發(fā)布時間：2018-06-26 14:05

  本文選題：腹腔鏡 + 胰腺　； 參考：《第一軍醫(yī)大學(xué)》2007年博士論文

【摘要】：目的和意義 自1987年法國Mouret醫(yī)師首次成功實施腹腔鏡膽囊切除術(shù)以來，在短短不到20年的時間內(nèi)，腹腔鏡技術(shù)因其創(chuàng)傷小、對患者生理干擾輕、術(shù)后恢復(fù)快等優(yōu)勢已經(jīng)受到全世界外科醫(yī)師的推崇和廣大傷病員的垂青。目前，腹腔鏡技術(shù)已廣泛應(yīng)用于普通外科、肝膽外科、泌尿外科、婦產(chǎn)科、胸心外科和小兒外科等臨床各領(lǐng)域，其適應(yīng)證正在不斷擴大。尤其是在腹部外科領(lǐng)域內(nèi)，幾乎所有傳統(tǒng)的開腹術(shù)式都有腹腔鏡術(shù)式的成功嘗試，而且大多數(shù)腹腔鏡術(shù)式正在逐步取代傳統(tǒng)的開腹術(shù)式。但是，由于胰腺組織結(jié)構(gòu)的特殊、解剖位置的深在、毗鄰關(guān)系的復(fù)雜，造成腹腔鏡技術(shù)在胰腺外科領(lǐng)域的應(yīng)用起步較晚，發(fā)展滯后。為促進腹腔鏡技術(shù)在胰腺外科領(lǐng)域的發(fā)展，我們利用腹腔鏡技術(shù)的特點，對腹腔鏡技術(shù)在胰腺外科領(lǐng)域內(nèi)發(fā)展的制約因素之一——臨床應(yīng)用解剖學(xué)進行了系列研究，并在臨床上進行了初步應(yīng)用。首先，我們受泌尿外科后腹腔鏡手術(shù)的啟示，對同樣位于腹膜后間隙中腎旁前間隙內(nèi)的胰體尾的后腹腔鏡外科手術(shù)入路和解剖標(biāo)志進行了探索，主要意義在于明確如何在腎旁前間隙內(nèi)建立一個較大的可操作空間?通過何種手術(shù)入路進入此間隙安全便捷?如何確定解剖標(biāo)志來進行腹腔鏡胰體尾外科手術(shù)?其次，我們對腹腔鏡胰十二指腸切除術(shù)中的關(guān)鍵和難點問題之一的腸系膜上血管的探查、顯露、分離進行了解剖觀測，試圖為腹腔鏡胰十二指腸切除術(shù)中探查、顯露、分離腸系膜上血管提供解剖學(xué)依據(jù)，并對腹腔鏡胰十二指腸切除術(shù)中處理腸系膜上血管的方法提出了我們的觀點。再次，我們復(fù)習(xí)文獻并通過解剖觀察，總結(jié)了脾動脈與脾靜脈的“騎跨”關(guān)系和胰體尾與脾血管的“懸掛”關(guān)系，提出保留脾血管的保脾胰體尾切除術(shù)的要點。最后，我們總結(jié)了5例腹腔鏡技術(shù)應(yīng)用于胰體尾囊腺瘤的臨床資料來探討腹腔鏡胰體尾切除術(shù)治療胰體尾囊腺瘤的臨床價值。 方法 1．對10例成人尸體經(jīng)左股動脈灌注紅色乳膠并經(jīng)10％福爾馬林常規(guī)固定，對其中3例在股動脈灌注的基礎(chǔ)上行經(jīng)肝門靜脈灌注藍(lán)色乳膠；對2例新鮮成人尸體，經(jīng)左股動脈灌注紅色乳膠同時經(jīng)肝門靜脈灌注藍(lán)色乳膠，并采用10％福爾馬林局部防腐和冷減處理。全組男7例，，女5例。解剖觀測從左髂嵴到左膈下腹膜后器官與胰體尾及各器官間的毗鄰關(guān)系，在對新鮮標(biāo)本進行解剖觀測之前模擬后腹腔鏡入路行胰體尾的分離和暴露。距離測量采用游標(biāo)卡尺點與點間平面測量。模擬操作時尸體取右側(cè)約30°仰臥位，第1個trocar位置在左腋中線髂嵴上方2cm交點處，橫行切開皮膚3cm，銳性加鈍性分開腹外斜肌、腹內(nèi)斜肌、腹橫肌，再用食指在腹膜外脂肪層內(nèi)分離出一腔隙，并用刀柄或鑷子柄擴大腔隙至足夠大后，插入12mm trocar，并加壓灌注自來水，插入0°腹腔鏡。然后在左腋后線第12肋緣下2cm交點處插入第2個10mm trocar，置入主分離鉗。最后在左腋前線與肋弓下2cm交點處插入第3個5mm trocar，置放副分離鉗。從腎下間隙鈍性分離進入腎旁前間隙，直至完全分離暴露出胰體尾。 2．對10例成人尸體經(jīng)左股動脈灌注紅色乳膠并經(jīng)10％福爾馬林常規(guī)固定，并對其中3例經(jīng)肝門靜脈灌注藍(lán)色乳膠；對2例新鮮成人尸體，經(jīng)左股動脈灌注紅色乳膠同時經(jīng)肝門靜脈灌注藍(lán)色乳膠，并采用10％福爾馬林局部防腐和冷藏處理。全組男7例，女5例。身長(167.48±8.35)cm。游標(biāo)卡尺、軟鋼尺各1把，手術(shù)顯微鏡、解剖器械、腹腔鏡手術(shù)器械各1套。