Name: laparoscopic pancreatoduodenectomy with modified blumgart pancreaticojejunostomy
Uploaded: 2018-06-17T13:00:00
Duration: 8 min 57 s
Description: Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy at JoVE.com

作者没有确认。所述技术在作者的两个机构中都使用。

由于这项手术是在例行的临床护理中进行的, 所以不需要具体的伦理批准。病人是一个67岁的女性与1厘米壶腹部肿瘤, 呈现与梗阻性黄疸, 苍白的彩色凳子, 深色的尿, 瘙痒和10公斤体重下降1年。病人的临床病史显示高血压和 II. 型糖尿病。内镜超声显示壶腹的大蒂息肉样病变。
1.患者选择
<ol><li>根据胰腺或壶腹肿瘤选择患者, 在最近 (最大4周) 对比增强 CT 扫描中没有任何主要血管参与的迹象。</li>
	<li>检查 CT 是否有血管异常, 如右肝动脉异常过程。</li>
	<li>在训练中, 排除患者的身体质量指数 > 35 公斤/米2, 复发性急性或慢性胰腺炎, 以前的主要腹部手术, 胰腺靶向放疗, 中胆管癌, 和大十二指肠癌, 由于预期的技术困难。一旦获得了与 lpd 的广泛经验, 血管切除也是可行的在 lpd20。</li>
</ol>2. 病人准备
<ol><li>进行术前内镜逆行胰胆管造影 (ERCP), 以缓解梗阻性黄疸。</li>
	<li>放置一个7Fr 的塑料胆道支架并进行活检。病理显示, tubulovillous 腺瘤的胆总管 (CBD) 与局灶性高等级发育不良。图 1显示了病变在 CT 扫描中的出现。</li>
</ol>3.外科技术
<ol><li>操作设置<ol>
<li>放置在法国位置的病人与一个加热装置在一个短的粮食床垫与右臂和左手臂被绑架到90°。</li>
		<li>在无菌博览会期间, 切记保持耻骨上的区域为 Pfannenstiel 切口免费切除标本。第一位外科医生站在病人的腿之间, 第一和第二助理分别在左侧和右侧。使用6端口技术执行此过程, 请参见图 2。</li>
		<li>气腹后, 放置子脐12毫米套管针, 然后4套管针沿半圆形平面 (两个12毫米套管针左和右的脐, 两个5毫米套管针四个手指右肋左, 右在前腋线)。</li>
		<li>将6次套管针放在 xiphoidal (图 2) 上, 用于肝脏收缩。</li>
		<li>选择一个拨 (阐明) 密封装置, 连同腹腔镜单钩和腹腔镜双极钳透热法。</li>
	</ol></li>
	<li>勘探阶段<ol>
<li>进行腹腔镜诊断, 排除腹膜和肝转移。将直针 transcutaneously 在上腹部区域, 周围圆韧带, 以收回韧带至腹腹壁。</li>
		<li>解剖胆囊门和囊性动脉, 然后将两个片段之间的导管分开, 并将哈特曼的眼袋缝合到腹腹壁上, 进一步进行肝回缩和肝十二指肠韧带的暴露。</li>
	</ol></li>
	<li>解剖阶段<ol>
<li>通过将 gastrocolic 韧带从胃网膜血管远端分开2厘米, 打开较小的囊。从胰腺中释放胃, 让助手收回胃前方。动员肝脏弯曲。此后, 左助理将十二指肠缩回病人的左侧, 而右助理则用纱布推结肠 caudo 内侧。</li>
		<li>科克机动<ol>
<li>执行宽科克机动, 暴露下静脉静脉, 肠系膜上动脉的起源 (SMA) 和韧带 Treitz。也显露肠系膜上静脉 (SMV) 和它的汇合与胃网膜静脉。解剖后, 它使用剪辑和阐明封口机。</li>
		</ol>
</li>
		<li>胰隧道<ol>
<li>现在, 创建一个广泛的胰隧道的开始。</li>
			<li>接下来, 释放胃远端, 仅1厘米近于幽门, 并在胃管被拉回后用 endostapler 进行横断面。在胰腺的颅侧, 解剖肝动脉淋巴结站 (8a 号), 并将其送往病理学。此后, 确定肝动脉、门静脉和胃十二指肠动脉。</li>
			<li>围胃十二指肠动脉与血管循环, 并划分它, 留下2锁定剪辑在病人的一侧和1的标本的一侧。用闭合的封口机, 用一条长度的血管环将胰腺固定, 用一个塑料自锁夹来保证胰腺隧道的钝夹层。</li>
		</ol>
</li>
		<li>Treitz 切除韧带<ol>
