Zaɓi da Amfani da Hankali na Stapler a Aikin Gastrointestinal

Zaɓi da Amfani da Hankali na Stapler a Aikin Gastrointestinal
Chen Lin, Bian Shibo

A cikin 'yan shekarun nan, ci gaban kayan aikin tiyata ya inganta haɓakar aikin tiyata na zamani.A fagen aikin tiyatar hanji, bullowa da shaharar masu amfani da ita sun tada anastomosis na ciki zuwa wani sabon mataki.Idan aka kwatanta da suture na gargajiya na gargajiya, aikace-aikacen staplers Sake gina sashin narkewar abinci na iya rage lokacin aiki sosai, yana rage lalacewar nama da zubar jini, ta yadda zai rage matsakaicin tsayin asibiti “A halin yanzu, likitoci da yawa sun fi son zaɓar anastomosis na inji. aikin asibiti.Duk da haka, anastomosis a cikin aikin tiyata na ciki A matsayin daya daga cikin manyan abubuwa uku da ke damun anastomosis na ciki, likitan tiyata da kansa yana taka muhimmiyar rawa wajen zabar stapler da fahimtar dabarun aiki, kuma nasarar anastomosis yana da alaka da shi.Masu alaƙa 2 Wannan labarin zai yi magana game da ra'ayi na game da zaɓi da amfani da ma'ana na staplers a cikin hanyoyin tiyata na gama gari don tiyata na ciki da na launi.
1. Rarraba staplers
Akwai nau'ikan staplers da yawa, waɗanda za'a iya raba su zuwa nau'in latsa-fit da nau'in madaidaicin bisa ga ka'idar aiki.Dangane da siffar stapler, ana iya raba shi zuwa madaidaicin yanke stapler, madauwari-yanke stapler, arc-cut stapler, maɓalli mai siffa da stapler mai siffar takarda.
2. Amfani da staplers a cikin laparotomy
(1) Zaɓi da aikace-aikacen staplers a cikin tiyata na ciki
1. Proximal Gastrectomy: Madauwari stapler (CDH25) gabaɗaya ana amfani da ita don anastomosis na esophagogastric, kuma ana amfani da stapler yankan layi (TLC10) don anastomosis na ciki.Nazarin ya nuna cewa yin amfani da 25mm stapler ga esophagus da gastrointestinal anastomosis na iya Rage faruwar rikitarwa bayan tiyata 3 Amma wannan ba cikakke ba ne.Dole ne mai aiki ya ƙayyade nau'in stapler bisa ga diamita na ciki na esophagus.Siffar nama don rage zub da jini na anastomotic Kada a ja da ƙarfi lokacin da stapler ya janye, musamman ma lokacin da tsintsin ɗin bai cika ba, yana iya haifar da firgita nama a cikin sauƙi.
Saboda zurfin yanayin jiki na esophagus, filin gani na intraoperative ba shi da kyau, anastomosis yana da wuyar gaske, karyewar ƙarshen esophagus yana da sauƙi a yage, kuma abin da ya faru na anastomotic leakage yana da yawa.Duk da haka, wannan ya kasance mai rikitarwa.A ka'ida, ƙarfafa suture na iya sa anastomosis ya zama cikakke kuma ya rage abin da ya faru na zubar anastomotic bayan tiyata.Sauƙi don samar da stenosis anastomotic Kwarewar marubucin shine cewa yakamata a zaɓi zaɓi bisa ga yanayin anastomotic yayin aikin.Idan filin gani ya bayyana a lokacin anastomosis, esophagus yana da kyauta, hemostasis ya cika, kuma tasirin anastomotic yana da gamsarwa, ba a buƙatar ƙarfafa suture;idan an sami rashin cikawar anastomotic ko zubar jini na anastomotic yayin aikin, za a iya amfani da suture na Seromuscular don ƙarfafa suture.Gabaɗaya, an zaɓi suture mai ɗaukar nauyi (nau'in 3-0 ko 4-0).Saboda yawan abin da jikin waje ke yi a cikin siliki anastomosis, yana da sauƙi don haifar da kumburin ulcer da zubar jini a anastomosis[4] zaren siliki, ko dai 3-0 ko 1-geuge waya za a iya amfani da shi.
Ko da yake reflux na ciki yana faruwa lokaci zuwa lokaci bayan esophagogastric anastomosis, wanda ke shafar ingancin rayuwar marasa lafiya, amma yawancin marasa lafiya ba su da alamun bayyanar, don haka har yanzu ana amfani da wannan aikin a aikin asibiti[5].
