Name: technical detail for robot assisted pancreaticoduodenectomy
Uploaded: 2019-09-28T14:45:00
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本议定书遵循匹兹堡大学医学中心人类研究伦理委员会（机构审查委员会：PRO15040497）的指导方针
1. 术前工作和选择
<ol><li>检查三脚椎CT扫描（即，胸部，腹部和骨盆与主要成像模式），以评估疾病的程度，排除转移，并划定异常或异常动脉血管。</li>
	<li>执行EUS和内窥镜逆行胆管造影术（ERCP），用于组织诊断和胆汁减压，特别是在胰腺癌计划新辅助化疗的设定中。</li>
	<li>...

<ol>
	<li>Tseng, J. F., 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+learning+curve+in+pancreatic+surgery.">The learning curve in pancreatic surgery.</a> Surgery. 141, 456-463 (2007).</li><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 the American College of Surgeons. 220, 530-536 (2015).</li><li>Birkmeyer, J., 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=Effect+of+hospital+volume+on+in-hospital+mortality+with+pancreaticoduodenectomy.">Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy.</a> Surgery. 125, 250-256 (1999).</li><li>Cirocchi, R., 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+systematic+review+on+robotic+pancreaticoduodenectomy.">A systematic review on robotic pancreaticoduodenectomy.</a> Surgical Oncology. 22, 238-246 (2013).</li><li>Giulianotti, P. C., 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=Robotics+in+general+surgery:+personal+experience+in+a+large+community+hospital.">Robotics in general surgery: personal experience in a large community hospital.</a> Archives of surgery. 138, 777-784 (2003).</li><li>Wang, S. -. E., Shyr, B. -. U., Chen, S. -. C., Shyr, Y. -. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+between+robotic+and+open+pancreaticoduodenectomy+with+modified+Blumgart+pancreaticojejunostomy:+A+propensity+score-matched+study.">Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy: A propensity score-matched study.</a> Surgery. 164 (6), 1162-1167 (2018).</li><li>Magge, 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=Robotic+pancreatoduodenectomy+at+an+experienced+institution+is+not+associated+with+an+increased+risk+of+post-pancreatic+hemorrhage.">Robotic pancreatoduodenectomy at an experienced institution is not associated with an increased risk of post-pancreatic hemorrhage.</a> HPB. 20, 448-455 (2018).</li><li>Zureikat, A. H., 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=Minimally+invasive+hepatopancreatobiliary+surgery+in+North+America:+an+ACS-NSQIP+analysis+of+predictors+of+conversion+for+laparoscopic+and+robotic+pancreatectomy+and+hepatectomy.">Minimally invasive hepatopancreatobiliary surgery in North America: an ACS-NSQIP analysis of predictors of conversion for laparoscopic and robotic pancreatectomy and hepatectomy.</a> The official journal of Hepato-Pancreato-Billiary Association. 19, 595-602 (2017).</li><li>Zureikat, A. H., 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+Multi-institutional+Comparison+of+Perioperative+Outcomes+of+Robotic+and+Open+Pancreaticoduodenectomy.">A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy.</a> Annals of Surgery. 264, 640-649 (2016).</li><li>McMillan, M. 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=A+Propensity+Score-Matched+Analysis+of+Robotic+vs+Open+Pancreatoduodenectomy+on+Incidence+of+Pancreatic+Fistula.">A Propensity Score-Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula.</a> JAMA Surgery. 152 (4), 327-335 (2016).</li><li>Nguyen, K., 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=Technical+Aspects+of+Robotic-Assisted+Pancreaticoduodenectomy+(RAPD).">Technical Aspects of Robotic-Assisted Pancreaticoduodenectomy (RAPD).</a> Journal of Gastrointestinal Surgery. 15, 870-875 (2011).</li><li>Zureikat, A. H., Nguyen, K. T., Bartlett, D. L., Zeh, H. J., Moser, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-Assisted+Major+Pancreatic+Resection+and+Reconstruction.">Robotic-Assisted Major Pancreatic Resection and Reconstruction.</a> Archives of Surgery. 146, 256-261 (2011).</li><li>Knab, M. 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=Evolution+of+a+Novel+Robotic+Training+Curriculum+in+a+Complex+General+Surgical+Oncology+Fellowship.">Evolution of a Novel Robotic Training Curriculum in a Complex General Surgical Oncology Fellowship.