ligasuretm的临床应用.pptx

Energy Based Tissue and Vessel Fusion Vessel ligation is a critical component of all surgical Vessel ligation is a critical component of all surgical dissection.dissection.血管的结扎是所有外科手术分离中的关键部分血管的结扎是所有外科手术分离中的关键部分Vessel and Tissue LigationWhat are your choices?Ligation TechniquesLigation TechniquesManufacturers Recommended Range of Vessel Size for Application(mm)0.51.01.52.02.53.03.54.04.55.05.56.06.57.07.58.08.59.09.5 10.0Suture Clips Staples Monopolar ES Bipolar ES Ultrasonic Coag Vessel Sealing*3 sizes of clips and appliersVascular Staples Vessel and Tissue FusionVessel and Tissue Fusion脉管和组织融合技术脉管和组织融合技术Electrosurgical Technology That Combines Electrosurgical Technology That Combines Pressure and Energy压力和能量压力和能量To Create a Fusion Zone产生一个融合带产生一个融合带Tissue and Vessel Fusion Tissue and Vessel Fusion an advance in a unique electrosurgical technology that combines pressure and energy to create a fusion zone一种先进电外科技术将压力和能量结合从而产生融合带Developed in response to surgeon requests for an additional option to current vessel ligation methods根据外科医生的需求发展的技术，从而提供目前血管结扎手段以外的方法。Vessel Fusion SystemVessel Fusion System脉管闭合系统脉管闭合系统uGenerator 主机主机nBipolar instrument configuration 双极工作模式双极工作模式nLow Voltage-180V 低电压低电压180V nHigh Current-4A 高电压高电压4A nTissue Response 组织反馈技术组织反馈技术uInstruments 器械器械nHigh pressure 高钳口压力高钳口压力nOpen(reposable and single use)开放器械（可重新组装的和一次性使开放器械（可重新组装的和一次性使用的）用的）nLaparoscopic(single use)腔镜器械（一次性使用）腔镜器械（一次性使用）System OperationSystem OperationnApplies optimal pressure to vessel/tissue bundle 在血管在血管/组织束上施加最佳的压力组织束上施加最佳的压力nEnergy delivery cycle:能量输送周期：能量输送周期：Measures initial resistance of tissue and chooses appropriate energy settings 测量组织的最初电阻并选择适当的能量设定Delivers pulsed energy with continuous feedback control 输送能量脉冲同时进行持续的反馈控制Pulses adapt as the cycle progresses随循环周期的进行调整能量脉冲Senses that tissue response is complete and stops the cycle 监测组织反馈当闭合完成时停止能量输送Fusion CharacteristicsFusion Characteristics融合带的特性融合带的特性nIntimal layers of vessel walls fused 融合血管壁的内膜融合血管壁的内膜nDoes not rely on a proximal thrombus 不依赖于近端血栓不依赖于近端血栓nPermanent 永久性闭合永久性闭合Tissue Effects of Coagulation Versus Vessel FusionTissue Effects of Coagulation Versus Vessel Fusion凝血和脉管闭合技术的组织效果的比较凝血和脉管闭合技术的组织效果的比较Coagulation relies on vessel shrinkage and a proximal thrombus for vessel occlusion.凝血依赖于血管的收缩和近端血栓凝血依赖于血管的收缩和近端血栓堵塞血管堵塞血管Vessel fusion fuses the intimal walls of the vessel,completely obliterating the lumen.脉管闭合技术融合了血管壁的内膜，从脉管闭合技术融合了血管壁的内膜，从而完全封闭管腔。而完全封闭管腔。*Porcine ModelFusion CharacteristicsFusion CharacteristicsnPlastic-like consistencydue to collagen remodeling 由于胶原蛋白的重塑，闭合带均由于胶原蛋白的重塑，闭合带均一而且富有弹性。一而且富有弹性。nDistinctive,possibly translucent fusion zone 独特的透明闭合带独特的透明闭合带nWithstands greater than three times normal systolic pressure 可承受可承受3倍以上的正常收缩压倍以上的正常收缩压Tissue Selection CriteriaTissue Selection Criteria选择组织的标准选择组织的标准nVeins and arteries up to and including 7mm 达到并包括达到并包括7mm的静脉和动脉的静脉和动脉nTissue bundles containing vessel(s)or lymphatics 包含有血管或淋巴管的组织束包含有血管或淋巴管的组织束nLymphatics up to and including 7 mm 达到并包括达到并包括7mm的淋巴管的淋巴管ResultsResultsHigh burst strength seals exhibited the following properties:高破裂压的闭合带具有以下特性：高破裂压的闭合带具有以下特性：Thin,translucent,plastic-like seal site 薄的透明弹性闭合带seal zone significantly compressed 被压缩的扁平闭合带intimal layers of vessel walls fused 融合血管壁内膜lateral thermal damage 2mm 外侧热损伤2mmH&E stained longitudinal section of sealed porcinerenal arteryH&E染色的猪肾动脉闭合带的纵切面The seal zone.Note the fused lumen of the vessel walls.