腹腔镜结直肠癌的治疗进展课件

腹腔镜辅助结直肠癌根治术腹腔镜辅助结直肠癌根治术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？2HuashanHospitalHaoHankun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腹腔镜发展史HuashanHospitalHaoHankun腹腔镜发展史HuashanHospitalHaoHan1991年 Flower和Jacobs行腹腔镜乙状结肠切除术1992年 Kokerling首次施行腹腔镜Miles手术1993年 Watanabe日本首例腹腔镜结肠手术1994年 Leahy首次报告手助腹腔镜手术1995年 香港郭宝贤完成亚洲首例乙状结肠手术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HuashanHospitalHaoHankun1991年Flower和Jacobs行腹腔镜乙状结肠切除腹腔镜面临的质疑Lancet.1994344(8914):58.Subcutaneousmetastasesafterlaparoscopiccolectomy.BerendsFJ,KazemierG,BonjerHJ,LangeJF.BrJSurg.199481(5):648-52.Abdominalwallmetastasesfollowinglaparoscopy.NdukaCC1,MonsonJR,Menzies-GowN,DarziA.BrJSurg.199481(11):1697.Abdominalwallmetastasesfollowinglaparoscopy.PrasadA,AveryC,FoleyRJ.HuashanHospitalHaoHankun腹腔镜面临的质疑Lancet.1994344(8914)腹腔镜医生迎接挑战COST(ClinicalOutcomesofSurgicalTherapy)COLOR(COloncancerLaparoscopicorOpenResection)CLASICC(Conventionalversus Laparoscopic-AssistedSurgeryInColorectalCancer)HuashanHospitalHaoHankun腹腔镜医生迎接挑战COST(ClinicalOutcom腹腔镜与结肠癌COST的结果NEnglJMed2004;350:2050-9.HuashanHospitalHaoHankunConclusionsInthismulti-institutionalstudy,theratesofrecurrentcancerweresimilarafterlaparoscopicallyassistedcolectomyandopencolectomy,suggestingthatthelaparoscopicapproachisanacceptablealternativetoopensurgeryforcoloncancer.腹腔镜与结肠癌COST的结果NEnglJMed200腹腔镜与结肠癌COLOR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;6:47784HuashanHospitalHaoHankun腹腔镜与结肠癌COLOR的结果LessbloodlossASCRSPracticeParameters(2012)Laparoscopicandopencolectomyachieveequivalentoncologicaloutcomesforlocalizedcoloncancer.Theuseofthelaparoscopicapproachshouldbebasedonthesurgeonsdocumentedexperienceinlaparoscopicsurgeryaswellasonpatient-andtumor-specificfactors.GradeofRecommendation:1ADisColonRectum2012;55:831843HuashanHospitalHaoHankunASCRSPracticeParameters(201NCCN指南的变化拒绝：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。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。HuashanHospitalHaoHankun医学百事通，在线医生咨询NCCN指南的变化拒绝：费用昂贵，术后恢复时间与开腹手术没有NCCN指南的变化HuashanHospitalHaoHankunNCCN指南的变化HuashanHospitalHao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。HuashanHospitalHaoHankun腹腔镜结直肠手术的主要适应证和禁忌证适应证：Huashan操作准备之体位选择充分利用地球引力方便术者操作A.头高脚低位 B.头低脚高位 C.分腿位D.左倾、右倾HuashanHospitalHaoHankun操作准备之体位选择HuashanHospitalHao操作准备之Trocar的放置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HuashanHospitalHaoHankun医学百事通，网络会诊操作准备之Trocar的放置第一穿刺孔往往选择在脐部Huas操作准备之气腹的建立在第一穿刺孔气腹针直视下，小切口可视穿刺器气腹压力1.72kPa或1013mmHg）HuashanHospitalHaoHankun操作准备之气腹的建立在第一穿刺孔HuashanHospit手术操作-分离技术电刀分离：1)凝固血管和切断组织2)电钩、电铲等超声刀分离：1)切断5mm以下血管(蛋白质变性)2)多用途：切割、止血、分离、抓持等HuashanHospitalHaoHankun手术操作-分离技术电刀分离：HuashanHospital手术操作-结扎技术夹闭法：可吸收夹不可吸收夹圈套器打结法体内打结体外打结HuashanHospitalHaoHankun手术操作-结扎技术夹闭法：HuashanHospital手术视频腹腔镜辅助右半结肠切除术HuashanHospitalHaoHankun手术视频腹腔镜辅助右半结肠切除术HuashanHospit腹腔镜与直肠癌技术上是否可行？肿瘤学是否安全？是否有优势？HuashanHospitalHaoHankun腹腔镜与直肠癌技术上是否可行？