Guhitamo no gukoresha neza Stapler mubikorwa bya Gastrointestinal

Guhitamo no gukoresha neza Stapler mubikorwa bya Gastrointestinal
Chen Lin, Bian Shibo

Mu myaka yashize, iterambere ryibikoresho byo kubaga ryateje imbere cyane iterambere ryokubaga kijyambere.Mu rwego rwo kubaga gastrointestinal, kugaragara no kumenyekanisha stapler byazamuye anastomose ya gastrointestinal igera ku ntera nshya.Ugereranije na suture gakondo y'intoki, ikoreshwa rya staplers Kongera kubaka inzira yigifu irashobora kugabanya cyane igihe cyo gukora, kugabanya cyane kwangirika kwinyama no kuva amaraso, bityo bikagabanya uburebure buringaniye bwibitaro “Muri iki gihe, abaganga benshi kandi benshi bahitamo guhitamo anastomose yimashini muri akazi k'ubuvuzi.Nyamara, anastomose mu kubaga gastrointestinal Nkimwe mubintu bitatu byingenzi bigira ingaruka kuri gastrointestinal anastomose, umuganga ubaga ubwe agira uruhare runini muguhitamo stapler no gufata tekinike yo kubaga, kandi gutsinda kwa anastomose nabyo bifitanye isano nayo.Bifitanye isano ya hafi 2 Iyi ngingo izavuga kubyanjye ubwanjye kubijyanye no gutoranya no gukoresha neza stapler muburyo busanzwe bwo kubaga kubaga gastric na colorectal.
1. Gutondekanya ibyiciro
Hariho ubwoko bwinshi bwa stapler, bushobora kugabanwa muburyo bukwiye bwo gukanda hamwe nubwoko bwibanze ukurikije ihame ryakazi.Ukurikije imiterere ya stapler, irashobora kugabanywamo ibice byacishijwe bugufi, bizengurutse uruziga, byacishijwe bugufi, byerekana imiterere ya buto na shapure.
2. Gukoresha stapler muri laparotomy
(1) Guhitamo no gukoresha stapler mugikorwa cyo kubaga gastric
1. Gastrectomy ya Proximal: Umuzenguruko uzenguruka (CDH25) muri rusange ukoreshwa muri anastomose ya esophagogastric, naho umurongo wo gukata umurongo (TLC10) ukoreshwa muri anastomose ya gastric.Ubushakashatsi bwerekanye ko gukoresha 25mm stapler kuri esofagus na anastomose gastrointestinal gastrointestinal anastomose irashobora kugabanya kubaho kwingaruka za nyuma yibikorwa 3 Ariko ibi ntabwo ari byimazeyo.Umukoresha agomba kumenya ubwoko bwa stapler ukurikije diameter y'imbere ya esofagus.Gukora imyenda kugirango ugabanye kuva amaraso ya anastomotike Ntugakwega cyane mugihe stapler yikuyemo, cyane cyane iyo igisebe kituzuye, gishobora gutera byoroshye avulion ya anastomotic.