闭合带；注意血管壁已被融合在一起，内腔消失。Burst Strength Study ResultsBurst Strength Study ResultsPercent success of fusion zone withstanding 3 times Percent success of fusion zone withstanding 3 times normal systolic pressure(360mmHg)normal systolic pressure(360mmHg)0%20%40%60%80%100%1.0-1.9mm 2-3.9mm4-7mmUltrasonics超声刀超声刀Bipolar双极双极Vessel Fusion脉管闭合技术脉管闭合技术Vessel sizesComparison Study ResultsComparison Study ResultsnProbability of seal failure below 400 mmHg:在在400mmHg压力下闭合带破裂的概率：压力下闭合带破裂的概率：lUltrasonic coagulator 超声凝血95.0%lStandard bipolar 标准双极 28.0%lClips*金属夹金属夹 0.4%lVessel sealer*脉管闭合技术脉管闭合技术 0.2%lLigatures*缝线缝线 0.0%nProbability of failure for ultrasonics and standard bipolar is significantly higher than other methods 超声刀和标准双极的闭合失败概率明显高于其他方法。超声刀和标准双极的闭合失败概率明显高于其他方法。nOther methods(*)not statistically different from each other 其他的方法（其他的方法（*）之间没有明显区别。）之间没有明显区别。Healing processHealing process A comparison*of the healing process following ligation with sutures and vessel sealing system have been studied at 7,14 and 28 days.缝线结扎和血管闭合技术的愈合过程中第7、14和28天比较At 7 days,both LigaSure and suture sites exhibited gross signs of inflammation.第第7 7天天：“LigaSure 和缝线的部位都有炎症的表现”At 14 days,numerous adhesions were noted at the suture sites whereas the LigaSure seals did not affect any of the surrounding tissue第第14天：天：“在缝线部位有许多的粘连，而LigaSure闭合带与周围组织没有粘连”At 28 days:“numerous evolved adhesions were present at the suture sites.The LigaSure sites were difficult to locate.”第第28天：天：“缝线部位有许多粘连形成，而LigaSure 闭合部位已经难以确认”The potential for seals composed of the patients native tissue reduce the inflammatory response and improves healing process.闭合带由患者自身的组织构成，从而减少了炎症反应，促进了愈合过程。*Comparison of Healing Process Following Ligation with Sutures and Bipolar Vessel Sealing PETERSON,STRANAHAN,SCHMALTZ,MIHAICHUK,COSGRIFF Surgical Technology International Sutures at 28 daysLigaSure at 28 daysVessel Fusion TechnologyVessel Fusion TechnologyuEnsures:nFusion strengths higher than other energy based techniques 闭合强度高于其他的能闭合强度高于其他的能量技术量技术nFusion strengths comparable to existing mechanical based techniques 闭合强度与现存的机械闭合强度与现存的机械闭合技术相当闭合技术相当Vessel Fusion TechnologyVessel Fusion TechnologyuEnsures:nReliable,consistent,permanent vessel wall fusion 可靠的、一致的、永久性血可靠的、一致的、永久性血管壁融合管壁融合nMinimal thermal spread 最小的热传导最小的热传导nReduced sticking and charring 较少的粘连和焦痂较少的粘连和焦痂Surgical specialties with experience in vessel fusion technology Surgical Applications Surgical ApplicationsLigaSureTM Clinical ApplicationsGeneral surgery普外科普外科Gynaecological surgery妇产科妇产科Urological surgery泌尿外科泌尿外科Thyroid surgery甲状腺手术甲状腺手术General SurgeryGeneral SurgerynGastrectomy 胃切除术胃切除术nGastrojejunostomy 胃空肠吻合术胃空肠吻合术nGastric Bypass 胃旁路手术胃旁路手术nMastectomy 乳房切除术乳房切除术nAxillary Dissection 腋窝淋巴结清扫腋窝淋巴结清扫nLiver Resection 肝切除肝切除nLiving Door Liver Transplant 