1、胸腔镜在胸外科的应用胸腔镜在胸外科的应用复旦大学附属中山医院胸外科 王群胸腔镜的历史胸腔镜的历史1910年,Jacobeus首先把膀胱镜技术应用到胸腔治疗空洞型肺结核。1973年,Ben-Isaac成功地将纤维支气管镜应用于胸腔检查。进入九十年代以来,随着科学技术的发展,产生了全新的影像监视胸腔镜外科手术(VATS)基本手术程序及器械全身麻醉(双腔气管插管)准备好常规开胸器械胸腔镜高分辨率电视监视器胸壁辅助小切口胸腔镜器械:内镜持物钳,剪,止血钳,血管夹,放夹器特殊器械Endo-GIA,Endo-TA,钛夹,肺钳,胸膜固定器等吸引器系统麻醉麻醉全麻双腔气管插管麻醉是手术成功的保证双腔管的应用是
2、术侧肺萎陷,术野良好暴露的保证体位侧卧,消毒铺巾按开胸手术准备,以便必要时该为开胸手术有时需要麻醉师不要坐在病人头侧组织安排手术过程中安排好医生,内腔镜器械,摄像机镜头,肺部病灶以及电视屏幕医生,镜头以及手术器械都应对准病灶医生,镜头,病变与屏幕互成一条直线 适应征适应征气胸(血气胸)自发性或继发性局限性/良性胸膜间皮瘤胸膜粘连形成术或固定术肺大疱型疾病周围型肺良性肿瘤切除术肺癌食管食管肌层切开术(Heller 术)食管囊肿切除食管平滑肌瘤切除抗返流手术食管切除术纵隔胸腺瘤切除伴有重症肌无力的胸腺切除术良性畸胎瘤切除术支气管囊肿/肠源性囊肿切除后纵隔神经源性肿瘤切除心包开窗术心脏PDA钳闭术二
3、尖瓣交界分离术二尖瓣置换术冠状动脉搭桥术其它胸交感神经节切断术椎旁脓肿引流术膈神经游离术胸椎融合术胸腔镜手术基本共同点胸腔镜手术基本共同点肺功能要求比剖胸手术低更强调术前定位诊断的必要性气管内双腔插管穿刺点之间呈“三角型”或立体“锥型”分布胸膜疾病胸膜疾病胸膜弥漫性病变胸膜渗出性病变纤维支气管镜检查自发性气胸和肺大疱自发性气胸和肺大疱持续肺漏气7天缩短为23天自发性血胸或外伤性血胸同期双侧自发性气胸,可行同期手术治疗复发性气胸大疱性肺气肿肺局部楔型切除肺局部楔型切除急性或慢性弥漫性肺间质或浸润性疾病未定性的单个肺结节a.直径小于3cm的无钙化结节b.常规检查无法定性的单个肺结节c.病灶位于肺外
4、围1/3d.没有支气管内播散I期T1N0M0外周型非小细胞癌VATS在肺结节诊断中的作用在肺结节诊断中的作用对于位于肺周边经细胞学和纤支镜检查未能确对于位于肺周边经细胞学和纤支镜检查未能确诊的病例适宜行诊的病例适宜行VATS检查检查1cm的的病变可术中直接观察、器械或手直接病变可术中直接观察、器械或手直接触摸定位触摸定位1cm的病变最好术前行的病变最好术前行CT引导下的引导下的细针穿刺定位细针穿刺定位一般采用切割吻合器楔形切除结节一般采用切割吻合器楔形切除结节 对于深埋在肺癌实质内的结节可采用激光切除对于深埋在肺癌实质内的结节可采用激光切除激光切除术激光切除术激光环切结节周围肺组织激光环切结节
5、周围肺组织单根血管、细支气管用钛夹夹闭单根血管、细支气管用钛夹夹闭用切割缝合器处理基底部用切割缝合器处理基底部VATS在肺癌分期中的作用在肺癌分期中的作用1.胸腔积液的病理学检查和胸膜转移的判断胸腔积液的病理学检查和胸膜转移的判断2.纵隔淋巴结转移的判断纵隔淋巴结转移的判断 (1)作为进步纵隔镜检查的补充,以明确下纵隔淋)作为进步纵隔镜检查的补充,以明确下纵隔淋巴结分期巴结分期(2)取代)取代chamberlain前纵隔切开术以探查主动脉窗淋前纵隔切开术以探查主动脉窗淋巴结巴结VATS下的肺癌部分切除术下的肺癌部分切除术肺癌部分切除术后局部复发率高肺癌部分切除术后局部复发率高影响患者的长期生存
