cea手术室篇学习教案

1、会计学1cea手术室篇手术室篇第1页/共60页第2页/共60页Operation room team position during CEA. S Surgeon, aS assisting surgeon, Ne neurophysiologist；A anaesthesiologist； N nurse；M microscope团队配置及体位团队配置及体位第3页/共60页I.Supine position;II.Head up: to reduce cervical venous pressure;III.Head is placed on a ring, with a sandbag u

2、nder the shoulders;IV.Exposing the full length of the sternomastoid muscle;手术体位要求手术体位要求第4页/共60页第5页/共60页第6页/共60页第7页/共60页General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trialMethod: a parallel group, multicentre, randomised controlled trial

3、 of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries.-general (n=1753) or local (n=1773) anaesthesia;-stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery;Conclusion: The two groups did n

4、ot significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。第8页/共60页第9页/共60页麻醉深度电极脑氧监测第10页/共60页第11页/共60页第12页/共60页麻醉机麻醉机第13

5、页/共60页第14页/共60页 Baseline (before induction) Pre-clamp (at heparin injection) Clamping, shunt insertion (if required) Post-clamping (15 min after clamping) Clamp release 5-min post-release 10-min post-release术中监测术中监测第15页/共60页第16页/共60页第17页/共60页第18页/共60页第19页/共60页第20页/共60页第21页/共60页第22页/共60页第23页/共60页粥样斑块

6、（粥糜样物）粥样斑块（粥糜样物）狭窄处的真腔缝隙狭窄处的真腔缝隙狭窄真腔狭窄真腔第24页/共60页第25页/共60页第26页/共60页Standard CEA technique. P Plaque, T superior thyroid artery, L longitudinal arteriotomyCEA technique with intraluminal shunt. IS Intraluminal shunt, R rubber band aroundthe CCA, C window aneurysm clip at the ICA, P plaque, T superior

7、 thyroid artery第27页/共60页Selective shunting with eversion carotid endarterectomy第28页/共60页Ann Vasc Surg 2013; 27: 178185第29页/共60页第30页/共60页第31页/共60页第32页/共60页颈阔肌颈阔肌External jugular vein: vein is ligated and divided; Arteria branch of the great auricular nerve;Great auricular nerve（耳大神经）External jugular

8、vein第33页/共60页颈动脉鞘The jugular vein is not dissected free; it is merely identifi ed and left untouched.触及CCA，分离方向：向头端，由CCA, ICA, ECA, superior thyroid arteries；向上：Posterior belly of the digastric muscle（二腹肌）;向下：Further exposure: Inferiorly the middle thyroid vein（甲状腺中静脉） may require ligation and the o

9、mohyoid muscle（肩胛舌骨肌）;需耐心处理的：淋巴结淋巴结需注意的：观察心率，必要时应用局麻药物；不要急于升压提升心率Posterior belly of the digastric muscle;Hypoglossal nerve 第34页/共60页重要标记：The hypoglossal nerve: crosses the internal and external carotid arteries;颈袢：Ansa cervicalis;调整方向及深度：Self-retaining retractor；此过程轻提血管外膜，分离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；

10、分离是为临时阻断做准备，不要过分游离血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后关系时，则需将分叉部尽可能分离；第35页/共60页肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;阻断顺序：-The first clip is applied to the ICA, then one each to the ECA and the superior thyroid artery and finally to the CCA.（试阻断）-Clamp

11、s were applied sequentially to the superior thyroid artery, the common carotid artery, internal carotid artery, and the external carotid artery.（持续阻断）-返血：分别提起ECA，ICA阻断带；或源于咽升A，使用较大的阻断夹完全阻断ECA；第36页/共60页重要标记：The hypoglossal nerve: crosses the internal and external carotid arteries;颈袢：Ansa cervicalis;调

12、整方向及深度：Self-retaining retractor；此过程轻提血管外膜，分离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；分离是为临时阻断做准备，不要过分游离血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后关系时，则需将分叉部尽可能分离；第37页/共60页动脉切开：longitudinal arteriotomy注意刀片方向：Cutting edge outwards so that once the lumen is entered, the blade can be drawn outwards to commence a longit

13、udinal arteriotomy.技巧：切开动脉壁时：可标记切口，以确保方向； The arteriotomy is slightly lateral to the midline (from the surgeons point of vision); especially at the bifurcation it runs some 3 mm lateral from the upper aspect of the bifurcation;第38页/共60页Potts angle scissors近端: the vessel is palpated to find a target

14、area of lesser disease where the endarterectomy can be stopped;远端: the arteriotomy on the anterolateral aspect of the internal carotid is taken beyond the severe disease, this being usually within 12 centimeters of its origin;第39页/共60页Dissector（剥离子的使用）（剥离子的使用）The inner is a thickened, irregular long

15、itudinal length of atheroma with the intima that may be ulcerated and covered with thrombus.The outer layer is yellow and uniform in thickness: it is a layer of thickened intimomedial fibers that may peel off easily as a circular strip, but which can also be left in situif firmly adherent to the wal

16、l.第40页/共60页第41页/共60页The inner core of atheroma is gently mobilized along its length until an end point is reached in the internal carotid artery;It thins down to a transparent thin layer of intima无残渣：无残渣：without residual frills.移形处的处理：移形处的处理： clean end point must be seen；PIN；The absence of any resid

17、ual frills is tested by flushing and careful excision.第42页/共60页Proximally, obtaining a satisfactory end point may be more difficult.Distally, it is advisable to follow the atheroma until it reaches its thin end point;斑块切断顺序：斑块切断顺序： -The plaque is transversally cut in the most caudal aspect of the ar

18、teriotomy.- the arteriotomy proceeds cranially stepwise always after the segment of the plaque is dissected free.第43页/共60页颈外动脉斑块处理：颈外动脉斑块处理：-Atheromatous core extends into the external carotid artery, usually for 510 mm.-Y型切开：型切开：第44页/共60页ICA斑块残端的处理：Technique to secure the distal end of the plaque.

19、In case it is not possible to remove all remnants of plaque in the distal end of ICA and the intima is loose, tacking sutures are used. The stitches are positioned at 6, 9 and 12 hours “looking into ICA lumen”. The 4th firm point is the first stitch starting the closure (at 3 hours). RP Residual pla

20、que6/0 tacking sutures第45页/共60页缝合前的要求：缝合前的要求：-good end points: all three carotid vessels; -Residual clot is flushed away.第46页/共60页I.Closure starts: above the endarterectomy at the upper extreme of the incision.II.6/0 running suture;III.Before its completion, the ICA is shortly opened and flushed. Th

21、e artery is flushed with heparin solution;IV.More knots are used usually 7 and the ends of the stitches are cut longer, some 56 mm from the knots.第47页/共60页肝素盐水冲洗：As the suture line is almost complete, further flooding of the segment with heparinized saline solution is undertaken to remove any residual debris and to fill the segment with fluid, removing any air bubbles.短暂松