Name: robotic myotomy and partial fundoplication for achalasia
Uploaded: 2023-08-11T12:00:00
Description: Watch this Scientific Journal Video about Robotic Myotomy and Partial Fundoplication for Achalasia at JoVE.com

向患者解释了外科手术的记录以及出于科学和教育原因使用其内容的情况;根据该机构的人类道德委员会的说法，他随后签署了一份同意书。还获得了手术和麻醉程序的书面知情同意书。
注意：通过测压和钡餐食管造影结果确诊为贲门失弛缓症的患者可以包含在机器人肌切开术和部分胃底折叠术方案中。进行术前麻醉前评估，排除手术风险增加的患者。不符合贲门失弛缓症诊?...

<ol>
	<li>Moonen, A., Boeckxstaens, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+diagnosis+and+management+of+achalasia.">Current diagnosis and management of achalasia.</a> Journal of Clinical Gastroenterology. 48 (6), 484-490 (2014).</li><li>Tuason, J., Inoue, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+status+of+achalasia+management:+a+review+on+diagnosis+and+treatment.">Current status of achalasia management: a review on diagnosis and treatment.</a> Journal of Gastroenterology. 52 (4), 401-406 (2017).</li><li>Pasricha, P. J., Rai, R., Ravich, W. J., Hendrix, T. R., Kalloo, A. 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F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B., Kavitt, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ACG+clinical+guidelines:+Diagnosis+and+management+of+achalasia.">ACG clinical guidelines: Diagnosis and management of achalasia.</a> American Journal of Gastroenterology. 115 (9), 1393-1411 (2020).</li><li>Triadafilopoulos, G., 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+Kagoshima+consensus+on+esophageal+achalasia.">The Kagoshima consensus on esophageal achalasia.</a> Diseases of Esophagus. 25 (4), 337-348 (2012).</li><li>Richards, W. O., 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=Heller+myotomy+versus+Heller+myotomy+with+Dor+fundoplication+for+achalasia:+A+prospective+randomized+double-blind+clinical+trial.">Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: A prospective randomized double-blind clinical trial.</a> Annals of Surgery. 240 (3), 405-415 (2004).</li><li>Wang, X. H., Tan, Y. Y., Zhu, H. Y., Li, C. J., Liu, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-thickness+myotomy+is+associated+with+a+higher+rate+of+postoperative+gastroesophageal+reflux+disease.">Full-thickness myotomy is associated with a higher rate of postoperative gastroesophageal reflux disease.</a> World Journal of Gastroenterology. 22 (42), 9419-9426 (2016).</li><li>Ali, A., Pellegrini, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+myotomy:+technique+and+efficacy+in+treating+achalasia.">Laparoscopic myotomy: technique and efficacy in treating achalasia.</a> Gastrointestinal Endoscopy Clinics of North America. 11 (2), 347-358 (2001).</li><li>Spiess, A. E., Kahrilas, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treating+achalasia:+from+whalebone+to+laparoscope.">Treating achalasia: from whalebone to laparoscope.</a> JAMA. 280 (7), 638-642 (1998).</li><li>Xie, J., Vatsan, M. S., Gangemi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+robotic-assisted+Heller+myotomy+for+the+treatment+of+achalasia:+A+systematic+review+with+meta-analysis.">Laparoscopic versus robotic-assisted Heller myotomy for the treatment of achalasia: A systematic review with meta-analysis.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 17 (4), e2253 (2021).</li><li>Kim, S. S., Guillen-Rodriguez, J., Little, A. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Optimal+surgical+intervention+for+achalasia:+laparoscopic+or+robotic+approach.">Optimal surgical intervention for achalasia: laparoscopic or robotic approach.</a> Journal of Robotic Surgery. 13 (3), 397-400 (2019).</li><li>Pallabazzer, G., 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=Clinical+and+pathophysiological+outcomes+of+the+robotic-assisted+Heller-Dor+myotomy+for+achalasia:+a+single-center+experience.">Clinical and pathophysiological outcomes of the robotic-assisted Heller-Dor myotomy for achalasia: a single-center experience.</a> Journal of Robotic Surgery. 14 (2), 331-335 (2020).</li><li>Baek, S. J., Kim, S. H. <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:+an+evidence-based+review.">Robotics in general surgery: an evidence-based review.</a> Asian Journal of Endoscopic Surgery. 7 (2), 117-123 (2014).</li><li>Bianchi, E. 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=Heller-Pinotti,+a+modified+partial+fundoplication+associated+with+myotomy+to+treat+achalasia:+technical+and+final+results+from+445+patients.">Heller-Pinotti, a modified partial fundoplication associated with myotomy to treat achalasia: technical and final results from 445 patients.</a> Mini-invasive Surgery. 1, 153-159 (2017).</li></ol>

该协议描述了机器人肌切开术和部分胃底折叠术作为贲门失弛缓症的治疗方法。本文重点介绍了Heller Pinotti胃底折叠术，该折叠术由经典Dor胃底折叠术的变体组成。本文中介绍的这种技术展示了三排缝合线的性能，而不是在Dor胃底折叠术中进行的经典的两排缝合线。文献中已广泛研究了胃底折叠术的最佳类型，包括全折叠、前折叠或后折叠，但围绕改善结局的最佳方法仍然存在争议17...

