Name: modified single-loop reconstruction for pancreaticoduodenectomy
Uploaded: 2019-09-28T12:30:00
Description: Watch this Scientific Journal Video about Modified Single-Loop Reconstruction for Pancreaticoduodenectomy at JoVE.com

该协议侧重于使用 mSLR 的 PD 重建阶段，并遵循德国鲁尔大学波鸿分校道德委员会的指导方针。
注：胰腺头、大肠状或严重难治性慢性钙化胰腺炎患者接受PD。如果肿瘤与围肠动脉的接触少于50%，且没有渗透门户静脉或优越的静脉。腺癌病例的远转移也是PD的禁忌症。PD 中的切除技术是标准化的，并在其他部分11、12中详细描述。它不...

<ol>
	<li>Cameron, J. L., He, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Two+thousand+consecutive+pancreaticoduodenectomies.">Two thousand consecutive pancreaticoduodenectomies.</a> Journal of American College of Surgeons. 220 (4), 530-536 (2015).</li><li>Keck, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatogastrostomy+Versus+Pancreatojejunostomy+for+RECOnstruction+After+PANCreatoduodenectomy+(RECOPANC,+DRKS+00000767):+Perioperative+and+Long-term+Results+of+a+Multicenter+Randomized+Controlled+Trial.">Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.</a> Annals of Surgery. 263 (3), 440-449 (2016).</li><li>Deng, L. H., Xiong, J. J., Xia, Q. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+Roux-en-Y+pancreaticojejunostomy+versus+conventional+pancreaticojejunostomy+after+pancreaticoduodenectomy:+a+systematic+review+and+meta-analysis.">Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.</a> Journal of Evidence Based Medicine. 10 (1), 37-45 (2017).</li><li>Klaiber, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+complication+rates+for+single-loop+versus+dual-loop+(Roux-en-Y)+with+isolated+pancreaticojejunostomy+reconstruction+after+pancreaticoduodenectomy.">Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 102 (4), 331-340 (2015).</li><li>Eshmuminov, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+and+meta-analysis+of+postoperative+pancreatic+fistula+rates+using+the+updated+2016+International+Study+Group+Pancreatic+Fistula+definition+in+patients+undergoing+pancreatic+resection+with+soft+and+hard+pancreatic+texture.">Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture.</a> HPB (Oxford). 20 (11), 992-1003 (2018).</li><li>Ke, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective,+randomized+trial+of+Roux-en-Y+reconstruction+with+isolated+pancreatic+drainage+versus+conventional+loop+reconstruction+after+pancreaticoduodenectomy.">A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy.</a> Surgery. 153 (6), 743-752 (2013).</li><li>El Nakeeb, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Isolated+Roux+loop+pancreaticojejunostomy+versus+pancreaticogastrostomy+after+pancreaticoduodenectomy:+a+prospective+randomized+study.">Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study.</a> HPB (Oxford). 16 (8), 713-722 (2014).</li><li>Tani, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+clinical+trial+of+isolated+Roux-en-Y+versus+conventional+reconstruction+after+pancreaticoduodenectomy.">Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy.</a> British Journal of Surgery. 101 (9), 1084-1091 (2014).</li><li>Machado, M. C., da Cunha, J. E., Bacchella, T., Bove, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+technique+for+the+reconstruction+of+the+alimentary+tract+after+pancreatoduodenectomy.">A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy.</a> Surgery Gynecology Obstetrics. 143 (2), 271-272 (1976).</li><li>Aghalarov, I., Herzog, T., Uhl, W., Belyaev, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+single-loop+reconstruction+after+pancreaticoduodenectomy+reduces+severity+of+postoperative+pancreatic+fistula+in+high-risk+patients.">A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients.</a> HPB (Oxford). 20 (7), 676-683 (2018).</li><li>Marangoni, G., Morris-Stiff, G., Deshmukh, S., Hakeem, A., Smith, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modern+approach+to+teaching+pancreatic+surgery:+stepwise+pancreatoduodenectomy+for+trainees.">A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees.</a> Journal of Gastrointestinal Surgery. 16 (8), 1597-1604 (2012).</li><li>. Pyloruserhaltende Duodenohemipankreatektomie nach Traverso-Longmire mit T-Drainage (pp-Whipple) Available from: <a target="_blank" href="https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple">https://www.webop.de/Allgemein-und-Viszeralchirurgie/Pankreas-und-Milz/Pyloruserhaltende-Duodenohemipankreatektomie-nach-Traverso-Longmire-mit-T-Drainage-pp-Whipple</a> (2019)</li><li>Machado, M. C., Machado, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+use+of+isolated+pancreatic+anastomosis+after+pancreatoduodenectomy:+Five+years+of+experience+with+zero+mortality.">Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality.</a> European Journal of Surgical Oncology. 42 (10), 1584-1590 (2016).</li><li>Pescio, G., Cariati, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+reconstructive+method+after+pancreaticoduodenectomy:+the+triple+Roux+on+a+"P"+loop.+Rationale+and+radionuclide+scanning+evaluation.">A new reconstructive method after pancreaticoduodenectomy: the triple Roux on a "P" loop. Rationale and radionuclide scanning evaluation.</a> HPB Surgery. 9 (4), 223-227 (1996).</li><li>Kingsnorth, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+function+of+isolated+Roux+loop+pancreaticojejunostomy+after+Whipple's+pancreaticoduodenectomy.">Safety and function of isolated Roux loop pancreaticojejunostomy after Whipple's pancreaticoduodenectomy.</a> Annals of the Royal College of Surgeons of England. 76 (3), 175-179 (1994).</li><li>Jester, A. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Impact+of+Hepaticojejunostomy+Leaks+After+Pancreatoduodenectomy:+a+Devastating+Source+of+Morbidity+and+Mortality.">The Impact of Hepaticojejunostomy Leaks After Pancreatoduodenectomy: a Devastating Source of Morbidity and Mortality.</a> Journal of Gastrointestinal Surgery. 21 (6), 1017-1024 (2017).</li><li>Funovics, J. M., Zoch, G., Wenzl, E., Schulz, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Progress+in+reconstruction+after+resection+of+the+head+of+the+pancreas.">Progress in reconstruction after resection of the head of the pancreas.</a> Surgery Gynecology Obstetrics. 164 (6), 545-548 (1987).</li><li>Jover, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Results+of+defunctionalized+jejunal+loop+after+pancreaticoduodenectomy.">Results of defunctionalized jejunal loop after pancreaticoduodenectomy.</a> Cirurgia Espanola. 80 (6), 373-377 (2006).</li><li>Albertson, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticoduodenectomy+with+reconstruction+by+Roux-en-Y+pancreaticojejunostomy:+no+operative+mortality+in+a+series+of+25+cases.">Pancreaticoduodenectomy with reconstruction by Roux-en-Y pancreaticojejunostomy: no operative mortality in a series of 25 cases.</a> The Southern Medical Journal. 87 (2), 197-201 (1994).</li></ol>

