腹股沟解剖及TAPP技术要点嵇振岭课件

Titelmasterformat durch Klicken bearbeiten,腹腔镜腹股沟区解剖,及,TAPP,技术要点,腹腔镜腹股沟区解剖及TAPP技术要点,1,东南大学附属中大医院普外科,东南大学疝与腹壁外科中心,2003,年，江苏省首例腹股沟疝,TAPP,修补术,2,008,年，江苏省首例腹腔镜食管裂孔疝修补术,2,009,年，开展各种腹腔镜腹壁疝修补手术,2010,年，疝补片研究获得教育部重点研究项目资助,2011,年，组织召开第五届国际内镜疝学会年会,2012,年，疝临床基础研究获得江苏省医学科技三等奖,2,013,年，江苏省首例单孔腹腔镜,TAPP,修补术,2,013,年，成立江苏省首家腔镜疝技术培训中心,东南大学附属中大医院普外科东南大学疝与腹壁外科中心2003,2,腹股沟区的解剖,腹股沟区的解剖,3,腹壁的结构,腹壁的结构,4,Hesselbachs,三角,A triangle region,Superolateral border:,inferior epigastric artery,Medial border:,Rectus abdominis muscle and joint outer tendon,Inferior border:,inguinal ligament,Hesselbachs 三角A triangle regi,5,Fruchaud,(,肌耻孔,),上界,：,弓状下缘,下界：耻骨梳,外界：髂腰肌,内界,：,腹直肌外缘,Fruchaud (肌耻孔)上界：弓状下缘,6,重要的骨性标志,重要的骨性标志,7,腹股沟管,层次结构,腹股沟管,8,腹股沟管,层次结构,腹股沟管,9,腹股沟管,层次结构,腹股沟管,10,腹股沟管,层次结构,腹股沟管,11,腹股沟管,层次结构,腹股沟管,12,腹股沟管,层次结构,腹股沟管,13,腹股沟解剖及TAPP技术要点嵇振岭课件,14,腹股沟解剖及TAPP技术要点嵇振岭课件,15,腹股沟解剖及TAPP技术要点嵇振岭课件,16,腹股沟解剖及TAPP技术要点嵇振岭课件,17,The operating surgeon knows little of the posterior wall of the inguinal canal, so well is it hidden from his view.,W.J. Lytle, 1945,Advent of laparoscopic hernia surgery,The operating surgeon knows li,18,疝,解,剖,的,重,要,结,构,疝解剖的重要结构,19,腹腔镜内面观：五个皱襞,median umbilical,ligament,medial umbilical ligament,lateral umbilical ligament,腹腔镜内面观：五个皱襞median umbilical li,20,supravesical fossa,medial fossa,lateral fossa,腹腔镜内面观：六个隐窝,supravesical fossamedial fossa,21,直疝与斜疝,直疝与斜疝,22,腹膜前间隙到,Retzius,间隙,(,medial compartment,),腹膜前间隙到Retzius间隙 (medial compar,23,transversalis,fascia,腹横筋膜,腹横,筋,膜,transversalis fascia腹横筋膜,24,内环及,Bogros,间隙,(,lateral compartment),内环及Bogros间隙(lateral compartmen,25,腹横筋膜索上肢,腹横筋膜索下肢,标志：腹横筋膜索,(inner inguinal ring),腹横筋膜索上肢腹横筋膜索下肢标志：腹横筋膜索,26,IP,CL,标志,:,Coopers,韧带,-,髂耻束,acc. to Annibali,IPCL标志: Coopers 韧带 - 髂耻束acc,27,Iliopubic tract,Iliopubic tract,28,Coopers ligament,Coopers ligament,29,Hesselbach,三角,rectus muscle,Epigastric vessels,symphysis,acc. to Annibali,Hesselbach三角rectus muscleEpiga,30,Hesselbach,三角,Hesselbach三角,31,重要的血管,重要的血管,32,腹股沟解剖及TAPP技术要点嵇振岭课件,33,IA,IV,髂外动静脉,acc. to Annibali,IAIV髂外动静脉acc. to