腹腔镜胰腺外科的应用解剖学及临床研究

发布时间：2018-06-26 14:05

本文选题：腹腔镜 + 胰腺　；参考：《第一军医大学》2007年博士论文

【摘要】：目的和意义自1987年法国Mouret医师首次成功实施腹腔镜胆囊切除术以来，在短短不到20年的时间内，腹腔镜技术因其创伤小、对患者生理干扰轻、术后恢复快等优势已经受到全世界外科医师的推崇和广大伤病员的垂青。目前，腹腔镜技术已广泛应用于普通外科、肝胆外科、泌尿外科、妇产科、胸心外科和小儿外科等临床各领域，其适应证正在不断扩大。尤其是在腹部外科领域内，几乎所有传统的开腹术式都有腹腔镜术式的成功尝试，而且大多数腹腔镜术式正在逐步取代传统的开腹术式。但是，由于胰腺组织结构的特殊、解剖位置的深在、毗邻关系的复杂，造成腹腔镜技术在胰腺外科领域的应用起步较晚，发展滞后。为促进腹腔镜技术在胰腺外科领域的发展，我们利用腹腔镜技术的特点，对腹腔镜技术在胰腺外科领域内发展的制约因素之一——临床应用解剖学进行了系列研究，并在临床上进行了初步应用。首先，我们受泌尿外科后腹腔镜手术的启示，对同样位于腹膜后间隙中肾旁前间隙内的胰体尾的后腹腔镜外科手术入路和解剖标志进行了探索，主要意义在于明确如何在肾旁前间隙内建立一个较大的可操作空间?通过何种手术入路进入此间隙安全便捷?如何确定解剖标志来进行腹腔镜胰体尾外科手术?其次，我们对腹腔镜胰十二指肠切除术中的关键和难点问题之一的肠系膜上血管的探查、显露、分离进行了解剖观测，试图为腹腔镜胰十二指肠切除术中探查、显露、分离肠系膜上血管提供解剖学依据，并对腹腔镜胰十二指肠切除术中处理肠系膜上血管的方法提出了我们的观点。再次，我们复习文献并通过解剖观察，总结了脾动脉与脾静脉的“骑跨”关系和胰体尾与脾血管的“悬挂”关系，提出保留脾血管的保脾胰体尾切除术的要点。最后，我们总结了5例腹腔镜技术应用于胰体尾囊腺瘤的临床资料来探讨腹腔镜胰体尾切除术治疗胰体尾囊腺瘤的临床价值。方法 1．对10例成人尸体经左股动脉灌注红色乳胶并经10％福尔马林常规固定，对其中3例在股动脉灌注的基础上行经肝门静脉灌注蓝色乳胶；对2例新鲜成人尸体，经左股动脉灌注红色乳胶同时经肝门静脉灌注蓝色乳胶，并采用10％福尔马林局部防腐和冷减处理。全组男7例，，女5例。解剖观测从左髂嵴到左膈下腹膜后器官与胰体尾及各器官间的毗邻关系，在对新鲜标本进行解剖观测之前模拟后腹腔镜入路行胰体尾的分离和暴露。距离测量采用游标卡尺点与点间平面测量。模拟操作时尸体取右侧约30°仰卧位，第1个trocar位置在左腋中线髂嵴上方2cm交点处，横行切开皮肤3cm，锐性加钝性分开腹外斜肌、腹内斜肌、腹横肌，再用食指在腹膜外脂肪层内分离出一腔隙，并用刀柄或镊子柄扩大腔隙至足够大后，插入12mm trocar，并加压灌注自来水，插入0°腹腔镜。然后在左腋后线第12肋缘下2cm交点处插入第2个10mm trocar，置入主分离钳。最后在左腋前线与肋弓下2cm交点处插入第3个5mm trocar，置放副分离钳。从肾下间隙钝性分离进入肾旁前间隙，直至完全分离暴露出胰体尾。 2．对10例成人尸体经左股动脉灌注红色乳胶并经10％福尔马林常规固定，并对其中3例经肝门静脉灌注蓝色乳胶；对2例新鲜成人尸体，经左股动脉灌注红色乳胶同时经肝门静脉灌注蓝色乳胶，并采用10％福尔马林局部防腐和冷藏处理。全组男7例，女5例。身长(167.48±8.35)cm。游标卡尺、软钢尺各1把，手术显微镜、解剖器械、腹腔镜手术器械各1套。观测探查、显露、分离肠系膜上血管的解剖标志和处理要点；观测肠系膜上血管与胰头钩突部和十二指肠空肠曲的解剖关系；对新鲜尸体进行解剖观测前模拟腹腔镜行肠系膜上血管的显露和分离。模拟操作时尸体均取仰卧位，用铁丝悬吊腹壁制造腹腔操作空间，脐下缘插入12mm trocar，插入0°腹腔镜。然后在平脐左右侧约腹直肌外缘各插入10mm trocar，置入操作钳。再在左右肋缘下腋前线处各插入10mmtrocar，置放操作钳。打开胃结肠韧带后，沿右胃网膜静脉寻找并分离出肠系膜上静脉，直至肝门静脉；再分离肠系膜上动脉。 3．整块切取20例经左股动脉灌注红色乳胶并经10％福尔马林常规固定的尸体胰脾器官簇标本，解剖观测脾血管及其与胰体尾的关系。并复习相关文献资料。 4．总结2003年2月-2006年4月我们对5例胰体尾囊腺瘤进行了LDP的临床资料，平均年龄32.8(27～43)岁。均采用气管插管全身麻醉。患者左侧垫高约30°，左臂上举固定。术者和持镜者立于患者右侧，另一助手立于左侧。5例手术均在全腹腔镜下进行，均采用4孔法。脐下缘为观察孔，主操作孔在左锁骨中线肋缘下4cm作10mm操作孔，副操作孔在右腹直肌外侧缘肋弓下缘3cm作5mm操作孔，另一辅助操作孔在左腋前线肋缘下2cm作5mm操作孔。常规建立气腹及操作空间后，全面探查腹腔。先以超声刀切开胃结肠韧带，从胃结肠韧带中间开始，先向左，原则上一直打开到脾胃韧带。后向右，向右打开胃结肠韧带距肿瘤右缘约5cm即可。再向右上推开胃，向下牵开结肠，进一步探查囊肿情况。打开肿瘤前的后腹膜，沿后腹膜与肿瘤壁间(即胰前间隙)进一步暴露肿瘤，注意保护受肿瘤推压的左结肠静脉等重要血管，于肿瘤右缘在胰腺上缘分离出脾动脉干予以钛夹或血管夹夹闭。2例先在脾动脉夹闭平面从胰腺下缘开始分离出胰后间隙，并于胰体后方分离出脾静脉，用血管夹夹闭但不切断，用Endo-GIA切断胰腺后，再进一步处理脾静脉，最后处理脾结肠、脾胃、脾肾、脾膈韧带及余下的胰后间隙，至胰体尾连同囊肿和脾整体切除。3例先用超声刀分别离断脾结肠、脾胃、脾肾及脾膈韧带，然后分离胰后间隙，并于胰体后方分离出脾静脉夹闭，将胰体尾连同肿块抬起，以Endo-GIA切断，其中1例先切断胰腺，再处理脾静脉。切除的标本装入一次性取物袋自左上腹扩大的戳孔中取出。常规于胰床及脾窝各放置1根粗乳胶引流管自左上腹戳孔中引出。各戳孔以可吸收线皮内缝合。5．对所用数据经SPSS10.0软件统计处理。结果 1．12例后腹腔入路全部成功分离出肾旁前间隙，并完整分离出胰体尾。2例摸拟操作成功，但在模拟操作过程中均有轻微的后腹膜损伤。