HuashanHospita腹腔镜与低位直肠癌（历史与现实）1991年，LeroyJ完成首例腹腔镜TMELaparoscopicsurgeryispreferredinthesettingofaclinicaltrialNCCNGuidelinesVersion3.2014(Rectal)HuashanHospitalHaoHankun腹腔镜与低位直肠癌（历史与现实）1991年，LeroyJ腹腔镜与低位直肠癌（ASCRS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.DisColonRectum2013;56:535550腹腔镜与低位直肠癌（ASCRS现状）Currentevid腹腔镜直肠癌手术的循证医学依据Conclusions：Accordingtotheseresults,laparoscopicsurgeryisthebestoptionforthesurgicaltreatmentofrectalcancer,withsimilarratesoflocalrecurrenceandsurvival.SurgEndosc(2013)27:295302HuashanHospitalHaoHankun腹腔镜直肠癌手术的循证医学依据Conclusions：Sur腹腔镜直肠癌手术的循证医学依据Todate,thehighestlevelofevidenceforthebenefitsofthelaparoscopicapproachcomesfromtheCLASICCtrialCLASICC:TheMedicalResearchCouncilConventionalversus Laparoscopic-AssistedSurgeryInColorectalCancertrial(1996)NCCNGuidelinesVersion3.2014RectalCancerHuashanHospitalHaoHankun腹腔镜直肠癌手术的循证医学依据Todate,thehiFive-yearfollow-upofCLASICCtrialBritish 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.The5-yearanalysesconfirmtheoncologicalsafetyoflaparoscopicsurgeryforbothcolonicandrectalcancerHuashanHospitalHaoHankunFive-yearfollow-upofCLASICCLong-termfollow-upofCLASICCtrialBritish 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 cancerHuashanHospitalHaoHankunLong-termfollow-upofCLASICC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4HuashanHospitalHaoHankunAPR/LAR/ISR5下切缘要求3腹腔镜直肠癌根治术TME指征2IMA高位/低位结扎1植物神经IMA处理细节IMA低位结扎/高位结扎？低位结扎理由：生存率与高位相当高位结扎理由：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高位清扫、低位结扎美国结直肠外科医师协会（2013）totheleveloftheoriginofthesuperiorrectalarteryHuashanHospitalHaoHankunDisColonRectum2013;56:535550IMA处理细节IMA低位结扎/高位结扎？HuashanHoTME指征Miles的贡献（1908）Heald的贡献（1993）TME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)TSME、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5cm以上HuashanHospitalHaoHankunTME指征Miles的贡献（1908）HuashanHosDistalresectionmarginsBrJSurg1951;39:199DisColonRectum2005;48:411AnnSurgOncol2003;10:805cm2cm1cmHuashanHospitalHaoHankunDistalresectionmarginsBrJSNCCN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。HuashanHospitalHaoHankunNCCN关于下切缘要求对于超低位直肠癌（5cm），1-2cASCRS关于下切缘HuashanHospitalHaoHankunDisColonRectum2013;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.ASCRS关于下切缘HuashanHospitalHao植物神经保护HuashanHospitalHaoHankun植物神经保护HuashanHospitalHaoHan植物神经保护HuashanHospitalHaoHankun医学百事通，咨询医师植物神经保护HuashanHospitalHaoHan植物神经保护HuashanHospitalHaoHankun植物神经保护HuashanHospitalHaoHan植物神经保护HuashanHospitalHaoHankun植物神经保护HuashanHospitalHaoHan植物神经保护HuashanHospitalHaoHankun植物神经保护HuashanHospitalHaoHa肿瘤学原则：充分的切缘功能学原则：良好的括约肌功能医生的选择：技术难度、潜在风险患者的选择：充分的医患沟通LAR,ISRorAPR?HuashanHospitalHaoHankun肿瘤学原则：LAR,ISRorAPR?HuashanLARorISR?LAR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ISR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HuashanHospitalHaoHankunLARorISR?LAR指征：HuashanHospi括约肌间切除(ISR)括约肌间切除（intersphinctericresection,ISR)最早(1994)由Schiessel等详细描述提高保肛率获得更确切的下切缘潜在的劣势：增加手术并发症局部复发控便功能损害BrJSurg.1994Sep;81(9):1376-8.HuashanHospitalHaoHankun括约肌间切除(ISR)括约肌间切除（intersphincISR评价DisColonRectum2005;48:18581867Intersphinctericresectionisavaluableprocedureforsphincter-savingrectalsurgery.Weshowedthatthistechniquehassatisfactorylong-termresultsinfunctionalandoncologicrespects.HuashanHospitalHaoHankunISR评价DisColonRectum2005;48ISR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;99:603612HuashanHospitalHaoHankunISR评价OncologicaloutcomesafteISR分类DisColonRectum2009;52:64-70HuashanHospitalHaoHankunISR分类DisColonRectum2009;52选择ISR需谨慎肿瘤分期基础括约肌功能是否需要辅助放疗患者性别以及年龄患者主观意愿HuashanHospitalHaoHankun选择ISR需谨慎肿瘤分期HuashanHospitalHAPR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。HuashanHospitalHaoHankunAPR指征APR适用于肿瘤侵犯外括约肌或提肛肌，或可能导致肛直肠癌手术原则肿瘤学良好的结果良好的功能保护不要盲目保肛HuashanHospitalHaoHankun直肠癌手术原则肿瘤学良好的结果HuashanHospita手术视频腹腔镜低位直肠癌根治（LAR）1HuashanHospitalHaoHankun手术视频腹腔镜低位直肠癌根治（LAR）1HuashanHo复旦大学附属华山医院 蒿汉坤ThankYou!复旦大学附属华山医院蒿汉坤