微創(chuàng)外科技術(shù)ppt課件

1、1,.,微創(chuàng)外科技術(shù)MINI-INVASIVE SURGERY,不低于或高于傳統(tǒng)治療效果前提下盡可能減少病人的近期和遠期的痛苦,.,2,微創(chuàng)外科技術(shù)MINI-INVASIVE SURGERY,包括 腔鏡外科 內(nèi)鏡外科 各種影像學(xué)介導(dǎo)下的治療技術(shù),3,.,外科腔鏡,LAPAROSCOPY,.,4,LAPAROSCOPY,.,5,腔鏡簡史,1901 KELLING膀胱鏡觀察狗腹腔 1910 JACOBAEUS腹腔鏡觀察人腹腔 1938 VERESS發(fā)明彈簧氣腹針 1950 HOPKING 柱狀透鏡 圖像清晰 1960 SEMM 婦科腹腔鏡手術(shù) 1987 MOURET 1988 DUBOIS腹腔鏡膽

2、囊切除術(shù),.,6,腹腔鏡設(shè)備器械,腹腔鏡 光學(xué)傳導(dǎo)作用 微型攝像頭及數(shù)模轉(zhuǎn)換器 顯示器 冷光源 錄像機及圖象存儲 CO2氣腹系統(tǒng) 手術(shù)設(shè)備器械,.,7,腹腔鏡設(shè)備器械,.,8,基本技術(shù),建立氣腹 1直接TROCAR穿刺法 2 氣腹針穿刺法 3開放法 止血 電凝 鈦夾 超聲刀 縫合 紗布填塞,.,9,基本技術(shù),組織分離切開 電刀 剪刀 超聲刀 分離鉗撕剝 腹腔鏡縫合 標(biāo)本取出 TROCAR孔 小切口 粉碎 標(biāo)本袋,.,10,建立氣腹,.,11,腹腔鏡手術(shù)資質(zhì),傳統(tǒng)外科培訓(xùn) 腹腔鏡基礎(chǔ)知識培訓(xùn) 動物實驗 非獨立完成一定數(shù)量腹腔鏡手術(shù),.,12,腹腔鏡手術(shù)適應(yīng)證,膽囊切除術(shù) 結(jié)腸良惡性疾病 闌尾切除

3、術(shù) 食管反流手術(shù) 小腸切除術(shù) 疝修補術(shù) 脾切除術(shù) 腎上腺切除術(shù) 淋巴清掃術(shù) 肝楔形切除術(shù) 婦科手術(shù) 腹腔鏡診斷術(shù),.,13,腹腔鏡診斷,單獨診斷應(yīng)用較少 有創(chuàng)檢查 需要麻醉 深部病變發(fā)現(xiàn)率低,.,14,腹腔鏡膽囊切除術(shù)LAPAROSCOPIC CHOLECYSTECTOMY,適應(yīng)證 與開腹手術(shù)指證相同 膽囊息肉 膽囊結(jié)石 充滿型膽囊結(jié)石 急性膽囊炎 膽總管探查 造影,.,15,.,16,LAPAROSCOPIC CHOLECYSTECTOMY,禁忌證 嚴(yán)重肝硬化 凝血障礙 妊娠 病理性肥胖 嚴(yán)重心肺功能不全,.,17,LAPAROSCOPIC CHOLECYSTECTOMY,相對禁忌證 上腹部

4、手術(shù)史 嚴(yán)重萎縮性膽囊炎,.,18,LAPAROSCOPIC CHOLECYSTECTOMY,.,19,LAPAROSCOPIC CHOLECYSTECTOMY,.,20,LAPAROSCOPIC CHOLECYSTECTOMY,.,21,LAPAROSCOPIC CHOLECYSTECTOMY,.,22,LAPAROSCOPIC CHOLECYSTECTOMY,.,23,LAPAROSCOPIC CHOLECYSTECTOMY,.,24,LAPAROSCOPIC CHOLECYSTECTOMY,.,25,Risks of surgery,Bleeding (needing transfusi

5、on) - 2% Infection - 2% Conversion to open surgery - 2% Bile leak - 2%,.,26,Risks of surgery,Retained stone in the common bile duct - variable depending on preoperative tests Injury to the common duct 0.2 % Injury to other structures in the abdomen including small intestines, liver, and blood vessel

