“五孔法”腹腔鏡胰十二指腸切除術(shù)手術(shù)流程的建立及33例分析
發(fā)布時(shí)間：2018-09-09 08:26
【摘要】：自1987年法國(guó)Mouret醫(yī)生成功將電視腹腔鏡應(yīng)用于膽囊切除術(shù)以來(lái),腹腔鏡手術(shù)憑借切口小而視野清,術(shù)中出血少、術(shù)后恢復(fù)快等優(yōu)勢(shì),深受醫(yī)生和患者歡迎。隨著腹腔鏡技術(shù)的不斷提高和腔鏡器械的快速發(fā)展,腹腔鏡技術(shù)在帶蒂器官如膽囊、脾臟,空腔臟器如胃、空腸,實(shí)質(zhì)臟器如肝臟、胰腺等器官的手術(shù)上都獲得成功,其在外科的各個(gè)領(lǐng)域得到了廣泛應(yīng)用。Gawande回顧新英格蘭醫(yī)學(xué)雜志創(chuàng)刊200年外科學(xué)發(fā)展史時(shí),評(píng)價(jià)腹腔鏡技術(shù)帶動(dòng)的外科手術(shù)微創(chuàng)化的意義與麻醉對(duì)醫(yī)學(xué)發(fā)展的意義類似。其已成為二十一世紀(jì)外科學(xué)發(fā)展的兩大方向之一。 胰十二指腸切除術(shù)(Pancreaticoduodenectomy, PD)是治療胰頭等壺腹周圍腫瘤的標(biāo)準(zhǔn)術(shù)式。PD臟器切除困難,消化道重建復(fù)雜,術(shù)后并發(fā)癥多且危險(xiǎn),是腹部外科最復(fù)雜的手術(shù)之一。腹腔鏡胰十二指腸切除術(shù)(Laparoscopic Pancreaticoduodenectomy, LPD)自然成為胰腺外科和腔鏡外科醫(yī)生心向往之的“珠峰”。1994年,美國(guó)Gagner和Pomp成功實(shí)施了保留幽門(mén)的LPD,標(biāo)志著外科醫(yī)生對(duì)這領(lǐng)域的首次探索。但早期效果不理想,手術(shù)時(shí)間過(guò)長(zhǎng),手術(shù)中轉(zhuǎn)開(kāi)腹率高,術(shù)后恢復(fù)無(wú)明顯優(yōu)勢(shì),使LPD受到了廣泛的爭(zhēng)議和反對(duì),Gagner對(duì)此也失去了信心。2007年,印度醫(yī)生Palanivelu等報(bào)道了42例LPD,不但手術(shù)時(shí)間較前明顯縮短,術(shù)中、術(shù)后結(jié)果也體現(xiàn)了其微創(chuàng)優(yōu)勢(shì),激起了胰腺外科醫(yī)生對(duì)LPD新的熱情。目前,根據(jù)Pubmed中LPD的文獻(xiàn)數(shù)量及病例數(shù),LPD已在美國(guó)掀起了新一輪高潮。國(guó)內(nèi)開(kāi)展LPD起步較晚,第一例LPD報(bào)道于2003年。但歷經(jīng)10年,LPD也只在極少數(shù)中心開(kāi)展,基本為個(gè)例報(bào)告,且圍手術(shù)期結(jié)果與國(guó)外的報(bào)道存在很大差距。 本團(tuán)隊(duì)承擔(dān)浙江省重大科技專項(xiàng)(“基于多學(xué)科協(xié)作的胰腺外科微創(chuàng)化和個(gè)體化”)及浙江省醫(yī)學(xué)重點(diǎn)學(xué)科適宜技術(shù)推廣項(xiàng)目(“微創(chuàng)胰胃外科學(xué)”),至Mayo Clinic觀摩學(xué)習(xí)LPD,并從2012年9月開(kāi)始開(kāi)展LPD。在臨床實(shí)踐過(guò)程中,本團(tuán)隊(duì)對(duì)手術(shù)流程不斷進(jìn)行優(yōu)化,建立了一種適合國(guó)人體型的“五孔法"LPD手術(shù)流程。截至2014年4月初,本團(tuán)隊(duì)已成功實(shí)施33例。本文將對(duì)該手術(shù)流程進(jìn)行詳細(xì)闡述,并對(duì)33例LPD進(jìn)行分析,探討其安全性和可行性。 第一部分：“五孔法,,腹腔鏡胰十二指腸切除術(shù)手術(shù)流程的建立 研究目的：建立“五孔法”腹腔鏡胰十二指腸切除術(shù)手術(shù)流程,并探討其優(yōu)劣勢(shì)。 研究方法：通過(guò)文獻(xiàn)調(diào)研、到Mayo Clinic觀摩LPD手術(shù)、臨床探索優(yōu)化,結(jié)合胰十二指腸以腸系膜上動(dòng)靜脈為中心的解剖特點(diǎn)、及“五孔法”腹腔鏡以門(mén)靜脈和腸系膜上靜脈為軸心的視野特點(diǎn),建立“五孔法"LPD手術(shù)流程。 研究結(jié)果：“五孔法”套管分布成“V”形：臍下放置10mm套管,用于置放腹腔鏡；右側(cè)腋前線肋緣下2cm及與平臍腹直肌外緣分別放置5mm、12mm套管,由主刀操作；左側(cè)腋前線肋緣下2cm及與平臍腹直肌外緣分別均放置5mm套管,由助手操作。