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李永彬, 蔡云强, 王昕, 等. 流程优化的全腹腔镜胰十二指肠切除术的临床总结(附手术视频)[J]. 四川大学学报(医学版), 2020, 51(4): 446-452. DOI: 10.12182/20200760108
引用本文: 李永彬, 蔡云强, 王昕, 等. 流程优化的全腹腔镜胰十二指肠切除术的临床总结(附手术视频)[J]. 四川大学学报(医学版), 2020, 51(4): 446-452. DOI: 10.12182/20200760108
LI Yong-bin, CAI Yun-qiang, WANG Xin, et al. Optimization of Operative Procedure in Total Laparoscopic Pancreaticoduodenectomy (with Video)[J]. Journal of Sichuan University (Medical Sciences), 2020, 51(4): 446-452. DOI: 10.12182/20200760108
Citation: LI Yong-bin, CAI Yun-qiang, WANG Xin, et al. Optimization of Operative Procedure in Total Laparoscopic Pancreaticoduodenectomy (with Video)[J]. Journal of Sichuan University (Medical Sciences), 2020, 51(4): 446-452. DOI: 10.12182/20200760108

流程优化的全腹腔镜胰十二指肠切除术的临床总结(附手术视频)

Optimization of Operative Procedure in Total Laparoscopic Pancreaticoduodenectomy (with Video)

  • 摘要:
      目的  探讨流程优化的全腹腔镜胰十二指肠切除术(LPD)的安全性及可行性,通过对手术中探查、切除和重建三大步骤的总结,提出适合中国人体形的流程优化的LPD。
      方法  纳入2015年12月−2017年12月在四川大学华西医院和上锦分院因壶腹部恶性肿瘤、胆总管下端恶性肿瘤、胰头良恶性肿瘤及胰头肿块性胰腺炎行LPD术患者为研究对象,分为采用流程优化的全腹腔镜胰十二指肠切除术患者(流程优化LPD组)和常规腹腔镜胰十二指肠切除术患者(对照LPD组)。流程优化LPD组和对照LPD组患者体位和Trocar布置相同,流程优化LPD组中采用“双主刀”模式,手术分为腹腔镜探查、切除和重建3个步骤,每个步骤都遵从逆时针的操作顺序,从左至右、由浅入深循序渐进地进行(操作见视频1~3);对照LPD组操作由主刀一人完成,手术没有特定的操作顺序。随访至术后90 d。回顾性分析比较两组患者的临床资料和预后。
      结果  共纳入146例患者,其中76例患者为流程优化LPD组,70例患者为对照LPD组。流程优化LPD组患者与对照LPD组患者在术前ASA分级、年龄、性别、体质量指数、实验室检查相似(P>0.05);流程优化LPD组手术时间缩短(341 min vs. 397 min,P<0.05),术中出血量减少(110 mL vs.180 mL,P<0.05),但两组患者手术中转率、输血率、术后住院时间、淋巴结清扫数目、胰腺术后出血、胆漏、B+C级胰瘘、再次手术、术后严重并发症(Clavien-DindoⅢ~Ⅳ级)、术后90 d死亡率差异无统计学意义。
      结论  流程优化的LPD(双主刀结合逆时针的手术操作顺序)安全可行,可缩短手术时间,减少术中出血量,值得推广和借鉴。

     

    Abstract:
      Objective  To optimize operative procedure on intraoperative exploration, resection and reconstruction in total laparoscopic pancreaticoduodenectomy (LPD).
      Methods  The clinical data of patients who underwent total LPD in West China Hospital (and Shangjin Hospital) of Sichuan University from Dec. 2015 to Dec. 2017 were retrospectively analyzed. The diagnosis of the patients included ampullar cancer, distal common bile duct cancer, benign and maligant tumors of pancreatic head and chronic pancreatitis of pancreatic head. The patients were divided into experimental group and control group according to weather the optimization of operative procedure was used. The position and Trocar arrangement in both groups were same. Two Chief Surgeons Model was used in experimental group, the procedure was divided into three key steps: laparoscopic exploration, resection and reconstruction, each followed anticlockwise operative process, from left to right, from shallow to deep (see the Videos 1 to 3 in Supplemental Contents, http://ykxb.scu.edu.cn/article/doi/10.12182/202007606108). As to control group, the chief operation was finished by chief surgeon and no specific operative procedure was applied. All the patients were followed up to postoperative 90 d.
      Results  A total of 146 patients were collected, including 76 patients undergoing LPD with optimization of operative procedure and 70 patients in the control group. There was no significant difference in preoperative data between the two groups regarding to ASA scoring, age, gender, body mass index and laboratory tests (P>0.05). Compared with the control group, the operative time in the experimental group was significantly shorter (341 min vs. 397 min, P<0.05), estimated blood loss was significantly reduced (110 mL vs. 180 mL, P<0.05). The conversive rate, transfusion rate, length of postoperative hospital stay, number of harvested lymph nodes, post pancreatectomy hemorrhage, bile leakage, pancreatic fistula (Grade B+C), reoperation, the occurrence of severe postoperative morbidity (Clavien-Dindo Ⅲ-Ⅳ), and postoperative 90 d mortality were no statistically difference.
      Conclusion  With Two Chief Surgeons Model combined with anticlockwise operative process could optimize operative procedure in total LPD. It is safe and feasible, and could shorten the operation time and reduce intraoperative blood loss.

     

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