<li>动员 duodenojejunal 弯曲 (Treitz 韧带), 并划分第一个空肠循环与 endostapler 使用血管筒。现在完成第一个循环的动员到肠系膜根。此后, 将空肠的两个游离端缝合, 并将肠系膜根部的两端都传给病人的右侧。</li>
		</ol>
</li>
		<li>胰切除术<ol>
<li>对于胰头解剖, 移动相机右侧12毫米套管针, 因为这提供了一个更好的看法 SMA 和 SMV。从 SMV 和第一空肠分支的侧面对钩过程进行解剖。从腹侧到背层工作, 同时缩回 SMV 内侧以暴露 SMA。</li>
			<li>用单透热法对胰腺进行样带, 用双极透热法处理出血。</li>
			<li>用剪刀对胰管进行横断面, 以避免导管的密封。解剖所有腹膜后淋巴结, 同时可视化 SMA。</li>
		</ol>
</li>
		<li>胆管切除术<ol>
<li>对肝动脉进行正常的肝动脉随访, 在血管解剖异常的情况下进行护理。此后, 用血管循环将肝导管包围, 并将其与远端肝导管上的腹腔镜牛头犬分开, 并将一个塑料锁紧夹 (或第二头斗牛犬) 放在上胆管上。</li>
			<li>接下来, 把标本放在一个塑料回收袋中, 暂时放在下腹部。与胆囊同时取出标本。在重建阶段开始前稍作停顿。</li>
		</ol>
</li>
	</ol></li>
	<li>重建阶段<ol>
<li>胰吻合术<ol>
<li>通过3D 腹腔镜手术, 根据修改后的 Blumgart 技术, 开始重建阶段执行 PJ, 4 刺缝线 (大钝针, 3/0, 23cm 长度) (图 3)。</li>
			<li>通过从切口边缘约1厘米的缝线通过胰腺, 然后通过背通过肠道和背部通过胰腺。通过后, 通过自己的循环驱动针, 收紧, 并把它远离胰腺。</li>
			<li>对每一个缝线重复此过程, 注意不要阻塞胰管 (图 3. 1)。3D 腹腔镜便于针的放置和缝合。</li>
		</ol>
</li>
		<li>导管-粘膜吻合术<ol>
<li>用透热法钩 (从胰管大约5毫米) 在空肠上创建一个2毫米 enterotomy。</li>
			<li>随后, 用一个小钝针 (5/0) 放置4-6 导管到黏膜缝合线。如有四缝线, 请将其放置在8、5、11和2点。选择的位置, 以克服更难缝合的典型的9和3点的时钟缝合在小胰导管。</li>
			<li>首先, 将8和5点缝合与里面的结。放置一个12厘米6或8法郎儿科鼻管作为内胰支架 (图 3. 2)。</li>
			<li>接下来, 将11和2点缝合带到外面的结。用原来的四刺缝线完成空肠腹侧的吻合, 先将其插入前方通过空肠壁, 然后向后穿过胰腹侧, 然后缩回脾以防止胰腺撕裂。</li>
			<li>在切割前用一个夹子固定每个缝线 (图 3. 3 和 3.4)。</li>
		</ol>
</li>
		<li>胆道吻合术<ol>
<li>大约5-7 厘米进一步在空肠循环, 创造一个 2-4mm antimesenterial enterotomy 与透热法钩。</li>
			<li>执行端对端空肠 (HJ) 与中断可吸收螺纹 (5/0) 缝合, 从6点在胆管之间的缝合开始到12点在 enterotomy。</li>
			<li>继续它从尾部到头骨交替在 HJ 的左和右两侧。在空肠循环和胆囊床之间可以放置张力释放缝合线。在一个宽, 厚壁胆管的情况下使用与外科医生站在病人的左侧或右侧的一个运行缝合。</li>
			<li>将一个外科引流从右右肋空间通过在 PJ 的高级边界结束的温斯洛孔。完成胆囊切除术并将胆囊放在第二个回收袋中。把第一个空肠循环拉到胃里。</li>
		</ol>
</li>
		<li>胃吻合术<ol>
<li>在小 enterotomy 和小胃造口术后, 只需从短纤线的腹侧执行一个装订的侧对侧 antecolic 空肠 (GJ)。用带刺3/0 缝线的单缝缝合其余的开口。</li>
			<li>创建一个 Pfannenstiel 切口5厘米, 以提取胰十二指肠切除标本和胆囊。关闭这个切口在层和 insufflate 腹部放置第二排泄通过最右侧5毫米套管针在睡衣的下边界, 与小费在 GJ 之下。</li>
			<li>用大网膜盖住睡衣和 GDA 的树桩。关闭三12毫米套管针的筋膜。通过皮内缝合 (4/0) 关闭所有切口 (图 4)。</li>
		</ol>
</li>
	</ol></li>
</ol>