觀測探查、顯露、分離腸系膜上血管的解剖標(biāo)志和處理要點；觀測腸系膜上血管與胰頭鉤突部和十二指腸空腸曲的解剖關(guān)系；對新鮮尸體進行解剖觀測前模擬腹腔鏡行腸系膜上血管的顯露和分離。模擬操作時尸體均取仰臥位，用鐵絲懸吊腹壁制造腹腔操作空間，臍下緣插入12mm trocar，插入0°腹腔鏡。然后在平臍左右側(cè)約腹直肌外緣各插入10mm trocar，置入操作鉗。再在左右肋緣下腋前線處各插入10mmtrocar，置放操作鉗。打開胃結(jié)腸韌帶后，沿右胃網(wǎng)膜靜脈尋找并分離出腸系膜上靜脈，直至肝門靜脈；再分離腸系膜上動脈。 3．整塊切取20例經(jīng)左股動脈灌注紅色乳膠并經(jīng)10％福爾馬林常規(guī)固定的尸體胰脾器官簇標(biāo)本，解剖觀測脾血管及其與胰體尾的關(guān)系。并復(fù)習(xí)相關(guān)文獻資料。 4．總結(jié)2003年2月-2006年4月我們對5例胰體尾囊腺瘤進行了LDP的臨床資料，平均年齡32.8(27～43)歲。均采用氣管插管全身麻醉�；颊咦髠�(cè)墊高約30°，左臂上舉固定。術(shù)者和持鏡者立于患者右側(cè)，另一助手立于左側(cè)。5例手術(shù)均在全腹腔鏡下進行，均采用4孔法。臍下緣為觀察孔，主操作孔在左鎖骨中線肋緣下4cm作10mm操作孔，副操作孔在右腹直肌外側(cè)緣肋弓下緣3cm作5mm操作孔，另一輔助操作孔在左腋前線肋緣下2cm作5mm操作孔。常規(guī)建立氣腹及操作空間后，全面探查腹腔。先以超聲刀切開胃結(jié)腸韌帶，從胃結(jié)腸韌帶中間開始，先向左，原則上一直打開到脾胃韌帶。后向右，向右打開胃結(jié)腸韌帶距腫瘤右緣約5cm即可。再向右上推開胃，向下牽開結(jié)腸，進一步探查囊腫情況。打開腫瘤前的后腹膜，沿后腹膜與腫瘤壁間(即胰前間隙)進一步暴露腫瘤，注意保護受腫瘤推壓的左結(jié)腸靜脈等重要血管，于腫瘤右緣在胰腺上緣分離出脾動脈干予以鈦夾或血管夾夾閉。2例先在脾動脈夾閉平面從胰腺下緣開始分離出胰后間隙，并于胰體后方分離出脾靜脈，用血管夾夾閉但不切斷，用Endo-GIA切斷胰腺后，再進一步處理脾靜脈，最后處理脾結(jié)腸、脾胃、脾腎、脾膈韌帶及余下的胰后間隙，至胰體尾連同囊腫和脾整體切除。3例先用超聲刀分別離斷脾結(jié)腸、脾胃、脾腎及脾膈韌帶，然后分離胰后間隙，并于胰體后方分離出脾靜脈夾閉，將胰體尾連同腫塊抬起，以Endo-GIA切斷，其中1例先切斷胰腺，再處理脾靜脈。切除的標(biāo)本裝入一次性取物袋自左上腹擴大的戳孔中取出。常規(guī)于胰床及脾窩各放置1根粗乳膠引流管自左上腹戳孔中引出。各戳孔以可吸收線皮內(nèi)縫合。5．對所用數(shù)據(jù)經(jīng)SPSS10.0軟件統(tǒng)計處理。 結(jié)果 1．12例后腹腔入路全部成功分離出腎旁前間隙，并完整分離出胰體尾。2例摸擬操作成功，但在模擬操作過程中均有輕微的后腹膜損傷。操作中以左側(cè)睪丸(卵巢)血管為進入腎旁前間隙的標(biāo)志，以左腎靜脈為到達(dá)胰腺下緣的標(biāo)志，左膈結(jié)腸韌帶為到達(dá)胰尾的標(biāo)志，腸系膜下靜脈左緣與胰腺下緣交點為到達(dá)胰頸的標(biāo)志。完全分離胰體尾后腎旁前間隙內(nèi)平均能一次性注水1.68L。 2．(1)腸系膜上靜脈的十二指腸水平部段長(3.80±0.72)cm、胰頭鉤突部段長(1.76±0.25)cm、胰頸后段長(3.81±0.64)cm、胰頸上段長(4.73±1.31)cm，其中胰頭鉤突部段屬支最多；(2)右胃網(wǎng)膜靜脈匯入SMV有6種類型：右胃網(wǎng)膜靜脈與右結(jié)腸靜脈合成Henle干(50.0％)，右胃網(wǎng)膜靜脈、右結(jié)腸靜脈、中結(jié)腸靜脈合干(16.7％)，右胃網(wǎng)膜靜脈、右結(jié)腸靜脈和中結(jié)腸靜脈分別匯入腸系膜上靜脈(8.3％)，右胃網(wǎng)膜靜脈與中結(jié)腸靜脈合干(8.3％)，右胃網(wǎng)膜靜脈、右結(jié)腸靜脈、中結(jié)腸靜脈與胰十二指腸上前靜脈合干(8.3％)，右胃網(wǎng)膜靜脈、右結(jié)腸靜脈與胰十二指腸上前靜脈合干(8.3％)；(3)腸系膜上動脈距腹腔干下方(1.12±0.15)cm起自腹主動脈前壁，主干長(3.97±0.54)cm，外徑(0.69±0.03)cm，胰十二指腸下動脈和第1空腸動脈起源SMA有5種類型：胰十二指腸下前、后動脈合干與第1空腸動脈分別起始于SMA(33.3％)，胰十二指腸下后動脈、第1空腸動脈合干與胰十二指腸下前動脈分別起始于SMA(25.0％)，胰十二指腸下前動脈、后動脈合干起始于第1空腸動脈(16.7％)，胰十二指腸下前、第1空腸動脈合干與胰十二指下后動脈分別起始于SMA(16.7％)，胰十二指腸下前動脈與中結(jié)腸動脈合干再與胰十二指腸下后動脈合干起始于SMA(8.3％)。 