迄今为止，POPF对PD1之后的术后发病率有显著贡献。
胆汁和胰腺汁的混合物可以导致两种分泌物的相互激活，增加对PJ或HJ9、13、14、15、16的不利影响。活性磷脂酶A2的细胞毒性活性，将胆汁卵磷脂转化为有害的利索西质，使胰腺麻醉风?...

胰腺切除术（PD）被认为是一个复杂的外科手术。虽然死亡率在过去几十年中有所下降，但发病率仍然很高。最频繁和害怕的并发症是术后胰腺瘘（POPF），它发生在超过20%的手术2，3，4，5。POPF可导致后续并发症，如产后造血、延迟胃排空、腹腔内脓肿和败血症。住院费用增加、住院时间过长、癌症患者化疗推迟，对2、3、4的社会经济影响巨大。
在过去的几十年中，人们采用了不同的手术方法来降低POPF的频率和严重程度。其中之一是双循环重建（DLR），与孤立的Roux-en-Y循环胆道和胰腺麻醉剂。胰腺汁从胆汁中分离出来被认为可以减少相互激活的分泌物对胰腺肌切除术（PJ）的有害影响。文学的结果一直鼓舞人心6，7，8。然而，使用DLR4，9，操作时间显著延长。
这里我们介绍了在PD期间修改的单循环重建（mSLR）技术，将胰腺分泌从胆汁中分离出来，而传统的单循环重建（SLR，图1）。在这种方法中，使用单个长的小肠环来构造肝热肌切除术（HJ）和PJ。HJ 的可致和可活动肢体之间的侧对侧麻醉有助于胆汁和胰腺分泌物的分离流动。2018年10月，我们小组报告了第一个有希望的结果，证实高危胰腺患者的死亡率和发病率有所下降。
与双循环重建相比，该方法通过分离胰腺液和胆汁来降低POPF的严重程度，同时不显著延长手术持续时间。

