腹部外科手术中英专家讲座

Abdominalsurgery腹部外科手术GertterHaar,DVM,PhD,MRCVS,DECVSSeniorLecturerSoftTissueSurgery–ENT软组织外科手术高级讲师——耳鼻喉科PresidentoftheIVENTASoftTissueSurgery

皇家兽医学院软组织外科腹部外科手术中英第1页Introduction序言Exploratoryceliotomy/laparotomy

剖腹探查术Gastrotomy&gastropexyforGDV

胃切开术&胃固定术治疗胃扭转Enterotomy&resection&anastomosis

肠切开术&切除术&吻合术Splenectomy脾切除术Liverbiopsy&liverlobectomy

肝脏活检&肝叶切除术腹部外科手术中英第2页ExploratoryCeliotomy

剖腹探查术Indications适应症Trauma创伤Penetratingwounds穿透伤Haemoabdomen腹腔有血液Tumors肿瘤Septicabdomen

腹部感染Ileus肠梗阻腹部外科手术中英第3页

MidlineCeliotomy

中线剖腹术Mostcommonapproach最常见方法Diagnosticprocedures诊疗程序

e.g.biopsy,exploratorysurgery

比如活组织检验，探查术Therapeuticsurgery治疗手术

e.g.gastricdilatationvolvulus,cystotomy

比如胃扩张肠扭转，膀胱切开术

Electivesurgery选择性外科手术

e.g.ovariectomy比如卵巢切除术腹部外科手术中英第4页MidlineCeliotomy

中线剖腹术Preoperativeaspects术前准备Correctanestheticprotocol(AB)

恰当麻醉方案Clipping剪毛Dorsalrecumbency背侧斜卧Sterilepreparationoperationsite无菌手术操作Draping覆盖创巾Basicsurgicalinstruments基本外科器械腹部外科手术中英第5页MidlineCeliotomy

中线剖腹术腹部外科手术中英第6页MidlineCeliotomy

中线剖腹术腹部外科手术中英第7页MidlineCeliotomy

中线剖腹术腹部外科手术中英第8页MidlineCeliotomy

中线剖腹术腹部外科手术中英第9页MidlineCeliotomy

中线剖腹术腹部外科手术中英第10页MidlineCeliotomy

中线剖腹术腹部外科手术中英第11页MidlineCeliotomy

中线剖腹术Goodseparationofsubcutisandrectussheathwillmakeclosingoftheabdomeneasier

良好分离皮下组织及腹直肌会更轻易地关闭腹腔Lifttheabdominalwallwithforcepswhenstabincisionismade

用镊子提起腹壁刺开切口Checkforadhesionsbeforecuttingthroughthelineaalba

切开腹白线之前检验是否有粘连Preventenclosingabdominalfatinsutureline

在缝合线处预防闭合腹部脂肪腹部外科手术中英第12页MidlineCeliotomy

中线剖腹术腹部外科手术中英第13页

ExploratoryCeliotomy

剖腹探查术ALWAYSchecktheentireabdominalcavityintheSAMEorder

要以相同次序检验整个腹腔Startwithabdominalwall,peritoneum(freefluid)

要从腹壁、腹膜（游离液体）开始腹部外科手术中英第14页ExploratoryCeliotomy

剖腹探查术Diaphragm&liver隔膜&肝腹部外科手术中英第15页ExploratoryCeliotomy

剖腹探查术Liver&bileducts肝&胆管腹部外科手术中英第16页ExploratoryCeliotomy

剖腹探查术Adrenalglandright右侧肾上腺腹部外科手术中英第17页ExploratoryCeliotomy

剖腹探查术Rightkidney右侧肾脏腹部外科手术中英第18页ExploratoryCeliotomy

剖腹探查术Femalereproductivetract雌性生殖系统腹部外科手术中英第19页ExploratoryCeliotomy

剖腹探查术Bladder&malereproductivetract

膀胱&雄性生殖系统腹部外科手术中英第20页ExploratoryCeliotomy

剖腹探查术Leftretroperitonealarea&adrenal

左侧腹膜后区&肾上腺腹部外科手术中英第21页ExploratoryCeliotomy

剖腹探查术Gastro-intestinaltract&pancreas

胃肠道&胰腺腹部外科手术中英第22页ExploratoryCeliotomy

剖腹探查术Gastro-intestinaltract&pancreas

胃肠道&胰腺腹部外科手术中英第23页ExploratoryCeliotomy

剖腹探查术Duodenum十二指肠腹部外科手术中英第24页ExploratoryCeliotomy

剖腹探查术Jejunum空肠腹部外科手术中英第25页ExploratoryCeliotomy

剖腹探查术Ileum,caecum&colon回肠，盲肠&结肠腹部外科手术中英第26页ExploratoryCeliotomy

剖腹探查术Spleen脾脏腹部外科手术中英第27页ExploratoryCeliotomy

剖腹探查术ALWAYScheckallinstruments&swabsareaccountedfor!!!!