Bitewe na anatomique yimbitse ya esofagusi, umurima wimyanya ndangagitsina urakennye, anastomose iragoye, impera yamenetse ya esofagus iroroshye gucika, kandi ibyago byo kumeneka kwa anastomotique ni byinshi.Ariko, ibyo ntibyigeze bivuguruzanya.Mubyukuri, gushimangira suture birashobora gutuma anastomose yuzuye kandi bikagabanya kubaho kwa anastomotique nyuma yo gutangira.Biroroshye gukora anastomotic stenosis Ubunararibonye bwumwanditsi nuko guhitamo bigomba guhitamo ukurikije imiterere ya anastomotique mugihe cyo kubaga.Niba umurima ugaragara neza mugihe cya anastomose, esofagus ni ubuntu, hemostasis iruzuye, kandi ingaruka ya anastomotique irashimishije, gushimangira suture ntibisabwa;niba anastomotic ituzuye cyangwa amaraso ya anastomotique abonetse mugihe cyo kubaga, suture ya seromuscular irashobora gukoreshwa mugushimangira suture.Mubisanzwe, suture ikurura (andika 3-0 cyangwa 4-0) iratoranijwe.Kubera ubwinshi bwimyitwarire yumubiri wamahanga muri silike anastomose, biroroshye gukora ibisebe byindwara no kuva amaraso kuri anastomose [4] Urudodo rwa silike, haba insinga 3-0 cyangwa 1-gauge irashobora gukoreshwa
Nubwo kugaruka kwa gastrica bibaho rimwe na rimwe nyuma ya anastomose ya esophagogastric, igira ingaruka ku mibereho y’abarwayi, ariko abarwayi benshi nta bimenyetso bigaragara bigaragara, bityo iki gikorwa kiracyakoreshwa kenshi mu buvuzi [5]
2
Mu bwoko bwa Bi I, uruziga ruzenguruka (CDH25) hamwe no gukata umurongo (TLC10) bikoreshwa kuri anastomose.Bamwe mu bahanga bavuga ko anastomose ya nyuma ya gastroduodenum, ku buryo impagarara za anastomose ari nto [6] Niba impagarara za anastomose ari nyinshi Ibyago byo kumeneka kwa anastomotique nyuma yo kubagwa biziyongera [7] Umwanditsi yemeza ko nubwo iki gikorwa ya anastomose iherezo-iherezo iragoye, mugihe cyose habayeho gutanga amaraso ahagije hamwe na anastomose itagira impagarara, ikibazo cyibibazo nyuma yo kubagwa muburyo bubiri bwa anastomotique ni kimwe.Nta tandukaniro rikomeye.
Mu bwoko bwa Bi II, uruziga ruzenguruka (CDH25) rusanzwe rukoreshwa muri anastomose, kandi umurongo wo gukata umurongo urashobora no gukoreshwa.Umwanditsi amenyereye gukoresha ibyanyuma kugirango arangize gastrojejunum anastomose.Endoscopic umurongo ugabanya stapler (6TB45) irashobora gukoreshwa mugukata duodenum.Stapler ifite imirongo 6 yingirakamaro, kandi imikorere ya suture hemostasis ninziza, kandi ntabwo byoroshye gukora fistula duodenal stump fistula no kuva amaraso nyuma yo kubagwa.Niba igishyitsi cya duodenal cyangiritse, suture yintoki irashobora gukoreshwa, hanyuma 6TB45 irashobora gukoreshwa kugirango urangize uruhande rwa gastrojejunal Kuburyo bwa anastomose kuruhande, hagomba kwitonderwa kumupaka wa mesenteric wa jejunum nurukuta rwa gastrica rwigifu gisigaye.Ntuzane tissue ya mesenteric muri anastomose.Kubibazo bitoroshye nyuma yubwoko bwa II anastomose, jejunum anastomose kuruhande (Braun anastomose) irashobora kongerwaho hashingiwe.Nyuma yubwoko bwa III anastomose, alkaline reflux gastritis na stomatite ya anastomotique ikunze kugaragara, bityo umwanditsi akoresha Bi-I cyangwa Roux-en-Y anastomose.
Gastrojejunum Roux-en-Y anastomose irashobora gukoresha ibice bibiri bizunguruka (CDH25) kugirango irangize anastomose hagati ya jejunum na gastrojejunum, cyangwa ikoreshe umurongo wo gukata umurongo kugirango ikore anastomose kuruhande rwa jejunum ya kure hamwe nigifu gisigaye binyuze munda. Imbere.Menya ko icyerekezo cya jejunum ya kure kiri hejuru, kandi icyerekezo cyibiti bya jejunum cyegeranye nacyo kigomba kuba hejuru mugihe anastomose kuruhande-kuruhande rwa jejunum.Amarira ya mesenteric kumpera yamenetse ya jejunum arashobora gufungwa hamwe na suture ya silike 3-0.
3. Gastrectomy yose: Esophagojejunostomy, jejunum isimbuza igifu, gusimbuza colon igifu na esophagojejunum Roux-en-Y?Ubuzima bukabije bw’ubuzima bw’abarwayi Gusimbuza Gastrici birashobora kuzamura cyane ubuzima bw’abarwayi, ariko kubaga biragoye Esophagus-jejunum Roux-en-Y anastomose iragoye kandi irashobora kunoza ibimenyetso byerekana Guhitamo uburyo bukwiye bwo kwiyubaka, umwanditsi arasaba Roux-en-Y anastomose ya esofagusi na jejunum.Uruziga ruzunguruka (CDH25) rushobora gukoreshwa kugirango urangize anastomose yanyuma-kuruhande rwa esofagusi imbere na jejunum, kandi umurongo wo gukata umurongo (nka 6TB45) urashobora gukoreshwa kugirango urangize anastomose kumpande zombi. na jejunum ya kure.Igiti cya jejunum cyafunzwe na 6TB45.
