胸腹腔镜下Ivor-Lewis食管癌根治术课件

食管癌的微创外科MinimallyInvasiveSurgery

ofEsophagealCancer武汉市黄陂区人民医院江汉大学附属第三医院张毅胸腹腔镜下Ivor-Lewis食管癌根治术HistoryandForeignExperience1946年Ivor-lewis提出经腹和右胸联合手术治疗中段食管癌，开始手术分为2期，即先经腹完成胃的游离，然后1~2周后再2期经右胸游离和切除食管，并胃代食管在胸内吻合。胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2000年美国匹兹堡大学胸部外科和微创外科中心J.D.Luketich等在AnnThoracSurg上报导1996~1999年对77位患者进行了minimallyinvasiveesophagectomy,MIE。胸腹腔镜下Ivor-Lewis食管癌根治术开始他们进行了完全腹腔镜下的胃游离，然后利用mini-thoracotomy进行食管游离、切除和胃代食管的胸内吻合。后来逐渐发展到完全胸腔镜下进行。胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术中国的经验胸腹腔镜下Ivor-Lewis食管癌根治术2007年8月至2008年7月完成23例胸腹腔镜下Ivor-Lewis食管癌根治术2007年12月完成1例胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2007年1月至12月完成12例胸腹腔镜下Ivor-Lewis食管癌根治术自己的体会从2010年5月开始，使用胸腹腔镜完成了9例Ivor-lewis食管癌根治术。胸腹腔镜下Ivor-Lewis食管癌根治术动物实验胸腹腔镜下Ivor-Lewis食管癌根治术一、麻醉1.双腔气管插管。2.术中因游离食管对双腔插管有挤压影响，使导管轻度移位，气道压明显上升，约3~5cmH2O，氧饱和度下降，呼气末CO2浓度上升，严重影响病人苏醒，此时应暂停手术，短暂双肺通气，使氧饱和度维持在95%以上再开始手术。胸腹腔镜下Ivor-Lewis食管癌根治术二、腹部胃游离和淋巴结清扫胸腹腔镜下Ivor-Lewis食管癌根治术2.1体位1.腹部手术时平卧位，头高脚低约25~30°；2.大字形，双上肢和下肢分开；3.胸部手术左侧卧位，稍前倾。胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2.2Trocar位置胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2.3游离胃大小弯胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2.4Kocher手法游离十二指肠二、三段胸腹腔镜下Ivor-Lewis食管癌根治术2.5胃脾韧带的游离胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2.6腹部淋巴结清扫1.切除大网膜，胃边缘距血管弓约3cm，标本单独取出病检。2.常规清除No7/8/9组淋巴结。胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2.7贲门和食管下段游离胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术2.8膈肌裂孔的处理胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术3胸段食管的游离和淋巴结清扫胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术4胸内食管胃吻合4.1腋后线与腋中线，第4或5肋间切口长约8~10cm，在胸腔镜辅助下使用荷包钳、荷包线缝合放置25mm抵钉座，然后经胃贲门切口放入吻合器完成吻合。胸腹腔镜下Ivor-Lewis食管癌根治术4.2腔镜下使用3/0可吸收线围绕食管缝合一周，一般4~5针，在锋线下方约0.5cm使用超声刀切开食管管径的1/2，使用靶式钳塞入抵钉座后打结；还可以切断食管后围绕食管断端坦边缝合一周后打结，可以使食管断端边缘围绕抵钉座中心杆更平整、更紧密。胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术4.3使用ORVIL系统进行吻合简便、节约时间价格较高，难以普及胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-Lewis食管癌根治术胸腹腔镜下Ivor-