体位对纵隔淋巴结的影响ppt课件.ppt

* 根据三原色原理叠加后的单色形成了第三种颜色并脱离了原本的单色颜色更加丰富象征着产品在原有空间的组合中产生了突破性的变化 胸、腹腔镜的食管癌根治术的淋巴结清扫问题—体位和插管对纵隔淋巴结清扫的影响 MIE经过20年的临床应用，虽然仍有争议，但已被多数的食管外科医师所接受 如同食管癌开放手术，MIE存在多种手术方式的共存 目前为止，不同MIE的手术方式其临床结果无显著差异 由于病理形式和综合治疗模式的不同，多数西方国家的文献并无食管癌手术中上纵隔淋巴结清扫的报道 迄今，食管鳞癌的手术标准仍以日本“扩大二野及三野淋巴结清扫”为较高标准 因此，胸腔镜下上纵隔尤其左侧喉返神经淋巴结清扫是这一技术不可绕过的问题 2010新版分期中N的重新定义 2010版分期中食管癌淋巴结引流区域 胸腔镜下如何做到纵隔淋巴结清扫？ Advantages of radical VAE the magnifying effect of the surgical field and alteration of the viewpoint of the surgeon VAE is performed using common visual information shared by all of the surgical staff. Udagawa et al. Rationale for video-assisted radical esophagectomy Gen Thorac Cardiovasc Surg (2009) 57:127–131 Disadvantages of video-assisted surgery loss of three-dimensional recognition limited tactile sensation The alteration of the viewpoint requires technically more sophisticated hand–eye coordination. Udagawa et al. Rationale for video-assisted radical esophagectomy Gen Thorac Cardiovasc Surg (2009) 57:127–131 Advantage of using VATS (example 1) The right recurrent laryngeal nerve can be observed in more detailed fashion with VATS. Identifi cation of its small branches and dissection of the nerve are more accurate Corresponding operative field under conventional thoracotomy. rrln, right recurrent laryngeal nerve; rv, right vagus nerve; rsc, right subclavian artery Advantage of using VATS (example 2) Left recurrent laryngeal nerve can be observed in more detailed fashion with VATS. Identification of its small branches and dissection of the nerve are more accurate Corresponding operative field under conventional thoracotomy. lrln, left recurrent laryngeal nerve; tr, trachea; sn, sympathetic nerve branch; ln, dissected lymph nodes 胸腔镜和开发手术纵隔淋巴结清扫的比较 胸腔镜下食管旁淋巴结清扫不存在争议 胸腔镜隆突下淋巴结清扫 规范的左上纵隔（喉返神经旁）淋巴结清扫 质量控制？ 每一例都能清晰显露左侧喉返神经？ 将淋巴结清扫导致的神经损伤降至最小？ 手术时间和Ergonomics? 理论上气管、左总支气管与主动脉弓距离越大，越能清晰暴露左侧喉返神经 手术野污染物越少越好 给手术器械留下的操作空间越大越好 左侧卧位时如何做到 向患者腹侧、上方牵拉气管 需要拉钩和优秀的助手 减少术野的污染：吸引器和优秀的助手 困难 双腔管尤其左侧双腔管使助手必须用一定的力量牵拉 原本狭小的空间放