3．脾動、靜脈被網(wǎng)膜囊后壁后方之結(jié)締組織所形成的血管鞘包裹，該血管鞘延續(xù)于脾動、靜脈血管外膜，嵌入胰腺實質(zhì)內(nèi)。脾動脈形態(tài)多樣，但不管形態(tài)變化如何，都通過胰腺分支“騎跨”于脾靜脈之上。胰體尾分別借胰背動脈、胰大動脈和胰尾動脈等脾動脈胰支“懸掛”于脾動脈，借脾靜脈的胰腺靜脈“懸掛”于脾靜脈。 4．手術(shù)均在全腹腔鏡下一次成功完成，平均手術(shù)時間258(95～430)min，平均出血140(50～300)ml。術(shù)后病理：漿液性囊腺瘤1例，黏液性囊腺瘤4例。1例發(fā)生胰漏，經(jīng)保守治療后痊愈。術(shù)后平均住院時間6.8(5～17)d。隨訪至2006年10月無復(fù)發(fā)。 結(jié)論 1．后腹腔鏡胰體尾外科手術(shù)經(jīng)左腎旁前間隙入路是安全可行的，能獲得足夠的操作空間，且有良好的解剖標(biāo)志。 2．(1)SMV的胰頭鉤突部段最短，屬支最多，顯露分離最難；(2)LPD中以右胃網(wǎng)膜靜脈為標(biāo)志來探查、顯露SMV較好；(3)對腸系膜上動靜脈的顯露分離應(yīng)采用不同的主操作孔來進行；(4)充分利用腹腔鏡的放大作用和超聲刀的精確切割特性是可以探查、顯露和分離好腸系膜上血管的。 3．保留脾血管的保脾胰體尾切除術(shù)的要點：一是不能單獨分離脾動脈、脾靜脈與胰體尾，而應(yīng)將脾血管看成一個整體，沿胰腺固有被膜甚至胰腺實質(zhì)整體將脾血管分離開來；二是要在脾靜脈與胰體尾之間的解剖間隙來尋找外科間隙，從而實現(xiàn)脾血管與胰體尾的分離；三是要根據(jù)脾血管的解剖類型，采取從近端向遠(yuǎn)端還是從遠(yuǎn)端向近端將胰體尾與脾血管分離。 4．有選擇地對胰體尾囊腺瘤進行LDP是安全、可行的，且具有創(chuàng)傷小、對患者生理狀態(tài)干擾輕、術(shù)后恢復(fù)快等優(yōu)點。
[Abstract]:Purpose and significance
Since the first successful implementation of laparoscopic cholecystectomy (LC) in French Mouret in 1987, in less than 20 years, laparoscopy has been widely used by surgeons all over the world and the majority of the wounded. Now, laparoscopic technology has been widely used. In the general surgery, Department of hepatobiliary surgery, Department of Urology, obstetrics and Gynecology, thoracic surgery and pediatric surgery, the indications are increasing. In the field of abdominal surgery, almost all traditional laparotomy has a successful trial of laparoscopy, and most laparoscopic operations are gradually replacing traditional laparotomy. However, due to the special structure of the pancreas, the depth of the anatomical position and the complexity of the adjacent relationship, the application of the laparoscopic technology in the field of pancreatic surgery is late and the development lags behind. In order to