经常清点全部器械和棉签腹部外科手术中英第28页Introduction;GastricSurgery

介绍；胃外科学Gastricforeignbodies胃异物inductionofvomiting诱导呕吐endoscopicremoval内窥镜移除gastrotomy胃切开术Hypertrophicpyloricstenosis肥厚性幽门狭窄Gastricdilatation-volvulus胃扩张肠扭转Gastropexy胃固定术腹部外科手术中英第29页

Gastrotomy

胃切开术Incisioningastricbody胃体切开Doublelayerclosure双层关闭simplecontinuous,alllayers全层简单连续缝合interruptedinverting(Lembert)伦伯特缝合腹部外科手术中英第30页Gastrotomy

胃切开术腹部外科手术中英第31页

Gastrotomy;closure

胃切开术；闭合腹部外科手术中英第32页

GastricDilatationVolvulus

胃扩张肠扭转Clinicalsigns临床症状AlgorithmforacuteGDV急性胃扭转Emergencytreatment急诊Surgicaltreatment外科治疗Radiography放射线摄影术Results结果腹部外科手术中英第33页

ClinicalsignsofGDV

急性胃扭转临床症状Unproductiveattemptstovomit无呕吐物呕吐Rapiddistensionoftheabdomen腹部快速膨胀Usuallyshortlyaftereating通常发生在进食后很快 Differentialdiagnosis:intestinalvolvulus

判别诊疗：肠扭转moreseriousgeneralsignsthaninGDV

比胃扭转更严重症状rapidprogression,usuallyfatal

病情进展快，通常是致命verypainful(ischemia)非常疼痛（局部缺血）腹部外科手术中英第34页

Intestinalvolvulus

小肠扭转腹部外科手术中英第35页intubationgastrocentesisradiographysurgeryobservationnononoyesnoyesyesyessuccessful?stomachempty?severedilatation?positionnormal?腹部外科手术中英第36页

Emergencytreatment

急诊治疗Intubationofthestomach胃插管Percutaneousgastrocentesis胃穿刺Shocktherapy休克疗法腹部外科手术中英第37页

Intubationofthestomach

插胃管Tube:LavacuatorII®

Mallinckrodtmouthpiece:InstruvetPObox170,5430ADCuijcktheNetherlands腹部外科手术中英第38页

Percutaneousgastrocentesis

经皮肤胃穿刺法腹部外科手术中英第39页

Surgicaltreatment

外科治疗Repositioningofthestomach胃重新定位Assessmentofgastricviability

胃可行性评定Removalofgastriccontents(gastrotomy)

除去胃内容物（胃切开术）Fixationofthepyloricantrum(gastropexy)

固定幽门窦（胃固定术）腹部外科手术中英第40页

Repositioningofthestomach

胃重新定位rightpp腹部外科手术中英第41页Assessmentofviability

可行性评定Clinicalassessment临床评价serosalcoloration浆膜着色gastricwalltexture胃壁结构vascularthrombosisoravulsion血管血栓或撕裂Intravenousfluorescein1静脉内荧光素1WheatonLGJ.JAmAnimHospAssoc1986;22:197-204腹部外科手术中英第42页

GastricNecrosis

胃坏死Uncommon:

不常见：30of285(11%)1;28of137(20%)2fundusandcorpus,greatercurvature

胃底，胃体，胃大弯ifresectable:partialgastrectomy

假如可切除：胃部分切除术 NB:significantlyincreasedmortality死亡率显著增加13of28(46%)vs24of137(18%)21MatthiesenDT.VetSurg1985;14:185-1932BrourmanJDetal.JAmVetMedAssoc1996;208:1855-58腹部外科手术中英第43页

Fixationofthepyloricantrum

固定幽门窦Tubegastrostomy(1976)1胃造口术Incisionalgastropexy(1982)2切口胃固定术Circumcostalgastropexy(1985)3肋周围胃固定术Muscularflapgastropexy(1986)4肌瓣胃固定1ParksJLetal.JAmAnimHospAssoc1976;12:168-1722McCoyDMetal.JAmAnimHospAssoc1982;18:763-683LeibMSetal.JAmVetMedAssoc1985;187:245-484SchulmanAetal.JAnimHospAssoc1986;22:339-46腹部外科手术中英第44页Fixationofthepyloricantrum