操作中以左侧睾丸(卵巢)血管为进入肾旁前间隙的标志，以左肾静脉为到达胰腺下缘的标志，左膈结肠韧带为到达胰尾的标志，肠系膜下静脉左缘与胰腺下缘交点为到达胰颈的标志。完全分离胰体尾后肾旁前间隙内平均能一次性注水1.68L。 2．(1)肠系膜上静脉的十二指肠水平部段长(3.80±0.72)cm、胰头钩突部段长(1.76±0.25)cm、胰颈后段长(3.81±0.64)cm、胰颈上段长(4.73±1.31)cm，其中胰头钩突部段属支最多；(2)右胃网膜静脉汇入SMV有6种类型：右胃网膜静脉与右结肠静脉合成Henle干(50.0％)，右胃网膜静脉、右结肠静脉、中结肠静脉合干(16.7％)，右胃网膜静脉、右结肠静脉和中结肠静脉分别汇入肠系膜上静脉(8.3％)，右胃网膜静脉与中结肠静脉合干(8.3％)，右胃网膜静脉、右结肠静脉、中结肠静脉与胰十二指肠上前静脉合干(8.3％)，右胃网膜静脉、右结肠静脉与胰十二指肠上前静脉合干(8.3％)；(3)肠系膜上动脉距腹腔干下方(1.12±0.15)cm起自腹主动脉前壁，主干长(3.97±0.54)cm，外径(0.69±0.03)cm，胰十二指肠下动脉和第1空肠动脉起源SMA有5种类型：胰十二指肠下前、后动脉合干与第1空肠动脉分别起始于SMA(33.3％)，胰十二指肠下后动脉、第1空肠动脉合干与胰十二指肠下前动脉分别起始于SMA(25.0％)，胰十二指肠下前动脉、后动脉合干起始于第1空肠动脉(16.7％)，胰十二指肠下前、第1空肠动脉合干与胰十二指下后动脉分别起始于SMA(16.7％)，胰十二指肠下前动脉与中结肠动脉合干再与胰十二指肠下后动脉合干起始于SMA(8.3％)。 3．脾动、静脉被网膜囊后壁后方之结缔组织所形成的血管鞘包裹，该血管鞘延续于脾动、静脉血管外膜，嵌入胰腺实质内。脾动脉形态多样，但不管形态变化如何，都通过胰腺分支“骑跨”于脾静脉之上。胰体尾分别借胰背动脉、胰大动脉和胰尾动脉等脾动脉胰支“悬挂”于脾动脉，借脾静脉的胰腺静脉“悬挂”于脾静脉。 4．手术均在全腹腔镜下一次成功完成，平均手术时间258(95～430)min，平均出血140(50～300)ml。术后病理：浆液性囊腺瘤1例，黏液性囊腺瘤4例。1例发生胰漏，经保守治疗后痊愈。术后平均住院时间6.8(5～17)d。随访至2006年10月无复发。结论 1．后腹腔镜胰体尾外科手术经左肾旁前间隙入路是安全可行的，能获得足够的操作空间，且有良好的解剖标志。 2．(1)SMV的胰头钩突部段最短，属支最多，显露分离最难；(2)LPD中以右胃网膜静脉为标志来探查、显露SMV较好；(3)对肠系膜上动静脉的显露分离应采用不同的主操作孔来进行；(4)充分利用腹腔镜的放大作用和超声刀的精确切割特性是可以探查、显露和分离好肠系膜上血管的。 3．保留脾血管的保脾胰体尾切除术的要点：一是不能单独分离脾动脉、脾静脉与胰体尾，而应将脾血管看成一个整体，沿胰腺固有被膜甚至胰腺实质整体将脾血管分离开来；二是要在脾静脉与胰体尾之间的解剖间隙来寻找外科间隙，从而实现脾血管与胰体尾的分离；三是要根据脾血管的解剖类型，采取从近端向远端还是从远端向近端将胰体尾与脾血管分离。 4．有选择地对胰体尾囊腺瘤进行LDP是安全、可行的，且具有创伤小、对患者生理状态干扰轻、术后恢复快等优点。
[Abstract]:Purpose and significance
Since the first successful implementation of laparoscopic cholecystectomy (LC) in French Mouret in 1987, in less than 20 years, laparoscopy has been widely used by surgeons all over the world and the majority of the wounded. Now, laparoscopic technology has been widely used. In the general surgery, Department of hepatobiliary surgery, Department of Urology, obstetrics and Gynecology, thoracic surgery and pediatric surgery, the indications are increasing. In the field of abdominal surgery, almost all traditional laparotomy has a successful trial of laparoscopy, and most laparoscopic operations are gradually replacing traditional laparotomy. However, due to the special structure of the pancreas, the depth of the anatomical position and the complexity of the adjacent relationship, the application of the laparoscopic technology in the field of pancreatic surgery is late and the development lags behind. In order to promote the development of the laparoscopic technology in the field of pancreatic surgery, we use the characteristics of laparoscopy and the laparoscopic technology in the field of pancreatic surgery. One of the restrictive factors of internal development, clinical applied anatomy, was