</a> Annals in Surgical Oncology. 25 (12), 3445-3452 (2018).</li><li>Wu, J., 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=Recurrent+GNAS+mutations+define+an+unexpected+pathway+for+pancreatic+cyst+development.">Recurrent GNAS mutations define an unexpected pathway for pancreatic cyst development.</a> Science Translational Medicine. 3, 92 (2011).</li><li>Singhi, A. 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=American+Gastroenterological+Association+guidelines+are+inaccurate+in+detecting+pancreatic+cysts+with+advanced+neoplasia:+a+clinicopathologic+study+of+225+patients+with+supporting+molecular+data.">American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: a clinicopathologic study of 225 patients with supporting molecular data.</a> Gastrointestinal Endoscopy. 83, 1107-1117 (2016).</li><li>Tanaka, 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=Revisions+of+international+consensus+Fukuoka+guidelines+for+the+management+of+IPMN+of+the+pancreas.">Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.</a> Pancreatology. 17, 738-753 (2017).</li><li>Malka, D., Castan, F., Conroy, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=FOLFIRINOX+Adjuvant+Therapy+for+Pancreatic+Cancer.">FOLFIRINOX Adjuvant Therapy for Pancreatic Cancer.</a> New England Journal of Medicine. 380, 1187-1189 (2019).</li><li>Nassour, I., 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=Robotic+Versus+Laparoscopic+Pancreaticoduodenectomy:+a+NSQIP+Analysis.">Robotic Versus Laparoscopic Pancreaticoduodenectomy: a NSQIP Analysis.</a> Journal of Gastrointestinal Surgery Official Journal of the Society for Surgery of the Alimentary Tract. 21, 1784-1792 (2017).</li><li>Gabriel, E., Thirunavukarasu, P., Attwood, K., Nurkin, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+disparities+in+minimally+invasive+surgery+for+pancreatic+tumors.">National disparities in minimally invasive surgery for pancreatic tumors.</a> Surgical Endoscopy. 31, 398-409 (2017).</li><li>Konstantinidis, I. 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=Robotic+total+pancreatectomy+with+splenectomy:+technique+and+outcomes.">Robotic total pancreatectomy with splenectomy: technique and outcomes.</a> Surgical Endoscopy. 32, 3691-3696 (2018).</li><li>Kornaropoulos, 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=Total+robotic+pancreaticoduodenectomy:+a+systematic+review+of+the+literature.">Total robotic pancreaticoduodenectomy: a systematic review of the literature.</a> Surgical Endoscopy. 31, 4382-4392 (2017).</li><li>Boone, B. 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=Assessment+of+Quality+Outcomes+for+Robotic+Pancreaticoduodenectomy:+Identification+of+the+Learning+Curve.">Assessment of Quality Outcomes for Robotic Pancreaticoduodenectomy: Identification of the Learning Curve.</a> JAMA Surgery. 150, 416-422 (2015).</li><li>Fisher, W. E., Hodges, S. E., Wu, M. -. F. F., Hilsenbeck, S. G., Brunicardi, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+the+learning+curve+for+pancreaticoduodenectomy.">Assessment of the learning curve for pancreaticoduodenectomy.</a> American Journal of Surgery. 203, 684-690 (2012).</li><li>Hmidt, C., 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=Effect+of+hospital+volume,+surgeon+experience,+and+surgeon+volume+on+patient+outcomes+after+pancreaticoduodenectomy:+a+single-institution+experience.">Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience.</a> Archives of Surgery. 145, 634-640 (2010).</li><li>Zureikat, A. H., Hogg, M. E., Zeh, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Utility+of+the+Robot+in+Pancreatic+Resections.">The Utility of the Robot in Pancreatic Resections.</a> Advances in Surgery. 48, 77-95 (2014).</li></ol>

随着手术技术的进步，腹腔镜和机器人辅助手术越来越多地用于胃肠道和肝胆手术。传统的腹腔镜检查与许多手术的开放式手术的好处有关。然而，固有的局限性，如手术灵巧性下降，人体工学不理想，缺乏手腕仪器，和二维可视化，限制了其传播的复杂胃肠道手术，如PD。
与腹腔镜检查相反，机器人平台允许在 3D 视觉下执行微创操作，增强灵巧性并使用铰接（手腕）仪器?...

