【作者】 胡明根；

【导师】 刘荣； 母义明；

【作者基本信息】 中国人民解放军军医进修学院 ， 外科学， 2009， 博士

【摘要】 目的:目前腹腔镜技术已被广泛应用于外科的各个领域,但在胰腺外科中的发展一直比较缓慢,腹腔镜胰腺切除仍被认为是一项技术复杂的高风险手术。本课题的目的包括:①通过研究胰腺的腹腔镜下解剖特点,设计出针对不同位置病灶的手术入路;②通过总结腹腔镜胰腺切除术的临床经验,探讨该手术的技术要点和并发症防治措施;③通过与开腹手术的回顾性对比研究,探讨胰岛素瘤的诊治方法及腹腔镜胰岛素瘤切除的应用价值。方法:①选取9例体型中等、拟行腹腔镜胰腺手术的病例,进行经腹腹腔镜胰腺探查,观察腹腔镜下胰腺的解剖结构和毗邻关系,寻找影响手术进程的重要解剖标志;分析5例后腹膜腹腔镜左肾切除术的手术录像,自后腹膜观察胰腺的解剖结构及毗邻关系;针对不同位置的病灶设计相应的手术入路。②应用设计的手术入路施行腹腔镜胰腺手术47例,其中男性17例,女性30例;术前诊断包括胰岛素瘤33例,胰腺囊腺瘤3例,胰腺囊腺癌1例,胰腺假性囊肿2例(其中1例合并左肝囊性占位),真性囊肿3例,无功能胰岛细胞瘤4例,实性假乳头状瘤1例。③回顾1993年1月至2008年12月在我院行手术治疗的胰岛素瘤89例,对腹腔镜组和开腹组的各项临床指标进行统计学分析。结果:①按照川页序探查胰头、胰体尾,均于腹腔镜下成功观察到肠系膜上静脉、胃十二指肠动脉、胰腺钩突等重要的解剖结构。于后腹膜腹腔镜左肾根治性切除的录像中,成功观察到胰腺及其毗邻结构。针对不同的病变位置和手术方式,成功设计出前、后、左、右四条入路。②2003年3月至2009年2月,应用设计的手术入路施行腹腔镜胰腺手术47例,其中37例按原计划于全腹腔镜下完成手术,(37/47),另有8例中转开腹完成手术,2例未找到病灶终止手术。手术总体成功率95.7%(45/47),腹腔镜手术成功率78.7%,手术中转率17.0%(8/47)。平均手术时间240±140.8(90～960)ml,出血量184.0±310.5(20～1500)ml。术后并发症包括:术后出血2例,引流管脱出1例,胰瘘(C级)4例(1例合并胆漏),均经保守治疗愈合。③符合标准的83例胰岛素瘤患者中,腹腔镜组与在一般情况、手术成功率、手术时间、出血量、并发症发生率等指标方面与开腹组对比无显著性差异;但在术后恢复、体温变化指标等方面优于开腹组。结论:①腹腔镜下可以寻找到胰腺的重要解剖标志,结合开腹胰腺应用解剖及术前影像学检查资料可以成功设计正确的手术入路和方案,从而提高腹腔镜胰腺手术的成功率和安全性。②应用我们设计的手术入路和技术方法,可以完成胰十二指肠切除、胰体尾切除等高难度手术,降低技术难度和手术并发症。在严格把握手术适应证的前提下,腹腔镜胰腺切除是一种治疗胰腺良性疾病和部分恶性疾病安全有效的方法。③与开腹手术相比,腹腔镜胰岛素瘤切除具有相同的疗效,同时具有创伤小、恢复快等优点,值得在临床上进一步推广。更多还原