carried out in a series of studies and was used clinically. First, we were inspired by retroperitoneal laparoscopic surgery in the Department of Urology, and explored the surgical approach and anatomical marks of the posterior celiac surgery, which is also located in the anterior space of the parparpara's parparpara space. The main significance is to make clear how to establish a larger workspace within the paranorma space? What is the safe and convenient way to enter the gap by which surgical approach? How to determine the anatomical signs for the laparoscopic surgery for the tail of the pancreas? Secondly, we have the mesentery, which is one of the key and difficult problems in the laparoscopic pancreatoduodenectomy Exploration, exposure, and separation of the upper vessels were observed to provide an anatomical basis for the exploration, exposure, separation of the mesenteric vessels in the laparoscopic pancreatoduodenectomy, and our view of the treatment of the superior mesenteric vessels during the laparoscopic pancreatoduodenectomy. Again, we review the literature and dissected the anatomy. The relationship between the "riding span" of the splenic artery and the splenic vein and the "suspension" relationship between the body and the tail of the pancreas and the blood vessels of the spleen were summarized, and the key points for the resection of the spleen and the tail of the spleen were put forward. Finally, we summed up the clinical data of 5 cases of laparoscopic technique applied to the caudal cystadenoma of the pancreas to discuss the treatment of the caudal caudal cysts of the pancreas by laparoscopic pancreatectomy. The clinical value of adenoma.
Method
1. of 10 adult cadavers were perfused with red latex in left femoral artery and fixed by 10% formalin. 3 of them were perfused with blue latex through the hepatic portal vein on the basis of femoral artery perfusion. 2 cases of fresh adult cadavers were injected with red latex into the left femoral artery and injected with blue latex through the portal vein, and 10% forma were used. A total of 7 male and 5 female cases were observed from the left iliac crest to the left diaphragm of the ventral membrane and the adjacent organs between the tail and the tail of the pancreas. The separation and exposure of the body and tail of the pancreas were simulated before the anatomic observation of the fresh specimens. The distance measurement was measured by the vernier caliper point and the interpoint plane. In the simulated operation, the cadaver was taken on the right side of the supine position in about 30 