儿科培训课件：《经胸腔镜手术治疗食管闭锁、膈疝病例报告》

江西省儿童医院新生儿外科

经胸腔镜手术治疗

食管闭锁、膈疝病例报告2010年1月至2011年5月

食管闭锁13例+1

膈疝9例+1+1

EA±TOFN=13（typeC11,A2）Numberofports:3portsDurationoftheoperation135~220minutesPostoperativehospitalstay:15-30daysConversion：1EA±TOFEA±TOF术后处理术后7天术后15天随访：术后4月EA±TOF9例基本情况表病例性别手术日龄(d)体重(kg)闭锁类型合并畸形两端距离(cm)手术时间(min)呼吸机支持时间(h)吻合口漏食道狭窄疗效住院天数(d)1男62.4ⅢB118036无是治愈182男102.1ⅠF44.5205168漏--放弃113女41.8ⅢB双胎早产2.015026无无治愈294男52.1ⅢA右足畸形2.616048漏是治愈335女52.7ⅢB0.51358无无治愈256男112.7ⅢAVSD3.01600无是治愈177男71.4ⅢA3.2中转72----死亡108男53.1ⅢBVSD,PH1.613519无无治愈209男23.1ⅢB1.01450无无治愈18先天性膈疝

congenitaldiaphragmatichernia(CDH)N=9（L8,R1）Numberofports:3~4portsDurationoftheoperation56~160minutesPostoperativehospitalstay:15-33daysConversion：0先天性膈疝手术方法1、气管插管+全麻2、侧卧位3、3~4孔，CO2气压4-13mmHg4、直接缝合/折叠先天性膈疝9例膈疝基本情况表病例性别手术日龄(d)类型疝囊手术方法手术时间(min)并发症疗效住院天数(d)1男3m左膈疝有3孔折叠121皮下积气治愈202男1d左膈疝无3孔缝合106左胸腔积液肺发育不良治愈293男1d左膈疝有3孔折叠102治愈154女7d左膈疝有3孔缝合102治愈335男1d左膈疝有3孔缝合56治愈256男4m22d右膈膨升-4孔折叠160治愈177男3d左膈疝有3孔缝合92治愈198男7d左膈疝有3孔缝合111治愈209男2m左膈膨升-4孔折叠119治愈18先天性膈疝术后6月术后3天术前讨论食道闭锁膈疝

Holcomb2005李龙、等2007.3吴晔明、等2009.5

黄金狮、等2011.病例数1043/64/69吻合口瘘7.60%022吻合口狭窄31.70%033.70%3胃底成形术

（lapNissen）24%000食道瘘复发率1.90%0001.Holcombetal.AnnalsofSurgery.20052.李龙、等。北京医学。2007.33.吴晔明、等.中华小儿外科杂志.

2009.5.3.黄金狮、等。临床小儿外科杂志。2011.6.EA±TOF讨论食道闭锁1、long-gap型EA手术处理congenitaldiaphragmatichernia(CDH)1.SilenML,CanvasserDA,KurkchubascheAG,etal.Video-assistedthoracicsurgicalrepairofaforamenofbochdalekhernia.AnnThoracSurg.1995;60:448–450.2.ChoSD,KrishnaswamiS,McKeeJC,etal.Analysisof29consecutivethoracoscopicrepairsofcongenitaldiaphragmaticherniainneonatescomparedtohistoricalcontrols.JPediatrSurg.2009;44:80–86.3.GourlayDM,CassidyLD,SatoTT,etal.Beyondfeasibility:acomparisonofnewbornsundergoingthoracoscopicandopenrepairofcongenitaliaphragmatichernias.JPediatrSurg.2009;44:1702–1707.4.GiacomelloL,NahSA,DeCoppiP,etal.Thoracoscopicrepairofcongenitaldiaphragmatichernia:intraoperativeventilationandrecurrence.In:56thAnnualCongressoftheBritishAssociationofPaediatricSurgeonsand10thAnnualCongressoftheEuropeanPaediatricSurgeons’Association;2009;Graz,Austria.5.LiemNT,DungLA.Thoracoscopicrepairforcongenitaldiaphragmatichernia:lessonsfrom45cases.JPediatrSurg.2006;41:1713–1715.6.FerreiraCG,ReinbergO,BecmeurF,etal.Neonatalminimallyinvasivesurgeryforcongenitaldiaphragmatichernias:amulticenterstudyusingthoracoscopyorlaparoscopy.SurgEndosc.2009;23:1650–1659.7.YangEY,AllmendingerN,JohnsonSM,etal.Neonatalthoracoscopicrepairofcongenitaldiaphragmatichernia:selectioncriteriaforsuccessfuloutcome.JPediatrSurg.2005;40:1369–1375.8.ArcaMJ,BarnhartDC,LelliJL,etal.Earlyexperiencewithminimallyinvasiverepairofcongenitaldiaphragmatichernias:resultsandlessonslearned.JPediatrSurg.2003;38:1563–1568.9.ShahAV,ShahA.Laparoscopicapproachtosurgicalmanagementofcongenitaldiaphragmaticherniainthenewborn.JPediatrSurg.2002;37:548–550.10.HolcombGW,OstlieDJ,MillerKA.LaparoscopicpatchrepairofdiaphragmaticherniaswithSurgisis.JPediatrSurg.2005;40:E1–E5.11.RothenbergSS,ChangJH,BealerJF.Experiencewithminimallyinvasivesurgeryininfants.AmJSurg.1998;176:654–657.先天性膈疝1.刘钢,李龙,黄柳明.腹腔镜治疗小儿先天性膈疝6例报告.解放军医学杂志.2006.31(3):258-2592.吴晔明,严志龙,洪莉,等.腔镜下矫治儿童先天性膈肌缺陷24例.临床小儿外科杂志.2008.7(1):40-423.吴哗明，DonaldCLiu，严志龙，等．腹腔镜Nissen、s胃底折叠术治疗小儿胃食管反流性疾病叨．中华小儿外科杂志，2003，24(5)：415．417．4.李龙，付京波，张军，等．腹腔镜下矫治膈肌和食管下端畸形的探讨叨．中华小儿外科杂志，2004，25(4)：295—297．congenitaldiaphragmatichernia(CDH)NeonatalthoracoscopicCDHrepairhasincreasedrecurrenceriskandoperativetimecomparedwithopenrepair

NickLansdale,etal.NeonatalEndosurgicalCongenitalDiaphragmaticHerniaRepairASystematicReviewandMeta-Analysis(AnnalsofSurgery•Volume252,Number1,July2010)讨论膈疝微创手术修补1、经腹腔不易成功

新生儿膈疝多数缺损大、疝入胸腔脏器多，腹腔发育小2、经胸腔易成功

疝内容易还纳，显露清晰，操作空间好讨论注意1、妥善选择troca的位置2、手术过程中应注意调整co2气压以维持适当的膈肌紧张度3、与传统开胸手术一样，经胸腔镜手术亦无法探查是否合并肠道发育畸形4、尚无运用补片修补经验先天性肥厚性幽门狭窄102十二指肠梗阻：闭锁6环胰2例肠旋23黄疸鉴别诊断63先天性巨