<table>
	<tbody>
		<tr>
			<td>Alexis O XXL</td>
			<td>Applied medical</td>
			<td>C8405</td>
			<td></td>
		</tr>
		<tr>
			<td>Bauchtuch Gr&#252;n 10x90</td>
			<td>Nobatrast</td>
			<td>603219</td>
			<td>abdominal compress</td>
		</tr>
		<tr>
			<td>Bauchtuch Gr&#252;n 45x45</td>
			<td>Nobatrast</td>
			<td>607544</td>
			<td>abdominal compress</td>
		</tr>
		<tr>
			<td>GIA 60mm-3.8mm</td>
			<td>Covidien/Medtronic</td>
			<td>GIA6038S</td>
			<td></td>
		</tr>
		<tr>
			<td>GIA Loading Unit</td>
			<td>Covidien/Medtronic</td>
			<td>GIA6038L</td>
			<td></td>
		</tr>
		<tr>
			<td>OP-Flex Yankauer</td>
			<td>Unomedical</td>
			<td>34094182</td>
			<td>suction device</td>
		</tr>
		<tr>
			<td>Pr&#228;pariertupfer-Set</td>
			<td>Fuhrmann</td>
			<td>32019</td>
			<td>sterile swab</td>
		</tr>
		<tr>
			<td>Schlinggazetupfer 30x40</td>
			<td>Fuhrmann</td>
			<td>32016</td>
			<td>sterile swab</td>
		</tr>
		<tr>
			<td>Telescopic Smoke Pencil</td>
			<td>LiNA Medical</td>
			<td>SHK-TSP-CL</td>
			<td>electro cautery</td>
		</tr>
		<tr>
			<td>Thermocover ECO</td>
			<td>PEMAX</td>
			<td>TC43-75EC2</td>
			<td>bowel cover</td>
		</tr>
		<tr>
			<td>Whipple-Set</td>
			<td>M&#246;lnlycke</td>
			<td>97016042-00</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Drainages:</td>
		</tr>
		<tr>
			<td>Drainagebeutel</td>
			<td>Coloplast</td>
			<td>?</td>
			<td>drainagebag</td>
		</tr>
		<tr>
			<td>Silikon-Kapillardrainage</td>
			<td>AsidBonz</td>
			<td>551012</td>
			<td>capillary drainage</td>
		</tr>
		<tr>
			<td>Trichteransatz f&#252;r T-Rohr</td>
			<td>R&#252;sch</td>
			<td>333169-000025</td>
			<td>2,5 mm</td>
		</tr>
		<tr>
			<td>T-Rohr nach Kehr</td>
			<td>R&#252;sch</td>
			<td>423600-000025</td>
			<td>t-tube 2,5 mm</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Sutures:</td>
		</tr>
		<tr>
			<td>Ethiloop 2mm 2x45cm</td>
			<td>Ethicon</td>
			<td>EH387</td>
			<td>loop</td>
		</tr>
		<tr>
			<td>Mersilene 0 FSL</td>
			<td>Ethicon</td>
			<td>EH7637</td>
			<td>fixation of the drainage</td>
		</tr>
		<tr>
			<td>PDS 1 CT</td>
			<td>Ethicon</td>
			<td>PDP9234</td>
			<td>suturing of the fascia</td>
		</tr>
		<tr>
			<td>Vicryl 2-0 , 6x45cm</td>
			<td>Ethicon</td>
			<td>VCP1226</td>
			<td>for ligature</td>
		</tr>
		<tr>
			<td>Vicryl 2-0 SHplus, 8x70</td>
			<td>Ethicon</td>
			<td>VCP7850</td>
			<td>for ligature</td>
		</tr>
		<tr>
			<td>Vicryl 3-0 MH-1plus</td>
			<td>Ethicon</td>
			<td>VCP245</td>
			<td>subcutaneous suture</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Pancreatic anastomoses:</td>
		</tr>
		<tr>
			<td>Prolene 5-0 c1</td>
			<td>Ethicon</td>
			<td>8890</td>
			<td>6 x</td>
		</tr>
		<tr>
			<td>PDS 5.0 RB-1plus</td>
			<td>Ethicon</td>
			<td>X1153</td>
			<td>2 x Multipack</td>
		</tr>
		<tr>
			<td>Prolene 4-0 RB-1</td>
			<td>Ethicon</td>
			<td>8871</td>
			<td>2 x holding sutures</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Hepaticojejunostomy:</td>
		</tr>
		<tr>
			<td>Prolene 5-0 c1</td>
			<td>Ethicon</td>
			<td>8890</td>
			<td>2 x holding sutures</td>
		</tr>
		<tr>
			<td>PDS 5-0 c1</td>
			<td>Ethicon</td>
			<td>PDP1013</td>
			<td>7 x</td>
		</tr>
		<tr>
			<td>PDS 6-0 c1</td>
			<td>Ethicon</td>
			<td>PDP1012</td>
			<td>1 x mucosa fixation sutures</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Gastrojejunostomy:</td>
		</tr>
		<tr>
			<td>PDS 4-0 SH-1 plus</td>
			<td>Ethicon</td>
			<td>X1154</td>
			<td>1 x Multipack</td>
		</tr>
		<tr>
			<td colspan="4"></td>
		</tr>
		<tr>
			<td colspan="4">Jejuno-Jejunostomy</td>
		</tr>
		<tr>
			<td>Ligasure</td>
			<td>Covidien</td>
			<td>LS1520</td>
			<td></td>
		</tr>
		<tr>
			<td>PDS 5-0 RB-1 plus</td>
			<td>Ethicon</td>
			<td>X1153</td>
			<td>1 x Multipack</td>
		</tr>
		<tr>
			<td>Prolene 2-0 SH</td>
			<td>Ethicon</td>
			<td>8833</td>
			<td>Vessel-suture, etc.</td>
		</tr>
		<tr>
			<td>Prolene 3-0 SH</td>
			<td>Ethicon</td>
			<td>8832</td>
			<td>Cystic duct, cystic artery</td>
		</tr>
		<tr>
			<td>Prolene 4-0 RB-1</td>
			<td>Ethicon</td>
			<td>8871</td>
			<td>2 mal suturing of the slit in the meso</td>
		</tr>
	</tbody>
</table>

