同济外科学A之微创外科技术

微创外科技术MINI-INVASIVE SURGERY,不低于或高于传统治疗效果前提下尽可能减少病人的近期和远期的痛苦,微创外科技术MINI-INVASIVE SURGERY,包括腔镜外科内镜外科 各种影像学介导下的治疗技术,外科腔镜,LAPAROSCOPY,LAPAROSCOPY,腔镜简史,1901 KELLING膀胱镜观察狗腹腔1910 JACOBAEUS腹腔镜观察人腹腔1938 VERESS发明弹簧气腹针1950 HOPKING 柱状透镜 图像清晰1960 SEMM 妇科腹腔镜手术1987 MOURET1988 DUBOIS腹腔镜胆囊切除术,腹腔镜设备器械,腹腔镜 光学传导作用微型摄像头及数模转换器显示器冷光源录像机及图象存储CO2气腹系统手术设备器械,腹腔镜设备器械,基本技术,建立气腹 1直接TROCAR穿刺法 2 气腹针穿刺法 3开放法止血 电凝 钛夹 超声刀 缝合 纱布填塞,基本技术,组织分离切开 电刀 剪刀 超声刀 分离钳撕剥腹腔镜缝合标本取出 TROCAR孔 小切口 粉碎 标本袋,建立气腹,腹腔镜手术资质,传统外科培训腹腔镜基础知识培训动物实验非独立完成一定数量腹腔镜手术,腹腔镜手术适应证,胆囊切除术 结肠良恶性疾病阑尾切除术 食管反流手术小肠切除术 疝修补术脾切除术 肾上腺切除术淋巴清扫术 肝楔形切除术妇科手术 腹腔镜诊断术,腹腔镜诊断,单独诊断应用较少有创检查 需要麻醉 深部病变发现率低,腹腔镜胆囊切除术LAPAROSCOPIC CHOLECYSTECTOMY,适应证 与开腹手术指证相同 胆囊息肉 胆囊结石 充满型胆囊结石 急性胆囊炎胆总管探查 造影,LAPAROSCOPIC CHOLECYSTECTOMY,禁忌证 严重肝硬化 凝血障碍 妊娠 病理性肥胖 严重心肺功能不全,LAPAROSCOPIC CHOLECYSTECTOMY,相对禁忌证 上腹部手术史严重萎缩性胆囊炎,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,LAPAROSCOPIC CHOLECYSTECTOMY,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 preoperative 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%,腹腔镜胆囊切除术并发症及处理,一血管损伤 1大血管损伤 腹主动脉 门静脉 肠系膜上动脉 下腔静脉立即开腹止血 2手术区出血 胆囊动脉 胆囊床出血电凝 钛夹 纱条填塞,腹腔镜胆囊切除术并发症及处理,二胆道损伤1胆管横断 修复 T管引流 ROUX-Y盆式吻合,腹腔镜胆囊切除术并发症及处理,2肝管侧面损伤T管引流 ENBD 3胆囊管漏腹腔引流 ENBD 4胆管损伤后狭窄ROUX-Y肝门盆式吻合,LC并发症预防,根据自身能力严格掌握适应症第一戳孔要小心将胆囊三角完全分离清晰后再断胆囊管近胆管处慎用电凝,LC并发症预防,出血时不盲目上钛夹胆囊破裂者要用标本袋解剖不清 手术困难 出血不能控制及时开腹放置腹腔引流管便于发现并发症,腹腔镜在胃肠道手术中的应用现状与展望,腹腔镜直结肠手术,结直肠恶性肿瘤 是腹腔镜消化道外科最成熟的手术 手助技术应用降低了中转开腹率 直肠全系膜切除更方便盆腔植物神经识别保护 更确切 前瞻性多中心随机对照研究表明生存率相当 长期存活率 卫生经济学评价是今后关注焦点 执业环境恶化价格昂贵是该技术推广的最大障碍,结直肠良性疾病,乙状结肠息室有望成为标准手术溃疡性结肠炎进展缓慢治疗CROHN病近期效果得到认可,腹腔镜胃手术,胃肿瘤手术 胃肿瘤局部切除 胃楔形切除 胃远端切除 后者手术困难推广有困难腹腔镜胃减容术胃短路手术胃底折叠术 如NISSEN手术小肠肿瘤手术,腹腔镜在腹部实质性脏器手术中的应用现状及展望,肝脏(LH),易出血为主要障碍 处于尝试阶段适应证 段 肿块直径10CM血管瘤 多发肝囊肿 肝内胆管结石肝腺瘤有气栓的危险缺乏理想的刀具（超声刀螺旋高压水刀 微波刀 LIGASURE ENDO-GIA）,肝脏(LH),胰腺,Diagnostic and exploratory laparoscopy in patients with cancer of the pancreaselaparoscopic distal pancreatectomy for endocrine and cystic tumors,急性坏死性胰腺炎假性胰腺囊肿内引流胰岛细胞瘤剜除术胰体胰尾切除胰十二指肠切除没给病人带来实质性好处,laparoscopic Whipple operation. chronic pancreatitis, and small cystic