两孔法全腹腔镜远端胃癌D2根治术中的团队配合体会
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摘要
目的总结两孔法全腹腔镜远端胃癌D2根治术中淋巴结清扫的团队配合体会。方法 2017年1月～2018年8月我们对48例胃癌行两孔法全腹腔镜远端胃癌D2根治术。在幽门下区6组淋巴结清扫时,术者左手器械从镜身下方进入,通过小纱布下压结肠系膜与第一助手形成对抗牵引,右手器械通过左上腹12 mm trocar进行切割、分离等操作;在幽门上区淋巴结清扫时应抓住解剖中心,第一助手向头侧腹侧上提12组淋巴结及结缔组织,术者下压血管形成对抗牵引,保证术野清晰、层次清楚。在胰腺上缘区7、9、11组淋巴结清扫时容易出现"筷子效应",镜身的空间变得很狭窄,扶镜手在狭小的空间通过调整30°镜寻找最佳视角。结果 48例均成功完成两孔法全腹腔镜远端胃癌D2根治术,手术时间(163. 5±26. 8)min,术中出血量(45. 7±28. 6) ml,切口长度(4. 3±0. 8) cm,肿瘤直径(3. 9±3. 3) cm,淋巴结清扫(24. 2±7. 9)枚。组织学分型:未分化或低分化腺癌18例,中分化腺癌14例,高分化腺癌16例;术后TNM分期:Ⅰ期18例,Ⅱ期19例,Ⅲ期11例,Ⅳ期0例。48例随访4～14个月,中位数8个月:1例术后13个月肝转移; 1例胃瘫,经过胃肠减压、补液支持及置入空肠营养管加强肠内营养治疗1个月后恢复胃动力; 1例十二指肠残端漏,通过保持腹腔引流管通畅、抑制分泌治疗后分次退管治愈。结论扶镜手和第一助手要学会以术者为导向,适应多孔穿刺器中器械碰撞,尽快找到合适视角和提拉角度、力度,为手术提供一个清晰稳定的画面,以便手术安全快速地完成。
Objective To summarize the experience of teamwork coordination of lymph node dissection in dual-port total laparoscopic D2 radical resection of distal gastric cancer. Methods A retrospective analysis was conducted on clinical data of 48 cases of D2 radical gastrectomy for gastric cancer in our department from January 2017 to August 2018. All the patients underwent dual-port total laparoscopic distal subtotal gastrectomy. During the lymph node dissection in the inferior pyloric region,the left-handed instruments were inserted under endoscope. The counter-traction was formed with the first assistant by pressing the mesocolon through the gauze. Then the right-handed instruments were used to cut and separate through a 12 mm trocar in the left upper abdomen. During the lymph node dissection of the superior pyloric region,the anatomical center should be focused on. The first assistant lifted and pulled the 12 th group of lymph nodes and connective tissue to the cephalic ventral side,and the surgeon pressed down the blood vessels to form counter-traction,so as to ensure a clear surgical field and clear hierarchy. During the 7 th,9 th and 11 th groups of lymph node dissection in the upper margin of the pancreas,the " chopstick effect" was prone to appear,when the endoscopic space became very narrow. The endoscope holder found the best angle of view by adjusting the 30 degree endoscope. Results The dual-port laparoscopic D2 radical resection was successfully completed in all the 48 patients. The operative time was( 163. 5 ± 26. 8) min,the intraoperative blood loss was( 45. 7 ± 28. 6) ml,the incision length was( 4. 3 ± 0. 8) cm,the maximum tumor diameter was( 3. 9 ±3. 3) cm,and the number of lymph nodes dissected was( 24. 2 ± 7. 9). Histological classification showed 18 cases of undifferentiated or low-differentiated tumors,14 cases of medium-differentiated tumors,and 16 cases of high-differentiated tumors. There were 18 cases of TNM stage Ⅰ,19 cases of stage Ⅱ,11 cases of stage Ⅲ,and no case of stage Ⅳ. All the patients were followed up for 4-14 months,with a median of 8 months. One case had liver metastasis 13 months after surgery. One case of gastroparesis recovered gastric motility after 1 month of gastrointestinal decompression,fluid rehydration support and enteral nutrition tube implantation. One case of duodenal stump leakage was cured by peritoneal drainage and secretion inhibition. Conclusion The endoscope holder and the assistant should learn to cooperate with the operator,adapt to the collision of the instruments in multi-port puncture,and find the appropriate angle of view,the pull angle and strength as soon as possible,to provide a clear and stable vision for the operation,so as to complete the operation safely and quickly.