6、s - 1% Hernia development at incision sites - 1%,.,27,腹腔鏡膽囊切除術(shù)并發(fā)癥及處理,一血管損傷 1大血管損傷 腹主動脈 門靜脈 腸系膜上動脈 下腔靜脈立即開腹止血 2手術(shù)區(qū)出血 膽囊動脈 膽囊床出血電凝 鈦夾 紗條填塞,.,28,腹腔鏡膽囊切除術(shù)并發(fā)癥及處理,二膽道損傷 1膽管橫斷 修復(fù) T管引流 ROUX-Y盆式吻合,.,29,腹腔鏡膽囊切除術(shù)并發(fā)癥及處理,2肝管側(cè)面損傷T管引流 ENBD 3膽囊管漏腹腔引流 ENBD 4膽管損傷后狹窄ROUX-Y肝門盆式吻合,.,30,LC并發(fā)癥預(yù)防,根據(jù)自身能力嚴(yán)格掌握適應(yīng)癥 第一戳孔要小心 將膽囊三

7、角完全分離清晰后再斷膽囊管 近膽管處慎用電凝,.,31,LC并發(fā)癥預(yù)防,出血時不盲目上鈦夾 膽囊破裂者要用標(biāo)本袋 解剖不清 手術(shù)困難 出血不能控制及時開腹 放置腹腔引流管便于發(fā)現(xiàn)并發(fā)癥,.,32,腹腔鏡在胃腸道手術(shù)中的應(yīng)用現(xiàn)狀與展望,.,33,腹腔鏡直結(jié)腸手術(shù),結(jié)直腸惡性腫瘤 是腹腔鏡消化道外科最成熟的手術(shù) 手助技術(shù)應(yīng)用降低了中轉(zhuǎn)開腹率 直腸全系膜切除更方便盆腔植物神經(jīng)識別保護 更確切 前瞻性多中心隨機對照研究表明生存率相當(dāng) 長期存活率 衛(wèi)生經(jīng)濟學(xué)評價是今后關(guān)注焦點 執(zhí)業(yè)環(huán)境惡化價格昂貴是該技術(shù)推廣的最大障礙,.,34,.,35,結(jié)直腸良性疾病,乙狀結(jié)腸息室有望成為標(biāo)準(zhǔn)手術(shù) 潰瘍性結(jié)腸炎進展緩

8、慢 治療CROHN病近期效果得到認可,.,36,腹腔鏡胃手術(shù),胃腫瘤手術(shù) 胃腫瘤局部切除 胃楔形切除 胃遠端切除 后者手術(shù)困難推廣有困難 腹腔鏡胃減容術(shù) 胃短路手術(shù) 胃底折疊術(shù) 如NISSEN手術(shù) 小腸腫瘤手術(shù),.,37,腹腔鏡在腹部實質(zhì)性臟器手術(shù)中的應(yīng)用現(xiàn)狀及展望,.,38,肝臟(LH),易出血為主要障礙 處于嘗試階段 適應(yīng)證 段 腫塊直徑10CM 血管瘤 多發(fā)肝囊腫 肝內(nèi)膽管結(jié)石肝腺瘤 有氣栓的危險 缺乏理想的刀具（超聲刀螺旋高壓水刀 微波刀 LIGASURE ENDO-GIA）,.,39,肝臟(LH),.,40,胰腺,Diagnostic and exploratory laparosc

9、opy in patients with cancer of the pancrease laparoscopic distal pancreatectomy for endocrine and cystic tumors,急性壞死性胰腺炎 假性胰腺囊腫內(nèi)引流 胰島細胞瘤剜除術(shù) 胰體胰尾切除 胰十二指腸切除沒給病人帶來實質(zhì)性好處,.,41,laparoscopic Whipple operation. chronic pancreatitis, and small cystic and endocrine tumors of the pancreas and patients who have

10、 ampullary cancer Enucleation of pancreatic islet cell tumorshttp pancreatic pseudocyst,.,42,脾臟 Laparoscopic Splenectomy,LS安全可靠 手助法 全腹腔鏡法 適應(yīng)證 ITP 脾占位 脾亢 脾外傷 脾蒂處理困難 ENDO-GIA昂貴,.,43,Laparoscopic Splenectomy,.,44,Laparoscopic Splenectomy,.,45,Laparoscopic Splenectomy,.,46,腹腔鏡在其它手術(shù)中的應(yīng)用,.,47,甲狀腺,滿足美容要求 并