胰腺切除术（PD）是一个复杂的操作，结合了具有挑战性的切除和甲子重建。在其早期，传统的开放方法与高并发症率和死亡率接近25%在过去三十年中，手术技术和围手术期护理的改进导致结果的相应改善，死亡率降至5%以下，特别是在高容量中心1，2，3. 尽管如此，发病率仍然很高。随着外科技术的进步，通过腹腔镜或机器人辅助手术的微创手术方法已经出现，以遏制这种发病率。自2003年首次报告以来，胰腺外科医生对机器人胰腺切除术（RPD）的兴趣有所增长。机器人平台的固有优势，包括三维 （3D） 视觉、手腕仪器和改进的人体工程学，使外科医生能够以微创方式概括开放式 PD （OPD） 原理，包括安全肿瘤学解剖，赫比沙，并精心重建4，6，7，8，9，10。本手稿的目的是提供在匹兹堡大学医学中心（UPMC）11、12、13进行RPD的详细步骤。
在所提出的案例研究中，一名42岁女性具有前肠内皮毛质粘质（IPMN）史，最初出现急性胰腺炎。腹部的脑血管造影（CT）显示一个3.3厘米的胰腺头部病变与主胰腺导管的相关扩张（图1A，B），与混合型IPMN。内窥镜超声（EUS）证实存在不规则的异质囊肿，测量3.1 x 2.0厘米的胰腺头部与混合固体和囊肿成分和主要PD导管扩张（图1C）。EUS细胞学显示，存在无高风险分子突变的非典型细胞14，15。包括血清肿瘤标记物在内的生化工作正常，CA19-9 12 U/mL。根据福冈标准，该患者被推荐为PD，并被认为是机器人方法16的合适人选。

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	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">3-0 V-Loc sutures</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">VLOCMo614</td>
			<td style="width:273px;">Barbed Absorable Suture</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">4-5 Fr Freeman Pancreatic Flexi-Stent</td>
			<td style="width:291px;">Hobbs Medical (Stafford Springs, CT)</td>
			<td style="width:119px;">6542, 6552</td>
			<td>Pancreatic Duct Stent</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">5-0 PDS (polydiosxanone)</td>
			<td style="width:291px;">Ethicon (Somerville, NJ)</td>
			<td style="width:119px;">D10063</td>
			<td>Synthetic Absorbable Suture</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Cad&#237;ere forceps</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470049</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Da Vinci Si</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;"></td>
			<td>Surgical Robot</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Da Vinci Xi</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;"></td>
			<td>Surgical Robot</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Endo Clip 10 mm Applier</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">176619</td>
			<td>Laparoscopic Titanium Clip Applier</td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:291px;">Endo GIA 45 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">EGIA45CTAVM</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:291px;">Endo GIA 60 mm Articulating Stapler with Tri-Stapler Technology</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">EGIA60AMT</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:291px;">Endo GIA 60 mm Curved Tip Articulating Vascular Stapler with Tri-Stapler Technology</td>
			<td style="width:291px;">Covidien (Dublin, Ireland)</td>
			<td style="width:119px;">EGIA60CTAVM</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">EndoCatch Gold 10 mm Specimen Pouch</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">173050G</td>
			<td>Specimen Extraction Bag</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">EndoCatch II 15 mm Specimen Pouch</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">173049</td>
			<td>Specimen Extraction Bag</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Fenestrated bipolar forceps</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470205</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">GelPOINT Mini Advanced Access Platform</td>
			<td>Applied Medical (Rancho Santa Margarita, CA)</td>
			<td style="width:119px;">CNGL3</td>
			<td>Laparoscopic Abdominal Access Platform</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Large needle driver</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470006</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Large SutureCut needle driver</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470296</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:291px;">LigaSure Blunt Tip Laparoscopic Sealer/Divider</td>
			<td style="width:291px;">Medtronic (Minneapolis, MN)</td>
			<td style="width:119px;">LF1844</td>
			<td>Laparoscopic Bioplar Device</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Mediflex liver retractor</td>
			<td style="width:291px;">Mediflex (Islandia NY)</td>
			<td style="width:119px;"></td>
			<td>Laparoscopic Liver Retractor</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Monopolar curved scissors</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470179</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">Permanent cautery hook</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470183</td>
			<td>Surgical Robot Instrument</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:291px;">ProGrasp forceps</td>
			<td style="width:291px;">Intuitive (Sunnyvale, CA)</td>
			<td style="width:119px;">470093</td>
			<td>Surgical Robot Instrument</td>
		</tr>
	</tbody>
</table>

