內(nèi)途徑介入

27、,化療栓塞術 栓塞術 血管成形術 藥盒置入術 內(nèi)支架術TIPS,血管外介入治療,PTCD 經(jīng)皮膽管球囊擴張術經(jīng)皮肝穿刺膽道內(nèi)支架術,,血管外介入治療,微波組織凝固術percutaneous implant microwave tissue coagulation射頻消融術radiofrequency ablation,radiofrequency ablation,,radiofrequency ablation,rad