“五孔法”腹腔镜胰十二指肠切除术手术流程的建立及33例分析

发布时间：2018-09-09 08:26

【摘要】：自1987年法国Mouret医生成功将电视腹腔镜应用于胆囊切除术以来,腹腔镜手术凭借切口小而视野清,术中出血少、术后恢复快等优势,深受医生和患者欢迎。随着腹腔镜技术的不断提高和腔镜器械的快速发展,腹腔镜技术在带蒂器官如胆囊、脾脏,空腔脏器如胃、空肠,实质脏器如肝脏、胰腺等器官的手术上都获得成功,其在外科的各个领域得到了广泛应用。Gawande回顾新英格兰医学杂志创刊200年外科学发展史时,评价腹腔镜技术带动的外科手术微创化的意义与麻醉对医学发展的意义类似。其已成为二十一世纪外科学发展的两大方向之一。胰十二指肠切除术(Pancreaticoduodenectomy, PD)是治疗胰头等壶腹周围肿瘤的标准术式。PD脏器切除困难,消化道重建复杂,术后并发症多且危险,是腹部外科最复杂的手术之一。腹腔镜胰十二指肠切除术(Laparoscopic Pancreaticoduodenectomy, LPD)自然成为胰腺外科和腔镜外科医生心向往之的“珠峰”。1994年,美国Gagner和Pomp成功实施了保留幽门的LPD,标志着外科医生对这领域的首次探索。但早期效果不理想,手术时间过长,手术中转开腹率高,术后恢复无明显优势,使LPD受到了广泛的争议和反对,Gagner对此也失去了信心。2007年,印度医生Palanivelu等报道了42例LPD,不但手术时间较前明显缩短,术中、术后结果也体现了其微创优势,激起了胰腺外科医生对LPD新的热情。目前,根据Pubmed中LPD的文献数量及病例数,LPD已在美国掀起了新一轮高潮。国内开展LPD起步较晚,第一例LPD报道于2003年。但历经10年,LPD也只在极少数中心开展,基本为个例报告,且围手术期结果与国外的报道存在很大差距。本团队承担浙江省重大科技专项(“基于多学科协作的胰腺外科微创化和个体化”)及浙江省医学重点学科适宜技术推广项目(“微创胰胃外科学”),至Mayo Clinic观摩学习LPD,并从2012年9月开始开展LPD。在临床实践过程中,本团队对手术流程不断进行优化,建立了一种适合国人体型的“五孔法"LPD手术流程。截至2014年4月初,本团队已成功实施33例。本文将对该手术流程进行详细阐述,并对33例LPD进行分析,探讨其安全性和可行性。第一部分：“五孔法,,腹腔镜胰十二指肠切除术手术流程的建立研究目的：建立“五孔法”腹腔镜胰十二指肠切除术手术流程,并探讨其优劣势。研究方法：通过文献调研、到Mayo Clinic观摩LPD手术、临床探索优化,结合胰十二指肠以肠系膜上动静脉为中心的解剖特点、及“五孔法”腹腔镜以门静脉和肠系膜上静脉为轴心的视野特点,建立“五孔法"LPD手术流程。研究结果：“五孔法”套管分布成“V”形：脐下放置10mm套管,用于置放腹腔镜；右侧腋前线肋缘下2cm及与平脐腹直肌外缘分别放置5mm、12mm套管,由主刀操作；左侧腋前线肋缘下2cm及与平脐腹直肌外缘分别均放置5mm套管,由助手操作。流程遵从从足端到头端,从前到后,从左到右的原则。具体手术流程为：①解剖性探查：探查全腹腔,排除腹膜及肝脏表面转移；离断胃十二指肠动脉,贯通门静脉前的胰后隧道,分离并悬吊胆管；②切除：先离断并游离近端空肠,将其通过肠系膜血管根部推向右侧；从前向后离断胃、胰颈；再作Kocher切口游离胰头十二指肠；沿肠系膜上动脉鞘完整切除胰腺钩突；最后离断胆管；③重建按Child式：胰肠吻合采用胰管空肠导管对粘膜端侧吻合；胆肠吻合采用端侧吻合；胃肠吻合采用侧侧吻合。结论：“五孔法"LPD可行,适合国人体型,经济。该手术流程操作无反复,能缩短手术时间。第二部分：“五孔法,,腹腔镜胰十二指肠切除术33例分析研究目的：探讨“五孔法”腹腔镜胰十二指肠切除术的安全性和可行性,总结手术相关经验。研究方法：分析2012年9月至2014年4月初本团队完成的“五孔法”腹腔镜胰十二指肠切除术病例的临床资料,包括术中出血量、手术时间、术后恢复情况、术后并发症、病理资料及随访情况等。研究结果：共33例,平均年龄58.9岁。33例LPD中,LDP术后三年再次LPD手术1例,联合右半肝切除术1例。平均手术时间366.67min,其中切除时间为177.59min,胰肠吻合时间为52.88min,胆肠吻合时间为38.52min,胃肠吻合时间为22.11min。术中平均出血量206.97ml。术后仅4例入住ICU,分别为1,1,2,5天。围手术期并发症率27.3%(9/33),均为三级以内,无四级及以上并发症。无围手术期死亡。其中A级胰瘘2例,B级胰瘘伴切口感染1例,胆漏1例,消化道出血2例,消化道出血伴腹腔出血伴胆漏1例,肺部感染2例。术后中位住院时间16天。术后病理：十二指肠乳头腺癌10例,胰腺癌9例,胆总管癌5例,胰腺神经内分泌肿瘤2例,胰腺导管内乳头状粘液瘤2例,十二指肠间质瘤2例,胰管结石伴慢性胰腺炎、胰腺囊肿1例,胰腺粘液性囊腺瘤1例,胰腺实性假乳头状瘤1例。中位随访时间5月,所有病例都存活。结论：基于“五孔法”的腹腔镜胰十二指肠切除术安全可行,近期疗效果满意。但其作为高难度的新技术,应根据病种的病理解剖改变,从易到难选择病例,并根据胰管和胆管大小选择个体化重建方案,稳步推进。