Annibali,34,IA,IV,IE,腹壁下血管（,IE,）,acc. to Annibali,IAIVIE腹壁下血管（IE）acc. to Annibal,35,IA,IV,IE,ES,PB,耻骨下吻合血管支,a,nastomotic ramus pubicus,(,PB),acc. to Annibali,IAIVIEESPB耻骨下吻合血管支acc. to Anni,36,a,nastomotic,ramus pubicus (PB),corona,mortis,anastomotic ramus pubicus (PB),37,a,nastomotic,ramus pubicus (PB),anastomotic ramus pubicus (PB),38,腹膜前间隙的血管丛,腹膜前间隙的血管丛,39,IS,精索血管,(,IS),acc. to Annibali,VD,VD,= vas deferens,IS精索血管 (IS)acc. to AnnibaliVDV,40,精索筋膜,精索筋膜,41,重要的神经,重要的神经,42,髂腹下,神经,髂腹下神经,43,iliohypogastric n.,femoral branch of,genitofemoral n.,ilioinguinal n.,genital branch of,genitofemoral n.,lateral femoral,cutaneous n.,intermediate and,medial cutaneous,femoral n.,saphenous n.,IL,髂腹股沟神经,(,IL),iliohypogastric n.femoral bran,44,iliohypogastric n.,femoral branch of,genitofemoral n.,ilioinguinal n.,genital branch of,genitofemoral n.,lateral femoral,cutaneous n.,intermediate and,medial cutaneous,femoral n.,saphenous n.,GB,FB,GN,IL,生殖股神经,(,GN),iliohypogastric n.femoral bran,45,iliohypogastric n.,femoral branch of,genitofemoral n.,ilioinguinal n.,genital branch of,genitofemoral n.,lateral femoral,cutaneous n.,intermediate and,medial cutaneous,femoral n.,saphenous n.,LC,IL,GB,FB,GN,股外侧皮神经,(,LC),iliohypogastric n.femoral bran,46,iliohypogastric n.,femoral branch of,genitofemoral n.,ilioinguinal n.,genital branch of,genitofemoral n.,lateral femoral,cutaneous n.,intermediate and,medial cutaneous,femoral n.,saphenous n.,FN,IL,GN,GB,FB,LC,股神经,(,FN),iliohypogastric n.femoral bran,47,小测试？,小测试？,48,生殖股神经和股外侧皮神经,生殖股神经和股外侧皮神经,49,生殖股神经和股外侧皮神经,生殖股神经和股外侧皮神经,50,生殖股神经和股外侧皮神经,生殖股神经和股外侧皮神经,51,死亡三角,(A),疼痛三角,(B),IL,LC,FN,GN,GB,FB,VD,IS,IP,VD,VD,输精管,IP,IP,髂耻束,死亡三角 (A) 疼痛三角 (B)ILLCFNGNGBFB,52,以前的认识,IL,LC,FN,GN,GB,FB,VD,IS,IP,In Surgical Textbook Min.-Inv. Chir.“,Edt.K,.,Kremer,et al Thieme,1995,以前的认识ILLCFNGNGBFBVDISIPIn Surg,53,以前的认识,-,错误,IL,LC,FN,GN,GB,FB,VD,IS,IP,In Surgical Textbook Min.-Inv. Chir.