2. Distal gastrectomy: Bi-type gastroduodenal karshen-zuwa-gefe ko karshen-zuwa-ƙarshen anastomosis Bi-type II gastrojejunostomy da Roux-en-Y gastrojejunostomy aka yafi amfani.
A cikin nau'in Bi I, ana amfani da stapler madauwari (CDH25) da madaidaiciyar yanke stapler (TLC10) don anastomosis.Wasu malaman suna ba da shawarar anastomosis na gastroduodenum daga ƙarshe zuwa ƙarshe, ta yadda tashin hankali na anastomosis ya kasance kaɗan[6] Idan tashin hankali na anastomosis ya yi yawa haɗarin zubar da jini bayan tiyata zai karu [7] Marubucin ya yi imanin cewa duk da cewa aikin ya yi. na karshen-zuwa-ƙarshen anastomosis yana da rikitarwa, idan dai an tabbatar da isasshen jini da anastomosis marasa tashin hankali, abubuwan da suka faru na rikice-rikicen bayan tiyata na hanyoyin anastomotic guda biyu iri ɗaya ne.Babu wani gagarumin bambanci.
A cikin nau'in Bi II, madauwari stapler (CDH25) gabaɗaya ana amfani da ita don anastomosis, kuma ana iya amfani da madaidaicin yankan madaidaiciya.Ana amfani da marubucin don amfani da na ƙarshe don kammala gastrojejunum anastomosis.Ana iya amfani da endoscopic linear yankan stapler (6TB45) don yanke duodenum.Stapler yana da jimlar 6 layuka na ma'auni, kuma aikin suture hemostasis yana da kyau, kuma ba shi da sauƙi don samar da kututturen duodenal fistula da zubar jini bayan aiki.Idan kututturen duodenal yana da edematous, ana iya amfani da suture na hannu, sa'an nan kuma za'a iya amfani da 6TB45 don kammala gefen gastrojejunal Don anastomosis na gefe, ya kamata a kula da iyakar mesenteric na jejunum da bangon ciki na ragowar ciki.Kada a kawo nama mai mesenteric a cikin anastomosis.Don rikitarwa bayan nau'in anastomosis na II, ana iya ƙara jejunum anastomosis (Braun anastomosis) daga gefe zuwa gefe.Bayan nau'in anastomosis na III, alkaline reflux gastritis da anastomotic stomatitis sau da yawa suna iya faruwa, don haka marubucin yana amfani da Bi-I ko Roux-en-Y anastomosis.
Gastrojejunum Roux-en-Y anastomosis na iya amfani da staplers madauwari guda biyu (CDH25) don kammala anastomosis tsakanin jejunum da gastrojejunum, ko amfani da madaidaicin yankan stapler don yin anastomosis na gefe-da-gefe na jejunum distal da ragowar ciki ta hanyar gaban hanjin.Lura cewa jagorar kututturen jejunum mai nisa yana sama, kuma jagorar kututturen jejunum mai kusanci shima yakamata ya kasance sama yayin anastomosis na gefe-da-gefe na jejunum.Za'a iya rufe hawayen mesenteric a karyewar ƙarshen jejunum tare da suturen siliki 3-0.
3. Jimlar gastrectomy: Esophagojejunostomy, maye gurbin jejunum na ciki, maye gurbin hanji na ciki da esophagojejunum Roux-en-Y?M, rashin ingancin rayuwar marasa lafiya Sauyawa na ciki na iya inganta rayuwar marasa lafiya sosai, amma aikin tiyata yana da hadaddun Esophagus-jejunum Roux-en-Y anastomosis yana da matukar wahala kuma yana iya inganta alamun reflux Don zaɓar hanyar sake ginawa mai dacewa, marubucin ya ba da shawarar Roux-en-Y anastomosis na esophagus da jejunum.Za'a iya amfani da madaidaicin madauwari (CDH25) don kammala anastomosis na ƙarshen-zuwa-gefe na esophagus na baya da jejunum, kuma ana iya amfani da madaidaicin yankan yankan (kamar 6TB45) don kammala anastomosis na gefe-da-gefe na kusanci. da distal jejunum.An rufe kututturen jejunum tare da 6TB45.