Objective To summarize the experience of teamwork coordination of lymph node dissection in dual-port total laparoscopic D2 radical resection of distal gastric cancer. Methods A retrospective analysis was conducted on clinical data of 48 cases of D2 radical gastrectomy for gastric cancer in our department from January 2017 to August 2018. All the patients underwent dual-port total laparoscopic distal subtotal gastrectomy. During the lymph node dissection in the inferior pyloric region,the left-handed instruments were inserted under endoscope. The counter-traction was formed with the first assistant by pressing the mesocolon through the gauze. Then the right-handed instruments were used to cut and separate through a 12 mm trocar in the left upper abdomen. During the lymph node dissection of the superior pyloric region,the anatomical center should be focused on. The first assistant lifted and pulled the 12 th group of lymph nodes and connective tissue to the cephalic ventral side,and the surgeon pressed down the blood vessels to form counter-traction,so as to ensure a clear surgical field and clear hierarchy. During the 7 th,9 th and 11 th groups of lymph node dissection in the upper margin of the pancreas,the " chopstick effect" was prone to appear,when the endoscopic space became very narrow. The endoscope holder found the best angle of view by adjusting the 30 degree endoscope. Results The dual-port laparoscopic D2 radical resection was successfully completed in all the 48 patients. The operative time was( 163. 5 ± 26. 8) min,the intraoperative blood loss was( 45. 7 ± 28. 6) ml,the incision length was( 4. 3 ± 0. 8) cm,the maximum tumor diameter was( 3. 9 ±3. 3) cm,and the number of lymph nodes dissected was( 24. 2 ± 7. 9). Histological classification showed 18 cases of undifferentiated or low-differentiated tumors,14 cases of medium-differentiated tumors,and 16 cases of high-differentiated tumors. There were 18 cases of TNM stage Ⅰ,19 cases of stage Ⅱ,11 cases of stage Ⅲ,and no case of stage Ⅳ. All the patients were followed up for 4-14 months,with a median of 8 months. One case had liver metastasis 13 months after surgery. One case of gastroparesis recovered gastric motility after 1 month of gastrointestinal decompression,fluid rehydration support and enteral nutrition tube implantation. One case of duodenal stump leakage was cured by peritoneal drainage and secretion inhibition. Conclusion The endoscope holder and the assistant should learn to cooperate with the operator,adapt to the collision of the instruments in multi-port puncture,and find the appropriate angle of view,the pull angle and strength as soon as possible,to provide a clear and stable vision for the operation,so as to complete the operation safely and quickly.
引文
1余佩武.腹腔镜胃癌手术的进展与展望.中国普外基础与临床杂志,2011,18(2):105-109.
2周均,曹永宽,宋亚宁,等.手助腹腔镜胃癌D2根治手术的团队配合.中国微创外科杂志,2014,14(10):892-895.
3郭吕.如何做好腹腔镜医师的持镜助手.中国微创外科杂志,2007,7(6):590.
4郑子芳,吴黎敏,简陈兴,等.扶镜手在腔镜甲状腺手术中配合的体会.中国微创外科杂志,2017,17(8):757-760.
5郑子芳,吴黎敏,简陈兴,等.扶镜手在腹腔镜胃癌D2根治术中淋巴结清扫的配合体会.中国微创外科杂志,2016,16(9):860-862.
6 Mori T,Kimura T,Kitaiima M.Skill accreditation system for laparoscopic gastroenterologic surgeons in Japan.Minim Invasive Ther Allied Technol,2010,19(1):18-23.
2周均,曹永宽,宋亚宁,等.手助腹腔镜胃癌D2根治手术的团队配合.中国微创外科杂志,2014,14(10):892-895.
3郭吕.如何做好腹腔镜医师的持镜助手.中国微创外科杂志,2007,7(6):590.
4郑子芳,吴黎敏,简陈兴,等.扶镜手在腔镜甲状腺手术中配合的体会.中国微创外科杂志,2017,17(8):757-760.
5郑子芳,吴黎敏,简陈兴,等.扶镜手在腹腔镜胃癌D2根治术中淋巴结清扫的配合体会.中国微创外科杂志,2016,16(9):860-862.
6 Mori T,Kimura T,Kitaiima M.Skill accreditation system for laparoscopic gastroenterologic surgeons in Japan.Minim Invasive Ther Allied Technol,2010,19(1):18-23.