我国普外腹腔镜手术的发展

null我国普外腹腔镜手术的发展我国普外腹腔镜手术的发展北京大学第一医院普外科 刘国礼 初期阶段初期阶段1991-1994 起步略晚，进展较快。 1991,2 腹腔镜胆囊切除术 1993 腹腔镜胃切除、结肠切除、胆总管切开取石 1994 腹腔镜肝切除、脾切除 启动快的原因启动快的原因人的因素 对腹腔镜手术的反应敏感，认识和承认它的优点，积极热情，愿为发展腹腔镜手术而尽力。在腹腔镜的发展过程中克服多种困难，成为推进我国腹腔镜发展的骨干。 腹腔镜手术确有微创优点 公司的支持停滞阶段停滞阶段1995-1999 医院增多，手术种类减少 原因 技术不成熟，中途放弃 结肠癌术后伤口种植 缺乏有效的和适用的器械 公司支持减少 国民经济尚不充裕大发展大发展 1999- 第一届外科周介绍和认识了腹腔镜超声刀 1997 国内用腹腔镜超声刀做胆囊切除、结肠切除 1998 国内用腹腔镜超声刀做肾上腺切除、脾切除 技术成熟、经验丰富 教学医院和专业医院的开展、专业医生的加入 微创优点得到承认 经济情况好转现状现状腔镜甲状腺切除 病种: 甲状腺瘤、结节性甲状腺肿、甲状腺机能亢进、甲状腺癌，甲状旁腺肿瘤。 手术：甲状腺部分切除、甲状腺次全切除、一叶全切一叶部分切除，甲状旁腺切除，甲状腺再次手术。 手术入路; 双乳晕胸前、胸前、腋下、腋乳现状现状腹腔镜肝脏手术 腹腔镜肝囊肿开窗术、肝包囊虫的腔镜治疗 肝切除术 病种：肝癌、血管瘤、结石、囊肿、脓肿等。 术式： 楔形切除、肝叶切除、左半肝切除、右半肝切除， 完全气腹，手助。 器械：超声刀、智能双极电凝刀（Ligasur,PK刀），刮吸刀，螺旋水刀，HWD-2型腹腔镜专用微波刀，钛夹，Endo GIA,等。 效果：近期好，转开腹，并发症，远期？ 上海、广州、北京、杭州、桂林、南通、武汉、济南、福州 现状现状胆道外科 腹腔镜胆囊切除 腹腔镜胆总管切开取石 腹腔镜胆总管囊肿切除术 胆肠吻合术 胆道肿瘤？现状现状胰腺手术 假性胰腺囊肿胃吻合术、肠吻合术 胰体尾切除术（保或不保脾） 胰岛细胞瘤切除术 胰十二指肠切除术 胰头或壶腹周围的小肿瘤，胰空肠端端吻合（缝或捆绑），胰胃吻合， 南宁、上海、杭州、南京、广州、等。现状现状腹腔镜脾脏手术 病脾切除： 血液病、脾囊肿、脾脓肿、脾脏脉管瘤，等。 外伤脾修补术。 门脉高压巨脾切除、门奇断流手术。 手助，改良Sugiura手术现状现状腹腔镜胃手术 胃良性肿瘤切除术、胃良性疾病切除、穿孔缝合术。迷走神经切断术。食管旁裂孔疝修补术，减肥手术，抗反流胃底折叠术。 胃癌根治术 完全气腹、腹腔镜辅助下、手助腹腔镜胃癌根治术。 上海、重庆、广州、南宁、温州 、北京等 现状现状腹腔镜结肠手术 是较成熟和开展较多的手术 良性病变：家族息肉病、溃疡性结肠炎、便秘、结肠息肉 结肠癌：左或右半结肠切除、横结肠切除 结直肠癌：TME。Dixon手术, 保肛低位吻合，Miles手术 。 技术比较成熟，微创优点已获承认，治疗效果亦得证实。国内尚缺循证医学资料。现状现状 其他 腹腔镜在小肠肿瘤诊治中的应用 腹腔镜在治疗粘连性不全肠梗阻的应用 乳腺癌腔镜下保乳和腋下淋巴结廓清术 腹腔镜疝修补术：斜疝、直疝、切口疝、食道裂孔疝、造口旁疝。 腹腔镜在急腹症、腹部外伤病人中的应用存在问题和发展方向存在问题和发展方向严格掌握适应症，防止误诊和漏诊 腹腔镜手术不同于开腹手术，不能触摸探查。术前需做好诊断和鉴别诊断。是否需要手术？ 需要做那种手术？ 术式按先进标准进行，不能自己会甚麽就做甚麽。 特别是肿瘤根治手术 提高认识和技术水平，减少并发症发生。 努力提高腹腔镜手术的治疗效果，才能发展和推广腹腔镜手术存在问题和发展方向存在问题和发展方向腹腔镜手术处于可行性的探索阶段，目前是手术技术的改革或革命。一旦手术定型，就应研究腹腔镜手术与开腹手术引起身体生理变化的异同，以及有关的术前准备和术后处理。这样才能形成完美的微创外科体系。 注意循证医学的研究 多中心、大规模、前瞻性、随机双盲临床评价研究。 成立专题组，联合、互助、共同提高 感谢各位的参与感谢各位的参与祝各位事业 成功The Development of General Laparoscopic Surgery In ChinaThe Development of General Laparoscopic Surgery In China Department of Surgery, First Hospital, Peking University Guoli LiuInitial StageInitial Stage1991-1994 The development of LS in China was started later but the progression was fast 1991-2 laparoscopic cholecystectomy 1993 laparoscopic gastrectomy laparoscopic colectomy laparoscopic choledochotomy 1994 laparoscopic hepatectomy laparoscopic splenectomyWhy the progression was fastWhy the progression was fastInterpersonal factors Sensitive, positive and enthusiastic to LS, recognized the advantage of LS Laparoscopic surgery is actually minimally invasive surgery Company supportsStagnant Stagnant 1995-1999 Hospitals carried out LS were increasing, but the kind of operations were decreasing. Causes 1 Technique is still Immature, 2 Postoperative port site recurrence of laparoscopic colorectal surgery 3 Lack effective、suitable instruments 4 company supports reduced Plentiful GDP further expansion are expectedGreat developmentGreat development1999—— introduction and well-known ultrasonic scalpel on ’99- Beijing Surgical Week 1997 laparoscopic cholecystectomy laparoscopic colectomy 1998 laparoscopic adrenalectomy laparoscopic splenectomy Mature technique, rich experience, specialized doctors . The advantage of LS were recognized by doctors and patients The GDP continuously increasing 11 大发展 1999- 第一届外科周介绍和认识了腹腔镜超声刀 1997 国内用超声刀作 腹腔镜胆囊切除、结肠切除 1998 国内用超声刀作 腹腔镜肾上腺切除、脾切除 技术成熟、经验丰富 教学医院、省立医院和专科医院的开展以及专业医生加入 腔镜手术的优点得到承认 经济情况好转Laparoscopic thyroidectmyLaparoscopic thyroidectmyKind of diseases thyroid tumor, nodular