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中华普外科手术学杂志(电子版) ›› 2020, Vol. 14 ›› Issue (05) : 441 -448. doi: 10.3877/cma.j.issn.1674-3946.2020.05.003

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3D腹腔镜右半结肠癌CME显露及意义
燕速1,(), 马新福1, 赵康1, 陈筱乾1, 郭灿1   
  1. 1. 青海大学附属医院胃肠肿瘤外科
  • 收稿日期:2020-01-23 出版日期:2020-10-26
  • 通信作者: 燕速

Anatomical exposure and its significance of 3D laparoscopic CME for right hemicolon cancer

Su Yan1,(), Xinfu Ma1, Kang Zhao1, Xiaoqian Chen1, Can Guo1   

  1. 1. Department of Gastrointestinal Surgery, Qinghai University Affiliated Hospital, Xining, 810001, China
  • Received:2020-01-23 Published:2020-10-26
  • Corresponding author: Su Yan
  • About author:
    Corresponding author: Yan Su, Email:
  • Supported by:
    Special project of Science and Technology achievements transformation of Qinghai provincial clinical medicine research center of digestive system diseases(2019-SF-L3); Special project of Science and Technology achievements transformation of Qinghai provincial clinical oncology medicine research center(2018-SF-113)
引用本文:

燕速, 马新福, 赵康, 陈筱乾, 郭灿. 3D腹腔镜右半结肠癌CME显露及意义[J/OL]. 中华普外科手术学杂志(电子版), 2020, 14(05): 441-448.

Su Yan, Xinfu Ma, Kang Zhao, Xiaoqian Chen, Can Guo. Anatomical exposure and its significance of 3D laparoscopic CME for right hemicolon cancer[J/OL]. Chinese Journal of Operative Procedures of General Surgery(Electronic Edition), 2020, 14(05): 441-448.

3D腹腔镜在临床的应用是工业与医学结合的产物,改变了外科医生对原有解剖结构的认识,使得曾今无法辨识的亚微结构真实而又立体地呈现在眼前。3D腹腔镜所具有的三维立体空间感,可以帮助外科医生在手术当中很容易地找寻到正确的解剖层面和筋膜间隙。3D腹腔镜右半结肠癌全直肠系膜切除术(CME)过程中,利用3D腹腔镜视野的纵深感和对亚微结构的真实呈现,沿着右侧Toldt筋膜与泌尿生殖筋膜之间的筋膜间隙拓展升结肠后间隙及横结肠后间隙,辨识胰十二指肠前筋膜、Treitz筋膜及Fredet筋膜,确保右半结肠脏层系膜和背侧的泌尿生殖筋膜的完整性,最终实现整块移除右半结肠及其系膜,完成右半结肠全系膜切除术。此外,3D腹腔镜呈现出立体的三维空间,可以清晰地显露外科干,并对血管根部淋巴结进行立体清扫,以实现D3根治术。完美的CME+D3根治术可以改善进展期右半结肠癌患者5年生存率并降低局部复发率。手术视野的良好显露和对筋膜层面的正确辨识,是实现右半结肠癌CME+D3根治术的关键,而3D腹腔镜在右半结肠癌CME+D3根治术中恰恰扮演了"导演"的角色,指引"一号主角"即主刀医生进入到神圣外科层面(surgical plane),保证了右半结肠癌CME+D3手术的安全性和手术质量。

The clinical application of 3D laparoscopy is the product of the combination of industry and medicine, which has changed the surgeon’s understanding of the original anatomical structure, and made the sub-microstructure that once could not be recognized present in reality and three-dimensional. The sense of three-dimensional space of 3D laparoscopy can help surgeons to find the correct anatomical layers and fascial space easily. 3D laparoscopic right hemicolectomy for colorectal cancer, In the process of CME, the longitudinal depth of 3D laparoscopic field of vision and the true presentation of sub-microstructure were used to expand the posterior space of ascending colon and the posterior space of transverse colon along the fascial space between the right Toldt fascia and urogenital fascia, so as to identify the anterior pancreaticoduodenal fascia, Treitz fascia and Fredet fascia, and to ensure the integrity of the visceral mesocolon and the dorsal urogenital fascia, and also to realize the right colon and its mesentery are removed in en bloc finally. In addition, 3D laparoscopy presents a three-dimensional space, which can clearly reveal the surgical trunk, and perform three-dimensional dissection of the lymph nodes at the root of the blood vessels to achieve D3 lymphadenectomy. The optimal CME + D3 radical operation can improve 5-year survival rate and reduce local recurrence rate of patients with advanced right colon cancer. Good exposure of operative field and correct identification of fascial layer are the key to achieve CME + D3 radical resection of right colon cancer, while 3D laparoscopy plays the role of " director" in CME + D3 radical resection of right colon cancer, and guides the chief surgeon as No.1 player into the holy plane, which ensures the safety and quality of CME + D3 operation.

图2 患者术后腹壁穿刺孔愈合情况
图4 回结肠血管下窝(IFIV)
图5 右半结肠及其系膜构成
图7 右侧Toldt筋膜间隙
图8A、B 右侧Toldt融合筋膜及其后方的筋膜间隙
图10 可见Gerota筋膜背侧的生殖血管
图11A、B 胰十二指肠前筋膜(Anterior pancreaticoduodenal fascia)
图12 A: Fredet融合筋膜;B:Fredet融合筋膜背侧隐约可见GTH
图13 外科干位于回结肠静脉与Henle干之间
图14 外科干头侧的GTH
图15A、B GTH的解剖构成存在个体差异
图17 中结肠动脉根部的No.223淋巴结清扫
图18 右半结肠癌D3根治术后手术野展示
图19 功能性端端吻合(functional end-to-end anastomosis, FEEA)
图20 回肠与横结肠overlap I式吻合示意图
图21 回肠与横结肠overlap Ⅱ式吻合示意图
图22A、B 回肠与横结肠overlap Ⅱ式吻合术中情况
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