Ikoreshwa ryizunguruka ryizunguruka muri gastrojejunostomy na esophagojejunostomy ryaremewe cyane, kandi abaganga benshi babaga bahitamo gukoresha imashini zizunguruka mugubaga kumugaragaro [8-9] Inaba nabandi.!Biravugwa ko ingaruka za gastrojejunal anastomose ukoresheje umurongo wa stapler munsi ya laparoskopi ari nziza.Umwanditsi akunda umurongo wa stapler cyangwa se stapler munsi yo kubagwa laparoskopi kugirango yubake inzira yigifu muri laparotomy.
kuko:
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(2) Anastomose ntabwo igarukira kuri diameter ya lumen;
(3) Nta maraso make mugihe cya anastomose, kandi ntabwo byoroshye gutera amarira yangirika cyangwa anastomose ituzuye mugihe cya anastomose;
(4) Gabanya igihe cyo gukora:
.Ugereranije na stapler izenguruka, niba ishobora kugabanya ibibazo byindwara nyuma yo kubagwa, Ibindi byemezo byamavuriro ntibirakorwa.
(2) Guhitamo no gukoresha stapler mugikorwa cyo kubaga amabara
1. Anastomose iherezo kuruhande rwa ileocolon nyuma ya hemicolectomie iburyo: stapler izenguruka (CDH29 cyangwa 33) irashobora gukoreshwa kugirango urangize anastomose yanyuma-kuruhande rwa ileocolon, kandi gufunga umurongo ugororotse (TL60 cyangwa TLC75) birashobora na Byakoreshejwe Kuri Gufunga Igishitsi Cyimbere..
2. Anastomose yanyuma-iherezo ya colorectum (umuyoboro wa anal) nyuma ya sigmoid cyangwa rectal resection: tekinike ya anastomose nuburyo bukoreshwa cyane muri laparotomie na laparoskopi yubaka inzira yigifu [11] hano haratangiza uburyo bubiri bwa anastomose Transanal uburyo gusya inzira.
Umuyoboro wo mu mara wegereye ushyirwa muri anvil izenguruka, kandi mbere yo gukata kure yikibyimba ifunga hamwe na stapler igororotse cyangwa igororotse.Impera yimbere ya stapler igomba gushyirwaho umuti wa iyode mbere yo koherezwa mumuyoboro wa anal kugirango usige amavuta.Umubiri wigikoresho ugomba gutera imbere gahoro gahoro kumuyoboro wa anal kugeza impera yimbere yigikoresho ikora buhoro buhoro imbere yimbere yikibaho.
Icyitonderwa: (1) Mugihe cyo gukomera kwa stapler, irinde amara yegeranye guhindagurika, bitabaye ibyo imiyoboro ya mesangial izahagarikwa:
(2) Ibitekerezo ku mpande zombi za anastomose ntibigomba kuba ubuntu igihe kirekire kugirango amaraso ahagije amara;
. gutanga amaraso yo mu mara kuri anastomose;
.Umwanya wurukuta rwinyuma rugomba kwemezwa mbere yuko stapler yirukanwa, kandi ubushakashatsi bwigitereko burashobora gukorwa nyuma ya anastomose irangiye;
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Mugihe cya anastomose, hagomba kwirindwa guhuzagurika kumirongo yumuzingi nu murongo wa stapler stastler anastomotic, bitabaye ibyo gutanga amaraso kuri anastomose bizaba bibi, kandi kumeneka kwa anastomotique bizaba byoroshye nyuma yo kubagwa.Mugihe ukoresheje icyuma cyumuyagankuba mwinshi, irinde kwangirika kurukuta nu rukuta.Nubwo ikoreshwa cyane, haracyari inenge.Kurugero, umurongo wibanze wumuzingi wizunguruka hamwe numurongo wumurongo byoroshye guhuzagurika mugihe cyo gukora [12].Nibikorwa byinshi byo gufunga umurongo mugihe cyo kubaga, bizatera guhuzagurika kumurongo wa anastomotique kandi byongere ibyago byo kumeneka kwa anastomotique [13].Byombi igishyitsi hamwe na rectum ya kure byashushanyijeho imigozi yisakoshi, ishobora kwirinda ibibi byubuhanga bwa anastomose.
