腹腔镜胃癌根治术中胃周血管变异及出血的处理.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,*,*,腹腔镜胃癌根治术中,胃周血管变异及出血的处理,南京鼓楼医院,普外科 孙喜太,录像,腹腔镜胃癌根治术中出血,丰富的开腹经验和微创解剖知识,充分熟悉胃周血管的变异情况,Multiple variations of the branching pattern of a cadaveric abdominal aorta,*RAIKOS A,，,et al.Romanian Journal of Morphology and Embryology 2010,51(3):585587,CHA:Common hepatic artery;,LGA:Left gastric artery;,SA:Splenic artery;,aHA:Accessory hepatic artery;,SMA:Superior mesenteric artery;,IMA:Inferior mesenteric artery.,腹腔干,*,陈吴兴,等,.,解剖学研究，,2009.,Michels classification,*Michels NA,，,et al.Philadelphia,PA:Lippincott,1995.,A=aorta,P=pancreas,D=duodenum,PHA=proper hepatic artery,LGA=left gastric artery,*Samarawickrama MB,，,et al.Galle Medical Journal,2010.,胃左动脉变异（,183,例,）,胃左动脉,录像,1.,正常门,V,、胃左,V,；,肝,A,、脾,A,、胃左,A,毗邻,录像,2.,正常胃左,A,毗邻,*,周义成,等,.,临床放射学杂志，,1990.,LHA,LGA,胃左,A,起自左肝,A,（,10%,）,胃左,A,起自腹主,A,（,1%,）,CHA,LGA,胃左,A,起自肝总,A,（,0.5%,）,*Uysal I I,，,et al.Singapore Med J,2010.,Nakamura H,，,et al.AJR,1980.,胃右动脉变异（,160,例,）,胃右动脉,录像,3.,正常胃右,A,毗邻,录像,4.,正常胃右,A,毗邻,*,周义成,等,.,临床放射学杂志，,1990.,胃网膜右动脉,录像,5.,正常胃网膜右,A,毗邻,录像,6.,正常胃网膜右,A,毗邻,*Yoshihara S,et al.Cardiology Journal,2010.,胃网膜右,A,起自,SMA,胃左静脉,*1,万玉碧,等,.,第三军医大学学报,1984.,2,姜均本,等,.,四川解剖学杂志,1982.,3,韩子玉,等,.,实用外科杂志,1981.,胃左静脉汇入的静脉,胃左静脉的变异（,46,例）,*,万玉碧,等,.,第三军医大学学报,1984.,录像,7.,正常胃左,V,走行,录像,8.,胃左,V,横跨脾,A,录像,9.,胃左,V,横跨脾,A,和肝总,A,录像,10.,胃左,V,越过胃左,A,前方,门静脉,录像,11.,门,V,在肝总,A.,前方,录像,12.,门,V,在肝总,A.,前方,外科干,外科干的上、下界,1.,右结肠静脉,5.,外科干,2.,胃网膜右静脉,6.,中结肠静脉,3.Henle,氏干,7.,胰十二指肠下静脉,4.,回结肠静脉,录像,13.,外科干,录像,14.,清扫,14V,，暴露,henle,干,录像,15.,清扫,14V,，暴露,henle,干,录像,16.,胃网膜右静脉起自,SMV,外科干与,SMA,分支的关系,*1,万玉碧,等,.,第三军医大学学报,1984.,2,宋翠娥,等,.,安徽医学院学报,1982.,录像,17.,右结肠动脉起自,SMA,越过外科干,腹腔镜胃癌根治术中出血,出血部位,胃癌根治术,(,共,312,例,),出血发生率,合计,处理及转归,全胃,(136,例,),远端胃,(165,例,),近端胃,(11,例,),术中,6,4,0,3.2%,胃左,V.,2,1,0,0.96%,钛夹夹闭，止血,肝总,A.,0,1,0,0.32%,转开腹，修补血管止血,胃右,A.,1,1,0,0.64%,转开腹，缝扎止血,胃短,A./V.,1,0,0,0.32%,钛夹夹闭，止血,大网膜血管,1,1,0,0.64%,钛夹夹闭，止血,脾下极,1,0,0,0.32%,转开腹，脾切除,腹腔镜胃癌根治术后腹腔内出血,出血部位,胃癌根治术,(,共,312,例,),出血发生率,合计,处理及转归,全胃,(136,例,),远端胃,(165,例,),近端胃,(11,例,),术后腹腔内,2,1,0,0.96%,吻合口,0,1,0,0.32%,二次手术，缝扎止血，术后发生胃漏；,再次手术，残胃切除,空肠残端,1,0,0,0.32%,二次手术，死于肺部感染,胰腺组织,1,0,0,0.32%,二次手术，缝扎止血,血管夹钳夹血管不牢靠,关腹前仔细止血,腹腔镜胃癌根治术后腹腔内出血,间断缝合加固胃残端,辨明胰腺组织,术中止血不彻底,腹腔镜胃癌根治术后上消化道出血,出血部位,胃癌根治术,(,共,312,例,),出血发生率,合计,处理及转归,全胃,(136,例,),远端胃,(165,例,),近端胃,(11,例,),术后上消化道,0,3,1,1.28%,保守治疗，止血,胃,空肠吻合口,胃壁切口探查,胃腔内间断缝合加固,外科,谢 谢！,