Kusarudzwa uye Kushandiswa Kwepfungwa kweStapler muGastrointestinal Operation

Kusarudzwa uye Kushandiswa Kwepfungwa kweStapler muGastrointestinal Operation
Chen Lin, Bian Shibo

Mumakore achangopfuura, kufambira mberi kwezviridzwa zvekuvhiya kwakakurudzira zvikuru kuvandudzwa kwekuvhiya kwemazuva ano.Mumunda wekuvhiyiwa kwepamuviri, kubuda uye kufarirwa kwevatambi kwakasimudza gastrointestinal anastomosis kusvika padanho idzva.Kuenzaniswa neyechinyakare manual suture, kushandiswa kwe staplers Iyo digestive turakiti reconstruction inoitwa inogona kupfupisa zvakanyanya nguva yekuvhiya, kuderedza zvakanyanya kukuvadzwa kwetishu uye kubuda ropa, nekudaro kuderedza avhareji urefu hwekuiswa muchipatara "Parizvino, vazhinji uye vazhinji vanovhiya vanosarudza kusarudza mechanical anastomosis mu. basa rekiriniki.Zvisinei, anastomosis mukuvhiyiwa kwepamuviri Sechimwe chezvinhu zvitatu zvikuru zvinokonzera gastrointestinal anastomosis, chiremba wacho pachake anoita basa rinokosha pakusarudzwa kwestapler uye kubata kwemaitiro ekushanda, uye kubudirira kweanastomosis kune chokuita nayo.Yakanyatsoenderana 2 Ichi chinyorwa chichataura nezve maonero angu pachangu pakusarudza uye kushandisa zvine musoro kwe staplers mune zvakajairika kuvhiya maitiro egastric uye colorectal kuvhiyiwa.
1. Kurongwa kwe staplers
Kune akawanda marudzi emastaplers, ayo anogona kukamurwa kuita press-fit type uye staple-type zvinoenderana nemusimboti wekushanda.Zvinoenderana nechimiro cheiyo stapler, inogona kukamurwa kuita yakatwasuka-yakatemwa stapler, denderedzwa-yakatemwa stapler, arc-cut stapler, bhatani-shaped stapler uye paperclip-shaped stapler.
2. Kushandiswa kwe staplers mu laparotomy
(1) Kusarudzwa uye kushandiswa kwemastaplers mukuvhiya gastric
1. Proximal gastrectomy: Circular stapler (CDH25) inowanzoshandiswa esophagogastric anastomosis, uye linear cutting stapler (TLC10) inoshandiswa kune gastric anastomosis.Zvidzidzo zvakaratidza kuti kushandiswa kwe25mm stapler yesophagus uye gastrointestinal anastomosis inogona Kuderedza kuitika kwemashure ekuvhiyiwa matambudziko 3 Asi izvi hazvisi zvachose.Mushandi anofanirwa kuona rudzi rwe stapler zvinoenderana nemukati dhayamita yesophagus.Kuumbwa kwetissue kuderedza kubuda kweanastomotic Usakwevera zvakasimba apo stapler inobvisa, kunyanya kana incision isina kukwana, inogona kukonzera nyore nyore anastomotic tissue avulsion.
Nekuda kwenzvimbo yakadzika yesophagus, iyo intraoperative yekuona nzvimbo haina kunaka, anastomosis yakaoma, kupera kwegurokuro kwakatsemuka kuri nyore kubvarura, uye chiitiko chekubuda kweanastomotic chakakwira.Zvisinei, izvi zvave zvichinetsa.Tichifunga, suture kusimbisa inogona kuita kuti anastomosis iwedzere kuzara uye kuderedza kuitika kwe postoperative anastomotic leakage.Zviri nyore kugadzira anastomotic stenosis Chiitiko chemunyori ndechekuti sarudzo inofanirwa kuitwa zvinoenderana neastomotic mamiriro panguva yekushanda.Kana iyo nzvimbo yekuona yakajeka panguva yeanastomosis, esophagus yakasununguka, hemostasis yakakwana, uye anastomotic effect inogutsa, suture reinforcement haidiwi;kana anastomotic incompleteness kana anastomotic kubuda ropa kunowanikwa panguva yekushanda, Seromuscular layer suture inogona kushandiswa kusimbisa suture.Kazhinji, suture inogona kunyura (mhando 3-0 kana 4-0) inosarudzwa.Nekuda kwekuwanda kwekuita kwemuviri wekunze mune silk anastomosis, zviri nyore kugadzira ulcer edema uye kubuda ropa paanastomosis [4] Sirika shinda, ingave 3-0 kana 1-gauge waya inogona kushandiswa.
