镜面人胸腔镜肺癌根治术PPT课件.ppt

“镜面人”胸腔镜手术经验分享,1,“镜面人”,“镜面人”又称“镜子人”或“镜像人”，即心脏、肝脏、脾脏、胆等器官的位置与正常人相反，心脏、脾脏在右边，肝脏位于左边，心、肝、脾的位置好像是正常脏器的镜中像。,2,左肺位于右侧，左肺门形态同正常右肺门，右肺及右肺门则相反。心脏大部分位于右侧胸腔，主动脉、心尖、胃泡轴线同在右侧。升主动脉、右心房、肝脏轴线在左侧，右肺低于左膈，形如“镜像”。,3,“镜面人”虽然内脏全部错位，但只是位置发生变化，相互间的关系并未改变，因此生理功能与正常人一样，对健康与生活都没有太大影响。但值得注意的是，“镜面人”一旦患病，医生如果照常规判断极有可能发生误诊。,4,“镜面人”虽然内脏全部错位，但只是位置发生变化，相互间的关系并未改变，因此生理功能与正常人一样，对健康与生活都没有太大影响。但值得注意的是，“镜面人”一旦患病，医生如果照常规判断极有可能发生误诊。,5,全内脏反位是人体胚胎发育过程中由于内脏发生旋转障碍而使全部内脏器官形成解剖结构的变异，发病率为12000014000，男女比例为3：2，患者通常无症状，与普通人寿命差异无统计学意义，确切的病因未知。它本身没有临床意义，但可能影响手术部位。目前，国内已有“镜面人”患者行肝脏、心脏、肾上腺手术的多例报道，关于全内脏反位同时合并肺癌的报道不多。,6,医疗特点,为“镜面人”做手术，极大地考验了术者的逆向思维能力，脏器的反位使手术难度和手术风险都增大。医生的手术习惯、技巧等也都要跟着一起“转位”。原本技术越熟练的医生可能越会犯错。对病人来说，风险也在增大。,7,给“镜面人”做手术，花费的时间远比正常人多，而且，有些内脏手术还可能需要重新准备手术器械。许多医生在为“镜面人”做手术之前，还要经过模拟演习。,8,病例介绍,患者男，64岁，2017年5月就诊，体检发现左肺肿物2周，行胸部PET-CT示：全内脏反位，镜面右位心；左中叶占位性病变，代谢增高，周围型肺癌可能双侧颈部、双侧肺门、4、5、6淋巴结，腹腔及双侧腹股沟多发淋巴结，考虑炎性；患者为行进一步诊治，就诊于天津一中心医院。否认家族中有类似病患者，否认两系三代家庭性疾病遗传史。,9,病例,查体：体温36.4，心率70次分，呼吸16次分，血压12080mmHg，体重70kg，发育正常，营养中等，自主体位，神清合作，颈软，无颈静脉怒张，心律齐，无杂音，胸廓对称无畸形，呼吸运动自如，两侧语颤基本正常，胸壁无压痛，叩诊呈清音，双肺呼吸音清，未闻及干湿罗音，双下肢无水肿。纤维支气管镜示：隆突锐利、黏膜光滑、活动度好、位置正常；总气管、左右主支气管、左上中下支气管、右上下支气管黏膜光滑，色泽正常，管腔通畅，无新生物及分泌物。（麻醉前气管插管前细镜）心电图示：I导联、avL导联P波倒置，QRS波以向下波为主，avR导联P波直立，V。一V，导联R波逐渐减小，s波逐渐增深，RS比例逐渐减小。将左右手反接，胸导联V，V。置于右胸对应部位的心电图示：V，V。导联R波逐渐增高，s波逐渐减少，RS比逐渐增大。,10,病例,11,病例,12,病例,13,手术记录,双腔插管全麻成功后，取右侧卧位，分别取第7肋间腋中线、第4肋间腋前线，第8肋间肩胛下角线分别做小切口，置入胸腔镜及操作器械，探查见肿物位于左肺中叶外侧段肺实质内，直径约1.5cm，质地韧，边界清楚，不光滑，不活动，表面脏层胸膜凹陷，肺门周围可见多发明显肿大淋巴结。肿物深在，无法行肺楔形切除术，遂按术前预案决定直接行胸腔镜下肺叶切除术。镜下游离肺门周围纵隔胸膜，切断下肺韧带。游离左侧中叶静脉，以内镜血管缝合切开器切断。打开斜裂，游离左肺中叶动脉外侧段分支，以内镜血管缝合切开器切断。游离左肺中叶支气管，以内镜直线缝合切开器闭合后，通气见左肺上下叶可充分复张，遂切断中叶支气管。游离中叶动脉内侧段分支，以内镜血管缝合切开器切断。以内镜直线缝合切开器切开分化不全的水平裂后将左肺中叶完整切除。清扫2、4、7-10组淋巴结,14,对全内脏转位伴肺癌患者进行肺外科手术时，麻醉医师及手术医师均应重视并理解异常的胸腔解剖。全内脏转位患者心脏及主动脉弓、食管位于右侧，右肺只有两叶，支气管及动静脉血供情况类似正常人左肺情况；左侧胸腔没有心脏及主动脉弓，有脐静脉弓、上腔静脉等结构，左肺有三叶，支气管及动静脉血供情况类似正常人右肺情况。术前气管镜检查、胸部CT扫描及心脏肺大血管三维重建可以显示支气管树及肺门结构异常，协助评估异常的胸腔解剖对肺癌手术的影响。,15,病理-腺癌,16,Lobectomyforlungcancerbyvideo-assistedthoracicsurgeryinsitusinversus.湘雅医院中南大学胸腔镜右下叶2017,A62-year-oldmanwithsitusinversustotalisandnon-small-celllungcancerunderwentarightlowerlobectomybyvideo-assistedthoracoscopicsurgery.Lobectomyinasitusinversustotalispatientcanbeperformedsafelyusingthisminimallyinvasiveprocedure.Preoperativeevaluationofthepulmonaryarteryandveinsbythree-dimensionalcomputedtomographyandthebronchialtreebybronchoscopy,isessentialtoavoidunanticipatedcomplicationsduringtheprocedure.AsianCardiovascThoracAnn.2017Mar;25(3):219-221,17,Abstract：Lungcancerandsitusinversustotalisaretwocompletelyirrelevantconditions.Thelikelihoodofbothconditionsoccurringsimultaneouslyinonepersonisveryrare.Wereporthereacaseofa50yearoldmanwhopresentedwithintermittentchestpain.Enhancedcomputedtomographyofthechestshowedsitusinversustotalisandaroundmediastinalmassembracingthethoracicaorta.