Kusankha ndi Kugwiritsa Ntchito Mwanzeru kwa Stapler mu Ntchito Yam'mimba

Kusankha ndi Kugwiritsa Ntchito Mwanzeru kwa Stapler mu Ntchito Yam'mimba
Chen Lin, Bian Shibo

M'zaka zaposachedwapa, kupita patsogolo kwa zida zopangira opaleshoni kwalimbikitsa kwambiri chitukuko cha opaleshoni yamakono.Pankhani ya opaleshoni ya m'mimba, kutuluka ndi kutchuka kwa ma staplers kwakweza m'mimba anastomosis pa gawo latsopano.Poyerekeza ndi chikhalidwe Buku suture, ntchito staplers The m`mimba thirakiti kumangidwanso anachita akhoza kwambiri kufupikitsa nthawi opareshoni, kwambiri kuchepetsa kuwonongeka kwa minofu ndi magazi, potero kuchepetsa pafupifupi kutalika kwa m`chipatala "Pakali pano, ambiri ndi madokotala opaleshoni amakonda kusankha anastomosis makina mu ntchito zachipatala.Komabe, anastomosis mu opaleshoni ya m'mimba Monga chimodzi mwa zifukwa zazikulu zitatu zomwe zimakhudza anastomosis ya m'mimba, dokotalayo mwiniwakeyo amagwira ntchito yofunika kwambiri pakusankhidwa kwa stapler ndi kumvetsetsa njira ya opaleshoni, ndipo kupambana kwa anastomosis kumagwirizananso ndi izo.Zogwirizana kwambiri 2 Nkhaniyi ilankhula za malingaliro anga pa kusankha ndi kugwiritsa ntchito moyenera kwa ma staplers munjira zodziwika bwino za opaleshoni ya m'mimba ndi m'matumbo.
1. Gulu la staplers
Pali mitundu yambiri ya ma staplers, omwe amatha kugawidwa m'magulu osindikizira komanso amtundu wamtundu malinga ndi mfundo yogwirira ntchito.Malinga ndi mawonekedwe a stapler, imatha kugawidwa kukhala stapler yodulidwa mowongoka, stapler-cut stapler, arc-cut stapler, stapler yooneka ngati batani ndi stapler yooneka ngati paperclip.
2. Kugwiritsa ntchito staplers mu laparotomy
(1) Kusankha ndi kugwiritsa ntchito staplers mu opaleshoni ya m'mimba
1. Proximal Gastrectomy: Circular stapler (CDH25) nthawi zambiri amagwiritsidwa ntchito pa esophagogastric anastomosis, ndipo linear cutting stapler (TLC10) amagwiritsidwa ntchito pa gastric anastomosis.Kafukufuku wasonyeza kuti ntchito 25mm stapler kwa kummero ndi m`mimba anastomosis akhoza Kuchepetsa zochitika za postoperative mavuto 3 Koma izi si mtheradi.Wogwira ntchitoyo ayenera kudziwa mtundu wa stapler malinga ndi kukula kwamkati kwa mmero.Kupanga minofu kuti muchepetse magazi a anastomotic Musakoke mwamphamvu pamene stapler ichoka, makamaka pamene kudulako sikukwanira, kungayambitse kupweteka kwa anastomotic.
Chifukwa cha kuzama kwa minyewa yam'mero, mawonekedwe opangira opaleshoni sawoneka bwino, ma anastomosis ndi ovuta, malekezero osweka am'mero ​​ndi osavuta kung'ambika, ndipo kuchuluka kwa kutulutsa kwa anastomotic ndikwambiri.Komabe, izi zakhala zotsutsana.Mwachidziwitso, kulimbitsa kwa suture kumatha kupangitsa kuti anastomosis ikhale yokwanira komanso kuchepetsa kupezeka kwa postoperative anastomotic leakage.Zosavuta kupanga anastomotic stenosis Zomwe wolembayo adakumana nazo ndikuti kusankha kuyenera kupangidwa molingana ndi momwe amachitira opaleshoni.Ngati mawonekedwe owoneka bwino pa nthawi ya anastomosis, kum'mero ​​ndi mfulu, hemostasis yatha, ndipo zotsatira za anastomotic ndizokhutiritsa, suture reinforcement sikufunika;ngati anastomotic kusakwanira kapena anastomotic magazi amapezeka pa opaleshoni, Seromuscular wosanjikiza suture angagwiritsidwe ntchito kulimbikitsa suture.Kawirikawiri, suture yotsekemera (mtundu wa 3-0 kapena 4-0) imasankhidwa.Chifukwa cha kuchuluka kwa thupi lachilendo mu anastomosis ya silika, ndikosavuta kupanga edema ya zilonda ndikutuluka magazi pa anastomosis[4] ulusi wa silika, mwina 3-0 kapena 1-geji waya angagwiritsidwe ntchito.