Kunyange zvazvo gastric reflux ichiitika nguva nenguva mushure me esophagogastric anastomosis, iyo inokanganisa mararamiro evarwere, asi varwere vazhinji havana zviratidzo zviri pachena, saka kuvhiyiwa uku kuchiri kushandiswa mumakiriniki maitiro[5]
2. Distal gastrectomy: Bi-type gastroduodenal end-to-side or end-to-end anastomosis Bi-type II gastrojejunostomy uye Roux-en-Y gastrojejunostomy inonyanya kushandiswa.
Mumhando yeBi I, denderedzwa stapler (CDH25) uye linear cutting stapler (TLC10) inoshandiswa paanastomosis.Dzimwe nyanzvi dzinokurudzira kupera-ku-kuguma anastomosis ye gastroduodenum, kuitira kuti tension yeanastomosis idiki[6] Kana kushushikana kweanastomosis kwakanyanya Dambudziko rekubuda kwemashure ekuvhiyiwa kweanastomotic kuchawedzera [7] Munyori anotenda kuti kunyange zvazvo kushanda. yekuguma-ku-kuguma anastomosis yakaoma, chero bedzi ropa rakakwana uye tension-free anastomosis inovimbiswa, chiitiko chemashure ekugadzirisa matambudziko emhando mbiri dzeanastomotic dzakafanana.Hapana musiyano unokosha.
Mumhando yeBi II, iyo denderedzwa stapler (CDH25) inowanzo shandiswa anastomosis, uye mutsara wekucheka stapler unogona zvakare kushandiswa.Munyori anoshandiswa kushandisa iyo yekupedzisira kupedzisa gastrojejunum anastomosis.Iyo endoscopic linear yekucheka stapler (6TB45) inogona kushandiswa kucheka duodenum.Iyo stapler ine mitsara mitanhatu yakazara, uye suture hemostasis basa rakanaka, uye hazvisi nyore kugadzira duodenal stump fistula uye kubuda ropa mushure mekuvhiyiwa.Kana duodenal stump iri edematous, manual suture inogona kushandiswa, uye ipapo 6TB45 inogona kushandiswa kupedzisa gastrojejunal side For lateral anastomosis, kutarisirwa kunofanira kubhadharwa kumuganhu we mesenteric wejejunum uye gastric wall yedumbu rakasara.Usaunza mesenteric tissue mu anastomosis.Nekunetsekana mushure merudzi rwechipiri anastomosis, side-ku-side jejunum anastomosis (Braun anastomosis) inogona kuwedzerwa pane izvi.Mushure memhando III anastomosis, alkaline reflux gastritis uye anastomotic stomatitis inowanzoita, saka munyori anoshandisa Bi-I kana Roux-en-Y anastomosis.
Gastrojejunum Roux-en-Y anastomosis inogona kushandisa maviri denderedzwa staplers (CDH25) kupedzisa anastomosis pakati pejejunum ne gastrojejunum, kana kushandisa linear cut stapler kuita side-to-side anastomosis ye distal jejunum uye dumbu rasara kuburikidza ne pamberi pekoroni.Ziva kuti kutungamira kweiyo distal jejunum stump iri kumusoro, uye kutungamira kweiyo proximal jejunum stump inofanirawo kunge iri kumusoro panguva yedivi-ku-side anastomosis yejejunum.Iyo mesenteric kubvarura pamucheto wakaputsika wejejunamu inogona kuvharwa ne 3-0 silk suture.