promote the development of the laparoscopic technology in the field of pancreatic surgery, we use the characteristics of laparoscopy and the laparoscopic technology in the field of pancreatic surgery. One of the restrictive factors of internal development, clinical applied anatomy, was carried out in a series of studies and was used clinically. First, we were inspired by retroperitoneal laparoscopic surgery in the Department of Urology, and explored the surgical approach and anatomical marks of the posterior celiac surgery, which is also located in the anterior space of the parparpara's parparpara space. The main significance is to make clear how to establish a larger workspace within the paranorma space? What is the safe and convenient way to enter the gap by which surgical approach? How to determine the anatomical signs for the laparoscopic surgery for the tail of the pancreas? Secondly, we have the mesentery, which is one of the key and difficult problems in the laparoscopic pancreatoduodenectomy Exploration, exposure, and separation of the upper vessels were observed to provide an anatomical basis for the exploration, exposure, separation of the mesenteric vessels in the laparoscopic pancreatoduodenectomy, and our view of the treatment of the superior mesenteric vessels during the laparoscopic pancreatoduodenectomy. Again, we review the literature and dissected the anatomy. The relationship between the "riding span" of the splenic artery and the splenic vein and the "suspension" relationship between the body and the tail of the pancreas and the blood vessels of the spleen were summarized, and the key points for the resection of the spleen and the tail of the spleen were put forward. Finally, we summed up the clinical data of 5 cases of laparoscopic technique applied to the caudal cystadenoma of the pancreas to discuss the treatment of the caudal caudal cysts of the pancreas by laparoscopic pancreatectomy. The clinical value of adenoma.