Theprimarydiagnosiswassuggestedaspseudoaorticdissectinganeurysm.However,atumorintherightlowerlungwasdiscoveredduringsurgery,whichenclosedandinvadedthethoracicaorta.Finally,thepatientsuccessfullyunderwentrightlowerlobectomyaccompaniedbylymphnodeexcisionandpartialreplacementofthethoracicaortawithanartificialvasculargraftundercardiopulmonarybypass.,Lungcancermimickingaorticdissectinganeurysminapatientwithsitusinversustotalis2016华西右下叶切除,18,Lungcancermimickingaorticdissectinganeurysminapatientwithsitusinversustotalis2016华西,ThoracCancer.2016Mar;7(2):254256.,19,Apatientwithsitusinversustotalisandlungcancer-ararecombination胸腔镜左下叶2016,Situsinversustotalis(SIT)isarareclinicalentitywhichischaracterizedbyacompletereverseanatomyofthethoraciccageandabdomen.ThereareafewreportsofpatientswithSITandlungcancer.Thenumberofthecasesthathavebeentreatedsurgicallyisalsoverysmall.Wereportacaseofan80yearsoldpatientwhounderwentleftlowerlobectomyafterstagingwithuniportalvideo-assistedthoracoscopicsurgery(VATS)andmediastinoscopy.AnnTranslMed.2016Nov;4(22):450.,20,Apatientwithsitusinversustotalisandlungcancer-ararecombination.AnnTranslMed.2016Nov;4(22):450.,21,Apatientwithsitusinversustotalisandlungcancer-ararecombination.AnnTranslMed.2016Nov;4(22):450.,22,Apatientwithsitusinversustotalisandlungcancer-ararecombination.AnnTranslMed.2016Nov;4(22):450.,Lymphnode(LN)4Lthatwereaccessedwithmediastinoscopy,23,LungSegmentectomyUsingVideo-assistedThoracicSurgeryforLungCancerinaPatientwithSitusInversusTotalis胸腔镜左上S3段切2016,Thecasewas83-year-oldmanwhohadcompletesitusinversus,andwaspointedouttohaveperipheraladenocarcinomawiththesizeof1.8cmattheleftupperlobe(S3).Becauseofsevereemphysemaandothermultiplecomorbidities,leftS3segmentectomywithhilarlymphnodesamplingwasperformedusingvideo-assistedthoracicsurgery(VATS).Preoperatively,thesimulationofoperationwasperformedusingthe3dimensioncomputedtomographyimagesofpulmonaryarteriovenousandbronchus(3DCTAB).Postoperativecoursewasuneventful.3DCTABwasthoughttobeusefulinunderstandingtheanatomicallocationofpulmonaryarteriovenousandbronchusdirectly,andinperformingsegmentectomyinthecaseofsitusinversuslikethis.KyobuGeka.2016Jul;69(7):521-4.,24,PET-CT诊断镜面人伴肺动脉发育异常1例2010广东医学,25,Lungresectionforlungcancerinpatientwithsitusinversustotalis胸腔镜左中叶切除+左上叶部分切除2013,Situsinversus,whichoccursin1-2ofevery10,000births,isacongenitalmalformationinwhichthethoracicandabdominalvisceraarearrangedinpartialoncompletemirrorimageofthenormalanatomy.Inthecaseofsitusinversus,specialattentionmustbetakeninperformingsurgery.Wepresentasurgicalcaseofprimarylungcancerinan81-year-oldpatientwithsitusinversustotalis.Duringsurgery,weusedtheUniventbronchialtubeforone-lungventilation.Theappearanceoftherightlungandthearrangementofthepulmonaryvesselsandthebronchicorrespondedtothosenormallyfoundontherightsidewasnotedatleftthoracotomy.Leftmiddlelobectomyandpartialresectionofleftupperlungweresuccessfullyperformed.Inlungresectionforsitusinversus,itisimportanttobeawarethemirrorimageanatomy.Thethreedimensionalcomputedtomography(3D-CT)imageswereusefulforpreoperativeevaluationofvesselvariation.MasudaY1,KyobuGeka.2013Jun;66(6):481-4.,26,Adenosquamouscarcinomaofthelunginapatientwithcompletesitusinversus.