Ngakhale kuti chapamimba reflux imapezeka nthawi ndi nthawi pambuyo esophagogastric anastomosis, yomwe imakhudza moyo wa odwala, koma odwala ambiri alibe zizindikiro zoonekeratu, kotero opaleshoniyi imagwiritsidwabe ntchito nthawi zambiri muzochita zachipatala [5]
2. Distal gastrectomy: Bi-type gastroduodenal end-to-side kapena end-to-end anastomosis Bi-type II gastrojejunostomy ndi Roux-en-Y gastrojejunostomy amagwiritsidwa ntchito makamaka.
Mu mtundu wa Bi I, stapler yozungulira (CDH25) ndi stapler yodula mzere (TLC10) imagwiritsidwa ntchito popanga anastomosis.Akatswiri ena amati mapeto a anastomosis a gastroduodenum, kotero kuti kupanikizika kwa anastomosis kumakhala kochepa[6] Ngati kupanikizika kwa anastomosis kuli koopsa Kuopsa kwa postoperative anastomotic leakage kudzawonjezeka [7] Wolembayo amakhulupirira kuti ngakhale opaleshoni Kumapeto kwa mapeto a anastomosis kumakhala kovuta, malinga ngati magazi okwanira ndi anastomosis opanda mphamvu amatsimikiziridwa, zochitika za zovuta za postoperative za njira ziwiri za anastomotic ndizofanana.Palibe kusiyana kwakukulu.
Mu mtundu wa Bi II, chozungulira chozungulira (CDH25) nthawi zambiri chimagwiritsidwa ntchito popanga anastomosis, ndipo chodulira chodulira chozungulira chimatha kugwiritsidwanso ntchito.Wolembayo amagwiritsidwa ntchito kugwiritsa ntchito chomaliza kumaliza gastrojejunum anastomosis.The endoscopic liniya kudula stapler (6TB45) angagwiritsidwe ntchito kudula duodenum.Stapler ili ndi mizere 6 yokhazikika, ndipo ntchito ya suture hemostasis ndi yabwino, ndipo sikophweka kupanga chitsa cha duodenal fistula ndi kutuluka magazi pambuyo pa opaleshoni.Ngati chitsa cha duodenal ndi edematous, suture yamanja ingagwiritsidwe ntchito, ndiyeno 6TB45 ingagwiritsidwe ntchito kumaliza mbali ya gastrojejunal Kwa lateral anastomosis, chidwi chiyenera kuperekedwa kumalire a mesenteric a jejunum ndi khoma lamimba la m'mimba yotsalira.Musabweretse minofu ya mesenteric mu anastomosis.Pazovuta pambuyo pa mtundu wachiwiri wa anastomosis, mbali ndi mbali ya jejunum anastomosis (Braun anastomosis) ikhoza kuwonjezeredwa pazifukwa izi.Pambuyo pa mtundu wa III anastomosis, alkaline reflux gastritis ndi anastomotic stomatitis nthawi zambiri zimakhala zosavuta, choncho wolemba amagwiritsa ntchito Bi-I kapena Roux-en-Y anastomosis.
Gastrojejunum Roux-en-Y anastomosis amatha kugwiritsa ntchito ma staplers awiri ozungulira (CDH25) kuti atsirize anastomosis pakati pa jejunum ndi gastrojejunum, kapena kugwiritsa ntchito chodulira chodulira kuti achite mbali ndi mbali anastomosis ya distal jejunum ndi m'mimba yotsalira kudzera m'mimba. kutsogolo kwa colon.Zindikirani kuti chitsa cha distal jejunum chili m'mwamba, ndipo chigawo cha proximal jejunum chiyeneranso kukhala chokwera panthawi ya anastomosis ya jejunum.Kung'ambika kwa mesenteric kumapeto kosweka kwa jejunum kumatha kutsekedwa ndi 3-0 silika suture.