modified single-loop reconstruction for pancreaticoduodenectomy

胰腺切除术中修饰的单循环重建分离胰腺分泌从胆汁。它在高风险胰腺残留物的情况下进行，以减少术后胰腺瘘的严重程度，以及术后的整体发病率。这种重建技术的特点是为胰腺肌切除术和肝切除术的超长环。这些麻醉剂和另外一个济州-杰朱诺-杰尤诺索托法之间的长距离距离，使肝胆肌切除术分离液体，防止胆汁回流到胰腺肌切除术。因此，分泌物不能相互激活，并加剧现有的麻醉漏。与传统的单回路重建相比，经改造的单回路重建后，严重术后胰腺瘘的发生率降低。与传统的双循环重建相比，该技术易于执行、安全且耗时更少。

每个接受PD的患者都接受胰腺组织调查，以评估mSLR的指示。高风险胰腺残余物（即软胰腺组织和微小的主胰腺导管）尽可能使用经过修饰的单回路进行重建。
我们确定了50名高危胰腺组织和一个小主胰腺导管患者。他们都接受了mSLR。平均年龄为63~13岁。男女比例为17：33。手术适应症是33例患者恶性疾病（66%）和良性疾病在17个患者（34%）。平均操作时间是365~77分钟。该组与两?...

