2233608837腹腔镜结直肠自动保存的

腹腔镜辅助结直肠癌根治术腹腔镜辅助结直肠癌根治术复旦大学附属华山医院 蒿汉坤Company Logo 主要内容主要内容腹腔镜结直肠癌根治是否可行？1如何行腹腔镜结直肠癌根治术？2Huashan Hospital Hao HankunCompany Logo 腹腔镜发展史腹腔镜发展史Huashan Hospital Hao HankunCompany Logo v 1991年 Flower和Jacobs行腹腔镜乙状结肠切除术v 1992年 Kokerling首次施行腹腔镜Miles手术v 1993年 Watanabe日本首例腹腔镜结肠手术v 1994年 Leahy首次报告手助腹腔镜手术v 1995年 香港郭宝贤完成亚洲首例乙状结肠手术v 1997年 上海郑民华完成内地首例乙状结肠手术腹腔镜结直肠手术发展腹腔镜结直肠手术发展Huashan Hospital Hao HankunCompany Logo 腹腔镜面临的质疑腹腔镜面临的质疑v Lancet.1994 344(8914):58.Subcutaneous metastases after laparoscopic colectomy.Berends FJ,Kazemier G,Bonjer HJ,Lange JF.v Br J Surg.1994 81(5):648-52.Abdominal wall metastases following laparoscopy.Nduka CC1,Monson JR,Menzies-Gow N,Darzi A.v Br J Surg.1994 81(11):1697.Abdominal wall metastases following laparoscopy.Prasad A,Avery C,Foley RJ.Huashan Hospital Hao HankunCompany Logo 腹腔镜医生迎接挑战腹腔镜医生迎接挑战v COST(Clinical Outcomes of Surgical Therapy)v COLOR(COlon cancer Laparoscopic or Open Resection)v CLASICC(Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer)Huashan Hospital Hao HankunCompany Logo 腹腔镜与结肠癌腹腔镜与结肠癌vCOST的结果的结果N Engl J Med 2004;350:2050-9.Huashan Hospital Hao HankunConclusionsIn this multi-institutional study,the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open colectomy,suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.Company Logo 腹腔镜与结肠癌腹腔镜与结肠癌vCOLOR的结果的结果Less blood lossRadicality of resection not differEarlier recovery of bowel functionFewer analgesicsShorter hospital stayMorbidity and mortality 28 days after colectomy did not differConclusion：Laparoscopic surgery can be used for safe and radical resection of cancer in the right,left,and sigmoid colon.Lancet Oncol 2005;6:47784Huashan Hospital Hao HankunCompany Logo ASCRS Practice Parameters(2012)Laparoscopic and open colectomy achieve equivalent oncological outcomes for localized colon cancer.The use of the laparoscopic approach should be based on the surgeons documented experience in laparoscopic surgery as well as on patient-and tumor-specific factors.Grade of Recommendation:1ADis Colon Rectum 2012;55:831843 Huashan Hospital Hao HankunCompany Logo NCCN指南的变化指南的变化v 拒绝：拒绝：费用昂贵，术后恢复时间与开腹手术没有区别，且缺乏相关生存数据，不推荐临床常规使用。v 部分接受：部分接受：要求术者具有丰富的腹腔镜手术经验；无直肠或远端结肠肿瘤；无远处转移、无梗阻或穿孔、无腹腔粘连；要求术者对腹腔全面探查；较小的肿瘤术前需要定位。Huashan Hospital Hao HankunCompany Logo NCCN指南的变化指南的变化Huashan Hospital Hao HankunCompany Logo 腹腔镜结直肠手术的主要适应证和禁忌证 适应证：腹腔镜手术适应证与传统开腹手术相似。包括结肠良恶性 肿瘤、炎性疾病、多发性息肉等；相对手术禁忌：肿瘤直径大于6cm或/和与周围组织广泛侵润；腹部严重粘连、重度肥胖者、大肠癌的急症手术（如急性梗阻、穿孔等）；心肺功能不良者；禁忌证：全身情况不良，虽经术前治疗仍不能纠正者；有严重心肺肝肾疾患，不能耐受手术；随着腹腔镜手术技术和器械的发展，以及麻醉和全身 支持水平的提高，腹腔镜手术适应证将进一步扩大和发展。Huashan Hospital Hao HankunCompany Logo 操作准备之体位选择操作准备之体位选择v 充分利用地球引力充分利用地球引力v 方便术者操作方便术者操作A.头高脚低位 B.头低脚高位 C.分腿位D.