technical detail for robot assisted pancreaticoduodenectomy

自2003年首次报告以来，机器人胰腺切除术（RPD）在胰腺外科医生中越来越受欢迎。机器人平台的固有优势，包括三维视觉、手腕仪器和改进的人体工学设计，使外科医生能够重述开放胰腺切除术的原则，从而安全进行肿瘤解剖、血相病、和细致的重建。在过去的十年中，在概述机器人 Whipple 的安全性、可行性和学习曲线方面取得了重大进展。当由在RPD中经验丰富的大容量胰腺外科医生进行手术时，最近的比较有效性研究表明，与开放技术相比，潜在的优势，包括减少住院和发病率。国家数据还显示，与腹腔镜相比，转化率有所降低。虽然仍然需要长期肿瘤数据，但边缘切除和淋巴结收获的短期肿瘤替代物表明，在肿瘤结果上不会妥协。随着胰腺外科医生越来越多地将机器人技术融入到他们的实践中，对于RPD的安全应用和传播，必须进行基于熟练程度的培训和认证。在这里，我们提供在匹兹堡大学医学中心进行的机器人胰腺切除术的详细步骤。

在代表性病例中，总手术时间是225分钟，估计失血（EBL）为50 mL（表1）。病人住进了外科病房。她的术后课程遵循UPMC机构ERAS路径。我们定期在POD+1和#3评估JP淀粉酶，以评估胰腺瘘，并尽可能在POD 3-5上练习早期排泄。患者的JP淀粉酶水平分别为403升和68升。因此，在 POD_3 上移除了排放。病人在POD+6号上出院了。
标本的病理学分析显示，侵入性中微分化腺癌（0.2厘?...

Watch this Scientific Journal Video about Technical Detail for Robot Assisted Pancreaticoduodenectomy at JoVE.com

Technical Detail for Robot Assisted Pancreaticoduodenectomy

以下手稿详细介绍了在匹兹堡大学医学中心进行的机器人辅助胰腺切除术的逐步方法。

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 ...