左下叶切除2011,Wepresentararecaseofadenosquamouscarcinomaofthelunginapatientwithcompletesitusinversus.Thepatientwasa76-year-oldwomanwiththechiefcomplaintofhemosputum.ChestX-rayandcomputedtomography(CT)scansofthethoraxshowedamirrorimageoftheorgansandvesselsandrevealedatumor3.5cmindiameter,intheleftlowerlungfield.ShewasreferredandadmittedtoKKRHokurikuHospital,Kanazawa,Japantoundergosurgery.Bronchoscopyshowedamirrorimageoftheusualarrangementofthebronchi,and5segmentalbranchesintheleftlowerbronchi.Duringsurgery,carewasexercisedwhenintubationwiththeUniventbronchialtubeforone-lungventilation.Onthoracotomy,thegrossappearanceoftheleftlungandthearrangementofthepulmonaryvesselsandthebronchicorrespondedtothosenormallyfoundontherightside.Weweresuccessfulinperformingaleftlowerlobectomy.Postoperativediagnosisconfirmedanadenosquamouscarcinomawithlocalizedpleuraldisseminationasp-t4n1m0,stageIIIa.Preoperativeimaging,includingCT,bronchoscopy,andangiographicexaminationofthepatient,willbeusefulforpreventionofvascularorbronchialinjuryduringsurgeryinpatientswithcompletesitusinversusundergoinglungresection.Possiblevascularorbronchialanomaliesshouldalwaysbetakenintoconsiderationwhileoperatingonthesepatients.AnnThoracCardiovascSurg.2011;17(2):178-81.,27,Rightbronchialintubationusingaleft-sideddouble-lumentubeinapatientwithsitusinversus左上叶切除2007,A74-year-oldmanwasscheduledforresectionofapulmonarytumorintheleftupperlobe.Hehadasymptomaticcompletesitusinversus,andthereforehisleftlunghadthreelobeswhereashisrightlunghadtwo.Sincethetumorhadbeengrowingthroughtheleftupperbronchusintotheleftmainbronchus,itseemedthattheuseofabronchialblockerintheleftbronchusshouldbeavoided.A37-Frleft-sideddouble-lumentubewasrotatedintheoppositedirection(clockwise)andadvancedeasilyintotheright(anatomicallyleft)mainbronchusunderfiberopticguidance.Onelungventilationduringtheoperationwasperformedsuccessfullyandtherewasnopostoperativeairwaycomplication.Severalwaysofachievingonelungventilationinpatientswithsitusinversusarediscussedinthisreport.Theuseofabronchialblockershouldbeconsideredfirst-choice,butsometimesitsuseisinappropriateasinthiscase.Commerciallyavailabledouble-lumentubesarenotintendedforuseincasesofsitusinversus.Ifadouble-lumentubeisdesired,intentionalrightbronchialinsertionofaleft-sideddouble-lumentubeseemstobeaneasyandreliableoption.Masui.2007Dec;56(12):1411-3.,28,Lungresectionforprimarybronchialca