同济外科学课件之微创外科技术

微创外科技术MINI-INVASIVESURGERY,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-INVASIVESURGERY,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,1901KELLING膀胱镜观察狗腹腔1910JACOBAEUS腹腔镜观察人腹腔1938VERESS发明弹簧气腹针1950HOPKING柱状透镜图像清晰1960SEMM妇科腹腔镜手术1987MOURET1988DUBOIS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LAPAROSCOPICCHOLECYSTECTOMY,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,LAPAROSCOPICCHOLECYSTECTOMY,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,LAPAROSCOPICCHOLECYSTECTOMY,相对禁忌证上腹部手术史严重萎缩性胆囊炎,LAPAROSCOPICCHOLECYSTECTOMY,LAPAROSCOPICCHOLECYSTECTOMY,LAPAROSCOPICCHOLECYSTECTOMY,LAPAROSCOPICCHOLECYSTECTOMY,LAPAROSCOPICCHOLECYSTECTOMY,LAPAROSCOPICCHOLECYSTECTOMY,LAPAROSCOPICCHOLECYSTECTOMY,Risksofsurgery,Bleeding(needingtransfusion)-2%Infection-2%Conversiontoopensurgery-2%Bileleak-2%,Risksofsurgery,Retainedstoneinthecommonbileduct-variabledependingonpreoperativetestsInjurytothecommonduct0.2%Injurytootherstructuresintheabdomenincludingsmallintestines,liver,andbloodvessels-1%Herniadevelopmentatincisionsites-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ENBD3胆囊管漏腹腔引流ENBD4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LIGASUREENDO-GIA）,肝脏(LH),胰腺,Diagnosticandexploratorylaparoscopyinpatientswithcancerofthepancreaselaparoscopicdistalpancreatectomyforendocrineandcystictumors,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,laparoscopicWhippleoperation.chronicpancreatitis,andsmallcysticandendocrinetumorsofthepancreasandpatientswhohaveampullarycancerEnucleationofpancreaticisletcelltumorshttppancreaticpseudocyst,脾脏LaparoscopicSplenectomy,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,LaparoscopicSplenectomy,LaparoscopicSplenectomy,LaparoscopicSplenectomy,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,Polypectomycanbedefinedastheendoscopicresectionofpolypsortumors,obviatingtheneedforopensurgery.Thisisoneofthemostimportantscientificadvancesinthefieldofgastroenterology,sinceitenablesustotreatmanygastricorcolonictumors,withouttheinconvenienceassociatedwithmajorsurgery,EndoscopicsnareresectionofavillousadenomaoftheampullaofVater,.,内镜外科的临床应用,胃肠道息肉gastricandcolonicpolyps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electrohydrauliclithotripsy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sphincterotomiesENBD,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.A57-year-oldmalewithcholedocho-choledochostomyafterlivingdonorlivertransplantation.A.Thecholangiographyobtainedaftertranshepaticinsertionofabiliarydrainagecathetershowsabiliaryanastomoticstricture,whichdividedthefifthandeighthsegmentductsfromthesixthandseventhsegmentducts(whiteandblackarrow).B.An8mmdiameterballooncatheterwaspositionedthroughtheanastomoticstricture.C.Twointernal-externalbiliarydrainagecatheters(12and14F)wereinsertedafterbiloplasty.D.Thecholangiogramafterthelargeprofilecathetermaintenancemethod(3months)showspatentbileducts(arrow),withexcellentflowofcontrastmediumintotheduodenalloop.,Fig.2.A56-year-oldmanwithcholedocho-choledochostomyafterlivingdonorlivertransplantation.A.Thecholangiographyobtainedduringtranshepaticinsertionofabiliarydrainagecathetershowsabiliaryanastomoticstricture(arrow).B.An8mmdiameterballooncatheterswaspositionedthroughtheanastomoticstricture.C.Apercutaneoustranshepaticcholangiographiccatheter(16F)wasinsertedafterbiloplasty.D.Thecholangiogramafterthelargeprofilecathetermaintenancemethod(2months)showspatentbileducts(arrow),withexcellentflowofcontrastmediumintotheduodenalloop.,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interventionaltherapy,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术内支架术TIPS,血管外介