Method
1. of 10 adult cadavers were perfused with red latex in left femoral artery and fixed by 10% formalin. 3 of them were perfused with blue latex through the hepatic portal vein on the basis of femoral artery perfusion. 2 cases of fresh adult cadavers were injected with red latex into the left femoral artery and injected with blue latex through the portal vein, and 10% forma were used. A total of 7 male and 5 female cases were observed from the left iliac crest to the left diaphragm of the ventral membrane and the adjacent organs between the tail and the tail of the pancreas. The separation and exposure of the body and tail of the pancreas were simulated before the anatomic observation of the fresh specimens. The distance measurement was measured by the vernier caliper point and the interpoint plane. In the simulated operation, the cadaver was taken on the right side of the supine position in about 30 degrees, and the first trocar position was located at the 2cm intersection above the iliac crest at the middle line of the left axillary. The skin was cut across the skin 3cm, the obtuse and obtuse ventral oblique muscles were separated, the intraperitoneal oblique muscle, the abdominal transverse muscle, and the outer space of the extraperitoneal fat layer was separated with the forefinger, and the cavity was enlarged to large enough with the knife handle or the forceps handle to insert 1. 2mm trocar, and pressure infusion of tap water, insert 0 degrees celioscope, and then insert second 10mm trocar at the 2cm intersection under the left axillary line twelfth ribs, and insert the main separation forceps. Finally, third 5mm trocar are inserted at the left axillary front and the rib arch at the intersection of the subribbed arch, and the accessory separation forceps are placed. Out of the tail of the pancreas.
2. of 10 adult cadavers were perfused with red latex in the left femoral artery and fixed by 10% formalin, and 3 of them were perfused with blue latex through the portal vein. 2 cases of fresh adult cadavers were perfused with red latex through the left femoral artery and injected with blue latex through the portal vein, and 10% formalin was used as a local anticorrosion and cold storage treatment. There were 7 men and 5 women in the whole group. The length (167.48 + 8.35) cm. vernier caliper, 1 soft steel ruler, surgical microscope, anatomical instruments and 1 laparoscopic surgical instruments. Observation, exposure, dissection of the superior mesenteric vessels and the anatomical relationship between the superior mesenteric vessels with the uncinate and duodenal jejunum; The cadavers were exposed and separated on the mesenteric vessels before the anatomical observation of the fresh cadavers. The supine position was taken in the simulated operation. The abdominal operation space was made with the wire suspended from the abdominal wall. The lower edge of the umbilical cord was inserted into the 12mm trocar and inserted into the 0 degree laparoscope. Then the 10mm trocar was inserted into the outer margin of the rectus abdominis muscle on the left and right side of the umbilicus, and the operation forceps were inserted. In the axillary frontline of the left and right ribs, the 10mmtrocar was inserted and the operation forceps were inserted. After opening the gastric and colonic ligaments, the superior mesenteric vein was found and separated along the right gastric omentum vein until the portal vein of the liver, and the superior mesenteric artery was separated.