6、肺癌的部分切除影响患者的长期生存肺癌的部分切除认为不是根治性手术认为不是根治性手术VATS行肺癌部分切除术行肺癌部分切除术 仅适用于心肺功能不良不能耐受开胸或肺叶切除术的仅适用于心肺功能不良不能耐受开胸或肺叶切除术的T1N0M0患者患者VATS下的肺癌部分切除术下的肺癌部分切除术位于肺周边的肺癌可采用切割吻合器楔位于肺周边的肺癌可采用切割吻合器楔形切除形切除对于深埋在肺癌实质内的结节可采用激对于深埋在肺癌实质内的结节可采用激光切除术光切除术VATS下的肺叶切除术下的肺叶切除术VATS行肺癌的肺叶切除术目前存在争论行肺癌的肺叶切除术目前存在争论 手术的彻底性手术的彻底性 能否做到纵隔淋巴结的系统
7、清扫能否做到纵隔淋巴结的系统清扫手术的安全性手术的安全性VATS下的肺叶切除术下的肺叶切除术McKenna 对对298例肺癌患者,其中例肺癌患者,其中I期期 233例例(78%),II 期期 27例例(9%),IIIA 期期 38 期期(13%)行行VATS肺叶切除术,肺叶切除术,转开胸率为转开胸率为6%,无术中大出血发生,围手术期仅一例,无术中大出血发生,围手术期仅一例病人死于肠系膜静脉血栓形成,其中病人死于肠系膜静脉血栓形成,其中I期患者的期患者的4年生年生存率为存率为70%研究认为研究认为VATS行肺叶切除是安全可行的,疗效不亚于行肺叶切除是安全可行的,疗效不亚于常规手术常规手术VATS
8、下的肺叶切除术下的肺叶切除术VATS下的肺叶切除术的手术方式目前尚无标准的模式下的肺叶切除术的手术方式目前尚无标准的模式普遍加用辅助小切口普遍加用辅助小切口在实际操作中有撑开小切口和不撑开小切口两种做法,在实际操作中有撑开小切口和不撑开小切口两种做法,撑开小切口可行部分直视下操作比较安全,不撑开小撑开小切口可行部分直视下操作比较安全,不撑开小切口减少术后的疼痛,但安全性较差切口减少术后的疼痛,但安全性较差目前国内大多采用撑开小切口的手术方法目前国内大多采用撑开小切口的手术方法VATS下的肺叶切除术下的肺叶切除术国内通常经小切口分支结扎肺动静脉,国外也有用内国内通常经小切口分支结扎肺动静脉,国外
9、也有用内镜切割吻合器处理血管,支气管常用残端关闭器处理镜切割吻合器处理血管,支气管常用残端关闭器处理国外也有用组织缝合器(国外也有用组织缝合器(TL60)一并处理肺门血管和)一并处理肺门血管和支气管的报道,其安全性有待进一步研究支气管的报道,其安全性有待进一步研究VATS下的肺叶切除术下的肺叶切除术日本的一项研究比较日本的一项研究比较VATS和常规手术清扫纵隔淋巴结和常规手术清扫纵隔淋巴结的情况。结果显示对于右侧纵隔淋巴结的情况。结果显示对于右侧纵隔淋巴结VATS可清扫可清扫40.3枚,左侧可清扫枚,左侧可清扫37.1枚,仅比常规手术切除的纵枚,仅比常规手术切除的纵隔淋巴结少隔淋巴结少1.2枚