流程遵從從足端到頭端,從前到后,從左到右的原則。具體手術(shù)流程為：①解剖性探查：探查全腹腔,排除腹膜及肝臟表面轉(zhuǎn)移；離斷胃十二指腸動(dòng)脈,貫通門(mén)靜脈前的胰后隧道,分離并懸吊膽管；②切除：先離斷并游離近端空腸,將其通過(guò)腸系膜血管根部推向右側(cè)；從前向后離斷胃、胰頸；再作Kocher切口游離胰頭十二指腸；沿腸系膜上動(dòng)脈鞘完整切除胰腺鉤突；最后離斷膽管；③重建按Child式：胰腸吻合采用胰管空腸導(dǎo)管對(duì)粘膜端側(cè)吻合；膽腸吻合采用端側(cè)吻合；胃腸吻合采用側(cè)側(cè)吻合。 結(jié)論：“五孔法"LPD可行,適合國(guó)人體型,經(jīng)濟(jì)。該手術(shù)流程操作無(wú)反復(fù),能縮短手術(shù)時(shí)間。 第二部分：“五孔法,,腹腔鏡胰十二指腸切除術(shù)33例分析 研究目的：探討“五孔法”腹腔鏡胰十二指腸切除術(shù)的安全性和可行性,總結(jié)手術(shù)相關(guān)經(jīng)驗(yàn)。 研究方法：分析2012年9月至2014年4月初本團(tuán)隊(duì)完成的“五孔法”腹腔鏡胰十二指腸切除術(shù)病例的臨床資料,包括術(shù)中出血量、手術(shù)時(shí)間、術(shù)后恢復(fù)情況、術(shù)后并發(fā)癥、病理資料及隨訪情況等。 研究結(jié)果：共33例,平均年齡58.9歲。33例LPD中,LDP術(shù)后三年再次LPD手術(shù)1例,聯(lián)合右半肝切除術(shù)1例。平均手術(shù)時(shí)間366.67min,其中切除時(shí)間為177.59min,胰腸吻合時(shí)間為52.88min,膽腸吻合時(shí)間為38.52min,胃腸吻合時(shí)間為22.11min。術(shù)中平均出血量206.97ml。術(shù)后僅4例入住ICU,分別為1,1,2,5天。圍手術(shù)期并發(fā)癥率27.3%(9/33),均為三級(jí)以內(nèi),無(wú)四級(jí)及以上并發(fā)癥。無(wú)圍手術(shù)期死亡。其中A級(jí)胰瘺2例,B級(jí)胰瘺伴切口感染1例,膽漏1例,消化道出血2例,消化道出血伴腹腔出血伴膽漏1例,肺部感染2例。術(shù)后中位住院時(shí)間16天。術(shù)后病理：十二指腸乳頭腺癌10例,胰腺癌9例,膽總管癌5例,胰腺神經(jīng)內(nèi)分泌腫瘤2例,胰腺導(dǎo)管內(nèi)乳頭狀粘液瘤2例,十二指腸間質(zhì)瘤2例,胰管結(jié)石伴慢性胰腺炎、胰腺囊腫1例,胰腺粘液性囊腺瘤1例,胰腺實(shí)性假乳頭狀瘤1例。中位隨訪時(shí)間5月,所有病例都存活。 結(jié)論：基于“五孔法”的腹腔鏡胰十二指腸切除術(shù)安全可行,近期療效果滿意。但其作為高難度的新技術(shù),應(yīng)根據(jù)病種的病理解剖改變,從易到難選擇病例,并根據(jù)胰管和膽管大小選擇個(gè)體化重建方案,穩(wěn)步推進(jìn)。
[Abstract]:Laparoscopic cholecystectomy has been well received by doctors and patients for its advantages of small incision, clear vision, less bleeding during operation and quick recovery after operation. With the continuous improvement of laparoscopic techniques and the rapid development of endoscopic instruments, laparoscopic techniques have been used in pedicled organs such as gallbladder. The capsule, spleen, and cavity organs such as stomach, jejunum, and parenchymal organs such as liver and pancreas have been successfully operated on and have been widely used in various fields of surgery. The significance of learning development is similar. It has become one of the two main directions of surgical development in twenty-first Century.