“,Edt.K,.,Kremer,et al Thieme,1995,以前的认识-错误ILLCFNGNGBFBVDISIPIn,54,效果,=,技术,TAPP,Trans,A,bdominal,Preperitoneal Patchplasty,效果 = 技术TAPP,55,TAPP,，,Stuttgart,技术要点,正确的手术操作规程可保证手术安全性和可靠性,TAPP，Stuttgart 技术要点正确的手术操作规程可保,56,气腹针穿刺进腹、套管位置,1 trocar 10mmm, 2 trocars 5mm,TAPP,，,Stuttgart,技术要点,气腹针穿刺进腹、套管位置1 trocar 10mmm, 2,57,使用,30,镜头上下反转,腹压,12,mm Hg,TAPP,，,Stuttgart,技术要点,使用30 TAPP，Stuttgart 技术要点,58,减少术后血肿、血清肿，应该应用电凝分离疝囊,TAPP,，,Stuttgart,技术要点,减少术后血肿、血清肿，应该应用电凝分离疝囊TAPP，Stut,59,轻柔分离,避免撕拉,TAPP,，,Stuttgart,技术要点,轻柔分离TAPP，Stuttgart 技术要点,60,Symphysis,Femoral,defect,Urinary,bladder,SymphysisFemoral defectUrinary,61,Epigastric vessels,Ileopubic tract,Inner inguinal ring,Hernia sac,切除内环附近的脂肪组,显露重要的解剖标志,TAPP,，,Stuttgart,技术要点,Epigastric vesselsIleopubic tr,62,Epigastric,vessels,Urinary bladder,:,Testicular,vessels,如果疝辨别不清，应用血管作为标志,TAPP,，,Stuttgart,技术要点,Epigastric vesselsUrinary blad,63,切除脂肪瘤,TAPP,，,Stuttgart,技术要点,切除脂肪瘤TAPP，Stuttgart 技术要点,64,分离结束后所有解剖标志显露清楚,没有脂肪组织,分离结束后所有解剖标志显露清楚,65,Lipoma,1,to 2 cm,TAPP,，,Stuttgart,技术要点,防止补片卷曲,脂肪瘤、疝囊等放置在补片外面,Lipoma1 to 2 cmTAPP，Stuttgart,66,补片的固定,补片的固定,67,Triangle of pain,Triangle of doom,TAPP,，,Stuttgart,技术要点,Triangle of painTriangle of do,68,TAPP,，,Stuttgart,技术要点,固定过多与疼痛密切相关,TAPP，Stuttgart 技术要点固定过多与疼痛密切相关,69,应用医用胶、,纤维蛋白胶固定,TAPP,，,Stuttgart,技术要点,应用医用胶、TAPP，Stuttgart 技术要点,70,腹膜缝合,安全,疼痛轻,TAPP,，,Stuttgart,技术要点,腹膜缝合TAPP，Stuttgart 技术要点,71,切口疝合并多发疝,TAPP,的重要性,切口疝合并多发疝TAPP的重要性,72,Can you teach an old,d,og,new tricks ?,My answer,is yes,：,I can,if he,wants,!,But,what about,the,young,trainees ?,TAPP,，培训的重要性,Can you teach an old dog new,73,腹股沟解剖及TAPP技术要点嵇振岭课件,74,TAPP,in,Stuttgart Merine Hospital,surgeon No. hernia n OP-dur. min morbidity % Rec.-rate %,1 5507 38 2,1,0,762 2159 40 3,7 0,73 1324 40 3,5 0,91,4 1195 42,2,1,0,255 1130 40,1,8,0,26,6 836 48,2,4 0,36,7 839 45,1,2 0,24,8 403 44,2,0 0,259 237 50,1,7 0,3610 216 48,- -11 207 60,1,9 0,9612 152 55,1,3,- 13 115 56,- 1,2,14 108 60 3,7 0,9,15 100 50 - -,16 87 55 - -,17 44 60 4,5 -,18 43 65 -,19 34 65 -,20 18 72 -,21 16 75 -,22 3 64 -,guest 15 75,-,TAPP in Stuttgart Merine Hosp,75,TAPP,:,Stuttgart,Technique,Be,the,change,you,want to,see,.,M.Gandhi,去做你想,要看到的改变，,而不是说说而已,。,15 000,TAPP:Be the change you want to,76,