固定幽门窦Belt-loopgastropexy(1989)1Belt环胃固定术Incorporatinggastropexy(1993)2

合并胃固定术Gastrocolopexy()3胃结肠固定术1WhitneyWOetal.JAmAnimHospAssoc1989;25:75-832MeyerLindenbergAJetal.JAmVetMedAssoc1993;203:1303-73EggertsdottirAVetal.VetSurg;30:546-51腹部外科手术中英第45页

Incisionalgastropexy

切口胃固定术McCoyD.M.,SykesG.P.,HofferR.E.,HarveyH.J.

AgastropexytechniqueforpermanentfixationofthepyloricantrumJAmAnimHospAssoc1982;18:736-738腹部外科手术中英第46页

Incisionalgastropexy

切口胃固定术leftcranial腹部外科手术中英第47页

Incisionalgastropexy

切口胃固定术腹部外科手术中英第48页

Incisionalgastropexy

切口胃固定术腹部外科手术中英第49页

Incisionalgastropexy

切口胃固定术腹部外科手术中英第50页Mortality

死亡率43of148(29%)

vanSluijsFJ.TijdschrDiergeneesk1991;116:112-2129of193(15%)

BrockmanDJJ.AmVetMedAssoc1995;270:460-6424of137(18%)

BrourmanJDetal.JAmVetMedAssoc1996;208:1855-5833of136(24%)

GlickmanLTetal.JAmAnimHospAssoc1998;34:253-59腹部外科手术中英第51页Complications

并发症Cardiacarrhythmias心律失常 78of193(40%)1 51of118(43%)2Woundinfection创口感染 13of118(11%)21

BrockmanDJ.JAmVetMedAssoc1995;207:460-642SluijsFJvan.TijdschrDiergeneesk1991;116:112-21腹部外科手术中英第52页

Recurrence

复发Gastropexy胃固定术4of61(7%)19of85(11%)214of97(15%)4Nofixation未固定39of55(71%)325of33(76%)11MeyerLindenbergAetal.JAmVetMedAssoc1993;203:1303-72GlickmanLTetal.JAmAnimHospAssoc1998;34:253-593EgertsdottirAVetal.ActVetScand1995;36:175-844SluijsFJvan.TijdschrDiergeneesk1991;116:112-21腹部外科手术中英第53页

ProphylacticGastropexy

预防性胃固定术laparoscopic-assistedgastropexy()1

腹腔镜检验辅助胃固定术grid-laparotomygastropexy()2

电网开腹胃固定术Cost-effective?

成本合算？1RawlingsCAetal.JAmVetMedAssoc;221:1576-812Steelman-SzymeczekSMetal.JAmAnimHospAssoc;39:397-402腹部外科手术中英第54页

LaparoscopicGastropexy

腹腔镜检验辅助胃固定术laparoscopic-assistedgastropexy()1grid-laparotomygastropexy()2Cost-effective?1RawlingsCAetal.JAmVetMedAssoc;221:1576-812Steelman-SzymeczekSMetal.JAmAnimHospAssoc;39:397-402腹部外科手术中英第55页

Introduction;IntestinalSurgery

介绍；肠外科Indications适应症ForeignBodies异物Intussusception肠套叠Tumor肿瘤Ulcera溃疡Trauma创伤Enterotomy肠切开术Resection&end-to-endanastomosis

切除术&端对端吻合术腹部外科手术中英第56页Enterotomy

肠切开术Anti-mesentericside反肠系膜侧Isolateintestines隔离肠子Incisehealthypart切割健康部分RemoveFB去除FBAppositionalsuture同位缝合，4-0缝线pattern,4-0monocrylOmentalpatch网膜修补腹部外科手术中英第57页Enterotomy

肠切开术腹部外科手术中英第58页

Enterotomy

肠切开术腹部外科手术中英第59页

Enterotomy

肠切开术腹部外科手术中英第60页

Resection

切除术Indications适应症Irreducibleintussusception不可复性肠套叠Narrowingofintestinallumen肠腔变窄

e.g.scartissueoradhesions比如结痂组织或粘连Severedamageofintestinalwall严重肠壁损坏

e.g.trauma,foreignbodyorstrangulation

比如创伤，异物或绞窄Intestinalneoplasm肠肿瘤腹部外科手术中英第61页Resection

切除术Preoperativeaspects术前准备Correctanaestheticprotocol:适当麻醉方案：Antimicrobialprophylaxisshortlybeforesurgery