Pancreatic duodenectomy (PD) is a standard procedure for the treatment of periampullary tumors of the head of the pancreas. PD is one of the most complex operations in abdominal surgery because of its difficulty in organ removal, complicated reconstruction of the digestive tract, and many and dangerous postoperative complications. Laparoscopic Pancreatic duodenectomy (LPD) is a natural procedure. In 1994, Gagner and Pamper successfully implemented pyloric-preserving LPD, marking the first exploration by surgeons in this field. However, the early results were unsatisfactory, the operation time was too long, the conversion rate to laparotomy was high, and there was no obvious advantage in postoperative recovery. In 2007, Indian doctor Palanivelu and others reported 42 cases of LPD, which not only shortened the operation time significantly, but also showed the advantages of minimally invasive surgery and postoperative results, arousing new enthusiasm for LPD among pancreatic surgeons. The first case of LPD was reported in 2003. However, after 10 years, LPD was only carried out in a few centers, basically as a case report, and there was a big gap between the perioperative results and foreign reports.
Our team undertook the major scientific and technological projects in Zhejiang Province ("minimally invasive and individualized pancreatic surgery based on multi-disciplinary collaboration") and the appropriate technology promotion project of key medical disciplines in Zhejiang Province ("minimally invasive pancreatic and gastric surgery"), to observe and study LPD at Mayo Clinic, and began to carry out LPD in September 2012. By the beginning of April 2014, 33 cases of LPD had been successfully performed by our team. This article will elaborate the procedure and analyze 33 cases of LPD to explore its safety and feasibility.
Part I: "five hole method, the establishment of laparoscopic pancreaticoduodenectomy procedure.
Objective: To establish a five-port laparoscopic pancreaticoduodenectomy procedure and explore its advantages and disadvantages.
Methods: Through literature research, to Mayo Clinic to observe LPD surgery, clinical exploration and optimization, combined with the pancreaticoduodenal anatomical characteristics of the superior mesenteric artery and vein as the center, and the "five-hole method" laparoscopic portal vein and superior mesenteric vein as the axis of visual field characteristics, to establish the "five-hole method" LPD operation process.
The results showed that the "five-hole" cannula was "V" shaped: 10 mm cannula was placed under umbilicus for laparoscopic placement; 5 mm and 12 mm cannula were placed under the costal margin of the right anterior axillary line and the external margin of the rectus abdominis flattened by the main knife; 5 mm cannula was placed under the costal margin of the left anterior axillary line and the external margin of the rectus abdominis flattened by the assistant. The procedure followed the principle of foot to head, from front to back, from left to right. The specific procedure was as follows: (1) anatomical exploration: exploration of the whole abdominal cavity, excluding peritoneal and hepatic metastases; gastroduodenal artery was cut off, the retropancreatic tunnel before portal vein was cut through, and the bile duct was separated and suspended; and (2) resection: the proximal jejunum was removed and the proximal jejunum was free. The pancreatic head and duodenum were dissected through the Kocher incision, the uncinate process of pancreas was completely removed along the superior mesenteric artery sheath, and the bile duct was severed finally. The reconstruction was performed according to Child's pattern: pancreaticojejunal catheter was used for pancreaticojejunal anastomosis, and the end-to-side anastomosis was used for cholangiojejunostomy. Anastomosis; side to side anastomosis for gastrointestinal anastomosis.
