非电手术操作在免气腹腹腔镜PPT课件

.,1,非电手术操作在免气腹腹腔镜中应用,交通大学医学院附属第九人民医院孙桦,.,2,前言,腹腔镜在妇科手术中应用已有40年历史,特别是近10余年,随着不断出现的更为先进腹腔镜手术器械和逐步改进、提高的手术技术，使得妇科腹腔镜手术的术式不断扩大,.,3,妇科腹腔镜手术术式,类手术：囊肿的细针穿刺组织活检局部注药轻度盆腔粘连分解-度子宫内膜异位症治疗黄体破裂的局部止血和腹腔清理类手术：输卵管妊娠手术治疗、输卵管绝育术卵巢囊肿剥出术附件切除术浆膜下肌瘤或小型肌壁间肌瘤切除、子宫穿孔修补术-度子宫内膜异位症治疗辅助生育技术如配子输卵管移植,.,4,妇科腹腔镜手术术式,类手术：较大肌壁间肌瘤挖出术（肌瘤直径5cm）子宫次全切除或子宫全切出术、腹腔镜辅助阴式子宫切除术类手术：盆腔淋巴结清扫术,.,5,腹腔镜手术的基本操作,气腹,暴露,分离,止血,缝合,打结,.,6,腹腔镜手术中不同止血方法,能量系统止血：激光电凝固（单极电凝、双极电凝、PK刀、LigaSure）超声刀微波刀氩气刀射频刀器械止血：钛夹自动切割吻合器缝扎内套圈结扎,.,7,电能凝固止血的优缺点,高频电凝固是利用高频电流与机体接触时产生的热效应达到切割与止血的效果。高频电凝是目前腹腔镜手术中应用广泛的一种止血器械。单极电凝优点是操作简单、省时、经济。缺点是：（1）产生大量烟致手术视野模糊，需不断排烟，延长了手术时间，且烟雾中含有大量有毒气体，主要有一氧化碳、氰化氢、丙烯腈和苯等（2）热效应明显，热损伤大，损伤周围组织可达15mm；（3）止血效果较差，术中出血较多，组织粘连严重，焦痂形成，（4）易发生电损伤，特别是会损伤邻近的重要组织，如原发性肠穿孔、肠坏死，操作不慎可损伤大血管及输尿管；（5）术后形成粘连；（6）不宜用于较精细的手术；（7）不宜用于安装了心脏起搏器的患者。,.,8,电能凝固止血的优缺点,双极电凝优点是：（1）止血效果较单极电凝好，可电凝直径3mm的血管，如子宫、卵巢血管等；（2）不易发生电损伤；（3）适用于安装了心脏起搏器的患者。缺点是：（1）产生大量烟雾，致手术视野模糊，需不断排烟，延长手术时间，且烟雾中含有大量有毒气体；（2）热效应大、热损较大，但远比单极小（3）组织粘连严重，焦痂形成，术后并发症多；（4）术后粘连形成；（5）不宜用于较精细的手术。,.,9,电能凝固止血的优缺点,PK刀优点是：（1）热效应小，作用热度为4070；热损伤较小，热损伤范围不超过4mm；（2）可以闭合7mm以下的血管、能支持300mmHg的持续压力；（3）具有抓持、电凝、切割、分离和钝性拨棒5种功能，缩短了手术时间，减少了术中出血；（4）蒸汽脉冲凝固可使凝血可靠和完全；（5）组织粘连较轻，焦痂形成少，术后并发症少；（6）切割准确快捷、操作简单。缺点是可产生有毒烟雾，但较电刀少。价格较贵。,.,10,电能凝固止血的优缺点,结扎速血管闭合系统（LigaSure）优点是：（1）热损伤小（侧向热传导距离12mm）；（2）能完全和永久闭合直径小于7mm的血管；（3）闭合带持久且几乎透明，且比其他所有以能量为基础的熔合方式都坚固，可达到与缝线结扎相似的强度，可承受3倍的正常人体动脉收缩压；（4）直接闭合组织束，无需切开和剥离；（5）没有或有极少粘连和焦痂形成，体内无异物存留。缺点是：（1）价格较贵；（2）虽产生烟雾，但较电刀产生的少；（3）不宜用于分离较精细的组织。,.,11,气腹环境下缝扎的优缺点,缝扎腹腔镜下缝合不像常规手术那样容易，所以腹腔镜下缝扎止血不是应急的好方法，只有在出血不明显，又有组织切割创伤，需要缝合时使用。优点是：（1）止血可靠，适用于较大的血管或用其他方法无法止血时；（2）组织有切割伤时，可选用缝扎。缺点是：（1）操作困难、费时；（2）易致误损伤。,.,12,小结,热损伤大，损伤周围组织可达15mm止血效果差,易致术后粘连电损伤大,易致周围脏器损伤在有生育要求妇女附件手术应慎用中,单极电凝,双极电凝,热损较大，但远比单极小组织粘连严重，焦痂形成，术后粘连形成；不宜用于较精细的手术。,止血效果好、损伤小但价格较贵不易在基层医院推广,PK刀、ligasure,腹腔镜下卵巢电灼打孔术电能过大时可严重影响卵巢功能，导致卵巢早衰，严兆华腹腔镜下不同电能对难治性多囊卵巢综合征预后的影响,.,13,免气腹腹腔镜下缝合基础,.,14,.,15,.,16,HotTip,ImageinformationinproductTitleImage:,CD:133HERTHINGS(imageDJ)Notetocustomers:ThisimagehasbeenlicensedtobeusedwithinthisPowerPointtemplateonly.Youmaynotextracttheimageforanyotheruse.,.,17,Clicktoedittitlestyle,Title,Title,Title,Descriptionofthecontents,Descriptionofthecontents,Descriptionofthecontents,.,18,Clicktoedittitlestyle,-ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,-ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,-ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Descriptionofthecompanyssubcontents,Descriptionofthecompanyssubcontents,Descriptionofthecompanyssubcontents,.,19,Clicktoedittitlestyle,Title,Descriptionofthesubcontents,DescriptionofthesubcontentsDescriptionofthesubcontents,Descriptionofthesubcontents,DescriptionofthesubcontentsDescriptionofthesubcontents,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Title,Title,Title,.,20,Clicktoedittitlestyle,feature01,feature02,55%,16%,45%,41%,16%,50%,Aproduct,Bproduct,Cproduct,ContentsThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,.,21,Clicktoedittitlestyle,Growth,Start,Jump,200820072006,200520042003,200220012000,DescriptionofthecontentsDescriptionofthecontentsDescriptionofthecontents,DescriptionofthecontentsDescriptionofthecontentsDescriptionofthecontents,DescriptionofthecontentsDescriptionofthecontentsDescriptionofthecontents,.,22,Clicktoedittitlestyle,2000,2004,2008,“ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.”,“ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.”,“ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.”,Textinhere,Descriptionofthecontents,Descriptionofthecontents,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Textinhere,Textinhere,.,23,Clicktoedittitlestyle,2000,2002,2004,2006,2008,2010,Descriptionofthecontents,Descriptionofthecontents,90%Textinhere,155%Textinhere,contents,contents,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,.,24,Clicktoedittitlestyle,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Textinhere,Textinhere,Textinhere,Textinhere,.,25,Clicktoedittitlestyle,Descriptionofthecontents,Textinhere,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Textinhere,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Textinhere,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,Textinhere,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.,.,26,Clicktoedittitlestyle,Descriptionofthecontents,ThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.DescriptionofthebusinessDescriptionofthebusinessDescriptionofthebusiness,ImageInfowww.wizdata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