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作者没有什么可透露的。

LPD 是一个技术上具有挑战性但标准化, 安全和可重复的程序。LPD 可提供微创方法的优势, 包括早期动员、肠功能提早恢复和短期住院停留21。人们普遍认为, 腹腔镜提供了更好的可视化质量, 扩大了手术领域的所有细节和最小的操作的组织22。病理结果也可比较的 LPD 和开放的技术。特别是, 同样的 R0 切除和淋巴结收获率已报告10。
使用法国的立场, 6 端口技术, 3D 腹腔镜 (特别是在吻合阶段) 和适当的腹腔镜设备可以减少的障碍, 最小侵入的方法。我们也建议一些技术提示, 以前描述的 Palanivelu等。23如经皮穿刺的上腹部区域, 以收回圆韧带或将哈特曼的眼袋缝合至腹腹壁, 以改善 hepatoduodeneal 韧带的暴露。
不幸的是, 有一个价格要支付;这种复杂的手术必须在高容量的中心进行, 外科医生在开放的胰腺切除和先进的腹腔镜手术中有丰富的经验15。虽然改良后的 Blumgart pancreaticojejunostomy 是一种可重复的胰腺吻合术, 但需要进行细致的手术。外科医生需要注意不要用带刺缝线的胰管阻塞。导管对黏膜缝合也需要精心放置。每条缝合线都置于直接可视化的位置, 但不需要立即收紧, 并且可以最初保持牵引。当最初切割胰管时, 它可能会保持一些较长的时间来促进这些缝合。
腹腔镜胰十二指肠切除术需要先进的腹腔镜技术和广泛的经验, 开放胰腺手术。进一步的研究需要调查这项技术的肿瘤结果。对于这些患者来说, 最小的侵入方法是否安全和有益, 必须建立在随机的环境中。在荷兰, LEOPARD-2 (试验登记处 NTR5689) 多中心试验目前随机患者使用所述技术24进行微创和开放性胰十二指肠切除术。

腹腔镜手术在过去几十年中有了快速的发展, 并且正在为越来越复杂的外科手术而进行。尽管越来越多的认识到这种方法的好处, 大多数胰腺外科医生仍然不确定这项技术的优势1,2,3,4,5.腹腔镜远端胰腺现在被证明是安全和容易获得的, 虽然它的使用在治疗腺癌仍然辩论2,4,6,7。自从81994年第一份关于腹腔镜胰十二指肠切除术 (LPD) 的报告中, 很少有研究描述了9、10、11、12的技术。非随机研究报告说, 与开放胰十二指肠切除术13,14相比, 延迟胃排空减少, 在估计的手术中失血量已报告为 LPD。一项随机试验和系统评价报告说, LPD 可以减少住院, 而不增加总费用15,16。不幸的是, LPD 似乎与术后胰瘘和再入院率较高有关, 特别是在低容量中心17。最好的胰腺吻合术仍有待讨论。在开放胰十二指肠切除术中最常见的吻合是在 LPD 中重现。然而, 对于开放性胰腺手术, 用 LPD 获得的结果是有争议的。胰腺吻合术的安全性、可行性、重现性和简便性对该技术的扩散和手术效果有重要作用。
Blumgart 胰吻合术是一种简单有效的方法, 它将导管-黏膜吻合与空肠覆盖在18胰腺原表面的原理结合起来。Blumgart 吻合术与胰瘘率比其他技术19相关。
本文旨在证明 pancreaticojejunostomy (PJ) 的安全性和可行性, 在一个壶腹肿瘤患者的改良 Blumgart 吻合和手术肿瘤结果。