degrees, and the first trocar position was located at the 2cm intersection above the iliac crest at the middle line of the left axillary. The skin was cut across the skin 3cm, the obtuse and obtuse ventral oblique muscles were separated, the intraperitoneal oblique muscle, the abdominal transverse muscle, and the outer space of the extraperitoneal fat layer was separated with the forefinger, and the cavity was enlarged to large enough with the knife handle or the forceps handle to insert 1. 2mm trocar, and pressure infusion of tap water, insert 0 degrees celioscope, and then insert second 10mm trocar at the 2cm intersection under the left axillary line twelfth ribs, and insert the main separation forceps. Finally, third 5mm trocar are inserted at the left axillary front and the rib arch at the intersection of the subribbed arch, and the accessory separation forceps are placed. Out of the tail of the pancreas.
2. of 10 adult cadavers were perfused with red latex in the left femoral artery and fixed by 10% formalin, and 3 of them were perfused with blue latex through the portal vein. 2 cases of fresh adult cadavers were perfused with red latex through the left femoral artery and injected with blue latex through the portal vein, and 10% formalin was used as a local anticorrosion and cold storage treatment. There were 7 men and 5 women in the whole group. The length (167.48 + 8.35) cm. vernier caliper, 1 soft steel ruler, surgical microscope, anatomical instruments and 1 laparoscopic surgical instruments. Observation, exposure, dissection of the superior mesenteric vessels and the anatomical relationship between the superior mesenteric vessels with the uncinate and duodenal jejunum; The cadavers were exposed and separated on the mesenteric vessels before the anatomical observation of the fresh cadavers. The supine position was taken in the simulated operation. The abdominal operation space was made with the wire suspended from the abdominal wall. The lower edge of the umbilical cord was inserted into the 12mm trocar and inserted into the 0 degree laparoscope. Then the 10mm trocar was inserted into the outer margin of the rectus abdominis muscle on the left and right side of the umbilicus, and the operation forceps were inserted. In the axillary frontline of the left and right ribs, the 10mmtrocar was inserted and the operation forceps were inserted. After opening the gastric and colonic ligaments, the superior mesenteric vein was found and separated along the right gastric omentum vein until the portal vein of the liver, and the superior mesenteric artery was separated.
