腹腔镜结直肠肿瘤切除术的难点及对策.DOCVIP

临床医学论文-腹腔镜结直肠肿瘤切除术的难点及对策 ?????? 作者：张思奋，赵江宁，袁晟，霍永忠，罗湛滨，何晶 【摘要】? 目的：探讨腹腔镜结直肠肿瘤切除的常见难点及对策。方法：回顾分析2005年2月至2007年6月83例腹腔镜结直肠肿瘤切除术患者的临床资料。结果：74例手术成功，9例中转开腹。手术并发症是皮下气肿5例(6.0%)、不完全性肠梗阻5例(6.0%)、术后大出血1例(1.2%)、肠管损伤3例(3.6%)、吻合口漏1例(1.2%)等。结论：腹腔镜结直肠肿瘤切除术的常见难点为血管的识别及处理、脏器损伤特别是输尿管及肠管损伤的预防及手术操作面的显露等。正确的解剖入路、开腹手术经验丰富及良好的腹腔镜培训可减少手术并发症的发生。 【关键词】? 结直肠肿瘤；结直肠外科手术；腹腔镜术 ??? 【Abstract】? Ｏbjective:To explore the difficulty analysis and measures of laparoscopic resection for colorectal carcinoma.Methods:The clinical data of 83 cases of laparoscopic resection for colorectal carcinoma from Feb.2005 to Jun.2007 were reviewed retrospectively.Results:There were 74 patients treated successfully by laparoscopic resection，9 cases were converted to open surgery.Operative complications were cutaneous emphysema and hypercapnia in 5 cases(6.0%),incomplete intestinal obstruction in 5 cases(6.0%),postoperative abdominal hemorrhea in 1 case(1.2%),intestinal damage in 3 cases(3.6%) anastomotic leak in 1 case(1.2%).Conclusions:The common nodus of laparoscopic resection for colorectal carcinoma contain identifying and handling blood vessel,prevention from organ injuries especially ureter and intestinal canal,identifying and exposing the operative planes.Correct anatomic approach,practised experience of open operation,good training of laparoscopic technique and? essential operating skills are operative guarantee and keys to reduce the complications. ??? 【Key words】? Colorectal neoplasms；Colorectal surgery;Laparoscopy ??? 2005年2月至2007年6月我院为83例结直肠肿瘤患者行腹腔镜切除术，现报道如下。 ??? 1? 资料与方法 ??? 1.1? 临床资料? 本组男44例，女39例，29～79岁，平均57岁。术前经纤维结肠镜、钡灌肠检查确诊及定位。其中升结肠癌4例，降结肠癌5例，乙状结肠癌18例，直肠癌55例，结肠多发性息肉1例。 ??? 1.2? 手术方法? 术前准备及肠道准备同常规开腹手术，麻醉采用持续硬膜外＋气管插管全麻，人工气腹压力设定为12～14mm Hg，多数患者取头低足高截石位。所有手术均以脐部上或下作腹腔镜观察孔，一般用4孔法行手术。 ??? 1.2.1? 直肠癌手术? 于右麦氏点置10mm Trocar作主操作孔，右中上腹及左中腹分别置5mm Trocar作辅助孔。先从观察孔置入腹腔镜探查腹腔，中低位直肠癌女性患者用荷包针直接经腹壁刺入腹腔，在子宫两侧韧带悬吊一针于腹壁以帮助显露。所有患者均采用中线入路，先游离及骨骼化肠系膜下血管，近端用可吸收夹，远端用钛夹钳夹、离断血管。然后再向下游离乙状结肠系膜，在直视下行直肠全系膜切除术（total mesorectal excision,TM