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laparoscopic pancreatoduodenectomy with modified blumgart pancreaticojejunostomy

微创胰腺切除在技术上要求, 但迅速增加的人气。与腹腔镜远端胰腺相比, 腹腔镜胰十二指肠切除术 (LPD) 尚未获得广泛接受, 可能是由于技术上的挑战, 特别是对胰腺吻合。
本研究描述并演示了 LPD 的所有步骤, 包括修改后的 Blumgart pancreaticojejunostomy。对 LPD 的适应症是所有胰腺和周围壶腹肿瘤, 没有血管介入。相对的反指是身体质量指数 > 35 公斤/米2, 慢性胰腺炎, 中胆管癌和大十二指肠癌。
患者在法国位置, 6 套管针被安置, 并且解剖使用 (阐明) 密封装置执行。改进后的 Blumgart 端对侧 pancreaticojejunostomy 用4大针 (3/0) 带刺的反式胰缝线和4到6的导管到黏膜缝合, 使用5/0 厘米, 12 或6法郎内支架使用3D腹腔 镜。两个外科排水管放在 pancreaticojejunostomy 旁边。
本文介绍了一种改进的 Blumgart 胰空肠的描述技术, 并对其优点进行了研究。这一复杂的手术应该在大容量的中心进行, 在那里外科医生在开放胰腺手术和先进的腹腔镜胃肠手术中有着丰富的经验。

手术时间为6小时, 失血150毫升。病人的术后病程很简单。未发现术后胰瘘。术后3天的淀粉酶水平在两个排水沟是 1373 u/升和 804 u/升, 已正常化的一天 5, 在下水道被删除。病人在术后6天出院 。病理学评估显示, 1.5 厘米 tubulovillous 腺瘤的壶腹部, 低等级发育不良。切除边缘为显微镜下根治 (R0), 十三个淋巴结中没有一个肿瘤细胞参与。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/56819/56819fig1.jpg"> 图 1术前 CT 扫描 图像显示壶腹肿瘤, 导致梗阻性黄疸。<a href="/files/ftp_upload/56819/56819fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/56819/56819fig2.jpg"> 图 2病人的设置 操作者分别在腿、第一和第二助理之间。该过程由6端口技术执行。<a href="/files/ftp_upload/56819/56819fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/56819/56819fig3.jpg"> 图 3Pancreaticojejunostomy Blumgart 技术的改进 改良的 Blumgart pancreaticojejunostomy 是用四刺缝线 (3/0), 大针, 为 transpancreatic U 缝合 (3.1)。一个12cm 内部6或8法郎胰腺支架, 并进行管黏膜吻合是使用4-6 可吸收螺纹5/0 缝合与一个小钝针 (3.2)。吻合术是通过提取空肠腹侧与原来的四刺缝线 (3.3, 3.4) 完成。最后的结果的横向看法 (3.5)。
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/56819/56819fig4.jpg"> 图 4术后结果 这是经改良的 Blumgart pancreaticojejunostomy 腹腔镜胰十二指肠切除术后的最终结果。

Watch this Scientific Journal Video about Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy at JoVE.com

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

腹腔镜 pancreatoduodenctomy (LPD) 可提供优于开放胰十二指肠切除术, 包括早期手术后动员, 减少胃排空延迟和缩短住院时间。然而, LPD 是技术上的挑战, 而不是标准化的, 特别是关于胰腺吻合。我们描述了一个标准化的技术, 胰腺吻合在 LPD: 改良 Blumgart pancreaticojejunostomy。

改良 Blumgart Pancreaticojejunostomy 腹腔镜胰十二指肠切除术

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

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