左倾、右倾Huashan Hospital Hao HankunCompany Logo 操作准备之操作准备之TrocarTrocar的放置的放置v 第一穿刺孔往往选择在脐部减少对腹部血管、神经和腹直肌的损伤腹部正中位置,便于术者观察腹壁最薄处脐部穿刺切口更加隐蔽，符合美学要求v 其余穿刺孔，按手术种类和手术方式决定一般是三到四个选择原则1.便于操作，打结、牵引、吸引2.互不干扰3.统筹兼顾，放置引流、切开、美观Huashan Hospital Hao HankunCompany Logo 操作准备之操作准备之气腹的建立气腹的建立v 在第一穿刺孔在第一穿刺孔 气腹针气腹针 直视下，小切口直视下，小切口 可视穿刺器可视穿刺器v 气腹压力气腹压力1.72kPa或或1013mmHg）Huashan Hospital Hao HankunCompany Logo 手术操作手术操作-分离技术分离技术v电刀分离电刀分离：1)1)凝固血管和切断组织凝固血管和切断组织2)2)电钩、电铲等电钩、电铲等v超声刀分离：超声刀分离：1)1)切断切断5 5mmmm以下血管以下血管(蛋白质变性蛋白质变性)2)2)多用途：切割、止血、分离、多用途：切割、止血、分离、抓持等抓持等Huashan Hospital Hao HankunCompany Logo 手术操作手术操作-结扎技术结扎技术v夹闭法：夹闭法：l 可吸收夹可吸收夹l 不可吸收夹不可吸收夹l 圈套器圈套器v打结法打结法l 体内打结体内打结l 体外打结体外打结Huashan Hospital Hao HankunCompany Logo 手术视频手术视频腹腔镜辅助右半结肠切除术Huashan Hospital Hao HankunCompany Logo 腹腔镜与直肠癌腹腔镜与直肠癌v技术上是否可行？v肿瘤学是否安全？v是否有优势？Huashan Hospital Hao HankunCompany Logo 腹腔镜与低位直肠癌（历史与现实）腹腔镜与低位直肠癌（历史与现实）v1991年，Leroy J完成首例腹腔镜TMEvLaparoscopic surgery is preferred in the setting of a clinical trialNCCN Guidelines Version 3.2014(Rectal)Huashan Hospital Hao HankunCompany Logo 腹腔镜与低位直肠癌（腹腔镜与低位直肠癌（ASCRS现状）现状）Current evidence indicates that laparoscopic TME can be performed with equivalent oncological outcomes in comparison with open TME when performed by experienced laparoscopic surgeons possessing the necessary technical expertise.Grade of Recommendation:Strong recommendation based on moderate quality evidence,1B.Dis Colon Rectum 2013;56:535550Company Logo 腹腔镜直肠癌手术的循证医学依据腹腔镜直肠癌手术的循证医学依据Conclusions：According to these results,laparoscopic surgery is the best option for the surgical treatment of rectal cancer,with similar rates of local recurrence and survival.Surg Endosc(2013)27:295302Huashan Hospital Hao HankunCompany Logo 腹腔镜直肠癌手术的循证医学依据腹腔镜直肠癌手术的循证医学依据v To date,the highest level of evidence for the benefits of the laparoscopic approach comes from the CLASICC trialv CLASICC:The Medical Research Council Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer trial(1996)NCCN Guidelines Version 3.2014 Rectal CancerHuashan Hospital Hao HankunCompany Logo Five-year follow-up of CLASICC trialBritish Journal of Surgery 2010;97:16381645No differences were found between laparoscopically assisted and open surgery in terms of overall survival,disease-free survival,and local and distant recurrence.The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancerHuashan Hospital Hao HankunCompany Logo Long-term follow-up of CLASICC trialBritish Journal of Surgery 2013;100:7582There were no statistically significant differences between open and laparoscopic groups in overall survivalLong-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancerHuashan Hospital Hao HankunCompany Logo 腹腔镜直肠癌根治术腹腔镜直肠癌根治术TME指征2IMA高位/低位结扎1植物神经如何保护4Huashan Hospital Hao HankunAPR/LAR/ISR5下切缘要求3Company Logo IMA处理细节处理细节v IMA低位结扎低位结扎/高位结扎？