3. Total gastrectomy: Esophagojejunostomy, jejunum kutsiva dumbu, colon kutsiva dumbu uye esophagojejunum Roux-en-Y?Yakanyanya, yakashata yehupenyu hwevarwere Kutsiviwa kwegastric kunogona kuvandudza zvakanyanya hupenyu hwevarwere, asi kuvhiya kwakaoma Esophagus-jejunum Roux-en-Y anastomosis yakaoma zvine mwero uye inogona kuvandudza reflux zviratidzo Kusarudza nzira yakakodzera yekuvakazve, munyori anokurudzira Roux-en-Y anastomosis yegurokuro uye jejunum.Iyo denderedzwa stapler (CDH25) inogona kushandiswa kupedzisa kuguma-ku-kurutivi anastomosis yeanterior esophagus uye jejunum, uye mutsara wekucheka stapler (se6TB45) inogona kushandiswa kupedzisa kudivi-kurutivi anastomosis yeproximal. uye distal jejunum.Iyo jejunum stump yakavharwa ne6TB45.
Kushandiswa kwema circular staplers mu gastrojejunostomy uye esophagojejunostomy yakagamuchirwa zvikuru, uye vazhinji vanovhiya vanosarudza kushandisa denderedzwa staplers mukuvhiya pachena [8-9] Inaba et al.!Zvinonzi mhedzisiro ye gastrojejunal anastomosis uchishandisa mutsara stapler pasi laparoscopy yakanaka.Iye munyori anofarira mutsara stapler kana kunyange stapler pasi pe laparoscopic kuvhiyiwa kwekugadzika turakiti rekuvakazve mu laparotomy.
nokuti:
(1) Rudzi urwu rwemudziyo rwuri nyore uye rwuri nyore kushandisa, kudzivirira nhanho dzinorema dzekushanda dzakadai sekuiswa kwechikwama chetambo suture anvil uye denderedzwa stapler ichipfuura nemudumbu remukati;
(2) Iyo anastomosis haina kuganhurirwa neiyo lumen dhayamita;
(3) Pane kuderera kwekubuda ropa panguva yeanastomosis, uye hazvisi nyore kukonzera kukuvara kwematishu kubvarura kana kusakwana anastomosis panguva yeanastomosis;
(4) Kupfupisa nguva yekushanda:
(5) Kana ichienzaniswa neiyo denderedzwa stapler, iyo mutsara stapler inongoda kutsiva iyo staple cartridge kana ichishandiswa kakawanda panguva yekushanda, iyo inoderedza mutengo wekushanda.Kuenzaniswa neiyo denderedzwa stapler, ingave inogona kuderedza chiitiko chemashure ekuvhiyiwa matambudziko, Kumwe kusimbiswa kwekiriniki kuchiri kuitwa.
(2) Kusarudzwa uye kushandiswa kwemastaplers mukuvhiya kwemavara
1. End-to-side anastomosis ye ileocolon mushure mekurudyi hemicolectomy: denderedzwa stapler (CDH29 kana 33) inogona kushandiswa kupedzisa kuguma-ku-side anastomosis ye ileocolon, uye kuvharwa kwemutsara wakarurama (TL60 kana TLC75) inogona. zvakare kushandiswa kuvhara chigutsa chemukati mekoloni.(TLC75) Side-to-side anastomosis ye transverse colon ye ileum Mukupedzisira-ku-side anastomosis pakati pekoni inotenderera kana kuruboshwe hemicolectomy colon, denderedzwa stapler (CDH29 kana 33) inofanira kuiswa mu proximal intestinal lumen.
2. End-to-end anastomosis ye colorectum (anal canal) mushure me sigmoid kana rectal resection: double anastomosis technique ndiyo nzira inowanzoshandiswa mune zvose laparotomy uye laparoscopic reconstruction of the digestive tract [11] pano inonyanya kuunza double anastomosis Transanal approach for. kugadziridzwa kwetsvina yekugaya.