[Abstract]:Laparoscopic cholecystectomy has been well received by doctors and patients for its advantages of small incision, clear vision, less bleeding during operation and quick recovery after operation. With the continuous improvement of laparoscopic techniques and the rapid development of endoscopic instruments, laparoscopic techniques have been used in pedicled organs such as gallbladder. The capsule, spleen, and cavity organs such as stomach, jejunum, and parenchymal organs such as liver and pancreas have been successfully operated on and have been widely used in various fields of surgery. The significance of learning development is similar. It has become one of the two main directions of surgical development in twenty-first Century.
Pancreatic duodenectomy (PD) is a standard procedure for the treatment of periampullary tumors of the head of the pancreas. PD is one of the most complex operations in abdominal surgery because of its difficulty in organ removal, complicated reconstruction of the digestive tract, and many and dangerous postoperative complications. Laparoscopic Pancreatic duodenectomy (LPD) is a natural procedure. In 1994, Gagner and Pamper successfully implemented pyloric-preserving LPD, marking the first exploration by surgeons in this field. However, the early results were unsatisfactory, the operation time was too long, the conversion rate to laparotomy was high, and there was no obvious advantage in postoperative recovery. In 2007, Indian doctor Palanivelu and others reported 42 cases of LPD, which not only shortened the operation time significantly, but also showed the advantages of minimally invasive surgery and postoperative results, arousing new enthusiasm for LPD among pancreatic surgeons. The first case of LPD was reported in 2003. However, after 10 years, LPD was only carried out in a few centers, basically as a case report, and there was a big gap between the perioperative results and foreign reports.
Our team undertook the major scientific and technological projects in Zhejiang Province ("minimally invasive and individualized pancreatic surgery based on multi-disciplinary collaboration") and the appropriate technology promotion project of key medical disciplines in Zhejiang Province ("minimally invasive pancreatic and gastric surgery"), to observe and study LPD at Mayo Clinic, and began to carry out LPD in September 2012. By the beginning of April 2014, 33 cases of LPD had been successfully performed by our team. This article will elaborate the procedure and analyze 33 cases of LPD to explore its safety and feasibility.
