肠切除术英语.ppt.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,小肠切除术,Resection of the Small Intestine,中南大学湘雅三医院,外科手术学教研室,任祖海 副教授,Anatomy,The,small intestine,小肠,comprises:,1.,Duodenum,十二指肠,:is an anatomically distinct structure;,2.,Jejunum,空肠,:the proximal 2/5 of the remaining small intestine;,3.,Ileum,回肠,:the distal 3/5 of that.,No true anatomic distinction between them!,Anatomy,The jejunum and ileum are suspended by a,mesentery,肠系膜,which travels obliquely from the left upper quadrant of the abdomen to right lower quadrant.The mesentery begins at,the ligament,韧带,of,Treitz,.From a base of about 15 cm,this mesentery fans out to connect to the entire 2.5 m of the small intestine.In the mesentery resides the intestinal blood supply as well as fat and lymphatic tissue.,Anatomy,The blood supply of the jejunum and ileum derives from the,SMA,肠系膜上动脉,which has extensive,anastomotic,network near the mesenteric border of the bowel called,the marginal artery,边缘动脉,which runs along the length of the small bowel.,Venous drainage follows the course of the arteries.,Anatomy,Although there is no true anatomic distinction between the jejunum and ileum,some anatomic features progress in an orderly fashion over the course of the intestine and help to distinguish the two portions of the bowel:,1.marginal artery;,2.the amount of fat;,3.The thickness,color and diameter.,Histology,Histology,The intestine has four distinct functional layers:,mucosa,submucosa,muscularis,and,serosa,.,Indications,Necrosis,of the wall of the small intestine with different etiologies:,各种原因引起的小肠肠管坏死：如绞窄性肠梗阻、肠扭转、绞窄性疝、急性肠系膜血管栓塞等。,Severe injury,：不能修补或修补困难。,Complications,of inflammatory bowel disease:,如穿孔、肠瘘、慢性梗阻等。,Indications,Tumor,Developmental anomalies,：,e.g.,Meckels,diverticulum,，,duplications,etc.,Extensive,intestinal adhesions,，分离困难；或虽经分离，但浆膜面损伤过大。,Others:,各种胸、腹部及泌尿系手术需要用小肠移植或转流手术。,Preoperative Workup,Mechanical bowel preparation,Oral antibiotics,A dose of prophylactic intravenous antibiotics(prevent wound infection,infused within 1 hour of the time of incision):generally,a second-generation cephalosporin,二代头孢,is appropriate.,General Aspects of Operation,Anesthesia,：,general or epidural,硬膜外,Position,：,supine,仰卧位,Choice of incisions,：,depends on the part of lesions,mostly right-sided exploratory incision.In Europe,a midline incision is more preferred.,Operative Procedures,Thorough exploration,of the entire abdomen:the liver,pancreas,colon,stomach,and spleen should be palpated for masses,the gallbladder for stones,the,omentum,and peritoneal surfaces for mass lesions,the,retroperitoneum,for,adenopathy,.,观查腹腔内液体的性质和量。要求：按顺序、轻柔。贯彻无菌、无瘤、微创三项基本原则。,Exploration of the small intestine and its mesentery,Exposure,After exploration is complete,a retractor,拉钩,should be placed in position.The small intestine may be moved to or packed to one side of abdominal cavity,and a specific section isolated for the planned procedure.,Prolonged evisceration,外置,of the intestine should be avoided desiccation,干燥,of the,serosa,and tension placed on the mesenteric vessels).,While entering the lumen of the small intestine,the area should be toweled off to prevent spillage of enteric contents and subsequent contamination of the peritoneal cavity.,Operative Procedures,A,Because of the motility,many lesions can be exteriorized.The,nondiseased,portion of the small bowel should be placed within the,intraperitoneal,space and cover with,moist towels,湿盐水垫,to prevent desiccation.,B,The