3. the splenic vessels and its relationship with the body and tail of the pancreas were observed and analyzed in 20 cases of red latex perfusion with left femoral artery and 10% formalin routinely fixed body and spleen.
4. to sum up the clinical data of 5 cases of pancreatic caudal cystadenoma in February 2003 -2006. The average age of LDP was 32.8 (27~43) years old. All the patients were anesthetized with tracheal intubation. The left arm was high about 30 degrees and the left arm was fixed on the left arm. The operator and the holder on the right side of the patient and the other hand on the left.5 were all under the full laparoscope. The 4 hole method was used. The subumbilical edge was the observation hole, the main operation hole was 10mm operation hole 4cm under the left clavicle middle rib edge, the auxiliary operation hole was 5mm operation hole in the lower edge of the right ventral right ventral edge of the right ventral muscle, and the other auxiliary operation hole was 2cm under the left axillary frontline ribbed edge 5mm operation hole. The abdominal cavity was explored in an all-round way after the routine establishment of air abdominal and operation space. First, the abdominal cavity was explored. First, ultrasonic examination was performed with ultrasound. Open the gastric colonic ligament, start from the middle of the stomach and colonic ligaments, first to the left, open to the ligaments of the spleen and stomach in principle. Then turn right, open the stomach and colonic ligaments to the right margin of the tumor about 5cm. Then push the stomach up to the right, pull the colon down, further explore the cyst condition. Open the retroperitoneum before the tumor, along the retroperitoneum and the tumor wall (that is the pancreas). To further expose the tumor, pay attention to the protection of the important blood vessels, such as the left colon vein, which is pushed by the tumor. On the right margin of the tumor, the splenic artery is separated from the upper edge of the pancreas, and the splenic artery is separated from the lower part of the pancreas from the lower edge of the pancreas, and the splenic vein is separated from the posterior part of the pancreas, and the splenic vein is separated from the posterior part of the pancreas, and the blood vessel clamp is used in the rear of the pancreas. After the pancreas was clipped but not cut, the splenic vein was further treated with Endo-GIA, and the spleen and stomach, spleen and stomach, spleen and kidney, spleen and kidney, spleen and diaphragm and the remaining posterior space of pancreas were treated, and the spleen and stomach, spleen and kidney and spleen diaphragm were separated, then the posterior space of the pancreas was separated and the pancreas body was separated from the pancreas body, and then the posterior space of the pancreas was separated and the pancreatic body was separated from the body of pancreas. The splenic vein was separated in the rear. The tail of the pancreas was lifted with a mass, and the pancreas was cut off with Endo-GIA. 1 cases were cut off the pancreas first and then the splenic vein was retreated. The excised specimens were taken out of the enlarged puncture hole in the left upper abdomen. 1 crude latex drainage tubes were placed in the pancreas bed and the splenic fossa. The absorptive line was sutured.5. inside the skin, and the data used were statistically processed by SPSS10.0 software.
Result
1.12 cases of posterior intraperitoneal approach were successfully separated from the parpara's parpara space, and a complete separation of the pancreatic body and tail.2 was completed successfully. However, there were slight retroperitoneal injuries during the simulated operation. The left testis (ovary) vessel was used as a sign to enter the parpara space, and left renal vein was the sign of the inferior margin of the pancreas, left diaphragm. The intestinal ligament is the sign of reaching the tail of the pancreas. The intersection of the left margin of the inferior mesenteric vein and the lower margin of the pancreas is the sign of the neck of the pancreas. The mean water injection of 1.68L. in the paraberrenal space after the complete separation of the body of the pancreas can be used in one time.