3. Kuchotsa mimba yonse: Esophagojejunostomy, jejunum m'malo mwa m'mimba, kusintha m'mimba ndi esophagojejunum Roux-en-Y?Zovuta, moyo wosauka wa odwala M'mimba m'malo akhoza kusintha kwambiri moyo wa odwala, koma opaleshoni ndizovuta Esophagus-jejunum Roux-en-Y anastomosis ndizovuta kwambiri ndipo zimatha kusintha zizindikiro za reflux Kusankha njira yoyenera yomanganso, wolemba akuvomereza Roux-en-Y anastomosis ya mmero ndi jejunum.The circular stapler (CDH25) angagwiritsidwe ntchito kumaliza kumapeto kwa mbali anastomosis ya anterior esophagus ndi jejunum, ndi mzere kudula stapler (monga 6TB45) angagwiritsidwe ntchito kumaliza mbali ndi mbali anastomosis wa proximal. ndi distal jejunum.Chitsa cha jejunum chidatsekedwa ndi 6TB45.
Kugwiritsa ntchito ma staplers ozungulira mu gastrojejunostomy ndi esophagojejunostomy kwavomerezedwa kwambiri, ndipo madokotala ambiri ochita opaleshoni amakonda kugwiritsa ntchito zida zozungulira pochita opaleshoni [8-9] Inaba et al.!Akuti zotsatira za gastrojejunal anastomosis ntchito liniya stapler pansi laparoscopy ndi zabwino.Wolembayo amakonda liniya stapler kapena stapler pansi laparoscopic opaleshoni kugaya thirakiti kumangidwanso mu laparotomy.
chifukwa:
(1) Chipangizo chamtundu uwu ndi chosavuta komanso chosavuta kugwiritsa ntchito, kupeŵa njira zolemetsa monga kuyika chikwama cha chikwama cha suture ndi stapler yozungulira kudutsa m'matumbo;
(2) The anastomosis si malire ndi lumen awiri;
(3) Pamakhala magazi ochepa pa nthawi ya anastomosis, ndipo sikophweka kuwononga minofu ya misozi kapena kusakwanira kwa anastomosis panthawi ya anastomosis;
(4) Kufupikitsa nthawi yogwira ntchito:
(5) Poyerekeza ndi stapler yozungulira, stapler yozungulira imangofunika kulowetsa cartridge yaikulu pamene imagwiritsidwa ntchito kangapo panthawi ya opaleshoni, yomwe imachepetsa mtengo wa opaleshoni.Poyerekeza ndi stapler yozungulira, kaya ingachepetse zovuta za postoperative, Kutsimikiziranso kwachipatala sikunachitikebe.
(2) Kusankha ndi kugwiritsa ntchito ma staplers mu opaleshoni ya colorectal
1. Kumapeto kwa mbali kwa anastomosis ya ileocolon pambuyo pa hemicolectomy yolondola: stapler yozungulira (CDH29 kapena 33) ingagwiritsidwe ntchito kumaliza anastomosis yotsiriza ya ileocolon, ndi kutsekedwa kwa mzere wolunjika (TL60 kapena TLC75) amagwiritsidwanso ntchito kutseka chitsa cha m'matumbo opingasa.(TLC75) Anastomosis ya mbali ndi mbali ya colon yodutsa ya ileamu Pamapeto ndi mbali anastomosis pakati pa colon yodutsa kapena kumanzere kwa hemicolectomy colon, stapler yozungulira (CDH29 kapena 33) iyenera kuikidwa mu lumen ya m'mimba.
2. Kutha mpaka kumapeto kwa anastomosis ya colorectum (anal canal) pambuyo pa sigmoid kapena rectal resection: njira yachiwiri ya anastomosis ndiyo njira yomwe imagwiritsidwa ntchito kwambiri mu laparotomy ndi laparoscopic reconstruction of the digestive tract [11] apa makamaka imayambitsa njira ziwiri za anastomosis Transanal kwa. kukonzanso m'mimba.