site of resection is selected,a small opening is created immediately adjacent to the bowel wall through the mesentery using a,hemostat,止血钳,.Care is taken not to traumatize small bowel vessels entering the bowel wall.,C,Small bowel vessels adjacent to the bowel wall are divided between,clamps,止血钳,and controlled with fine ligatures,enlarging the window.,D,The area of resection is outlined by dividing the peritoneal surfaces on the mesentery.For benign lesions,the amount of mesentery that is,resected,may be minimal.For disease that is suspected or proved to be malignant,a,wedge-shaped,楔形,portion of the small intestinal mesentery,containing drainage of lymphatic vessels,should be included with the specimen.,E,mesenteric vessels are individually controlled with hemostats and,ligated,with fine sutures.,F,Completed mesenteric division.,Operative Procedures,G-1,The bowel wall is divided using a,scalpel,手术刀,after application of occluding,bowel clamps,肠钳,.The clamps are applied to the bowel wall at an angle so that a,spatulated,anastomosis,can be,created,enalrging,the luminal cross-section of the,anostomosis,.,G-2,Alternatively,a GIA-type stapler can be used to divide the bowel.Spillage is prevented.,H,Seromuscular,sutures are placed as“corner stitches for retraction.A non-absorbable suture,3-0 silk,may be used.,I,Interrupted No.3-0 silk,seromuscular,sutures are placed and tied for completion of the posterior row.,J,A full-thickness inner layer of mucosal sutures is next placed.Absorbable suture is used.,K,The mucosal suture is continued onto the anterior wall.,Operative Procedures,L,Completion of the inner mucosal layer of,interrupted sutures,间断缝合,anteriorly,.,M,A,continuous suture,连续缝合,technique may also be used.,N,a second layer of interrupted,seromuscular,No.3-0 silk sutures is used to complete the anterior aspect of the,anastomosis,.,O,If discrepancy in bowel size exists,a side-to-side,enteroenterostomy,may be preferable.,P,A posterior layer of full-thickness mucosal suture is placed,using absorbable material.,Q,The mucosal suture is continued on the anterior aspect of the,anastomosis,.,Operative Procedures,R,A layer of,seromuscular,interrupted No.3-0 silk sutures,anteriorly,completes the,anstomosis,.,S,The mesenteric defect is,reapproximated,through interrupted or continuous suture,to prevent internal hernia formation.,T,A bowel resection can be also performed,laparoscopically,in selected patients.,U,The loop of bowel to be,resected,is brought through,tne,abdominal wall and exteriorized.The resection can be performed in the standard fashion.,V,An,anastomosis,is performed,extracorporeally,and the bowel is then returned to the abdominal cavity and incision is closed.,Operative Procedures,Stapled,side-to-side,anastomosis,Operative Procedures,Stapled,side-to-side,enteroenterostomy,Operative Procedures,Stapled,side-to-side,enteroenterostomy,Operative Procedures,肠吻合技术要求：吻合处肠壁应保持内翻，浆膜与浆膜对合，防止肠粘膜外翻而影响吻合口的愈合。,Instructions,检查肠管走向，防止肠管扭曲。,确认肠壁的系膜缘和对系膜缘。,浆肌层缝合必须包含粘膜下层。但不能进针过深穿透肠壁。,要求浆膜对合。不可粘膜外翻或吻合的肠壁间夹有脂肪或其他组织。,吻合口处无张力。,Instructions,吻合口处有良好的血液供应。可清晰看到血管分支供应吻合口；肠管断端切缘应有活动性出血；手指可扪及肠管断端系膜的动脉搏动。故肠系膜分离距断端,1cm,。,避免缝合过松或过密，打劫过松或过紧。,Instructions,内翻不能过多。,关闭肠系膜裂孔时，留孔不宜过大，缝针不宜过深。,术中注意无菌操作，做好隔离。保护手术野；吸尽肠内容；消毒擦拭；肠吻合完毕，更换所用器械和碘伏棉球擦洗手套。,Instructions,正确判断肠管的生活力，保留尽可能多的肠管。一般，远、近端各切除健康肠管约,5cm,左右；肠梗阻肠坏死，多切一些；恶性肿瘤，包括区域淋巴结在内的广泛切除。,两端肠腔大小相差悬殊，可加大口径小的肠管端端的切除线的角度或采用端侧吻合法。,Instructions,作侧,-,侧吻合时，应尽量靠近断端，以防止盲袢综合症的发生；肠梗阻时尽量不做旁路手术，必须做时，吻合口尽量靠近梗阻部位。,