端到端吻合技术在机器人中心胰腺中的应用
Summary
端到端吻合的机器人中心胰腺在胰腺颈部和胰腺体近端肿瘤中是可行的、安全的。介绍了该手术的手术技术。
Abstract
中心胰腺进行治疗的良性或低恶性潜在肿瘤位于胰腺颈部或近端的胰腺体。随着技术的发展, 机器人手术系统在微创手术中显示出了优势, 并越来越多地应用于中心胰腺。然而, 在机器人中心胰腺后, 用端到端吻合术重建胰腺的连续性尚未得到应用。在本研究中, 我们报告的手术技术的机器人中心胰腺与端到端吻合。胰管经导管与导管吻合术重建胰腺, 胰管置入胰管内两树桩, 胰实质端到端吻合。与传统的中央胰腺 pancreaticoenteric 吻合术相比, 该方法降低了患者的手术损伤, 同时也能有效的维持消化道和胰管的完整性和连续性。机器人手术系统结合多器械灵活、精确的运动, 特别适用于胰管的解剖和重建。我们发现, 机器人中心胰腺端到端吻合是安全可行的, 我们需要更多的经验来评估其最佳适应症和远期结果。
Introduction
中央胰腺正在越来越多地进行治疗的良性或低恶性潜在肿瘤位于胰腺颈部或近端的胰腺体1。与胰十二指肠切除或远端胰腺相比, 中枢胰腺切除掉组织少, 保存胰腺实质和功能。目前, 胰腺重建的主要方法是过度缝合头胰残端, 并执行 pancreaticojejunostomy 或 pancreaticogastrostomy 到远端残端2,3。这两种方法广泛应用于开放, 腹腔镜和机器人中心 pancreatectomies4,5,6,7。然而, 上述两种重建方法打破了消化道的解剖连续性和胰腺液排泄的途径。胰残端与肠道果汁直接接触可能增加出血和瘘管的可能性8。虽然胃液可以不活跃的胰腺酶, 以避免吻合的侵蚀, 它可能导致胰腺外分泌不足, 并长期危害患者的营养状况9,10。
随着微创手术的发展, 机器人手术在其3维放大视图、稳定性和运动灵活性、等等方面显示了巨大的优势, 为吻合术提供了增强的解剖缝合能力和止血11,12。根据我们在机器人胰腺和修复受伤的胰管的经验13,14, 我们已经执行了一系列的机器人中心胰腺端到端吻合, 看到良好的结果。与 pancreaticojejunostomy 或 pancreaticogastrostomy 相比, 端到端胰腺吻合避免了消化道损伤;因此, 理论上减少了 pancreaticoenteric 瘘的可能性。但另一方面, 端到端的胰腺吻合造成了更大的技术困难。作为常规中央胰腺的更新, 常规中央胰腺的候选者也有资格参加这项手术。在此, 我们介绍了在本视频案例演示中, 在第三个 hepatopancreatobiliary 中心进行端到端吻合的机器人中心胰腺的操作技术。
迹象：
(1) 位于胰颈及近体的良、低恶性电位肿瘤适用于本手术。
(2) 主胰管的缺损在中央胰腺后应小于5厘米, 肿瘤大小不是重建的主要关注。
案例演示:
病人是一名31岁的男子。2年前在一次体检中无意中发现了胰腺颈部的病变。他进行了定期复查, 发现病灶最近 asymptomatically 扩大。他以前没有做过腹部手术的病史。在体检中, 没有积极的迹象存在。胰腺 MRI 表现为大约14毫米的胰腺颈部的准圆形病变;这被推定为神经内分泌肿瘤。在 T1 和 T2-weighted 成像方面, 病灶分别显示 hypointense 和 hyperintense 信号。在扩散加权成像中, 病灶显示 hyperintense 信号。病变在动脉期略有增强, 在实质阶段和延迟阶段显示了渐进增强模式 (图 1)。重度脂肪肝也由 MRI 诊断。胰管未发现扩张或狭窄。常规血液检查、IgG 异构体试验、肿瘤生物标志物、心电图和胸部 x 线均正常。生化试验显示, 在 53.9U/l 的 147.3 U/升和 AST (天门冬氨酸转氨酶) 轻微升高, 可能是由脂肪肝引起。
Protocol
从病人那里获得书面知情同意, 以便发表本报告以及随附的视频和图像。 1. 术前准备 仔细评估 CT 或 MRI 对肿瘤的确切位置及其与周围组织的关系的术前图像。 在手术前一天给病人一个软饮食, 在手术前的午夜开始禁食。 把病人放在手术台上。然后, 放置一个外周静脉导管, 并通过标准程序诱发全身麻醉。介绍一种中心静脉导管, 通过右颈内静脉的药物治?…
Representative Results
操作过程顺利。手术时间为141分钟, 术中失血约50毫升。切除的胰腺的大小约为 5.5 x 2.5 x 2.5 厘米 (图 4)。病人在手术后顺利康复, 并于 6th术后出院。当病人出院时, 他有正常的饮食和正常的排便, 没有发烧, 没有腹痛或腹胀。常规血液检查和血液生化检查无明显异常。Postopertative CT 扫描显示胰腺周围有轻微渗出, 胰管没有扩张或狭窄 (<strong class=…
Discussion
恶性肿瘤位于胰颈和胰体近端, 常以胰十二指肠切除或远端胰腺治疗。然而, 对于良性或低恶性潜在肿瘤的那些部位, 标准的胰十二指肠切除术或远端胰腺将清除过多的正常组织, 并导致过度的伤害。因此, 中央胰腺或胰腺摘除, 称为 “实质保留胰腺”, 成为治疗良性和低恶性潜在肿瘤的胰腺颈部和身体的首选选择。
早在 1908, Ehrhardt 报告了中央胰腺15。目前, 最常?…
Declarações
The authors have nothing to disclose.