手稿描述了一种机器人辅助胰腺切除术的技术。代表患者为42岁女性，有IPMN病史，患有胰腺炎急性发作。诊断成像，包括CT扫描和内窥镜超声显示，一个复杂的隔膜异质质量测量3.3厘米。生化工作是正常的。她被推荐为机器人 RAPD 。患者被定位在裂开腿的桌子上，右臂夹着，压力点填充。操作台转动 45 度，以适应 Si 机器人。习机器人可以从侧面对接。机器人和辅助端口与图保持一对。肝脏缩回器放置在最左侧的侧端口。如果肝脏缩回器缩回胆囊，并提升肝脏优于整个切除。切除阶段随着进入小囊的入口而启动。通过胃皮球以下的较大卵精进入小囊。助手提供温和的反回回。解剖沿着更大的曲率向皮罗卢斯进行。结肠被完全从十二指肠中调动。胃皮骨被保存，在这一点上不转切。进行十二指肠的增高化。十二指肠的横向纤维被抓住并转换。床边助理提供十二指肠的温和中式反缩回。动员的十二指肠，包括其第三和第四部分进行到特雷茨的韧带。使用 A3 的动态前缩数和颅体缩回是出色曝光的关键。广泛的科泽化允许全面可视化劣质的静脉卡瓦，插入左肾静脉，和大动脉。特雷茨韧带的完全释放允许暴露近近的杰朱努姆。然后，通过特雷茨缺陷的韧带提取到右上部绞合上象限。接下来，对杰里茨韧带的距离大约10厘米。中肠容器用容器密封装置。利用线性血管订书机，将转导。十二指肠的线性化是在近体jejunum的内肠血管的连续连接中进行，一直进行到未inate过程。杆状松是开放的，注意不要进入异常左肝动脉。胃的转切点被带到大约五厘米近到皮罗鲁斯。使用容器密封装置将右侧胃气密封容器连接。然后，使用厚厚的线性订书机负载将胃转点。右胃动脉与腹腔镜钛血管10毫米夹连接，接近其从适当的肝动脉起飞。然后使用钝尖容器密封装置进行连接。A3 抓住大肠胃主食线，横向和劣质地收回标本，将常见的肝动脉和波塔肝动脉置于张力下。解剖继续通过胰腺的优越边界，并进入波塔肝。常见的肝动脉淋巴结被识别和切除。它被检索与10毫米腹腔镜标本检索袋，因此，送去永久病理分析。这允许对胃肠动脉进行完全可视化。胃肠动脉在从普通肝动脉起飞时被识别。利用机器人钩烧机对胃肠动脉进行完全周长解剖。船环在GDA周围通过。GDA 与血管订书机进行转换。近位树桩用腹腔镜钛血管10毫米夹加强。在头型方向上，入口静脉被解剖为2到3厘米。普通胆管之间的平面，以及入口静脉之间的平面被识别和开发。普通胆管与胆管支架水平以上的60毫米弯曲尖端血管线性订书机进行横切。利用机器人钩烧，进一步剖析了入口静脉的横向边界。经常遇到优越的胰腺动脉，并利用助手的钝尖血管密封装置进行连接。门户静脉的上级解剖一直延续到胰腺的优越边界。这种解剖允许暴露优越的隧道。A3 抓住并收回近叶胃主食线横向和头，把胃皮静脉在伸展，因为它进入内部SMV。利用电烧开胰腺低劣边界附近的脂肪组织。SMV 现在已可视化。助手提供温柔的解剖，使劣质隧道。正确的胃皮静脉可追溯到其插入SMV。解剖，放置容器环，并利用助手的钝尖容器密封装置进行连接。A3 现在横向收回大肠胃主食线的标本，将胰腺颈部伸展。胰腺帕伦奇玛是利用单极弯曲剪刀与电烧的转换。注意识别主管道。助理在转液期间将胰腺从 SMV 上抬离。主胰腺导管是利用剪刀转开的，无需电烧。四到五个法国胰腺导管支架被放置在主管道中，以确保其识别。剩余的胰腺帕伦奇玛是利用电烧的转越。切除的这一部分需要缓慢、细致的解剖，因为在没有操作员精度的情况下可能发生严重的出血。在此阶段进行未解剖的关键为 A3，它提供了样品的优越和横向缩回。A3 在切除过程中是动态的，需要频繁评估其放置情况。不连续过程由三个不同的层组成。第一层由SMV入口静脉与胰腺头之间的丝纤维组成，并未分层过程。A1被钩烧机所取代，主要用于解剖。第二层由第一济朱尔静脉、贝尔彻静脉和不结扎枝组成。A1和辅助钝尖容器密封装置主要用于解剖和结扎。第三层是 SMA 逆行边缘。助手使用 A2 立即旋转 SMV 和入口静脉。助手的容器密封装置用于这种结扎。胰腺炎切除术是在两层，端到边，导管到粘膜，在一个修改的Blumgart技术。A3 通常用于抓住先前放置的缝合线，以提供颅内缩回和曝光。放置两个全丝跨胰腺水平床垫缝合线，以固定胰腺膜瘤到jejunum。放置三个缝合线，一个在上面显示在这里，一个在下面，一个跨越。所有三根缝合线都绑起来，针子也放在缝合线上。在连接横跨主胰腺导管的中间缝合线时注意，以避免意外的导管结扎。胰管支架通常用于询问导管的帕蒂。然后，A1 被切换到单极剪刀，用于执行肠切除术。然后，这被替换为针头驱动器。中断的 5-0 PDS 缝合线用于近似到胰腺导管的 jejunum 粘膜。始终可以放置至少六个缝合线。如果管道尺寸较大，可以放置更多的缝合线。然后，在放置前 5-0 PDS 缝合之前，通过肠切除术安装胰管支架。一旦结膜炎完成，以前用于放置后层的同一个3-0丝线线被重新用于胰腺结切除术前层。肝细胞切除术进行约10厘米的胰腺结切除术。动脉瘤在单个层中进行，无论是中断的还是运行方式的。A1 与单极弯曲剪刀用于横贯常见的胆管订书线。利用胆汁抓钳使胆汁离普通胆管更近。A1 用单极弯曲剪刀重新武装，并用于进行肠切除术。对于直径小于一厘米的管道，使用 5-0 PDS 缝合线进行 anstomosis。对于较大的管道，两个运行 4-0 带刺的缝合线以单层连续方式使用。对于中断的动脉瘤，后缝合首先放置并绑住。对于小于一厘米大小的管道，我们通常使用四到五个法国胆道支架来保持动脉瘤的性。接下来，放置额外的 5-0 PDS 缝合线，以完成前前切除术。一旦所有的缝合线被放置，缝合线被绑住，动脉瘤就完成了。胃结切除术是一种手工缝制的，抗绞痛的端到端同位素肛门切除术。两，3-0丝绸标记缝放在jejunum约40至60厘米的赫帕蒂科耶诺切除术。这标志着近位和近在外，表示 jejunum 的四肢。A1 和 A2 替换为条形抓手。腹腔镜助手反射奥门托和中糖体，使外科医生能够定位新肺。然后，将侧背 jejunum 减少，并放回红外隔间。两个标记缝线被识别，和jejunum被带到一个抗绞痛，即腹性时尚。A1 和 A2 替换为大型双功能针头驱动器。放置一个中断的外层，有两个全丝缝合线。最头脑缝合由 A3 持有，用作缩回缝合。A1 替换为单极弯曲剪刀。这被用于转切胃主食线。剪刀也被用来把肠切除术放在杰朱努姆。以运行运河的方式使用两个 3 - 0 的刺线缝合进行。用2-0丝线线缝合的中断外层被放置在完成胃结切除术。在完成动脉瘤切除术后，19-法国圆形通道排水管被放置在胰腺炎切除术和肝切除术前。假形式韧带皮瓣用于覆盖GDS树桩。仪器被拆下，机器人被拆坞。筋膜和切口层层闭合。手术总时间为225分钟，估计失血25mLs，无术后并发症。最终病理学揭示了由分支管道IPMN引起的侵入性中度分化腺癌。手稿提供了在匹兹堡大学医学中心进行的机器人辅助胰腺切除术的详细步骤。