2. (1) the upper duodenal segment of the superior mesenteric vein was long (3.80 + 0.72) cm, long (1.76 + 0.25) cm of the uncinate segment of the head of the pancreas, the posterior segment of the neck of the pancreas (3.81 + 0.64) cm, and the upper part of the neck of the pancreas (4.73 + 1.31) cm, and the most of the branches of the uncinate process were the branches of the pancreatic head; (2) there were 6 types of SMV in the right gastroomentum vein to SMV: the right gastroomental vein and the right colonic vein synthesized Henle. Dry (50%), right gastroomental vein, right colonic vein, middle colonic vein dry (16.7%), right gastroomentum vein, right colonic vein and middle colon vein (8.3%), right gastroomental vein and middle colon vein (8.3%), right gastroomentum vein, right colon vein, middle colonic vein and pancreatic duodenum Arterial occlusion (8.3%), right gastroomental vein, right colonic vein and anterior superior pancreaticoduodenal vein (8.3%); (3) the superior mesenteric artery (1.12 + 0.15) cm from the anterior wall of the abdominal aorta, the trunk length (3.97 + 0.54) cm, outer diameter (0.69 + 0.03) cm, and the origin of the inferior pancreaticoduodenal artery and first jejunal artery in 5 types: pancreas twelve Before the lower intestine, the posterior artery occlusion and the first jejunal artery started from the SMA (33.3%), the posterior inferior pancreaticoduodenal artery, the first jejunal artery and the anterior inferior pancreaticoduodenal artery starting from SMA (25%), the anterior inferior pancreaticoduodenal artery, and the trunk of the posterior artery starting from the first jejunum artery (16.7%), the first jejunum artery before the pancreatoduodenal, and the first jejunum artery. The twelve posterior inferior arteries of the combined trunk and the pancreas started from SMA (16.7%), the arterial occlusion of the anterior and middle inferior duodenal arteries and the middle colon and the trunk of the posterior and posterior inferior pancreaticoduodenal artery began at SMA (8.3%).
3. the splenic movement is wrapped in the vascular sheath formed by the connective tissue behind the posterior wall of the omentum capsule. The vascular sheath extends to the spleen and is embedded in the parenchyma of the pancreas. The form of the splenic artery is diverse. However, the splenic artery is "riding" over the splenic vein, regardless of the morphological changes. The tail of the pancreas is by the dorsal pancreatic artery and the large pancreatic artery, respectively. The pancreas branch of the splenic artery, such as the pancreatic tail artery, "hangs" in the splenic artery, and hangs through the splenic vein of the pancreatic vein in the splenic vein.
The 4. operations were performed successfully with a total of 258 (95~430) min and 140 (50~300) ml. postoperative pathology: serous cystadenoma, 4 cases of mucinous cystadenoma and 4.1 cases with pancreatic leakage and recovered after conservative treatment. The average postoperative hospital time was 6.8 (5~17) d. followed up to no recurrence in October 2006.
conclusion
1. retroperitoneal laparoscopic surgery is safe and feasible through the left para renal anterior space approach. It can obtain enough space for operation and has good anatomical marks.
2. (1) SMV had the shortest uncinate segment of the head of the pancreas, most of the branch, and the most difficult to reveal and separate; (2) the right gastric omentum vein was found in LPD, and SMV was better. (3) different main operation holes should be used for the exposure and separation of the superior mesenteric arteriovenous; (4) the enlargement of the laparoscope and the precise cutting characteristics of the ultrasonic knife were full. It is possible to detect and separate superior mesenteric vessels.
3. the main points of splenopananopanretomy for preserving splenic vessels: one is that the splenic artery, the splenic vein and the tail of the pancreas can not be separated, and the spleen vessels should be regarded as a whole, and the splenic vessels are separated along the intrinsic membrane of the pancreas and even the whole pancreatic substance, and the two is to find the surgical clearance between the splenic vein and the tail of the pancreas. The separation of the spleen vessels and the tail of the body of the pancreas is achieved; three it is to separate the tail of the pancreas from the distal end to the proximal end and the splenic vessels, according to the anatomical types of the splenic vessels.
4. selectively to the tail of the body of the pancreas
【学位授予单位】：第一军医大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R322;R657.5

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