活体肝移植手术活体肝移植手术nSplenectomy 脾切除术脾切除术nThyroidectomy 甲状腺切除术甲状腺切除术nLap Nissen 腔镜腔镜Nissen手术手术nEsophagectomy 食道切除术食道切除术nBowel Resection 小肠切除术小肠切除术nAbdominal Perineal Resection 经腹会阴联合切除术经腹会阴联合切除术nLow Anterior Resection 低位前切除低位前切除nColectomy 结肠切除术结肠切除术nHemorrhoidectomy 痔切除术痔切除术nWhipple 胰十二指肠切除术胰十二指肠切除术nOmentectomy 网膜切除术网膜切除术nIleo-anal Pull-through 拖出式回肠肛管吻合术拖出式回肠肛管吻合术nRectal Prolapse 直肠脱垂手术直肠脱垂手术nAdrenalectomy 肾上腺切除术肾上腺切除术nLap Colectomy 腔镜结肠切除术腔镜结肠切除术Gynaecology妇产科LigaSureLigaSureTM TM Use in GYN Procedures Use in GYN ProceduresLigaSureLigaSureTM TM 在妇产科手术中的使用在妇产科手术中的使用uAnatomy解剖解剖uVaginal Hysterectomy经阴道子宫切除术经阴道子宫切除术 uTAH经腹子宫切除术经腹子宫切除术 uLAVH腔镜辅助的经阴道子宫切除术腔镜辅助的经阴道子宫切除术 uSupracervical Hysterectomy子宫颈上子宫切除术子宫颈上子宫切除术子宫解剖子宫解剖腹腔镜子宫切除术腹腔镜子宫切除术Study by:Barbara Levy,MDClinical Assistant Professor of OB/GYN,U of WA Seattle,WASealableNot recommendedVaginal HysterectomyVaginal Hysterectomy经阴道的子宫切除术经阴道的子宫切除术n84 patients 共共84例患者例患者nBlood loss decreased in all cases compared to average expected loss 所有病例的失血量均少于平均预期失血量所有病例的失血量均少于平均预期失血量n5 cases suture used on one side,vessel fusion used on the other 5例在一侧使用缝线，另一侧使用脉管闭合例在一侧使用缝线，另一侧使用脉管闭合技术技术nOperative time consistently decreased 10-20 minutes 手术时间平均下降手术时间平均下降1020minStudy by:Robert McLellan,MDDepartment of GynecologyLahey Clinic,Burlington,MATotal Abdominal HysterectomyTotal Abdominal Hysterectomyn50 patients(randomized vessel fusion/suture)50例患者（随机使用血管闭合技术例患者（随机使用血管闭合技术/缝线）缝线）nProcedure time(abdominal incision to closure of vaginal cuff with satisfactory hemostasis 手术时间（从做腹部切口到关闭阴道袖并得到满手术时间（从做腹部切口到关闭阴道袖并得到满意的止血效果）意的止血效果）Vessel fusion 30.6 min.(18-62)使用血管闭合技术：使用血管闭合技术：30.6min(1862)Suture 48.2 min.(30-109)使用缝线：使用缝线：48.2min(30109)nBlood loss 失血量失血量 Vessel fusion 32-50ccSuture 25-250ccSealableNot recommended结肠解剖结肠解剖Colon AnatomyColon Anatomy结肠的解剖结肠的解剖结肠的解剖结肠的解剖Right Hemicolectomy右半结肠切除术右半结肠切除术Transverse Colectomy横结肠切除术横结肠切除术Left Colectomy左半结肠切除术左半结肠切除术Sigmoid Colectomy乙状结肠切除术乙状结肠切除术Low Anterior Resection低位前切除低位前切除Laparoscopic Assisted ColectomyLaparoscopic Assisted Colectomy腔镜辅助的结肠切除术腔镜辅助的结肠切除术uIndicationsColon carcinoma 结肠癌结肠癌 Rectosigmoid cancers 直乙结肠癌直乙结肠癌Rectal cancer直肠癌直肠癌 Benign colon polyps良性结肠息肉良性结肠息肉 Diverticulitis憩室憩室 Volvulus肠扭转肠扭转 Crohns disease of the bowel克隆氏病克隆氏病Squamous cell carcinoma of the anus肛管鳞状上皮细胞癌肛管鳞状上皮细胞癌 nAnal or rectal sarcomasn肛门或直肠肉瘤肛门或直肠肉瘤 nCrohns disease of the rectum n直肠克隆氏病直肠克隆氏病nAnal or rectal melanoman肛门或直肠黑色素瘤肛门或直肠黑色素瘤 Laparoscopic SurgeryLaparoscopic SurgeryuLess pain 较少的疼痛较少的疼痛uFaster recovery 更快的恢复更快的恢复uEarlier discharge 住院时间短住院时间短uEarlier return to work 更快的恢复工作更快的恢复工作u?Better survival from cancer？肿瘤患者的生存率更高？肿瘤患者的生存率更高uMASSIVE PATIENT DEMANDDown Sides of LaparoscopyDown Sides of LaparoscopyuMore difficult 操作更困难操作更困难uLearning curve(20-30 cases)学习曲线（学习曲线（2030例）例）uLonger operating time,initially 更长的手术时间（最开始时）更长的手术时间（最开始时）uTechnology dependant 依赖于医生的技术依赖于医生的技术ContraindicationsContraindications禁忌症禁忌症uInadequately trained surgeon/surgical team 未经充分训练的外科医生未经充分训练的外科医生/手术组手术组uLarge,locally advanced cancers 大的局部进展期肿瘤大的局部进展期肿瘤uMultiple previous surgeries 多次手术史多次手术史uHeart failure,chronic lung disease 心脏衰竭、慢性肺部疾病心脏衰竭、慢性肺部疾病Questions