Watch this Scientific Journal Video about Modified Single-Loop Reconstruction for Pancreaticoduodenectomy at JoVE.com

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

胰腺切除术后修饰的单循环重建技术将胰腺分泌从胆汁中分离出来，从而降低了POPF的严重程度，同时延长了手术时间。

胰腺切除术的改性单循环重建

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

胰腺分泌物与胆汁分离可减少相互激活分泌物对胰腺切除术的有害影响。这可降低术后胰腺管炎的严重程度，但不是发病率。单环重建是胰腺切除术中一种频繁进行的重建技术。双环重建于1976年首次引入。它实现了胰腺液和胆汁分离的理论。但是，与传统的单环重建相比，此过程要耗时得多。修改后的单环重建旨在将胰腺体液与胆汁分离，胆汁具有长的杰朱尔肢体，并在肝结切除术的异肢和发泡肢体之间增加一种杰朱纳尔肛门病。此图展示了经过修改的单环重建的胰腺切除术的完成重建阶段。绿色箭头演示胰腺结切除术、肝细胞切除术和杰朱诺耶肌切除术。在这张照片中可以清楚地看到超长的杰朱纳尔肢体。这项研究涉及人类手术的研究方案只得到了波鸿鲁尔大学伦理委员会的批准。所有患者都获得书面知情同意。这是准备的韧带补丁。它将被包裹在肝动脉后完成动脉的结膜病，以减少侵蚀出血的风险，在动脉瘤泄漏的情况下。开始重建阶段，固定一个长，移动的Jejunal循环。重新测量前 10 英寸的 jejunum， 以提供足够的长度的梅内蒂。在右上腹部象限中重新置置 jejunal 循环。进行双层地间导管到粘膜胰腺结膜切除术。对外层使用中断的聚二甲酮 5-0 缝合线，对内层使用中断的聚丙烯 5-0 缝合线。不需要支架或密封剂。此序列显示胰腺结膜内层的缝合与中断的聚丙烯 5-0 缝合。将缝合线彼此靠近，以避免动脉瘤功能不全。不要将缝合线放置得太近，以免缝合组织坏死。在这里，我们看到胰腺结膜切除术的外层与中断的多二酮5-0缝合的构造。缝合线按此顺序进行准备。再一次，不要把缝合线彼此太近。这是完成的双层到导管到粘膜胰腺结膜切除术。在构建肝结切除术之前，先建造杰诺耶诺切除术的外墙。这有利于肝切除术的建设。现在，我们可以清楚地看到长杰朱尔肢体将如何放置。肝切除术和胰腺切除术之间的杰朱纳尔循环测量25至35厘米，而不是10厘米。这创造了动脉瘤之间的距离，使分泌物的转移。它进一步促进在肝切除和肝切除的四肢之间再构建一个jejunojejun切除术。执行单层中断多二酮 5-0 缝合的肝素结膜切除术。用T管分离薄壁和微小的普通胆管。使用四个粘膜固定缝合线开始肝细胞切除术。两个聚丙烯 5-0 持有缝合线有利于肝细胞切除术的构建。使用中断的多二酮 5-0 缝合线开始构建肝素结膜切除术。准备手术结，但不要在开始时绑它们。准备好的手术结随后被绑上，使每个缝合线具有相等的张力。在这里，我们可以清楚地看到超长的Jejunal肢体修改的单环重建。在这里，我们看到肝切除术前墙的建造。jejenojejunostomy 是一种 1.5 厘米测量双层 jejunal 肛门病，用多二酮 5-0 缝合进行。在肝切除术和肝切除术的发性肢体之间的最低点构建动脉瘤。构建胰腺结切除术和肝细胞切除术的这种结石，因为它们是最复杂的。使用单极烧灼热打开jejunum，用于建造jejunojejunotomy。使用多二酮 5-0 缝合进行连续缝合，用于 jejunojejunostomy 后壁的内层。连续的苏特允许在动脉瘤上均匀分布张力。在这里，我们看到动脉瘤前壁内层的构造。这是前墙外层的构造。在这里，我们看到胰腺炎切除术，jejunojejun切除术，和肝细胞切除术的背景。在转位下肢后，缩小中异子龙的间隙，以避免内气喘。每个有软胰腺组织和小主胰管的患者都尽可能进行经过修改的单环重建。调动长杰朱尔肢体通常没有问题。在极少数情况下，由于极端的内脏肥胖或由于过去的手术史导致的严重粘附，动员受到限制。小病人在上腹部自然更小的空间，也妨碍了准备。在患者中，连续进行双层重建。术后无一功能不全。这种方法可减少所有高风险胰腺残留物患者严重术后胰腺管病的发生率。通过修改的单环重建，产后切除术出血和再手术的数量明显减少。与双环重建相比，此过程在技术上要求显著降低，耗时也更低。修改的单环重建是将胰腺分泌物与胆汁分离的简单技术，可降低术后发病率。与双环重建，它既安全又不耗时。