3. the splenic vessels and its relationship with the body and tail of the pancreas were observed and analyzed in 20 cases of red latex perfusion with left femoral artery and 10% formalin routinely fixed body and spleen.
4. to sum up the clinical data of 5 cases of pancreatic caudal cystadenoma in February 2003 -2006. The average age of LDP was 32.8 (27~43) years old. All the patients were anesthetized with tracheal intubation. The left arm was high about 30 degrees and the left arm was fixed on the left arm. The operator and the holder on the right side of the patient and the other hand on the left.5 were all under the full laparoscope. The 4 hole method was used. The subumbilical edge was the observation hole, the main operation hole was 10mm operation hole 4cm under the left clavicle middle rib edge, the auxiliary operation hole was 5mm operation hole in the lower edge of the right ventral right ventral edge of the right ventral muscle, and the other auxiliary operation hole was 2cm under the left axillary frontline ribbed edge 5mm operation hole. The abdominal cavity was explored in an all-round way after the routine establishment of air abdominal and operation space. First, the abdominal cavity was explored. First, ultrasonic examination was performed with ultrasound. Open the gastric colonic ligament, start from the middle of the stomach and colonic ligaments, first to the left, open to the ligaments of the spleen and stomach in principle. Then turn right, open the stomach and colonic ligaments to the right margin of the tumor about 5cm. Then push the stomach up to the right, pull the colon down, further explore the cyst condition. Open the retroperitoneum before the tumor, along the retroperitoneum and the tumor wall (that is the pancreas). To further expose the tumor, pay attention to the protection of the important blood vessels, such as the left colon vein, which is pushed by the tumor. On the right margin of the tumor, the splenic artery is separated from the upper edge of the pancreas, and the splenic artery is separated from the lower part of the pancreas from the lower edge of the pancreas, and the splenic vein is separated from the posterior part of the pancreas, and the splenic vein is separated from the posterior part of the pancreas, and the blood vessel clamp is used in the rear of the pancreas. After the pancreas was clipped but not cut, the splenic vein was further treated with Endo-GIA, and the spleen and stomach, spleen and stomach, spleen and kidney, spleen and kidney, spleen and diaphragm and the remaining posterior space of pancreas were treated, and the spleen and stomach, spleen and kidney and spleen diaphragm were separated, then the posterior space of the pancreas was separated and the pancreas body was separated from the pancreas body, and then the posterior space of the pancreas was separated and the pancreatic body was separated from the body of pancreas. The splenic vein was separated in the rear. The tail of the pancreas was lifted with a mass, and the pancreas was cut off with Endo-GIA. 1 cases were cut off the pancreas first and then the splenic vein was retreated. The excised specimens were taken out of the enlarged puncture hole in the left upper abdomen. 1 crude latex drainage tubes were placed in the pancreas bed and the splenic fossa. The absorptive line was sutured.5. inside the skin, and the data used were statistically processed by SPSS10.0 software.
Result
1.12 cases of posterior intraperitoneal approach were successfully separated from the parpara's parpara space, and a complete separation of the pancreatic body and tail.2 was completed successfully. However, there were slight retroperitoneal injuries during the simulated operation. The left testis (ovary) vessel was used as a sign to enter the parpara space, and left renal vein was the sign of the inferior margin of the pancreas, left diaphragm. The intestinal ligament is the sign of reaching the tail of the pancreas. The intersection of the left margin of the inferior mesenteric vein and the lower margin of the pancreas is the sign of the neck of the pancreas. The mean water injection of 1.68L. in the paraberrenal space after the complete separation of the body of the pancreas can be used in one time.