【Abstract】 Objective:In recent years,laparoscopy has been widely used in many areas of surgery, however,laparoscopic pancreatic resection is still regarded as a complicated and high-risk operation.This study focused on the following objects:1.Based on the observation of the laparoscopic pancreatic anatomy,this study aimed to design the optimal approaches for laparoscopic pancreatic surgery according to the lesions with different localization.2.Through summarizing the experiences of laparoscopic pancreatic resection,this study aimed to discuss the key techniques and the prevention of complications for laparoscopic pancreatic resection.3.To discuss the diagnosis and treatment of insulinoma and to evaluate the efficacy and safety of laparoscopic insulinoma resections through a retrospectively comparing study with the laparotomic procedure.Methods:1.9 patients with normal body mass index were enrolled into the study which proposed to laparoscopic pancreatic surgery.During the laparoscopic operations, the whole pancreas were explored and the pancreatic anatomic structure and adjacent relationship were detected.And some important anatomic signs which play important roles in the pancreatic resections were tried to be identified. Furthermore,5 videos of laparoscopic left nephrectomy through posterior peritoneum were analyzed,and the pancreatic anatomic structure and adjacent relationship were observed through the posterior peritoneum.Finally,according to the above research,we tried to design the eligible laparoscopic approaches for the lesions with different localization in the pancreas.2.Then,with utilizing the designed laparoscopic approaches,47 cases,17 males and 30 females,underwent laparoscopic pancreatic resections in our hospital. Preoperative diagnosis included 33 cases of insulinoma,3 cases of pancreatic cystadenoma,1 case of pancreatic cystadenocarcinoma,2 cases of pseudocyst(1 case combined with hepatic cystic lesion),3 cases of true cyst,4 cases of nonfunctional islet cell tumor and 1 case of solid pseudo-papillary neoplasm.3.The medical records of 89 patients with insulinomas which underwent surgical treatment during Jan 1993 to Dec 2008 in our hospital were analyzed retrospectively,and the related index were compared between the laparoscopic and laparotomic groups.Results:1.The whole pancreas could be explored successfully under laparoscopy,some important anatomic structures of pancreas,such as the superior mesenteric vein,the gastroduodenal artery and the uncinate process of pancreas,could be identified successfully.From the videos of laparoscopic left nephrectomy through posterior peritoneum,the pancreas tail and adjacent structure also could be observed clearly. And according to the different localization and surgical plan,4 corresponding laparoscopic approaches were designed.2.During Mar 2003 to Feb 2009,47 cases of laparoscopic pancreatic resections were completed with the application of the designed laparoscopic approaches.The operations were successfully completed in 45 cases,the procedures included 37 cases of total laparoscopic resections and 8 cases of converting to open resections. We failed in the other 2 cases because the pancreatic lesions could not be identified during the operation.The success rate of the whole operations was 95.7%(45/47 ), for laparoscopic approach was 78.7%(37/47),the conversion rate was 17.0% (8/47 ).The mean operative time was 240±140.8 min(range:90-960 ),the mean blood loss was 184.0±310.5 ml(range:20-1500 ).Severe complications occurred in 7 cases postoperatively,including 2 cases of bleeding,1 case of drainage tube prolapse accidently and 4 cases of type C pancreatic fistula(1 case combined with biliary leak).All of these complications were healed by conservative treatments.3.There was no significant differences in success rate,operation time,blood loss, complication rate between the laparoscopic and open groups.And the laparoscopic group seemed to have less invasion and taster recovery than the open approach.Conclusions:1.According to the pancreatic anatomy and the preoperative image,the optimal laparoscopic approaches could be designed successfully.Through those laparoscopic approaches,laparoscopic pancreatic resection could be completed smoothly.2.Utilizing designed laparoscopic approaches,we could complete some difficult pancreatic resection,such as pancreaticoduodenectomy and distal pancreatectomy, and the technique of laparoscopic pancreatic resection could be simplified.This study suggests that,with selected patients,laparoscopic pancreatic resection is feasible and sate for the patients with presumed benign lesions and some early malignancies of pancreas.3.Laparoscopic insulinoma resection has the same clinic efficacy as open approach, and it has less invasion and faster recovery.So it is worthwhile to be further extended in clinic.更多还原