modified-single-loop-reconstruction-for-pancreaticoduodenectomy

Research

JoVE Journal

Medicine

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

改性技术在小鼠冠状动脉结扎

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

科研

医学

A Modified Method for Heterotopic Mouse Heart Transplantion

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents available. A difficulty is presented due to the small size of the animal and the considerable technical challenges of the microsurgery involved in heart transplantation. In particular, a high rate of technical failure early after transplantation may result from recipient death and post-operative complications such as hind limb paralysis or a non-beating heart. Here, the complete technique for heterotopic mouse heart transplantation is demonstrated, involving harvesting the donor heart and its subsequent implantation into a recipient mouse. The donor heart is harvested immediately following in situ perfusion with cold heparinized saline and transection of the ascending aorta and pulmonary artery. The recipient operation involves preparation of the abdominal aorta and inferior vena cava (IVC), followed by end-to-side anastomosis of the donor aorta with the recipient aorta using a single running 10-0 microsuture and a similar anastomosis of the donor pulmonary artery with the recipient IVC. Following the operation the animal is injected with 0.6 ml normal saline subcutaneously and allowed to recover on a 37&#160;&#176;C heating pad. The results from 227 mouse heart transplants are summarized with a success rate at 48 hr of 86.8%. Of the 13.2% failures within 48 hr, 5 (2.2%) experienced hind limb paralysis, 10 (4.4%) had a non-beating heart due to graft ischemic injury and/or thrombosis, while 15 (6.6%) died within 48 hr.

A technique is demonstrated for the microsurgical procedure for heterotopic transplantation of hearts in mice, including simplified methods for donor harvesting and recipient vessel anastomosis.

对于异位小鼠心脏移植技术的一种改进方法

Mice are often used as heart transplant donors and recipients in studies of transplant immunology due to the wide range of transgenic mice and reagents ...

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Methods for designing a computer-aided design/computer-aided manufacturing (CAD/CAM) surgical guide are shown. Cutting planes are separated, united, and thickened to easily visualize the necessary bone transfer. These designs can be three-dimensional printed and checked for accuracy.

用内部方法设计上颌重建的 cad/cam 手术指南

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes have been available for years in many surgical fields. We used the female (because they are easy to handle for the procedure) Yorkshire pigs for the head and neck reconstruction by harvesting the deep inferior epigastric artery perforator or the superior epigastric artery perforator flap. The anastomosis site (neck skin defect or tracheal wall defect) was prepared via the dissection of the common carotid artery and the internal jugular vein, in which 3.5&#215; loupe magnification was used for anastomosis as we use on human cases in real life. This procedure demonstrates a new training method using a reliable learning model and provides a detailed anatomy in a live scenario. We focused on the ischemia time, harvesting, vessel anastomosis, and designing the flap to fit the defect site. This model improves tissue handling and with the use of proper instruments can be repeated many times so that the surgeon is fully confident before starting the surgery on humans.

Here we present a protocol for the use of the pig superior epigastric artery perforator flap as a learning module for head and neck microvascular reconstruction.

猪作为头颈部微血管重建训练模块

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes ...