贲门失弛缓症是一种原发性神经退行性食管动力障碍，其特征是蠕动异常和食管下括约肌松弛失败1.贲门失弛缓症的治疗旨在降低食管下括约肌的静息压力，从而允许食管排空2。治疗贲门失弛缓症有多种选择，例如口服药物治疗、内镜药物治疗3、气动扩张术 4、经口内镜下肌切开术 （POEM）5 和手术肌切开术 6。
手术肌切开术将食管下括约肌的肌纤维分开，已被描述为非晚期贲门失弛缓症的三种确定性疗法之一，另外还有充气扩张术和经口内镜下肌切开术7，8。由于肌切开术可降低食管下括约肌的压力，因此增加胃底折叠术是一种抗反流手术，这可能导致潜在的胃食管反流病9，10。
腹腔镜 Heller 肌切开术已成为治疗贲门失弛缓症的最常见外科手术，因为与其他手术方法（如开胸术、剖腹手术和胸腔镜11，12）相比，术后疼痛减轻，发病率降低。机器人Heller肌切开术已成为腹腔镜治疗贲门失弛缓症的微创替代方案，因为机器人方法提供了机械优势，例如放大的高分辨率三维可视化和最小化的生理震颤13，14，15。
本文介绍了一个 32 岁慢性吞咽困难、反流和体重减轻患者的案例。吞咽困难最初与固体有关，也慢慢发展为液体。患者否认其他临床症状，如发热、上腹部疼痛和餐后饱胀感。最初进行内镜评估以排除恶性肿瘤（图1）。检查显示食道扩张和曲折，以及食物滞留，食物被内窥镜完全吸出。还发现了粘膜增厚，未检测到肿瘤病变。窄带成像显示正常的血管和粘膜模式。胃食管交界处位于膈肌结节的水平。
然后进行食管测压（图2）和食管钡（图3）的调查。测压显示胃食管交界处松弛受损，食管无蠕动。食管钡显表现为食管扩张和钡排空延迟。然后通过测压和食管钡检查结果确定贲门失弛缓症的诊断。该患者被认为有资格进行机器人辅助肌切开术和部分胃底折叠术。
本文的目的是逐步描述在圣保罗大学进行的机器人辅助海勒肌切开术。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Da Vinci Surgical System</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Needle driver</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar forceps</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar Fenestrated Grasper</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ultracision</td>
			<td>Johnson &#38;&#160; Johnson</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

robotic myotomy and partial fundoplication for achalasia

腹腔镜海勒肌切开术目前被认为是贲门失弛缓症的标准确定性治疗方法。随着技术的进步，机器人 Heller 肌切开术已成为传统腹腔镜检查的替代方法，因为机器人提供的三维 （3D） 可视化、精细运动控制和改进的人体工程学。 
尽管缺乏随机对照试验，但与腹腔镜方法相比，机器人辅助 Heller 肌切开术似乎与较低的术中穿孔率有关。机器人方法还可以通过提供更完整的肌切开术来改善手术结果。 
在这里，我们描述了机器人肌切开术和部分胃底折叠术治疗贲门失弛缓症的详细步骤。

代表性结果如 表1所示。手术时间为112分钟，测得的失血量为20毫升。术后病程并不复杂。术后护理在普通病房进行。由于没有并发症，因此不需要重症监护室。手术第一天后开始流质饮食 - 患者没有报告吞咽困难。患者在术后第2天以流质饮食出院，状况良好。在第5天之后逐渐引入软食。患者在随访期间未出现任何并发症。手术后30天进行食管钡餐造影（图5）?...