Iyo proximal intestinal canal inoiswa mudenderedzwa stapler anvil, uye distal pre-cut yebundu yakavharwa neakatwasuka kana arc-shaped cut cut stapler.Kumucheto kwemberi kwe stapler kunofanirwa kuvharwa nemushonga weiodine usati watumirwa mugero rekumashure kunozora nekuuraya utachiona.Muviri wemudziyo unofanirwa kukwidziridzwa zvishoma nezvishoma mugero rekumashure kusvika kumucheto wepamberi wemudziyo wabata zvinyoro nyoro rutivi rwemukati rwerectal chigutsa.
Ongorora: (1) Panguva yekuomeswa kweiyo stapler, dzivirira iyo proximal intestine kubva kumonyoroka, zvikasadaro mesangial midziyo inomanikidzwa:
(2) Mesentery kumativi ose maviri eanastomosis haafaniri kunge akasununguka kwenguva yakareba kuti ave nechokwadi chekupa ropa rakakwana muura;
(3) Iyo adipose tissue pamagumo ose emukati wechubhu paanastomosis inofanira kubviswa kudzivirira kusakwana kweanastomosis kunokonzerwa nekuwanda kwenyama yakabatanidzwa panguva yeanastomosis, asi zvakanakisisa kusapfuudza huwandu hwe2cm, kana zvisina kudaro ichakanganisa ropa rekupa mudumbu chubhu pane anastomosis;
(4) Munguva yeanastomosis, zvinodikanwa kudzivirira mamwe matukisi asina basa kubva pakuiswa mukati meiyo stapler, kunyanya iyo posterior vaginal wall yevarwere vechikadzi.Nzvimbo yemashure emadziro emadziro inofanira kusimbiswa musati stapler yadzingwa, uye kuongorora kwechikadzi kunogona kuitwa mushure mokunge anastomosis yapera;
(5) Mushure mokunge anastomosis yapera, zviri nani kutarisa kana anastomosis yakakwana ne "inflating test" kana injecting methylene blue solution kuburikidza neanus, uye chengetedza anastomosis nekuongorora kwedhijitari mushure mekushanda.
Munguva yeanastomosis, kupindirana kwedenderedzwa uye mutsara stapler anastomotic mitsara kunofanira kudzivirirwa, zvikasadaro ropa rinowanikwa paanastomosis richave rakashata, uye kubuda kweanastomotic kunoitika nyore mushure mekushanda.Paunenge uchishandisa high-frequency electric banga, dzivirira kukuvadzwa kune rectum uye madziro emukadzi.Kunyangwe ichishandiswa zvakanyanya, pachine zvimwe zvinokanganisa.Semuenzaniso, mutsara weiyo denderedzwa stapler uye mutsara stapler zviri nyore kupindirana panguva yekushanda[12].Iko kushandiswa kwakawanda kwekuvharwa kwemutsara wekucheka panguva yekushanda, izvo zvinozokonzera kupindirana kwemutsara weanastomotic uye kuwedzera njodzi yeanastomotic leakage[13].Zvose chigutsa uye distal rectum zvakashongedzwa netambo dzechikwama, izvo zvinogona kudzivirira kuipa kwemaitiro maviri anastomosis.
3. Rectal resection uye colorectal (anal canal) end-to-side anastomosis: The stapler body inogona kupedzwa kuburikidza nedumbu kana nzira yekubuda nayo.Kukosha kwekushandisa denderedzwa stapler (CDH33 kana 29) uye mutsara stapler Inoumba "J"-yakaita loop yekoloni, iyo inowedzera simba rekuchengetedza tsvina ye rectum uye inoderedza ngozi ye postoperative anastomotic leakage.Brisinda et al.[16] akawana kuti kuguma-kune-kurutivi anastomosis kwakachengeteka uye kunogoneka.Kuitika kwekudonha kweanastomotic kwakadzikira, asi saizi yemuenzaniso yebvunzo iyi idiki, uye miyedzo yekiriniki yakakura ichiri kudiwa kuti ionekwe.