A Training and Testing System for Performing Vascular Reconstruction In Vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has yet to be developed. In this study, we introduce an in vitro training and testing system using a magnetic anchoring technique with which a trainee can practice manual vascular reconstruction individually. Additionally, this system can also be used to test the quality of the reconstruction. The described system includes a vascular reconstruction training machine, magnetic tractors, and a magnetic suture puller. In this manuscript, we detail an end-to-end vein anastomosis using porcine right and left iliac veins. To identify the potential damage caused by a magnetic suture puller on the suture, we created three groups with six segments of 4-0 polypropylene sutures each: a control group with no intervention on the polypropylene suture, a group in which the polypropylene suture is manually pulled with sterile gloves 20x, and a magnetic puller group in which the magnetic puller pulled the polypropylene suture 20x. These groups were tested by light microscopy and breaking strength tests, and the effect of reconstruction was assessed. In the light microscopy test, the control group was less likely to be damaged (p &#60; 0.05) and the number of damaged points of the manual group and magnetic puller group were similar (p &#62; 0.05). The results of the breaking strength test were compared across groups and no significant difference was observed (p &#62; 0.05). The end-to-end anastomosis of the porcine iliac veins was successfully performed using this training system, and the reconstructed veins could undergo 2.0 kPa perfusion pressure. Using this training and testing system the trainee can practice manual vascular reconstruction in vitro individually with the aid of magnetic tractors and a magnetic suture puller, and the quality of the reconstruction can be tested.

Here we present a training and testing system where a trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique. The system can also be used to test the quality of reconstruction.

在体外进行血管重建的训练和测试系统

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

机器人辅助胰腺切除术的技术细节

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging modalities, mandibular defect classification, and evaluation methodologies between studies. This guideline uses a step-by-step approach guiding the process of imaging, classification of mandibular defects and volume assessment of three-dimensional (3D) models, after which a legitimized quantitative accuracy evaluation method can be performed between the postoperative clinical situation and the preoperative virtual plan. The condyles and the vertical and horizontal corners of the mandible are used as bony landmarks to define virtual lines in the computer-assisted surgery (CAS) software. Between these lines the axial, coronal, and both sagittal mandibular angles are calculated on both pre- and postoperative 3D models of the (neo)mandible and subsequently the deviations are calculated. By superimposing the postoperative 3D model to the preoperative virtually planned 3D model, which is fixed to the XYZ axis, the deviation between pre- and postoperative virtually planned dental implant positions can be calculated. This protocol continues and specifies an earlier publication of this evaluation guideline.

Here, we propose a practical, feasible and reproducible evaluation guideline for computer-assisted reconstruction of the mandible in order to create uniformity between studies regarding postoperative accuracy evaluation. This protocol continues and specifies an earlier publication of this evaluation guideline.

可读机辅助重建术后评估指南

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging ...

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

接受选择性神经转移的上肢截肢者的治疗干预

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

Complete resection of the uncinate process and mesopancreas is one of the most important and difficult processes in laparoscopic pancreatoduodenectomy (LPD). This article presents a method for managing the uncinate process in no-touch LPD using the median-anterior and left-posterior approaches to the superior mesenteric artery (SMA).

非接触式腹腔镜胰十二指肠切除术中未接触突的管理

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of ...

Digital Model for Horizontal 3D Reconstruction of Pulmonary Nodules

To reconstruct the three-dimensional digital model of the pulmonary nodules, implement the Three-Dimensional Lung Horizon Function in the MATLAB workspace. Then open the Graphical User Interface, or GUI, to check the horizontal three-dimensional model. Drag the scroll bar on the GUI with the mouse to observe the continuous three-dimensional lung structure, allowing for the clear visualization of various types of pulmonary nodules and their relative spatial relationships with the lung tissue.Use the Zoom function to observe the local features of the lesions and relevant three-dimensional structural output pictures. To measure the size of the nodules, use the Mark Pixel Coordinates button to calculate the distance between two points. The default color bar, jet colormap, displays values from low to high in a blue to red range.To reset the GUI, right click the color bar and select the standard gray colormap. If the filter window is not satisfactory, use the left mouse button to adjust the window level by dragging up and down in the middle of the figure. Drag left and right to adjust the window width to display the accurate filtering range on the color bar.The continuous three-dimensional reconstruction resulted in the axial view of the pulmonary nodules and the relationship between the nodules and the surrounding lung tissue.