Aikace-aikacen staplers madauwari a cikin gastrojejunostomy da esophagojejunostomy an yarda da su sosai, kuma yawancin likitocin fiɗa sun fi son amfani da madauwari staplers a buɗe tiyata [8-9] Inaba et al.!An ba da rahoton cewa tasirin gastrojejunal anastomosis ta amfani da stapler madaidaiciya a ƙarƙashin laparoscopy yana da kyau.Marubucin ya fi son stapler madaidaiciya ko ma stapler a karkashin tiyatar laparoscopic don sake gina sashin narkewar abinci a cikin laparotomy.
saboda:
(1) Irin wannan nau'in na'urar yana dacewa kuma yana da sauƙi don aiki, yana guje wa matakan aiki masu wuyar gaske kamar shigar da tsummoki na jakar jaka da ma'auni na madauwari da ke wucewa ta cikin rami na hanji;
(2) Anastomosis ba'a iyakance shi ta hanyar lumen diamita;
(3) Ana samun raguwar zub da jini a lokacin anastomosis, kuma ba abu ne mai sauƙi ba don haifar da lalacewar nama ko kuma rashin cikakkiyar anastomosis yayin anastomosis;
(4) Rage lokacin aiki:
(5) Idan aka kwatanta da madauwari madauwari, madaidaicin madaidaicin kawai yana buƙatar maye gurbin katako mai mahimmanci lokacin da aka yi amfani da shi sau da yawa yayin aikin, wanda ya rage farashin aiki.Idan aka kwatanta da madauwari stapler, ko zai iya rage faruwar rikice-rikicen bayan tiyata, ƙarin tabbatarwa na asibiti har yanzu ba a yi ba.
(2) Zaɓi da aikace-aikacen staplers a aikin tiyata na launi
1. Ƙarshen-zuwa-gefe anastomosis na ileocolon bayan hemicolectomy na dama: za'a iya amfani da stapler madauwari (CDH29 ko 33) don kammala anastomosis na ƙarshen-zuwa-gefe na ileocolon, da kuma rufe layi madaidaiciya (TL60 ko TLC75) zai iya. Hakanan za'a yi amfani da shi don rufe kututturen hanji.(TLC75) Anastomosis na gefe-da-gefe na maɗaukakin ƙwayar ƙwayar cuta A ƙarshen-zuwa-gefe anastomosis tsakanin maɗaukakiyar ƙwayar cuta ko hagu na hemicolectomy, ya kamata a sanya stapler madauwari (CDH29 ko 33) a cikin lumen na hanji na kusa.
2. Ƙarshe-zuwa-ƙarshen anastomosis na colorectum (canal canal) bayan sigmoid ko rectal resection: biyu anastomosis dabarar hanya ce da aka fi amfani da ita a cikin laparotomy da laparoscopic sake ginawa na narkewa kamar fili [11] a nan yafi gabatar da sau biyu anastomosis Transanal tsarin kula don sake gina tsarin narkewa.
Ana sanya canal na hanji na kusa a cikin madaidaicin madaidaicin madaidaicin madaidaicin madauwari, kuma an rufe ɓangarorin da aka riga aka yanke na ƙari tare da madaidaiciya ko siffa mai siffar baka.Ya kamata a lulluɓe gaban ƙarshen stapler tare da maganin iodine kafin a aika shi cikin magudanar tsuliya don shafawa da lalata.Dole ne jikin na'urar ya ci gaba a hankali a cikin magudanar tsuliya har sai ƙarshen gaban na'urar ya taɓa gefen ciki na kututturen dubura a hankali.
Lura: (1) Yayin da ake matsawa stapler, hana hanjin da ke kusa da shi karkata, in ba haka ba za a matsar da tasoshin mesangial:
(2) Mesentery a duka ƙarshen anastomosis bai kamata ya zama 'yanci da yawa ba don tabbatar da isasshen jini ga hanji;
(3) Za a cire naman adipose na biyun ƙarshen bututun hanji a cikin anastomosis don hana rashin cikawar anastomosis wanda ya haifar da yawan nama da aka saka a lokacin anastomosis, amma yana da kyau kada ya wuce iyakar 2cm, in ba haka ba zai shafi samar da jini na bututun hanji a anastomosis;
(4) A lokacin anastomosis, ya zama dole don hana wasu kyallen takarda marasa mahimmanci daga shigar da su cikin stapler, musamman bangon farji na baya na mata marasa lafiya.Ya kamata a tabbatar da matsayin bangon farji na baya kafin a harba stapler, kuma ana iya yin binciken farji bayan an gama anastomosis;
(5) Bayan an kammala anastomosis, yana da kyau a duba ko anastomosis ya cika ta hanyar "gwajin kumbura" ko allurar methylene blue ta cikin dubura, kuma duba anastomosis ta hanyar nazarin dijital bayan aiki.