Conclusion: "Five-hole method" LPD is feasible, suitable for Chinese physique, economic. The operation procedure without repeated operation, can shorten the operation time.
The second part: five hole method, 33 cases of laparoscopic pancreaticoduodenectomy.
Objective:To explore the safety and feasibility of laparoscopic pancreatoduodenectomy with five-hole method and summarize the experience of operation.
Methods: The clinical data of five-hole laparoscopic pancreaticoduodenectomy performed by our team from September 2012 to early April 2014 were analyzed, including intraoperative bleeding volume, operation time, postoperative recovery, postoperative complications, pathological data and follow-up.
Results: Among 33 cases, the average age was 58.9 years. Among the 33 cases, 1 case underwent LPD and 1 case underwent right hepatectomy three years after LDP. The average operation time was 366.67 minutes, including 177.59 minutes, 52.88 minutes of pancreaticoenteric anastomosis, 38.52 minutes of biliary-enteric anastomosis and 22.11 minutes of gastrointestinal anastomosis. Only 4 patients were admitted to ICU after operation for 1,1,2,5 days, respectively. The perioperative complications rate was 27.3%(9/33), all of them were within grade 3, without grade 4 or more complications. There was no perioperative death, including grade A pancreatic fistula in 2 cases, grade B pancreatic fistula with incision infection in 1 case, bile leakage in 1 case, gastrointestinal hemorrhage with abdominal hemorrhage in 1 case, and pulmonary infection in 2 cases. Postoperative pathology: 10 cases of duodenal papillary adenocarcinoma, 9 cases of pancreatic carcinoma, 5 cases of common bile duct carcinoma, 2 cases of pancreatic neuroendocrine tumor, 2 cases of pancreatic ductal papillary myxoma, 2 cases of duodenal stromal tumor, 2 cases of pancreatic duct stones with chronic pancreatitis, 1 case of pancreatic cyst, 1 case of pancreatic mucinous cystadenoma, 1 case of pancreatic solid pseudopapillary 1 cases were tumor. Median follow-up time was May. All cases survived.
Conclusion: Laparoscopic pancreatoduodenectomy based on "five-hole method" is safe and feasible, and the short-term results are satisfactory. However, as a new technique with high difficulty, it is necessary to select cases from easy to difficult according to the pathological and anatomical changes of the disease, and to select individual reconstruction schemes according to the size of pancreatic duct and bile duct.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R656
本文編號(hào)：2231848
[Abstract]:Laparoscopic cholecystectomy has been well received by doctors and patients for its advantages of small incision, clear vision, less bleeding during operation and quick recovery after operation. With the continuous improvement of laparoscopic techniques and the rapid development of endoscopic instruments, laparoscopic techniques have been used in pedicled organs such as gallbladder. The capsule, spleen, and cavity organs such as stomach, jejunum, and parenchymal organs such as liver and pancreas have been successfully operated on and have been widely used in various fields of surgery. The significance of learning development is similar. It has become one of the two main directions of surgical development in twenty-first Century.
Pancreatic duodenectomy (PD) is a standard procedure for the treatment of periampullary tumors of the head of the pancreas. PD is one of the most complex operations in abdominal surgery because of its difficulty in organ removal, complicated reconstruction of the digestive tract, and many and dangerous postoperative complications. Laparoscopic Pancreatic duodenectomy (LPD) is a natural procedure. In 1994, Gagner and Pamper successfully implemented pyloric-preserving LPD, marking the first exploration by surgeons in this field. However, the early results were unsatisfactory, the operation time was too long, the conversion rate to laparotomy was high, and there was no obvious advantage in postoperative recovery. In 2007, Indian doctor Palanivelu and others reported 42 cases of LPD, which not only shortened the operation time significantly, but also showed the advantages of minimally invasive surgery and postoperative results, arousing new enthusiasm for LPD among pancreatic surgeons. The first case of LPD was reported in 2003. However, after 10 years, LPD was only carried out in a few centers, basically as a case report, and there was a big gap between the perioperative results and foreign reports.
Our team undertook the major scientific and technological projects in Zhejiang Province ("minimally invasive and individualized pancreatic surgery based on multi-disciplinary collaboration") and the appropriate technology promotion project of key medical disciplines in Zhejiang Province ("minimally invasive pancreatic and gastric surgery"), to observe and study LPD at Mayo Clinic, and began to carry out LPD in September 2012. By the beginning of April 2014, 33 cases of LPD had been successfully performed by our team. This article will elaborate the procedure and analyze 33 cases of LPD to explore its safety and feasibility.