Part I: "five hole method, the establishment of laparoscopic pancreaticoduodenectomy procedure.
Objective: To establish a five-port laparoscopic pancreaticoduodenectomy procedure and explore its advantages and disadvantages.
Methods: Through literature research, to Mayo Clinic to observe LPD surgery, clinical exploration and optimization, combined with the pancreaticoduodenal anatomical characteristics of the superior mesenteric artery and vein as the center, and the "five-hole method" laparoscopic portal vein and superior mesenteric vein as the axis of visual field characteristics, to establish the "five-hole method" LPD operation process.
The results showed that the "five-hole" cannula was "V" shaped: 10 mm cannula was placed under umbilicus for laparoscopic placement; 5 mm and 12 mm cannula were placed under the costal margin of the right anterior axillary line and the external margin of the rectus abdominis flattened by the main knife; 5 mm cannula was placed under the costal margin of the left anterior axillary line and the external margin of the rectus abdominis flattened by the assistant. The procedure followed the principle of foot to head, from front to back, from left to right. The specific procedure was as follows: (1) anatomical exploration: exploration of the whole abdominal cavity, excluding peritoneal and hepatic metastases; gastroduodenal artery was cut off, the retropancreatic tunnel before portal vein was cut through, and the bile duct was separated and suspended; and (2) resection: the proximal jejunum was removed and the proximal jejunum was free. The pancreatic head and duodenum were dissected through the Kocher incision, the uncinate process of pancreas was completely removed along the superior mesenteric artery sheath, and the bile duct was severed finally. The reconstruction was performed according to Child's pattern: pancreaticojejunal catheter was used for pancreaticojejunal anastomosis, and the end-to-side anastomosis was used for cholangiojejunostomy. Anastomosis; side to side anastomosis for gastrointestinal anastomosis.
Conclusion: "Five-hole method" LPD is feasible, suitable for Chinese physique, economic. The operation procedure without repeated operation, can shorten the operation time.
The second part: five hole method, 33 cases of laparoscopic pancreaticoduodenectomy.
Objective:To explore the safety and feasibility of laparoscopic pancreatoduodenectomy with five-hole method and summarize the experience of operation.
Methods: The clinical data of five-hole laparoscopic pancreaticoduodenectomy performed by our team from September 2012 to early April 2014 were analyzed, including intraoperative bleeding volume, operation time, postoperative recovery, postoperative complications, pathological data and follow-up.
Results: Among 33 cases, the average age was 58.9 years. Among the 33 cases, 1 case underwent LPD and 1 case underwent right hepatectomy three years after LDP. The average operation time was 366.67 minutes, including 177.59 minutes, 52.88 minutes of pancreaticoenteric anastomosis, 38.52 minutes of biliary-enteric anastomosis and 22.11 minutes of gastrointestinal anastomosis. Only 4 patients were admitted to ICU after operation for 1,1,2,5 days, respectively. The perioperative complications rate was 27.3%(9/33), all of them were within grade 3, without grade 4 or more complications. There was no perioperative death, including grade A pancreatic fistula in 2 cases, grade B pancreatic fistula with incision infection in 1 case, bile leakage in 1 case, gastrointestinal hemorrhage with abdominal hemorrhage in 1 case, and pulmonary infection in 2 cases. Postoperative pathology: 10 cases of duodenal papillary adenocarcinoma, 9 cases of pancreatic carcinoma, 5 cases of common bile duct carcinoma, 2 cases of pancreatic neuroendocrine tumor, 2 cases of pancreatic ductal papillary myxoma, 2 cases of duodenal stromal tumor, 2 cases of pancreatic duct stones with chronic pancreatitis, 1 case of pancreatic cyst, 1 case of pancreatic mucinous cystadenoma, 1 case of pancreatic solid pseudopapillary 1 cases were tumor. Median follow-up time was May. All cases survived.
Conclusion: Laparoscopic pancreatoduodenectomy based on "five-hole method" is safe and feasible, and the short-term results are satisfactory. However, as a new technique with high difficulty, it is necessary to select cases from easy to difficult according to the pathological and anatomical changes of the disease, and to select individual reconstruction schemes according to the size of pancreatic duct and bile duct.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R656

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