2. (1) the upper duodenal segment of the superior mesenteric vein was long (3.80 + 0.72) cm, long (1.76 + 0.25) cm of the uncinate segment of the head of the pancreas, the posterior segment of the neck of the pancreas (3.81 + 0.64) cm, and the upper part of the neck of the pancreas (4.73 + 1.31) cm, and the most of the branches of the uncinate process were the branches of the pancreatic head; (2) there were 6 types of SMV in the right gastroomentum vein to SMV: the right gastroomental vein and the right colonic vein synthesized Henle. Dry (50%), right gastroomental vein, right colonic vein, middle colonic vein dry (16.7%), right gastroomentum vein, right colonic vein and middle colon vein (8.3%), right gastroomental vein and middle colon vein (8.3%), right gastroomentum vein, right colon vein, middle colonic vein and pancreatic duodenum Arterial occlusion (8.3%), right gastroomental vein, right colonic vein and anterior superior pancreaticoduodenal vein (8.3%); (3) the superior mesenteric artery (1.12 + 0.15) cm from the anterior wall of the abdominal aorta, the trunk length (3.97 + 0.54) cm, outer diameter (0.69 + 0.03) cm, and the origin of the inferior pancreaticoduodenal artery and first jejunal artery in 5 types: pancreas twelve Before the lower intestine, the posterior artery occlusion and the first jejunal artery started from the SMA (33.3%), the posterior inferior pancreaticoduodenal artery, the first jejunal artery and the anterior inferior pancreaticoduodenal artery starting from SMA (25%), the anterior inferior pancreaticoduodenal artery, and the trunk of the posterior artery starting from the first jejunum artery (16.7%), the first jejunum artery before the pancreatoduodenal, and the first jejunum artery. The twelve posterior inferior arteries of the combined trunk and the pancreas started from SMA (16.7%), the arterial occlusion of the anterior and middle inferior duodenal arteries and the middle colon and the trunk of the posterior and posterior inferior pancreaticoduodenal artery began at SMA (8.3%).
3. the splenic movement is wrapped in the vascular sheath formed by the connective tissue behind the posterior wall of the omentum capsule. The vascular sheath extends to the spleen and is embedded in the parenchyma of the pancreas. The form of the splenic artery is diverse. However, the splenic artery is "riding" over the splenic vein, regardless of the morphological changes. The tail of the pancreas is by the dorsal pancreatic artery and the large pancreatic artery, respectively. The pancreas branch of the splenic artery, such as the pancreatic tail artery, "hangs" in the splenic artery, and hangs through the splenic vein of the pancreatic vein in the splenic vein.
The 4. operations were performed successfully with a total of 258 (95~430) min and 140 (50~300) ml. postoperative pathology: serous cystadenoma, 4 cases of mucinous cystadenoma and 4.1 cases with pancreatic leakage and recovered after conservative treatment. The average postoperative hospital time was 6.8 (5~17) d. followed up to no recurrence in October 2006.
conclusion
1. retroperitoneal laparoscopic surgery is safe and feasible through the left para renal anterior space approach. It can obtain enough space for operation and has good anatomical marks.
2. (1) SMV had the shortest uncinate segment of the head of the pancreas, most of the branch, and the most difficult to reveal and separate; (2) the right gastric omentum vein was found in LPD, and SMV was better. (3) different main operation holes should be used for the exposure and separation of the superior mesenteric arteriovenous; (4) the enlargement of the laparoscope and the precise cutting characteristics of the ultrasonic knife were full. It is possible to detect and separate superior mesenteric vessels.
3. the main points of splenopananopanretomy for preserving splenic vessels: one is that the splenic artery, the splenic vein and the tail of the pancreas can not be separated, and the spleen vessels should be regarded as a whole, and the splenic vessels are separated along the intrinsic membrane of the pancreas and even the whole pancreatic substance, and the two is to find the surgical clearance between the splenic vein and the tail of the pancreas. The separation of the spleen vessels and the tail of the body of the pancreas is achieved; three it is to separate the tail of the pancreas from the distal end to the proximal end and the splenic vessels, according to the anatomical types of the splenic vessels.
4. selectively to the tail of the body of the pancreas
【學(xué)位授予單位】：第一軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2007
【分類號】：R322;R657.5

【引證文獻】

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1 劉志軍;腹腔鏡背側(cè)入路在輸尿管手術(shù)中應(yīng)用的解剖學(xué)及臨床研究[D];河北醫(yī)科大學(xué);2010年

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