The proximal intestinal ngalande imayikidwa mu zozungulira stapler anvil, ndipo distal chisanadze kudula chotupa chatsekedwa ndi chowongoka kapena arc woboola pakati kudula stapler.Kutsogolo kwa stapler ayenera yokutidwa ndi ayodini mankhwala pamaso kutumizidwa ku ngalande kumatako kuti mafuta ndi mankhwala ophera tizilombo.Thupi la chipangizocho liyenera kupita patsogolo pang'onopang'ono mu ngalande yakuthako mpaka kumapeto kwa chipangizocho kukhudza pang'onopang'ono mbali yamkati ya chitsa.
Zindikirani: (1) Pakumizidwa kwa stapler, tetezani matumbo ozungulira kuti asagwedezeke, apo ayi ziwiya za mesangial zidzapanikizidwa:
(2) The mesentery pamapeto onse a anastomosis sayenera kukhala omasuka motalika kwambiri kuti atsimikizire kuti magazi okwanira amalowa m'matumbo;
(3) Minofu ya adipose pamapeto onse a matumbo a m'mimba pa anastomosis iyenera kuchotsedwa kuti muteteze anastomosis yosakwanira chifukwa cha minofu yambiri yomwe imayikidwa panthawi ya anastomosis, koma ndibwino kuti musapitirire 2cm, apo ayi zidzakhudza magazi a m'mimba chubu pa anastomosis;
(4) Panthawi ya anastomosis, ndikofunikira kuti tipewe minofu ina yosafunikira kuti isalowe mu stapler, makamaka khoma lakumbuyo la nyini la odwala achikazi.Malo a khoma lakumbuyo kwa nyini ayenera kutsimikiziridwa musanayambe kuthamangitsidwa stapler, ndipo kufufuza kwa ukazi kungathe kuchitidwa pambuyo pomaliza anastomosis;
(5) Pambuyo pa anastomosis, ndi bwino kufufuza ngati anastomosis yatha ndi "inflating test" kapena jekeseni ya methylene blue solution kupyolera mu anus, ndikuyang'ana anastomosis ndi kufufuza kwa digito pambuyo pa opaleshoni.
Panthawi ya anastomosis, kuphatikizika kwa mizere yozungulira komanso yozungulira ya stapler anastomotic kuyenera kupewedwa, apo ayi magazi pa anastomosis adzakhala osauka, ndipo kutayikira kwa anastomotic kumachitika mosavuta pambuyo pa opaleshoni.Mukamagwiritsa ntchito mpeni wamagetsi wothamanga kwambiri, pewani kuwonongeka kwa khoma la rectum ndi kumaliseche.Ngakhale kuti amagwiritsidwa ntchito kwambiri, pali zolakwika zina.Mwachitsanzo, mzere wokhazikika wa stapler yozungulira ndi mzere wa stapler ndi wosavuta kugwirizanitsa panthawi ya opaleshoni[12].Ndiko kugwiritsa ntchito kangapo kwa kutsekeka kwa mzere panthawi ya opareshoni, zomwe zingayambitse kuphatikizika kwa mzere wa anastomotic ndikuwonjezera chiwopsezo cha kutayikira kwa anastomotic[13].Chitsa ndi distal rectum zidalumikizidwa ndi zingwe zachikwama, zomwe zimatha kupewa kuipa kwa njira yapawiri ya anastomosis.
3. Rectal resection ndi colorectal (anal canal) end-to-side anastomosis: Thupi la stapler limatha kumalizidwa kudzera m'mimba kapena kumatako.Tanthauzo la kugwiritsa ntchito stapler yozungulira (CDH33 kapena 29) ndi stapler yozungulira Imapanga chipika cha "J" cha m'matumbo, chomwe chimawonjezera mphamvu yosungira ndowe ya rectum ndi kuchepetsa chiopsezo cha postoperative anastomotic leakage.Brisinda et al.[16] adapeza kuti anastomosis yakumapeto ndi yotetezeka komanso yotheka.Kuchuluka kwa kutayikira kwa anastomotic ndikocheperako, koma kukula kwachitsanzo kwa mayesowa ndikochepa kwambiri, ndipo mayeso akulu azachipatala amafunikirabe kuti atsimikizire.