高位结扎？v 低位结扎理由：低位结扎理由：生存率与高位相当v 高位结扎理由：高位结扎理由：更高的淋巴结检出率、更准确的分期 利于降低张力，尤其是低位直肠前切 理论上更好的预后 并不增加手术风险和时间v 高位清扫、低位结扎高位清扫、低位结扎v 美国结直肠外科医师协会（美国结直肠外科医师协会（2013）to the level of the origin of the superior rectal arteryHuashan Hospital Hao HankunDis Colon Rectum 2013;56:535550Company Logo TME指征指征vMiles的贡献（1908）vHeald的贡献（1993）vTME的指征 直肠中1/3和下1/3的肿瘤,无论行低位前切除术(LAR)还是腹会阴联合切除术(APR),均应采用全直肠系膜切除技术(TME)vTSME、PME 对于直肠上1/3的肿瘤,可根据肿瘤情况进行系膜的切除,但要保证远切缘距肿瘤5 cm以上Huashan Hospital Hao HankunCompany Logo Distal resection marginsBr J Surg 1951;39:199Dis ColonRectum 2005;48:411Ann Surg Oncol 2003;10:805 cm 2 cm1 cmHuashan Hospital Hao HankunCompany Logo NCCN关于下切缘要求关于下切缘要求对于超低位直肠癌（5cm），1-2cm的阴性下切缘是可以接受的，但必须送冰冻证实。Huashan Hospital Hao HankunCompany Logo ASCRS关于下切缘关于下切缘Huashan Hospital Hao HankunDis Colon Rectum 2013;56:535550A 2-cm distal mural margin is adequate for most rectal cancers when combined with a TME.For cancers located at or below the mesorectal margin,a 1-cm distal mural margin is acceptable.Grade of Recommendation:Strong recommendation based on moderate quality evidence,1B.Company Logo 植物神经保护植物神经保护Huashan Hospital Hao HankunCompany Logo 植物神经保护植物神经保护Huashan Hospital Hao HankunCompany Logo 植物神经保护植物神经保护Huashan Hospital Hao HankunCompany Logo 植物神经保护植物神经保护Huashan Hospital Hao HankunCompany Logo 植物神经保护植物神经保护Huashan Hospital Hao HankunCompany Logo v肿瘤学原则：充分的切缘v功能学原则：良好的括约肌功能v医生的选择：技术难度、潜在风险v患者的选择：充分的医患沟通LAR,ISR or APR?Huashan Hospital Hao HankunCompany Logo LAR or ISR?vLAR指征：肿瘤下缘距离齿状线大于3cm 无括约肌和周围脏器侵犯 双吻合器vISR指征：肿瘤下缘距离齿状线小于3cm 肿瘤下缘距离括约肌间沟大于1cm 无外括约肌或提肛肌侵犯Huashan Hospital Hao HankunCompany Logo 括约肌间切除(ISR)v括约肌间切除（intersphincteric resection,ISR)最早(1994)由Schiessel等详细描述 v提高保肛率v获得更确切的下切缘v潜在的劣势：增加手术并发症 局部复发 控便功能损害Br J Surg.1994 Sep;81(9):1376-8.Huashan Hospital Hao HankunCompany Logo ISR评价评价Dis Colon Rectum 2005;48:18581867Intersphincteric resection is a valuable procedure for sphincter-saving rectal surgery.We showed that this technique has satisfactory long-term results in functional and oncologic respects.Huashan Hospital Hao HankunCompany Logo ISR评价评价Oncological outcomes after ISR for low rectal cancer are acceptable,with diverse,oftenimperfect functional results.These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.British Journal of Surgery 2012;99:603612Huashan Hospital Hao HankunCompany Logo ISR分类分类Dis Colon Rectum 2009;52:64-70Huashan Hospital Hao HankunCompany Logo 选择选择ISR需谨慎需谨慎v肿瘤分期v基础括约肌功能v是否需要辅助放疗v患者性别以及年龄v患者主观意愿Huashan Hospital Hao HankunCompany Logo APR指征指征APR适用于肿瘤侵犯外括约肌或提肛肌，或可能导致肛门失禁的保肛术。Huashan Hospital Hao HankunCompany Logo 直肠癌手术原则直肠癌手术原则v肿瘤学良好的结果v良好的功能保护v不要盲目保肛Huashan Hospital Hao HankunCompany Logo 手术视频手术视频腹腔镜低位直肠癌根治（LAR）1Huashan Hospital Hao Hankun复旦大学附属华山医院 蒿汉坤