Colonic pouch-rectal (anal canal) anastomosis inogona zvakare kushandiswa, uchishandisa mutsara wekucheka stapler kugadzira 6-7cm J-kupeta pamahara colon end uye nekuisa denderedzwa stapler (CDH29 kana 33) pamusoro kuti usimbise chipikiri. Meta-analysis yakaratidza kuti, kana ichienzaniswa nekuguma-kurutivi-kurutivi anastomosis, pakanga pasina mutsauko wakakosha muhuwandu hwekunetsekana kwepashure, kufa, uye kuita tsvina pakati pehomwe yekoloni [15], asi kushanda kwehomwe yekoloni kwaive kwakaoma uye. zvinodhura Zviri kuna chiremba anovhiya kuti asarudze nzira yekusarudza.
Mumakore achangopfuura, curved cutting staplers zvishoma nezvishoma zvave zvakakurumbira mukiriniki maitiro.Dzimwe nyanzvi dzinotenda kuti pakucheneswa kwegomarara rekenza yakaderera, mastaplers akakombama ari nyore kupinda mukati me pelvic cavity pane linear staplers, uye anastomotic effect iri nani[16].Mhando imwe neimwe ye stapler ine maitiro ayo uye zviratidzo.Kune varwere vane pelvic stenosis uye mapundu anowanikwa munzvimbo yakaderera uye ane distal intestinal turakiti haigoni kutemwa zvakakwana neine linear stapler, arc-cutting stapler inogona kufungwa.Hazvina mhosva kuti ndeipi stapler yaunosarudza, iwe unofanirwa Nheyo yeTME inofanirwa kuteverwa, iyo anatomy inofanirwa kujeka panguva yekuvhiya, uye yakanaka yekuvhiya ndima yekuona inofanirwa kuve nechokwadi.
3. Kushandiswa kwe staplers mu laparoscopic uye da Vinci robhoti kuvhiyiwa
1. Gastrointestinal reconstruction of laparoscopic gastrointestinal surgery: yakakamurwa kuva yakazara laparoscopic digestive tract reconstruction, duku incision yakabatsira kugadziriswa kwegumbo rekudya uye kushandiswa nemaoko laparoscopic digestive tract reconstruction.Complete laparoscopic operation inoshandisa akasiyana mitsara yekucheka staplers uye staplers Kana denderedzwa stapler yakazara laparoscopic anastomosis ine diki yekuvhiya incision uye yakajeka nzvimbo yekuona yevarwere vanokurumidza kupora, asi nekuda kwenzvimbo yakatetepa yekushanda, yakakwirira tekinoroji zvinodiwa kuna chiremba anovhiya, kudhura kwakanyanya kwekuvhiya, uye parizvino hapana nzira yekuvhiya yakajairwa yekuwana Iyo inocherechedzwa nekiriniki diki-yekuchekwa-inobatsira oparesheni ndeyekukweva matishu kuti ive anastomotic kunze kwemudumbu mhango, kupedzisa kuvakazve in vitro kana kuisa stapler pasi perubatsiro rwekuchekwa kudiki kweanastomosis. .Nzira yekuvhiya yakafanana neye laparotomy.Parizvino, laparoscopy inobatsirwa nemaoko inoshandiswa zvakanyanya.Digestive tract reconstruction ndeye kutambanudza ruoko mudumbu remudumbu kuburikidza nediki diki mumadziro emimba kubatsira mukushanda kweanastomosis.Zvisinei, ruoko mudumbu remudumbu rinowanzokanganisa munda wekuona kwekushanda kwelaparoscopic, uye iyo anastomotic effect haina kunaka, saka haiwanzoshandiswa.
2. Digestive canal reconstruction muDa Vinci robotic gastrointestinal kuvhiyiwa: zvakafanana nekuvhiyiwa kwechinyakare laparoscopic yeamentary canal reconstruction, inogona kupatsanurwa kuita diki incision yakabatsirwa uye yakazara laparoscopic anastomosis.