goiter, hyperthyroidism, thyroid carcinoma parathyroidoma Operations partial or subtotal thyroidectomy, parathyroidectomy, Entrances anterior thoracic wall, anterior axillary line, axillary-areola of mamma Laparoscopic hepatic surgeryLaparoscopic hepatic surgeryFenestration for liver cyst Laparoscopic treatment of hydatid cyst Hepatectomy Kind of diseases: hepatocelllular carcinama, hepatic hemangioma, hepatolithiasis, hepatic cyst, liver abscess Operations: hepatic wedge resection, lobectomy of liver, Complete laparoscope, Hand assistant. Instruments: ultrasonic scalpel, ligasure , new type of microwave knife, PMOD, water jet dissection, Endo GIA Shanghai, Guangzhou, Beijing, Hangzhou, Guilin, Nantong, Wuhan, Jinan, Fuzhou, et. Laparoscopic biliary tract surgeryLaparoscopic biliary tract surgeryLaparoscopic cholecystectomy Laparoscopic choledocholithotomy Laparoscopic resection of choledochocele Laparoscopic choledochojejunostomy or cholecystojejunostomy Tumor of biliary tract ? Laparoscopic pancreatic surgeryLaparoscopic pancreatic surgerypancreatic pseudocystogastrostomy or pseudocystojejunostomy Resection of pancrea body laparoscopic enucleation of pancreatic islet cell tumors Pancreatoduodenectomy peri ampulla carcinoma, pancreaticojejunostomy Nanning ,Shanghai,Hangzhou,Nanjing,Guangzhou,Laparoscopic splenic surgeryLaparoscopic splenic surgeryLaparoscopic splenectomy ITP, splenic cyst, splenic abscess, splenic hemangioma, et al. Neoplasty of injured spleen Portal hypertension Hand assisted, splenectomy and pericardial devascularization, Sugiura operationLaparoscopic surgery of stomachLaparoscopic surgery of stomachPartial & subtotal gastrectomy for benign disease or tumor Laparoscopic repair for perforation of peptic ulcer Laparoscopic vagotomy Surgical treatment of paraesophageal hiatal hernia Laparoscopic antireflux surgery Laparoscopic gastric banding Carcinoma of stomach Ⅰ、Ⅱ、Ⅲ stages，complete laparoscope, laparoscopic assisted , hand assisted. Shanghai,Chongqing,Guangzhou,Nanning,Wenzhou,Beijing, et al. Laparoscopic colonrectal surgeryLaparoscopic colonrectal surgeryAre mature and common laparoscopic operation Benign diseases: familial intestinal polyposis, ulcerative colitis, colic polyp. Carcinoma of colon left or right hemicolectomy, Rectal carcinoma TME, Dixon, miles. Good result ,minimally invasive surgeryOthersOthersLaparoscopic surgery for small bowel tumor Laparoscopic surgery for adhesiolysis Endoscopic surgery for breast cancer Laparoscopic hernia repair, oblique, direct, inciesion, Laparoscopic surgery for emergency or abdominal injury Questions and DirectionsQuestions and Directions Strictly control operative indications, avoid misdiagnosis and missed diagnosis Operating must according to the standard procedure Enhance knowledge and technique, decrease complications Make great efforts to yield LS good results, promote the development of laparoscopic surgery Questions and directionsQuestions and directionsMy personal opinion that LS is still in operative explore stage, is an operative technique reform or revolution . One should study the deferences of pathophysiological changes between OS and LS, and the managements of perioperation. A completed minimally invasive surgery would be formed perfectly in the future Evidence-based medicine(EBM) study Thank youThank youWelcome to Beijing