手术前抗菌药品预防Appropriateanalgesia(noNSAID’s)

适当镇痛（没有类固醇消炎药）Considerurinarycatheter考虑导尿管Extensiveclipping大面积切除Dorsalrecumbency背侧斜卧Sterilepreparationoperationsite无菌手术操作Draping覆盖创巾腹部外科手术中英第62页Resection

切除术Technicalaspects技术方面Basicsurgicalinstruments基础外科器械Specificsurgicalinstruments:特定外科器械：Selfretainingabdominalretractor自动牵开器Noncrushingforceps组织钳Suction抽吸Surgicalspongeswithradiopaquemarker外科纱布Woundprotector保护伤口Cleanglovesandinstrumentsforclosure

清洁手套和关闭器械腹部外科手术中英第63页Resection

切除术Technicalaspects技术方面Suturematerials缝合材料Anastomosis吻合术2-0,3-0or4-0syntheticmonofilamentabsorbable(Biosyn/Maxon®,Monocryl®)2-0，3-0或4-0人造可吸收缝线腹部外科手术中英第64页

Case病例Labradorretriever,male,5months拉布拉多，雌性，5个月Bloodydiarrhoea,vomiting便血，呕吐Palpableabdominalmass显著腹部肿块腹部外科手术中英第65页

Intussusception

肠套叠Manualreduction手动复位Intestinalresection肠切除术Onelayerend-to-endanastomosis

单层端对端吻合术Simpleinterruptedapproximatingsuture

简单间断缝合腹部外科手术中英第66页

Resection&anastomosis

切除术&吻合术腹部外科手术中英第67页Resection&anastomosis

切除术&吻合术腹部外科手术中英第68页

Resection&anastomosis

切除术&吻合术腹部外科手术中英第69页

Resection&anastomosis

切除术&吻合术腹部外科手术中英第70页

Tips关键点Usestaysuturesonmesentericandanti-mesentericside

在肠系膜和反肠系膜侧使用固定缝线Placesuturesapproximately2-3mmapartand1-2mmfromincision离切口1-2mm处设置固定缝合线，缝线间距2-3mmPreventeversionofmucosa预防黏膜外翻Mesentericsideismostdifficulttosuture肠系膜侧最难缝合Useomentalpatchorserosalpatch使用网膜和浆膜贴Staplers钉腹部外科手术中英第71页Postoperativeaspects

术后护理Post-operativecaredependspatient术后护理取决于患病动物Discontinueantibioticswithin2-6hours,unlessperitonitisispresent

在2-6小时内停顿使用抗生素，除非发生腹膜炎Offerwaterassoonaspatientisgoodawake

一旦患者完全清醒就提供水Encourageearlyambulationandfeeding

勉励早日活动和喂养Ifperitonitisissuspectedperformabdominocentesis,chemistryprofileandcompletebloodcellcount

假如怀疑是腹膜炎进行腹腔穿刺、全血细胞计数腹部外科手术中英第72页Introduction;Splenectomy

介绍；脾切除术Indications适应症Tumor肿瘤Trauma(haemo)创伤Torsion扭转Immune-mediated免疫介导Partialvstotal局部和整体腹部外科手术中英第73页

AnatomySpleen

脾解剖stomachspleengastrosplenicligamentShortgastricvesselsleftgastroepiploicsplenica+vbranchtopancreas腹部外科手术中英第74页

FunctionsoftheSpleen

脾功效Redbloodcellmaintenance,ironmetabolism维持红细胞，铁代谢Bloodreservoir储血Immunefunctions免疫功效Haematopoiesis造血腹部外科手术中英第75页

Splenectomy

脾切除术Preoperativeconsiderations术前注意事项Dogswithsplenicmasseshaveahighriskofcardiacarrythmias(especiallythosewithanaemia,haeomoabdomen)

脾有肿块犬有高风险心律失常（尤其是患有贫血时）Treathypovolaemicshock治疗低血容量休克Antidysrhythmicdrugifstillsevereenoughtocausehypotensionorpulsedeficits假如疾病依然较重低血压或脉冲赤字，那么要使用抗节律不齐药

腹部外科手术中英第76页Splenectomy

脾切除术Preoperativeconsiderations术前注意事项AnimalswithsplenicneoplasiaortorsionareatriskofDIC:

有脾肿瘤或扭转动物有弥散性血管内凝血风险：PerformPT/APTTtests,bloodtype,PCV/TP

进行PT/APTT检测、血型、PCV/TPBereadytoprovideextrastabilisation/postopcare

随时提供额外稳定术后护理Prophylacticantibioticsaregivenifthereisatorsionoralongsurgeryisexpected