4. Chengetedzo yekushandisa zvine musoro kwe stapler:
Kunyange zvazvo stapler yakaunza zvakasiyana-siyana kune varapi, kuchine matambudziko akakomba mushure mekuvhiyiwa ayo anokanganisa zvakanyanya kushanda kwegastrointestinal tract [17] Anastomotic leakage, anastomotic stenosis uye kubuda ropa kweanastomotic zvinowanzoitika mushure mekuvhiyiwa matambudziko Kuti kuderedze kuitika kwematambudziko. , munyori anotenda kuti zvinotevera zvinofanirwa kutariswa kune:
(1) Mushandi anofanirwa kuve nehunyanzvi mune yekushanda musimboti uye nzira yekushandisa yeiyo stapler, uye nekunyatsotevera akajairwa mashandiro matanho;
(2) Panguva yekuvhiya, zvinodikanwa kunyatsoongorora kana anastomotic anastomosis yakakwana, kana mhete yakakwana, uye kana pane kubuda ropa kudiki panzvimbo yeanastomotic.Kana imwe anastomosis isina kukwana yawanikwa, inofanirwa kugadziriswa nemanual suture nekukurumidza kana iyo yepakutanga anastomotic intestinal segment inofanira kubviswa kune imwezve kuvakwazve kwegumbo rekudya.Panguva ino, usatora mikana.Paunenge uchiita manyore anastomosis, munyori anowanzo shandisa kaviri-layer yakakanganiswa suture nzira.Kunyange zvazvo nguva yekushanda ye-single-layer suture method iri nyore uye nguva yekushanda ipfupi Simba guru, hazvisi nyore kuumba anastomotic leakage Kuenderera mberi suture nzira iri nyore kuumba anastomotic stenosis mushure mekuenderera mberi kwesuture, saka suture yakakanganiswa inoshandiswa;
(3) Zvakakodzerastaplerinofanira kusarudzwa maererano nehukuru hwenhengo uye mamiriro ehutano hwemurwere.Usati washandisa stapler, inofanira kusimbiswa kuti yakasimba uye hapana zvisizvo zvisipo kana zvikamu zvisipo;
(4) Chiremba anovhiya anofanirwa kugona nzira yakakosha yekuvhiya yemanyorero suturing, nekuti mamwe mamiriro anogona kunge asina kukodzera mechanical anastomosis;
(5) Ita shuwa kuti hapana kukakavara pane anastomosis uye kupihwa kweropa kwakanaka.Panguva imwecheteyo, mitsipa yeropa pamuganhu we mesenteric yemidziyo yakapoteredza anastomosis inofanira kunge yakanyatsobatanidzwa, kana zvisina kudaro kubuda ropa kunoitika nyore nyore;
(6) Kukundikana kwe stapler anastomosis kunowanzoitika mune anastomosis yegurokuro uye mudumbu kana mudumbu mudiki uye yakaderera rectal anastomosis.Mazhinji acho anokonzerwa nekusaona kwekuona nzvimbo uye nhete yekushanda nzvimbo panguva yekushanda.Nokudaro, kupatsanurwa kwakajeka, kugadzirisa kwakarurama uye hemostasis yakakwana inofanira kuitwa panguva yekushanda., suture yakasimba.
Parizvino, mastaplers anogona kupedzisa dzinenge dzese gastrointestinal anastomoses, uye ichangoburwa meta-analysis inoratidzawo kuti mune digestive turakiti kuvakazve gastrointestinal kuvhiyiwa, mechanical anastomosis ine zvakanakira zvisingakwanisi kuenzaniswa nemanual suture [18], asi mechanical anastomosis inongova gastric anastomosis Imwe yenzira dze intestinal anastomosis haigoni kutsiva zvachose manual suturing.Kuburikidza nekutevera misimboti yekuvhiya uye kugona nhanho dzekushanda dzakamira, varapi vanogona kuwana mhedzisiro yekuvhiya inogutsa uye kubatsira varwere.

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