Watch this Scientific Journal Video about Robotic Myotomy and Partial Fundoplication for Achalasia at JoVE.com

Robotic Myotomy and Partial Fundoplication for Achalasia

部分胃底折叠术的手术肌切开术可用于特定患者，作为贲门失弛缓症的确定性治疗。本文逐步介绍了一名 32 岁巨食管患者的机器人肌切开术和部分胃底折叠术。

机器人肌切开术和部分胃底折叠术治疗贲门失弛缓症

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

部分胃底折叠术的手术肌切开术可用于特定患者，作为贲门失弛缓症的确定性治疗。该视频演示了一名 30 岁巨食管患者的机器人肌切开术和部分胃底折叠术的步骤。将Nathanson肝脏牵开器置于剑突下位置，以抬高肝脏的左叶。通过划分短胃血管开始手术，从胃的大曲率中间一直到希斯的角度。使用超声波谐波手术刀将其从腹膜后释放出来，同时自动抓握器将胃缩回胃部，对胃底进行完全活动。将胃肝韧带划分到迷走神经肝分支下方，并逐渐解剖以识别和暴露两个膈肌结。在解剖过程中，请注意保留迷走神经的肝分支。在食道周围贴上胶带，以便轻轻牵引。通过钝性解剖将其与左右结核分开，继续分离食道。在夹层过程中，注意识别并保留前后迷走神经干以及两个胸膜。前迷走神经躯干粘附或嵌入食管壁，后躯干位于食管后方的脂肪组织层上。向周围活动食管，形成更长的腹内食管。通过握住位于食管韧带上方的脂肪组织来取出脂肪垫，并用谐波手术刀将其与食道壁圆周分开，以暴露和更好地观察胃食管交界处。在进行肌切开术之前，用食管前中线的双极镊子标记食管壁，并在胃食管交界处上方延伸约 6 厘米处。抓住肌切开术的边界，破坏肌肉层，同时将边界彼此远离，直到粘膜下层暴露。通过将手术刀的不活动下颌插入粘膜下和肌肉层之间并激活触发器以切割和烧灼，用谐波手术刀进行肌切开术。在解剖过程中，请确保横向分离肌切开术的肌肉边缘，从而避免它们在愈合时融合。使用无菌测量条确保肌切开术的长度在胃食管交界处上方 6 厘米，在其下方 3 厘米处。继续在胃食管交界处下方进行分界和肌切开术，横向进入胃部，因为肌肉纤维的方向从圆形变为倾斜。充分扩展肌切开术对于获得良好的术后效果和避免吞咽困难复发至关重要。用八针数字进行裂缝修复，用2.0棉缝合线。注意不要收紧裂孔，这可能导致术后吞咽困难。继续进行海勒-皮诺蒂胃底折叠术。动员胃底，并将其带到食管后部，以便将胃底缝合到食管远端的后壁。用2-0棉缝线进行断断缝合，并将胃的血清肌肉层连接到食道的肌肉层上。缝合线的延伸应与肌切开术的延伸相对应。通常，缝两到三针就足够了。该行的第一针也应包含中断。虽然这种动作不会阻止阀门的迁移，但它会限制其旋转。必要时在胃食管交界处切除肌肉条。接下来，进行从胃底到肌切开术左边缘的第二排缝合。与第一排一样，初始针迹也应附在裂缝上。进行从胃底到肌切开术右边缘的第三排也是最后一排缝合。在这些步骤结束时，食道暴露的粘膜下层应被胃浆覆盖。手术时间为112分钟，实测失血量为20毫升。术后病程并不复杂。手术第一天后开始流质饮食，患者未报告吞咽困难。患者在术后第二天以流质饮食出院，状况良好。第五天后逐渐引入软食。患者在随访期间未出现任何并发症。手术后30天进行食管钡涂图检查。检查显示钡剂充分排空，无造影剂潴留，胃底折叠术正常。虽然腹腔镜Heller肌切开术目前被认为是贲门失弛缓症的金标准治疗，但机器人辅助肌切开术在经验丰富的外科医生手中也可以是一种成功的替代方案，并且应该被视为在微创治疗领域，贲门失弛缓症的可行治疗选择。

Research

JoVE Journal

Medicine

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

遥控磁导航导管定位准确，实时和心脏电生理消融程序

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

科研

医学

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

部分原位肝移植大鼠模型的肝动脉重建的外科手术

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

Robotic Ablation of Atrial Fibrillation

房颤消融机器人

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Visualization of Vascular and Parenchymal Regeneration after 70% Partial Hepatectomy in Normal Mice

之后，正常小鼠70％部分肝切除血管和实质再生的可视化

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the ...

Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine

完全性和部分主动脉闭塞治疗猪失血性休克

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the ...

Generation of a Rat Model of Acute Liver Failure by Combining 70% Partial Hepatectomy and Acetaminophen

通过结合70%部分切除术和对乙酰氨基酚，生成急性肝衰竭大鼠模型

Acute liver failure (ALF) is a clinical condition caused by various etiologies resulting in the loss of metabolic, biochemical, synthesizing, and ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

慢性胰腺炎的机器人侧胰腺肌切除术

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand

使用双骨外骨骼机器人手开发面向任务的新康复计划

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor ...

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

使用3D机器人超 声进行小鼠 肾脏体内分析

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

机器人泰姬陵肝切除术治疗肺门胆管癌

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...