Research

JoVE Journal

Medicine

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

微血管减压：突出的手术原则和技术的细微差别

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

科研

医学

Microsurgical Venous Pouch Arterial-Bifurcation Aneurysms in the Rabbit Model: Technical Aspects

显微静脉袋分岔动脉瘤在兔模型：技术问题

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials ...

Technical Aspects of the Mouse Aortocaval Fistula

在的鼠标Aortocaval瘘的技术方面

Technical aspects of creating an arteriovenous fistula in the mouse are discussed. Under general anesthesia, an abdominal incision is made, and the aorta ...

Accuracy in Dental Medicine, A New Way to Measure Trueness and Precision

精度在牙科医学，一种新的方法来测量正确度与精密度

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base ...

A Novel Murine Model of Arteriovenous Fistula Failure: The Surgical Procedure in Detail

动静脉内瘘失败的新型小鼠模型：在详细介绍手术过程

The arteriovenous fistula (AVF) still suffers from a high number of failures caused by insufficient remodeling and intimal hyperplasia from which the ...

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

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 ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

机器人辅助基质前体模块化胰腺切除术，包括切除和重建的斯普尔诺-梅森特克结

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

OP-IVM: Combining In vitro Maturation after Oocyte Retrieval with Gynecological Surgery

OP-IVM：将卵母细胞取回后的体外成熟与妇科手术相结合

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte ...

Robot-Assisted Kidney Transplantation

机器人辅助肾移植

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

机器人辅助全直肠系膜切除术和盆腔外侧淋巴结清扫术治疗局部晚期中低直肠癌

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...