3. Kwanga urukiramende hamwe na colorectal (anal kanal) iherezo kuruhande rwa anastomose: Umubiri wa stapler urashobora kuzuzwa binyuze munda cyangwa muburyo bwa anal.Akamaro ko gukoresha uruziga (CDH33 cyangwa 29) hamwe na stapler y'umurongo Ikora "J" imeze nk'umugozi wa colon, wongera ubushobozi bwo kubika umwanda wa rectum kandi bikagabanya ibyago byo kumeneka kwa anastomotique nyuma yo gutangira.Brisinda n'abandi.[16] basanze anastomose iherezo kuruhande ifite umutekano kandi birashoboka.Ikibazo cyo kumeneka kwa anastomotique ni gito, ariko ingano yicyitegererezo cyiki kizamini ni gito cyane, kandi nubuvuzi bunini bwamavuriro buracyakenewe kugirango hagenzurwe.
Anastomose ya colonic pouch-rectal (anal kanal) irashobora kandi gukoreshwa, ukoresheje umurongo wo gukata umurongo kugirango ukore J-inshuro 6-7cm kumpera yubusa hanyuma ushireho uruziga ruzengurutse (CDH29 cyangwa 33) hejuru kugirango ushireho umusumari. Isesengura ryakozwe ryerekanye ko, ugereranije na anastomose iherezo ku rundi, nta tandukanyirizo rishingiye ku mibare ryagaragaye mu kigero cy’ingutu nyuma yo kubagwa, impfu, ndetse no gukora umwanda hagati y’isakoshi y’umukondo [15], ariko imikorere y’isakoshi nini yari igoye kandi bihenze Ni kubaga abaganga guhitamo uburyo bwo guhitamo.
Mu myaka ya vuba aha, gukata kugoramye byamenyekanye buhoro buhoro mubikorwa byubuvuzi.Bamwe mu bahanga bemeza ko mu kurwanya kanseri yo mu muyoboro muke, stapler zigoramye byoroshye kwinjira mu cyondo cya pelvic kuruta stapler, kandi ingaruka za anastomotique ni nziza [16].Buri bwoko bwa stapler bugira ibiranga nibimenyetso.Ku barwayi barwaye pelvic stenosis hamwe nibibyimba biherereye mumwanya muto kandi inzira yo munda ya kure ntishobora gucibwa bihagije hamwe numurongo umwe, hashobora gutekerezwa gukata arc.Ntakibazo waba wahisemo, ugomba gukurikiza ihame rya TME rigomba gukurikizwa, anatomiya igomba kuba isobanutse mugihe cyibikorwa, kandi hagomba kubaho ingamba nziza zo kubaga.
3. Gukoresha staplers muri laparoscopic na da Vinci kubaga robotic
1. Kwiyubaka kwa Gastrointestinal yo kubaga laparoskopi yo kubaga gastrointestinal: igabanijwemo ibyubaka umubiri byuzuye bya laparoskopi, gusya kworoheje bifasha inzira yigifu no kwiyubaka kwa laparoskopi.Igikorwa cyuzuye cya laparoskopi gikoresha imirongo itandukanye yo gukata umurongo hamwe na staplers Cyangwa uruziga ruzengurutse rwuzuye laparoscopic anastomose hamwe nuduce duto two kubaga hamwe n'umwanya ugaragara w'icyerekezo ku barwayi bafite gukira vuba, ariko kubera umwanya muto ukoreramo, ibisabwa bya tekinike bihanitse kubaga, amafaranga menshi yo kubaga, kandi kuri ubu nta buryo busanzwe bwo kubaga bwokubona Igikorwa gito cyemewe na clinique cyemewe ni ugukurura tissue kugirango ibe anastomotic munda yinda, kurangiza kwiyubaka muri vitro cyangwa gushyiramo stapler ubifashijwemo n'agace gato ka anastomose .Uburyo bwo gukora busa nubwa laparotomy.Kugeza ubu, laparoscopi ifashwa n'intoki irakoreshwa cyane.Kwiyubaka kwinzira ni ukurambura ukuboko mu cyuho cyo mu nda binyuze mu gutemagura gato mu rukuta rw'inda kugira ngo bifashe mu gikorwa cya anastomose.Nyamara, ikiganza kiri munda yinda gikunze kugira ingaruka kumurima wo kureba imikorere ya laparoskopi, kandi ingaruka ya anastomotique ni mibi, kuburyo idakoreshwa gake.