Colonic pouch-rectal (anal canal) anastomosis ingagwiritsidwenso ntchito, pogwiritsa ntchito chodulira chodulira mzere kupanga 6-7cm J-fold kumapeto kwa m'matumbo aulere ndikuyika stapler yozungulira (CDH29 kapena 33) pamwamba kuti azimitsa msomali. Kuwunika kwa meta kunawonetsa kuti, poyerekeza ndi anastomosis yopita kumbali, panalibe kusiyana kwakukulu pamlingo wazovuta zomwe zimachitika pambuyo pa opaleshoni, kufa, komanso kuchita chimbudzi pakati pa thumba la coloni [15], koma ntchito ya thumba la coloni inali yovuta komanso zokwera mtengo Zili kwa dokotala kusankha njira yoti asankhe.
M'zaka zaposachedwa, zokhotakhota kudula staplers pang'onopang'ono akhala otchuka mu ntchito zachipatala.Akatswiri ena amakhulupirira kuti pochotsa khansa ya rectum, zokhotakhota zimakhala zosavuta kulowa m'matumbo a chiuno kusiyana ndi ma linear staplers, ndipo zotsatira za anastomotic ndizabwinoko[16].Mtundu uliwonse wa stapler uli ndi mawonekedwe ake ndi zisonyezo.Kwa odwala omwe ali ndi stenosis ya pelvic ndi zotupa zomwe zili pamalo otsika komanso omwe matumbo a m'mimba sangathe kudulidwa mokwanira ndi mzere wokhazikika, arc-cutting stapler angaganizidwe.Ziribe kanthu kuti mwasankha stapler iti, muyenera Mfundo ya TME iyenera kutsatiridwa, mawonekedwe a anatomy ayenera kukhala omveka panthawi ya opaleshoni, ndipo malo abwino opangira opaleshoni ayenera kutsimikiziridwa.
3. Kugwiritsa ntchito staplers mu laparoscopic ndi da Vinci robotic opaleshoni
1. Kumanganso kwa m'mimba kwa opaleshoni ya m'mimba ya laparoscopic: kugawidwa m'magawo athunthu a laparoscopic m'mimba thirakiti, kudulidwa kwazing'ono kumathandizira kukonzanso chigawo cham'mimba ndi kumangidwanso ndi dzanja la laparoscopic m'mimba.Complete laparoscopic opaleshoni ntchito zosiyanasiyana liniya kudula staplers ndi staplers Kapena zozungulira stapler wathunthu laparoscopic anastomosis ndi pang'onopang'ono opareshoni incision ndi bwino munda wa masomphenya odwala ndi kuchira mwamsanga, koma chifukwa cha yopapatiza malo opaleshoni, mkulu luso zofunika kwa dokotala wa opaleshoni, mkulu opaleshoni mtengo, ndipo pakali pano palibe njira yopangira opaleshoni yopezera Opaleshoni yodziwika bwino yomwe imadziwika kuti ndi yodula ndikukoka minofu kuti ikhale yamimba, kumaliza kukonzanso mu vitro kapena kuyika stapler mothandizidwa ndi kadulidwe kakang'ono ka anastomosis. .Njira yopangira opaleshoni ndi yofanana ndi laparotomy.Pakadali pano, laparoscopy yothandizidwa ndi manja imagwiritsidwa ntchito kwambiri.Kupanganso kugaya chakudya ndikokulitsa dzanja kulowa m'mimba kudzera pakhoma lamimba kuti lithandizire ntchito ya anastomosis.Komabe, dzanja m'mimba patsekeke zambiri amakhudza munda maganizo a laparoscopic opaleshoni, ndi anastomotic zotsatira ndi osauka, choncho kawirikawiri ntchito.
2. Kumanganso ngalande ya m'mimba mu da Vinci opaleshoni ya m'mimba ya robotic: mofanana ndi opaleshoni yamtundu wa laparoscopic yomanganso ngalande, ikhoza kugawidwa m'magulu ang'onoang'ono othandizidwa ndi laparoscopic anastomosis.