11、非微創(chuàng) 局限良性疾病 對甲狀腺癌的腔鏡手術(shù)存在疑慮 手術(shù)時間長,.,48,乳腺良性腫瘤切除 腋窩淋巴清掃 乳腺前哨淋巴結(jié)活檢 疝修補術(shù)LIHR 有四種方法內(nèi)環(huán)關(guān)閉 IPOM腹腔內(nèi)補片植入法 TAPP經(jīng)腹腹膜前補片植入法 TEP全腹膜外補片植入法,.,49,內(nèi)鏡外科技術(shù),.,50,內(nèi)鏡種類,胃鏡 十二指腸鏡 結(jié)腸鏡 小腸鏡 膽道鏡 胰管鏡 乳管鏡 腹腔鏡 胸腔鏡,氣管鏡 膀胱鏡 輸尿管鏡 腎盂鏡 宮腔鏡 關(guān)節(jié)鏡 椎間盤鏡 腦室鏡 心鏡,.,51,gastroscope,.,52,十二指腸鏡duodenoscope,.,53,colonoscope,.,54,colonoscope,.,55,co

12、lonoscope,.,56,choledochoscope,.,57,腹腔鏡laparoscope,.,58,內(nèi)鏡配置,內(nèi)鏡系統(tǒng) 內(nèi)鏡 主機光源 監(jiān)視器 手術(shù)設(shè)備 手術(shù)器械,.,59,內(nèi)鏡外科基本技術(shù),注射術(shù) 鉗夾術(shù) 切除術(shù) 導(dǎo)線置入術(shù) 擴張術(shù) 支架置放術(shù) 引流術(shù) 碎石術(shù),.,60,內(nèi)鏡外科基本技術(shù),氬氣刀凝切術(shù) 十二指腸乳頭切開術(shù),.,61,內(nèi)鏡外科的臨床應(yīng)用,消化道出血 食管胃底曲張靜脈破裂出血 潰瘍出血 消化道腫瘤出血 消化道息肉出血,.,62,內(nèi)鏡外科的臨床應(yīng)用,消化道惡性腫瘤 早期腫瘤拒絕手術(shù)或無法手術(shù)者 晚期腫瘤止血 再通,.,63,. 內(nèi)鏡外科的臨床應(yīng)用,Polypectomy

13、 can be defined as the endoscopic resection of polyps or tumors, obviating the need for open surgery. This is one of the most important scientific advances in the field of gastroenterology, since it enables us to treat many gastric or colonic tumors, without the inconvenience associated with major s

14、urgery,.,64,Endoscopic snare resection of a villous adenoma of the ampulla of Vater,.,.,65,內(nèi)鏡外科的臨床應(yīng)用,胃腸道息肉gastric and colonic polyps 良性腫瘤,.,66,內(nèi)鏡外科的臨床應(yīng)用,良性狹窄 食管瘺 胃石癥 肝膽胰疾病,乳頭切開支架術(shù),.,67,內(nèi)鏡外科的臨床應(yīng)用,肝外膽管結(jié)石 乳頭切開取石術(shù) 碎石術(shù)electrohydraulic lithotripsy 引流術(shù),.,68,十二指腸乳頭切開術(shù)sphincterotomies,.,69,ERCP取石,.,70,內(nèi)鏡外科的臨

15、床應(yīng)用,膽道梗阻 漏與炎癥 外引流術(shù)ENBD 內(nèi)引流術(shù),.,71,內(nèi)鏡外科的臨床應(yīng)用,肝內(nèi)膽管結(jié)石 PTCS+EHL 急性胰腺炎sphincterotomies ENBD,.,72,外科手術(shù)并發(fā)癥的內(nèi)鏡治療,食管穿孔 食管吻合口瘺 吻合口狹窄 膽道狹窄 膽瘺 肝移植術(shù)后膽道狹窄,.,73,肝移植術(shù)后膽道狹窄,.,74,Fig. 1. A 57-year-old male with choledocho-choledochostomy after living donor liver transplantation. A. The cholangiography obtained after t

16、ranshepatic insertion of a biliary drainage catheter shows a biliary anastomotic stricture, which divided the fifth and eighth segment ducts from the sixth and seventh segment ducts (white and black arrow). B. An 8 mm diameter balloon catheter was positioned through the anastomotic stricture. C. Two

17、 internal-external biliary drainage catheters (12 and 14 F) were inserted after biloplasty. D. The cholangiogram after the large profile catheter maintenance method (3 months) shows patent bile ducts (arrow), with excellent flow of contrast medium into the duodenal loop.,Fig. 2. A 56-year-old man wi

18、th choledocho-choledochostomy after living donor liver transplantation. A. The cholangiography obtained during transhepatic insertion of a biliary drainage catheter shows a biliary anastomotic stricture (arrow). B. An 8 mm diameter balloon catheters was positioned through the anastomotic stricture. C. A percutaneous transhepatic cholangiographic catheter (16 F) was inserted after biloplasty. D. The cholangiogram after the large profile cathe