10、枚该研究的结论认为该研究的结论认为VATS在技术上可以做到纵隔淋巴结在技术上可以做到纵隔淋巴结的系统清扫的系统清扫纵隔疾病纵隔疾病纵隔淋巴结检查和肺癌的分期纵隔淋巴结检查和肺癌的分期纵隔肿瘤纵隔肿瘤后纵隔神经源性肿瘤先天性支气管/食管、心包囊肿和良性畸胎瘤胸腺瘤心包疾病心包疾病良性心包积液恶性肿瘤所致的心包积液食管疾病食管疾病贲门失弛症食管平滑肌瘤摘除术食管癌的治疗其它其它雷诺氏综合症雷诺氏综合症手汗症手汗症椎旁脓肿引流椎旁脓肿引流胸椎融合术迷走神经切断胸椎融合术迷走神经切断肺减容术肺减容术动脉导管钳闭术动脉导管钳闭术二尖瓣交界分离术二尖瓣交界分离术冠状动脉旁路搭桥冠状动脉旁路搭桥二尖瓣置换术
11、二尖瓣置换术禁忌症中央型肺癌中央型肺癌严重肺气肿严重肺气肿无顺应性肺无顺应性肺深部的肺间质肿块深部的肺间质肿块严重的胸膜粘连、胸腔闭锁严重的胸膜粘连、胸腔闭锁恶性纵隔肿瘤恶性纵隔肿瘤有外侵的食管肿瘤等有外侵的食管肿瘤等问题问题虽小切口,手术方式仍较复杂,需与开胸手术同等重视。出现严重出血应立即开胸止血。VATS手术时应常规备开胸包。术后要保持引流通常。展望肺血管处理的安全性影像监视胸腔镜手术可能带来的胸膜种植手术指证的盲目扩大和对疾病分期不明而滥用影像监视胸腔镜手术谢谢9+ZPFvlb1!RHxnd3%TJyoe4&UKAqg6(WMCsi8-YOEuka0#QFvlb1!RHxnd3%TJz
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26、yoe4&UKAqg6(WMBrh7)XNDtj9+ZPFvlb1!RHxnd3%TIyoe4&UKAqg6(WMCsi8-YOEuka0#PFvlb1!RHxnd3%TJzpf5*VLBrh7)WMCsi8-YOEuka0#QGwmc2$SIyoe4%TJzmc2$SIyoe4&UKAqg6*VLBrh7)XNDtj9+ZPFvlb1!RHxnd2$SIyoe4&UKAqg6(WMCsi8-YOEuk9+ZPFvlb1!RHxnd3%TJzpf5*VLBrg6(WMCsi8-YOEuka0#QGwmc2$SIynd3%TJzpf5*VLBrh7)XNDqf5*VLBrh7)XNDtj9+ZP
27、Fvlb1!RHxmc2$SIyoe4&UKAqg6(WMCsi8-YODtj9+ZPFvlb1!RHxnd3%TJzpf5*VKAqg6(WMCsi8-YOEuka0#QGwmc2$RHxnd3%TJzpf5*SIyoe4&UJzpf5*VLBrh7)XNDtj9+ZPFvlb1!QGwmc2$SIyoe4&UKAqg6(WMCsi8-XNDtj9+ZPFvlb1!RHxnd3%TJzpf5&UKAqg6(WMCsi8-YOEuka0#QGwmb1!RHxnd3%TJzpf5*VLBrh7)XNDti5*VLBrh7)XNDtj9+ZPFvla0#QGwmc2$SIyoe4&UKAqg6(WMCsh7)XNDtj9+ZPFvlb1!RHxnd3%TJzoe4&UKAqg6(WMCsi8-YOEuka0#QGvlb1!RHxnd3%QGwmc2$SIynd3%TJzpf5*VLBrh7)XNDtj9+ZPEuka0#QGwmc2$SIyoe4&UKAqg6(WL