2. Kwubaka umuyoboro wigifu muri da Vinci robotic gastrointestinal kubagwa: kimwe no kubaga laparoskopi gakondo yo kubaga imiyoboro ya alimentaire, irashobora kugabanywamo uduce duto twafashijwe na anastomose yuzuye ya laparoskopi.
4. Icyitonderwa cyo gushyira mu bikorwa gushyira mu gaciro:
Nubwo stapler yazanye ibyokurya bitandukanye kubaganga, haracyari ibibazo bikomeye nyuma yo kubagwa bigira ingaruka zikomeye kumikorere isanzwe yinzira yigifu [17] Kumeneka kwa Anastomotic, stenosis ya anastomotique no kuva amaraso ya anastomotique nibisanzwe bikunze kugaragara nyuma yibikorwa kugirango ugabanye ibibazo byingutu. , umwanditsi yemera ko ingingo zikurikira zigomba kwitabwaho:
(1) Umukoresha agomba kuba azi neza ihame ryakazi no gukoresha uburyo bwa stapler, kandi agakurikiza byimazeyo intambwe zisanzwe zikorwa;
.Iyo anastomose ituzuye imaze kuboneka, igomba gusanwa ako kanya na suture yintoki cyangwa igice cyambere cyo mu nda cya anastomotic kigomba gucukurwa kugirango hongere hubakwe inzira yigifu.Muri iki gihe, ntugafate amahirwe.Iyo ukora anastomose yintoki, umwanditsi muri rusange akoresha uburyo bubiri bwo guhagarika suture.Nubwo igihe cyo gukora cyuburyo bumwe bwo gusudira cyoroshye kandi igihe cyo gukora ni kigufi Imbaraga nyinshi, ntabwo byoroshye gukora anastomotic leakage Uburyo bukomeza bwo kudoda biroroshye gukora stenosis ya anastomotic nyuma yo kudoda bikomeje, bityo suture yahagaritswe ikoreshwa;
(3) Birakwiyestaplerbigomba gutoranywa ukurikije ubunini bwurugingo nuburyo bwimiterere yumurwayi.Mbere yo gukoresha stapler, bigomba kwemezwa ko bidahwitse kandi nta bikoresho byabuze cyangwa ibice byabuze;
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(5) Menya neza ko nta mpagarara kuri anastomose kandi gutanga amaraso nibyiza.Muri icyo gihe, imiyoboro y'amaraso ku mupaka wa mesenteric y'imiyoboro ikikije anastomose igomba guhuzwa neza, bitabaye ibyo kuva amaraso nyuma yo kubagwa bikazabaho byoroshye;
.Byinshi muribi biterwa numwanya muto ugaragara hamwe n'umwanya muto wo gukora mugihe cyo gukora.Kubwibyo, gutandukana neza, kwanga neza na hemostasis ihagije bigomba gukorwa mugihe cyo gukora., suture irakomeye.
Kugeza ubu, staplers irashobora kuzuza hafi ya anastomose ya gastrointestinal hafi ya yose, kandi meta-isesengura iheruka yerekana kandi ko muburyo bwo gusya ibyubaka igifu cyo kongera kubaga gastrointestinal, anastomose yumukanishi ifite ibyiza bidashobora kugereranywa na suture yintoki [18], ariko anastomose yubukanishi ni a gusa. gastric anastomose Bumwe muburyo bwa anastomose yo munda ntibushobora gusimbuza rwose intoki.Gusa gukurikiza amahame shingiro yo kubaga no kumenya intambwe zisanzwe zikorwa zishobora kuvura abaganga bashobora kubona ibisubizo bishimishije byo kubaga kandi bikagirira akamaro abarwayi.

Inkomoko: Isomero rya Baidu