A lokacin anastomosis, ya kamata a guje wa overlapping na madauwari da layin stapler anastomotic, in ba haka ba wadatar jini a anastomosis zai zama mara kyau, kuma anastomotic leakage zai iya faruwa cikin sauƙi bayan aiki.Lokacin amfani da wuka mai ƙarfi na lantarki, guje wa lalacewa ga dubura da bangon farji.Kodayake ana amfani da shi sosai, har yanzu akwai wasu lahani.Misali, madaidaicin layi na madauwari stapler da madaidaicin madaurin suna da sauƙin haɗuwa yayin aiki[12].Yana da aikace-aikacen da yawa na ƙulli yanke madaidaiciya yayin aiki, wanda zai haifar da ruɗewar layin anastomotic kuma yana ƙara haɗarin zubar anastomotic [13].Dukan kututturen da duburar nisa an ɗinke su da igiyoyin jaka, wanda zai iya guje wa rashin lahani na fasahar anastomosis sau biyu.
3. Rectal resection da colorectal (canal canal) karshen-zuwa-gefe anastomosis: The stapler jiki za a iya kammala ta ciki ko tsuliya kusanci.Muhimmancin yin amfani da madauwari stapler (CDH33 ko 29) da madaidaicin madauri Yana samar da madauki mai siffar "J" na hanji, wanda ke ƙara ƙarfin ajiyar najasa na dubura kuma yana rage haɗarin zubar da anastomotic bayan tiyata.Brisinda et al.[16] gano cewa anastomosis na ƙarshe-zuwa-gefe yana da aminci kuma mai yiwuwa.Abubuwan da ke faruwa na zub da jini na anastomotic ya ragu, amma girman samfurin wannan gwajin ya yi ƙanƙanta, kuma har yanzu ana buƙatar manyan gwaje-gwaje na asibiti don tabbatarwa.
Hakanan za'a iya amfani da anastomosis, ta amfani da madaidaicin yankan stapler don yin 6-7cm J-fold a ƙarshen hanji na kyauta da kuma sanya madauwari stapler (CDH29 ko 33) a saman don ɗaure ƙusa. Wani bincike-bincike ya nuna cewa, idan aka kwatanta da anastomosis na ƙarshe-zuwa-gefe, babu wani bambanci mai mahimmanci a cikin ƙimar rikice-rikicen bayan tiyata, mace-mace, da aikin bayan gida tsakanin jakar mallaka [15], amma aikin jakar mallaka ya kasance mai rikitarwa kuma Mai tsada Ya rage ga likitan tiyata ya yanke shawarar hanyar da zai zaba.
A cikin 'yan shekarun nan, masu lankwasa yankan staplers sannu a hankali sun zama sananne a aikin asibiti.Wasu malaman sun yi imanin cewa a cikin resection na ƙananan ciwon daji na dubura, masu lankwasa staplers sun fi sauƙi don shiga cikin kogon pelvic fiye da masu layi na layi, kuma tasirin anastomotic ya fi kyau[16].Kowane nau'in stapler yana da halaye da alamomi.Ga marasa lafiya da ciwon ƙashin ƙugu da ciwace-ciwacen daji waɗanda ke cikin ƙananan matsayi kuma waɗanda ba za a iya yankewa na hanji mai nisa ba tare da madaidaicin layi, ana iya yin la'akari da stapler na arc-yanke.Ko da wane nau'in sitiriyo da kuka zaɓa, dole ne ku bi ka'idar TME, tsarin jiki ya kamata ya bayyana a fili yayin aikin, kuma yakamata a tabbatar da kyakkyawan filin duba.
3. Amfani da staplers a laparoscopic da da Vinci robotic tiyata
1. Sake gina jiki na ciki na laparoscopic gastrointestinal tiyata: an raba zuwa cikakken tsarin gyaran gyare-gyare na laparoscopic na narkewa, ƙananan ƙaddamarwa na taimakawa wajen sake ginawa da kuma sake ginawa ta hanyar hannu.Cikakken laparoscopic aiki yana amfani da daban-daban madaidaiciya yankan staplers da staplers Ko madauwari stapler cikakken laparoscopic anastomosis tare da kananan tiyata incision da fili filin hangen nesa ga marasa lafiya da sauri murmurewa, amma saboda kunkuntar sarari aiki, high fasaha bukatun ga likitan tiyata, high tiyata kudin, kuma a halin yanzu babu wani daidaitaccen hanyar tiyata don samun Aikin da aka gane ƙananan aikin tiyata shine a jawo nama don zama anastomotic daga cikin rami na ciki, kammala sake ginawa a cikin vitro ko shigar da stapler a ƙarƙashin taimakon ƙananan ƙwayar cuta don anastomosis. .Hanyar aiki yayi kama da na laparotomy.A halin yanzu, ana amfani da laparoscopy na hannu da hannu.Sake gina tsarin narkewar abinci shine a mika hannu zuwa cikin kogon ciki ta hanyar dan karamin katanga a bangon ciki don taimakawa wajen aikin anastomosis.Duk da haka, hannun a cikin rami na ciki yakan shafi filin ra'ayi na aikin laparoscopic, kuma tasirin anastomotic ba shi da kyau, don haka da wuya a yi amfani da shi.
