胃癌切除术后消化道重建的组织管理科学.ppt

统计12项研究1589例手术，回顾性研究表明使用加固后发生吻合口漏的可能性是未加固的1.45倍。 但该项研究是回顾性研究，样本量有限，该回顾性同样表明，在糖尿病完成胃袖状切除后对于缝钉线尤其是缝钉线结合部进行加固是有利于减少吻合口漏的发生。 建议在以下情况采取缝线加固方法： 甜甜圈不完整 明显的吻合口出血 吻合口张力大（建议松解周围组织或血管） 缝钉成型不良 吻合口组织被挤裂 Chen, B., Kiriakopoulos, A., Tsakayannis, D., Wachtel, M.S., Linos, D., Frezza, E.E. Reinforcement does not necessarily reduce the rate of staple line leaks after sleeve gastrectomy. A review of the literature and clinical experiences (2009) Obesity Surgery, 19 (2), pp. 166-172. 要点四 ：避免过度加缝 为了确保血供，要点在于将系膜处理到钉砧头的边缘。 避免钉合系膜是十分重要的。 否则可能会出现在吻合钉损伤动脉后出血的止血困难。 系膜与钉砧边缘平齐。当心不要进入钉合范围。 可能会有缺血风险。 要点五：系膜的正确处理 放心之声 喀嗒 垫圈的切断就是告诉你切割已经完成。 钉砧内置的切割垫圈 发挥“砧板”作用的部位 切割垫圈的横截面 击发前 切割中 切割完成 咔嚓！ 临床经验总结 – 机械吻合操作要点 要点六：正确、稳定的击发吻合器 总结 组织特性要知道，器械原理很重要； 成钉高度选择好，张力晃动都不要； 操作细节请注意，患者医生麻烦少！ Thanks！ * FACILITATION TIP: NOTES: Components of tissue management For example, when we think about tissue management, we need to think about the dynamics of the tissue. What’s actually happening with the tissue as we apply different types of forces on the tissue? If we’re talking about surgical stapling, it could be how compression affects tissue, and ultimately the effect on hemostasis. We need to understand that the characteristics of living tissue have a biomechanical set of attributes. That understanding helps to ensure that the devices that are chosen to touch tissue can in fact respond appropriately to that tissue. We also want to understand human factors. For some, human factors means ergonomics, the device-to-user interaction. We also discuss this in terms of the relationship of the individual who is on the table at the receiving end of the device. We’ll share a little bit more about that as we dig deeper, but recognize that for the most part, human factors typically refers to the user and device interaction, less so to the patient and how they might respond to the technology that’s being introduced into them. And certainly, we also want to look at the technology itself. How is it going to interact with