4. Njira zopewera kugwiritsa ntchito stapler moyenera:
Ngakhale kuti stapler yabweretsa zothandiza zosiyanasiyana kwa asing'anga, pali zovuta zambiri zapambuyo pa opaleshoni zomwe zimakhudza kwambiri ntchito yanthawi zonse ya m'mimba [17] Kutayikira kwa Anastomotic, stenosis ya anastomotic ndi magazi a anastomotic ndizofala zomwe zimachitika pambuyo pa opaleshoni Kuti muchepetse zovuta. , wolemba akukhulupirira kuti mfundo zotsatirazi ziyenera kutsatiridwa:
(1) Wogwira ntchitoyo ayenera kukhala wodziwa bwino ntchito ndi njira yogwiritsira ntchito stapler, ndikutsatira mosamalitsa njira zogwirira ntchito;
(2) Panthawi ya opaleshoni, m'pofunika kufufuza mosamala ngati anastomotic anastomosis yatha, ngati mpheteyo yatha, komanso ngati pali magazi pang'ono pa malo a anastomotic.Pamene anastomosis yosakwanira yapezeka, iyenera kukonzedwa ndi suture yamanja nthawi yomweyo kapena gawo loyambirira la matumbo liyenera kuchotsedwa kuti limangidwenso m'mimba.Panthawiyi, musatengere mwayi.Pochita ma anastomosis pamanja, wolemba nthawi zambiri amagwiritsa ntchito njira ya suture yokhala ndi magawo awiri.Ngakhale kuti nthawi yogwiritsira ntchito njira imodzi yokha ya suture ndi yosavuta ndipo nthawi yogwiritsira ntchito ndi yochepa Mphamvu yapamwamba, sizovuta kupanga kutayikira kwa anastomotic Njira yopitilira suture ndiyosavuta kupanga anastomotic stenosis pambuyo pa suture mosalekeza, motero suture yosokoneza imagwiritsidwa ntchito;
(3) Zoyenerastaplerziyenera kusankhidwa molingana ndi kukula kwa chiwalo ndi momwe thupi limakhalira.Musanagwiritse ntchito stapler, ziyenera kutsimikiziridwa kuti ndizosasunthika ndipo palibe zotsalira kapena zosowa;
(4) Dokotalayo ayenera kudziwa njira yofunikira kwambiri yopangira suturing pamanja, chifukwa zina sizingakhale zoyenera kwa anastomosis yamakina;
(5) Onetsetsani kuti palibe zovuta pa anastomosis ndipo magazi ndi abwino.Panthawi imodzimodziyo, mitsempha ya magazi pamalire a mesenteric a mitsempha yozungulira anastomosis iyenera kukhala yolimba, mwinamwake kutuluka magazi pambuyo pa opaleshoni kudzachitika mosavuta;
(6) Kulephera kwa stapler anastomosis nthawi zambiri kumachitika m'mimba ndi m'mimba kapena matumbo aang'ono ndi otsika rectal anastomosis.Ambiri aiwo ndi chifukwa chosawoneka bwino komanso malo ocheperako ogwirira ntchito.Choncho, kupatukana momveka bwino, kutulutsa kolondola ndi hemostasis yokwanira iyenera kuchitidwa panthawi ya opaleshoni., suture ndi yolimba.
Pakadali pano, ma staplers amatha kumaliza pafupifupi ma anastomoses onse am'mimba, ndipo kusanthula kwaposachedwa kukuwonetsanso kuti m'matumbo am'mimba kukonzanso opaleshoni ya m'mimba, mechanical anastomosis ili ndi zabwino zomwe sizingafanane ndi suture yamanja [18], koma mechanical anastomosis ndi chabe. Chapamimba anastomosis Imodzi mwa njira za matumbo anastomosis sangathe m'malo kwathunthu pamanja suturing.Pokhapokha potsatira mfundo zazikuluzikulu za opaleshoni ndi kudziŵa njira zoyendetsera ntchito zomwe madokotala amatha kupeza zotsatira zogwira mtima za opaleshoni ndi kupindula odwala.

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