假如是扭转或预计手术时间过长要使用预防性抗生素?Longertermantibioticstoimmunosuppressedanimalsfollowingsplenectomy(routinelydoneinhumanmedicine)

？长久给非免疫抑制动物使用抗生素时要实施脾切除

腹部外科手术中英第77页

Splenectomy

脾切除术Hilarapproach(manyligatures)门式方法Quicksplenectomy快速脾切除术Lotsofforceps!许多镊子Ligatespecificvessels结扎特定血管Doubleligationsplenicartery+vein双结扎脾动脉和静脉Staplingdevices(alsoforpartial)装订设备（局部也适用）Bipolarelectrosurgicaldevice(ligasure)双击电装置（结扎束）腹部外科手术中英第78页

SplenectomystomachspleengastrosplenicligamentShortgastricvesselsleftgastroepiploicsplenica+vbranchtopancreasXXXXXHosgoodetal1989Hardtodoifanatomyisdistortedbymass/adhesions假如解剖由肿物或粘连而扭曲，那么实施难度更大腹部外科手术中英第79页Splenectomy

脾切除术Intraoperativeconsiderations术前注意事项Useabdominalretractors,suction,waterproofdrape,swabswithradio-opaquemarker

使用腹部拉钩，吸痰，防水性创巾，无线电不透明标识棉签Examineentireabdomen;countswabsinandout;weighswabsandmeasurefluidinsuctionbottles

检验整个腹部；计算外部和内部棉签数量；称重棉签并测量吸滤瓶中液体1mlblood=1.3g腹部外科手术中英第80页

Splenectomy

脾切除术Intraoperativeconsiderations术前注意事项LDS,vascularclipsandvesselsealantdevicescanallspeedupsurgeryandhavebeenusedsafelytoremovespleensLDS、血管钳和血管填充剂等装置都会加速手术过程，而且都能够确保安全实施脾摘除

腹部外科手术中英第81页

Hilarsplenectomy

肝门部脾切除术腹部外科手术中英第82页

LigationsplenicA+V

结扎脾动脉和静脉腹部外科手术中英第83页

ComplicationsSplenectomy

脾切除术并发症Haemorrhage出血Technicalfailure技术故障DIC弥散性血管内凝血Cardiacarrhythmias心律失常Gastritisorpancreatitis胃炎或胰腺炎?Increasedriskofinfection？增加感染风险PotentiationofsubclinicaldiseasewithRBCparasites红细胞寄生虫亚临床疾病腹部外科手术中英第84页

Introduction;Hepaticlobectomy

介绍；肝叶切除术Indications适应症Trauma创伤Neoplasia肿瘤Focalabscess

病灶脓肿Hepaticarteriovenousfistula肝动静脉瘘Volvulusofliverlobe肝叶肠扭转腹部外科手术中英第85页

Hepaticlobectomy

肝叶切除术Sixlobes(papillaryprocess)六叶Efferentbloodflow(portalveinandhepaticarterie)

输出血流（门静脉和肝动脉）Afferentbloodflow(hepaticveins)输入血流（肝静脉）Gallbladder胆囊Hepaticducts;cysticduct;ductuscholedochus肝胆管；胆囊管；胆总管Interlobularfibroustissue

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Preoperativeaspects

术前准备Correctanestheticprotocol适当麻醉方案Cavecoagulopathies;serumalbuminlevel;decreasedhepaticfunction凝血障碍；血清白蛋白水平；肝功效下降Prophylacticantibiotics预防性抗生素Dorsalrecumbency背侧斜卧Clippingventralabdomenfromxiphoidtoumbilicus

切口从腹部剑状软骨到脐部Sterilepreparationoperationsite

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Technicalaspects

技术方面Basicsurgicalinstruments基本外科器械Specificsurgicalinstruments:特殊外科器械：Largecurvedhaemostaticormixterforceps

大号弯止血钳或mixter式钳SelfretainingBalfourretractor自动牵拉器Staplingdevice/Ligasure装订装置/结扎术Fingerfracturemethod,guillotinetechnique

手指骨折方法、剪断技术Countedgauzespongeswithradiopaquemarkers

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Fingerfracturetechnique

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Hepaticlobectomy

肝叶切除术腹部外科手术中英第90页Hepaticlobectomy

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Technicalaspects

技术方面Beforeclosingtheabdomen闭合腹部前Haemmorhagefromtheremaininglivertissueisusuallyminimal

保留肝组织出血通常要最小化Checkthehilusforhaemmorhage检验肝门出血