Acknowledgements
作者没有确认。
Materials
| da Vinci Robotic Surgical System | Intuitive Surgical, USA | Si | |
| EndoWrist Permanent Cautery Hook | Intuitive Surgical, USA | 420183 | |
| Harmonic Ace Curved Shears | Ethicon, USA | 420275 | |
| EndoWrist Large needle Driver | Intuitive Surgical, USA | 420006 | |
| EndoWrist Cadiere Forceps | Intuitive Surgical, USA | 420049 | |
| EndoWrist Black Diamond Micro Forceps | Intuitive Surgical, USA | 420033 | |
| Lapro-Clip 8 mm Absorbable Clips | Covidien , USA | 8886848882 | |
| 5-0 non-absorbable suture | Ethicon, USA | M8717 | |
| 4-0 non-absorbable suture | Ethicon, USA | D9775 | |
| 5-0 absorbable suture | Ethicon, USA | D9943 | |
| Absorbable hemostas | Ethicon, USA | W1912 | |
| Laparoscopic Ultrasound Probe | BK Ultrasound, Denmark | 8666-RF | transducer contact surface: 30*5mm; Frequence: 4.3-10 MHz |
| Pancreatic stent | Yaxin Medical, Suzhou, China | 1.2 mm | |
| Antibiotics (ceftriaxone sodium for injection) | Roche, Shanghai, China | H10983036 | ceftriaxone sodium (2g) adding to normal saline (100ml), once per day. |
| Proton pump inhibitors (lansoprazole injection) | Luoxin Pharmaceutical, Linyi, China | H20055118 | lansoprazole injection (30 mg) adding to normal saline (100ml), twice per day. |
| Somatostatin (Somatostatin for injection) | Merck Serono, Germany | H20090929 | Somatostatin for injection (6000ug) adding to nornal saline to a total of 48ml, 2 ml/h |
| Analgesic | |||
| Analgesic (sufentanil Citrate injection) | Humanwell Healthcare, Fuzhou, China | H20054171 | sufentanil Citrate (200ug), Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 1 ml/h |
| Analgesic (Ondansetron hyrochloride injection) | Qilu Pharmaceutical, Hainan, China | H10970065 | sufentanil Citrate (200ug), Ondansetron hyrochloride (20mg), adding to normal saline to a total of 80 ml, 2 ml/h |
| Parenteral nutrition | |||
| Parenteral nutrition(10% glucose injection) | Shijiazhuang No.4 Pharmaceutical，Shijiazhuang, China | H20133313 | 1000 ml |
| Parenteral nutrition(5% glucose injection) | Shijiazhuang No.4 Pharmaceutical，Shijiazhuang, China | H13022474 | 250 ml |
| Parenteral nutrition(Compond vitamin injection) | Pude Pharmaceutical, Datong, China | H20093720 | 1 piece |
| Parenteral nutrition(Compond amino acid injection) | Kelun Pharmaceutical, Chengdu, China | H20066058 | 500 ml |
| Parenteral nutritionz(Fat emulsion injection) | Fresenius Kabi AB, Sweden | H20160019 | 250 ml |
| Parenteral nutrition(10%KCl injection) | Jinyao Pharmaceutical, Tianjin, China | H12020518 | 50 ml |
| Parenteral nutrition(10%NaCl injection) | CR, Double-Crane, Beijing, China | H11020865 | 50 ml |
| Parenteral nutrition(Insulin injection) | No.1 biochemical and pharmaceutical, Shanghai, China | H31020519 | 28 Unit |
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Tags
Robotic Central PancreatectomyEnd-to-end AnastomosisPancreaticoenterostomyGastrointestinal Tract ConservationRobotic Surgical TechniqueTrocar PlacementRobotic Arm DockingPancreas MobilizationGastrocolic Ligament DissectionPancreas TransectionPancreatic Duct IdentificationEnd-to-end Pancreatic Anastomosis
Citar este artigo
Liu, R., Wang, Z., Gao, Y., Xu, Y. Application of End-to-end Anastomosis in Robotic Central Pancreatectomy. J. Vis. Exp. (136), e57495, doi:10.3791/57495 (2018).