2. Gyaran canal na narkewa a cikin da Vinci robotic gastrointestinal tiyata: daidai da aikin tiyata na gargajiya na laparoscopic don sake gina canal na alimentary, ana iya raba shi zuwa ƙananan incision da aka taimaka da cikakken laparoscopic anastomosis.
4. Kariya don dacewa da aikace-aikacen stapler:
Ko da yake stapler ya kawo jin daɗi iri-iri ga likitocin, har yanzu akwai matsaloli masu tsanani da suka biyo bayan tiyata waɗanda ke yin tasiri sosai ga aikin al'ada na gastrointestinal tract [17] Anastomotic leakage, anastomotic stenosis da anastomotic jini suna da alaƙa da rikitarwa bayan tiyata don rage abubuwan da suka faru na rikitarwa. , marubucin ya yi imanin cewa ya kamata a kula da waɗannan abubuwan:
(1) Dole ne ma'aikaci ya kasance ƙwararren a cikin ƙa'idar aiki da hanyar amfani da stapler, kuma ya bi matakan aiki na yau da kullun;
(2) Yayin aikin, wajibi ne a bincika a hankali ko anastomotic anastomotic anastomosis ya cika, ko zoben ya cika, da kuma ko akwai ɗan jini a wurin anastomotic.Da zarar an sami anastomosis wanda bai cika ba, yakamata a gyara shi ta hanyar suture na hannu nan da nan ko kuma a fitar da asalin sashin hanji na anastomotic don sake gina sashin narkewar abinci.A wannan lokacin, kada ku yi nasara.Lokacin yin anastomosis na hannu, marubucin gabaɗaya yana amfani da hanyar sutu mai katsewa mai Layer Layer.Ko da yake lokacin aiki na hanyar suture guda ɗaya yana da sauƙi kuma lokacin aiki yana da gajere Babban ƙarfi, ba sauƙin samar da leakage anastomotic Hanyar ci gaba mai sauƙi yana da sauƙi don samar da stenosis na anastomotic bayan ci gaba da sutura, don haka ana amfani da suturar katsewa;
(3) Wanda ya dacestaplerdole ne a zaba bisa ga girman sashin jiki da yanayin yanayin mai haƙuri.Kafin amfani da stapler, dole ne a tabbatar da cewa ba shi da kyau kuma babu wasu abubuwan da suka ɓace ko ɓarna;
(4) Dole ne likitan fiɗa ya ƙware mafi mahimmancin dabarun aiki na suturar hannu, saboda wasu yanayi bazai dace da anastomosis na inji ba;
(5) Tabbatar cewa babu tashin hankali a anastomosis kuma jinin yana da kyau.A lokaci guda kuma, jijiyoyin jini a kan iyakar mesenteric na tasoshin da ke kusa da anastomosis ya kamata a cika su sosai, in ba haka ba za a iya samun sauƙin zubar da jini bayan aiki;
(6) Rashin gazawar stapler anastomosis yakan faru a cikin anastomosis na esophagus da ciki ko ƙananan hanji da ƙananan anastomosis na dubura.Yawancin su na faruwa ne saboda rashin kyawun filin gani da kunkuntar wurin aiki yayin aiki.Don haka, dole ne a yi rarrabuwar kawuna, daidaitaccen resection da isasshen hemostasis yayin aiki., dinkin yana da ƙarfi.
A halin yanzu, staplers na iya kammala kusan dukkanin anastomoses na gastrointestinal fili, kuma sabon binciken meta-bincike kuma ya nuna cewa a cikin sake gina tsarin narkewar aikin tiyata na gastrointestinal, injin anastomosis yana da fa'idodi waɗanda ba za a iya kwatanta su da suture na hannu[18] ba, amma anastomosis na inji shine kawai Anastomosis na ciki Ɗaya daga cikin hanyoyin anastomosis na hanji ba zai iya maye gurbin suturing na hannu gaba ɗaya ba.Ta hanyar bin ƙa'idodin ƙa'idodin tiyata da ƙware daidaitattun matakan aiki ne kawai likitocin za su iya samun sakamako mai gamsarwa na tiyata da fa'idar marasa lafiya.

Source: Baidu Library