Part I: "five hole method, the establishment of laparoscopic pancreaticoduodenectomy procedure.
Objective: To establish a five-port laparoscopic pancreaticoduodenectomy procedure and explore its advantages and disadvantages.
Methods: Through literature research, to Mayo Clinic to observe LPD surgery, clinical exploration and optimization, combined with the pancreaticoduodenal anatomical characteristics of the superior mesenteric artery and vein as the center, and the "five-hole method" laparoscopic portal vein and superior mesenteric vein as the axis of visual field characteristics, to establish the "five-hole method" LPD operation process.
The results showed that the "five-hole" cannula was "V" shaped: 10 mm cannula was placed under umbilicus for laparoscopic placement; 5 mm and 12 mm cannula were placed under the costal margin of the right anterior axillary line and the external margin of the rectus abdominis flattened by the main knife; 5 mm cannula was placed under the costal margin of the left anterior axillary line and the external margin of the rectus abdominis flattened by the assistant. The procedure followed the principle of foot to head, from front to back, from left to right. The specific procedure was as follows: (1) anatomical exploration: exploration of the whole abdominal cavity, excluding peritoneal and hepatic metastases; gastroduodenal artery was cut off, the retropancreatic tunnel before portal vein was cut through, and the bile duct was separated and suspended; and (2) resection: the proximal jejunum was removed and the proximal jejunum was free. The pancreatic head and duodenum were dissected through the Kocher incision, the uncinate process of pancreas was completely removed along the superior mesenteric artery sheath, and the bile duct was severed finally. The reconstruction was performed according to Child's pattern: pancreaticojejunal catheter was used for pancreaticojejunal anastomosis, and the end-to-side anastomosis was used for cholangiojejunostomy. Anastomosis; side to side anastomosis for gastrointestinal anastomosis.
Conclusion: "Five-hole method" LPD is feasible, suitable for Chinese physique, economic. The operation procedure without repeated operation, can shorten the operation time.
The second part: five hole method, 33 cases of laparoscopic pancreaticoduodenectomy.
Objective:To explore the safety and feasibility of laparoscopic pancreatoduodenectomy with five-hole method and summarize the experience of operation.
Methods: The clinical data of five-hole laparoscopic pancreaticoduodenectomy performed by our team from September 2012 to early April 2014 were analyzed, including intraoperative bleeding volume, operation time, postoperative recovery, postoperative complications, pathological data and follow-up.
Results: Among 33 cases, the average age was 58.9 years. Among the 33 cases, 1 case underwent LPD and 1 case underwent right hepatectomy three years after LDP. The average operation time was 366.67 minutes, including 177.59 minutes, 52.88 minutes of pancreaticoenteric anastomosis, 38.52 minutes of biliary-enteric anastomosis and 22.11 minutes of gastrointestinal anastomosis. Only 4 patients were admitted to ICU after operation for 1,1,2,5 days, respectively. The perioperative complications rate was 27.3%(9/33), all of them were within grade 3, without grade 4 or more complications. There was no perioperative death, including grade A pancreatic fistula in 2 cases, grade B pancreatic fistula with incision infection in 1 case, bile leakage in 1 case, gastrointestinal hemorrhage with abdominal hemorrhage in 1 case, and pulmonary infection in 2 cases. Postoperative pathology: 10 cases of duodenal papillary adenocarcinoma, 9 cases of pancreatic carcinoma, 5 cases of common bile duct carcinoma, 2 cases of pancreatic neuroendocrine tumor, 2 cases of pancreatic ductal papillary myxoma, 2 cases of duodenal stromal tumor, 2 cases of pancreatic duct stones with chronic pancreatitis, 1 case of pancreatic cyst, 1 case of pancreatic mucinous cystadenoma, 1 case of pancreatic solid pseudopapillary 1 cases were tumor. Median follow-up time was May. All cases survived.
Conclusion: Laparoscopic pancreatoduodenectomy based on "five-hole method" is safe and feasible, and the short-term results are satisfactory. However, as a new technique with high difficulty, it is necessary to select cases from easy to difficult according to the pathological and anatomical changes of the disease, and to select individual reconstruction schemes according to the size of pancreatic duct and bile duct.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R656
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