and endocrine tumors of the pancreas and patients who have ampullary cancerEnucleation of pancreatic islet cell tumorshttp pancreatic pseudocyst,脾脏 Laparoscopic Splenectomy,LS安全可靠手助法 全腹腔镜法适应证 ITP 脾占位 脾亢 脾外伤脾蒂处理困难ENDO-GIA昂贵,Laparoscopic Splenectomy,Laparoscopic Splenectomy,Laparoscopic Splenectomy,腹腔镜在其它手术中的应用,甲状腺,满足美容要求并非微创局限良性疾病对甲状腺癌的腔镜手术存在疑虑手术时间长,乳腺良性肿瘤切除腋窝淋巴清扫乳腺前哨淋巴结活检疝修补术LIHR 有四种方法内环关闭 IPOM腹腔内补片植入法 TAPP经腹腹膜前补片植入法 TEP全腹膜外补片植入法,内镜外科技术,内镜种类,胃镜 十二指肠镜结肠镜小肠镜胆道镜胰管镜乳管镜腹腔镜胸腔镜,气管镜膀胱镜输尿管镜肾盂镜宫腔镜关节镜椎间盘镜脑室镜心镜,gastroscope,十二指肠镜duodenoscope,colonoscope,colonoscope,colonoscope,choledochoscope,腹腔镜laparoscope,内镜配置,内镜系统 内镜 主机光源 监视器手术设备 手术器械,内镜外科基本技术,注射术钳夹术切除术导线置入术扩张术支架置放术引流术碎石术,内镜外科基本技术,氩气刀凝切术十二指肠乳头切开术,内镜外科的临床应用,消化道出血食管胃底曲张静脉破裂出血溃疡出血消化道肿瘤出血消化道息肉出血,内镜外科的临床应用,消化道恶性肿瘤早期肿瘤拒绝手术或无法手术者晚期肿瘤止血 再通,. 内镜外科的临床应用,Polypectomy can be defined 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 gastric or colonic tumors, without the inconvenience associated with major surgery,Endoscopic snare resection of a villous adenoma of the ampulla of Vater,.,内镜外科的临床应用,胃肠道息肉gastric and colonic polyps良性肿瘤,内镜外科的临床应用,良性狭窄食管瘘胃石症肝胆胰疾病,乳头切开支架术,内镜外科的临床应用,肝外胆管结石乳头切开取石术碎石术electrohydraulic lithotripsy引流术,十二指肠乳头切开术sphincterotomies,ERCP取石,内镜外科的临床应用,胆道梗阻 漏与炎症 外引流术ENBD 内引流术,内镜外科的临床应用,肝内胆管结石 PTCS+EHL急性胰腺炎sphincterotomies ENBD,外科手术并发症的内镜治疗,食管穿孔食管吻合口瘘吻合口狭窄胆道狭窄胆瘘肝移植术后胆道狭窄,肝移植术后胆道狭窄,Fig. 1. A 57-year-old male with choledocho-choledochostomy after living donor liver transplantation. A. The cholangiography obtained after transhepatic insertion of a biliary 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 positioned 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 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 cholangiography 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 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 excellent flow of contrast medium into the duodenal loop.,超声内镜外科技术,诊断 活检 治疗（有限） 显示食管曲张静脉 显示早期胃癌 显示巨脾压迫胃,介入治疗技术 interventional therapy,通过现代影像学技术和导管对远处外科疾病实施治疗的技术,血管内途径介入,药物灌注术,血管内途径介入,化疗栓塞术 栓塞术 血管成形术 药盒置入