胰肠吻合术(PJ)是胰十二指肠切除术等胰腺手术的重要组成部分，既是技术难点，也是术后胰瘘等严重并发症的好发部位。为了更好地适应腹腔镜时代的新要求，简化PJ，提升其质量，笔者团队创新性地将胰颈直线切割闭合技术应用于胰腺离断，将连续单层缝合技术应用于PJ，取得了满意的初步效果。本文通过分析PJ常见并发症及其发生机制，提出高质量PJ的技术细节要求，阐述胰颈直线切割闭合加连续单层PJ的合理性。

目的:探讨腹腔镜胰十二指肠切除术(LPD)中胰颈直线切割闭合后主胰管分型及处理策略。方法:回顾性分析2022年2~12月于滨州市第二人民医院、首都医科大学附属北京朝阳医院石景山院区、日照市肝胆胰脾外科研究所、朝阳市中心医院、山东莒县人民医院、威海市立医院、滨州市中心医院和赤峰学院附属医院应用胰颈直线切割闭合技术的51例LPD患者的临床资料。按照胰腺断端主胰管的可视性、位置及直径，将主胰管分为Ⅰ型、Ⅱ型、Ⅲa型和Ⅲb型。观察每个主胰管分型的病例数及相应的处理策略。结果:51例患者实施LPD均获得成功。51例LPD中，男性占56.9%(29/51)，女性占43.1%(22/51)，年龄为31~88岁。胰腺断端主胰管的类型：Ⅰ型7例(13.7%)，Ⅱ型39例(76.5%)，Ⅲa型2例(3.9%)，Ⅲb型3例(5.9%)。根据不同的主胰管分型采取相应的处理策略，均成功找到主胰管并插入支撑引流管。结论:胰颈直线切割闭合后，根据主胰管分型采取相应的处理策略，有助于提高找到主胰管并置入支撑引流管的成功率。

目的:探讨胰颈直线切割闭合加连续单层胰肠吻合在胰十二指肠切除术(PD)中的应用价值。方法:回顾性分析2022年2月至5月首都医科大学附属北京朝阳医院西院、日照市肝胆胰脾外科研究所、滨州市第二人民医院和朝阳市中心医院应用胰颈直线切割闭合加连续单层胰肠吻合治疗的21例PD患者资料，其中男性12例，女性9例，年龄范围31.0~82.0岁，中位年龄63.0岁。分析胰颈直线切割闭合成功率、胰肠吻合时间、术后并发症、胰瘘风险评分、住院时间等。结果:21例患者中开腹PD 3例，腹腔镜PD 18例，均顺利完成胰颈直线切割闭合加连续单层胰肠吻合，成功率100.0%。在胰腺残端寻找胰管并插入引流管的成功率为100.0%(21/21)，其中有3例(14.3%)在残胰断端可见明显的胰管断端。3例开腹PD患者手术时间分别为220.0、245.0、260.0 min，胰肠吻合时间为12.0、13.0、12.0 min，术中出血量为300.0、450.0、600.0 ml，住院时间为14.0、15.0、21.0 d。18例腹腔镜PD患者手术时间为(295.9±14.5)min，胰肠吻合时间为(22.3±1.5)min，术中出血量为(180.0±40.0)ml，住院时间(范围)为8.0~16.0 d，中位数10.5 d。21例患者胰瘘风险评分为(4.7±1.5)分。3例(14.3%)发生术后急性胰腺炎，4例(19.0%)发生胃排空延迟，保守治疗后痊愈。21例患者均无术后出血、院内感染，无B、C级术后胰瘘，无围手术期死亡。结论:胰颈直线切割闭合后连续单层胰肠吻合具有质量可靠、操作简单易行等特点，具有预防临床相关术后胰瘘及胰肠吻合口出血的潜质，值得谨慎推广应用。

目的:探讨运用直线切割闭合器的胰体尾切除术后胰瘘的危险因素.方法:回顾性分析24例运用直线切割闭合器的胰体尾切除术患者的临床资料.收集患者指标包括性别、年龄、是否糖尿病、体重指数、术前白蛋白、胰颈厚度、手术方式、手术时间、失血量、胰腺质地、病理类型等,分析各指标与术后胰瘘的关系.结果:单因素及多因素分析结果显示,胰瘘与性别、年龄、是否糖尿病、体重指数、术前白蛋白、手术方式、手术时间、失血量、胰腺质地、病理类型等因素无关,差异均无统计学意义(P＞0.05),而与胰颈厚度有关,差异有统计学意义(P＜0.05).结论:胰颈厚度是运用直线切割闭合器的胰体尾切除术后胰瘘的危险因素.

一、理念美国医疗的基础是循证医学,而我国医师的临床行为富有更多经验色彩.在查房、门诊或手术中与美国医师讨论问题时,听得最多的是数据.西方的医师和患者一直生活在“数据”的环境中,所以患者更容易接受和选择数据.门诊时我见过1例患者把Kendrick教授说的术后出血率、胰瘘发生率、胆瘘发生率记下来,计算出自己发生并发症的概率,并与医师进一步探讨手术的获益和风险.在对待临床问题时,数据和文献更是他们的依靠.有一次我看到Kendrick教授在用直线切割闭合器断胰腺,他不仅能说出每个步骤需要的精确时间,还能说出出处、并发症发生率和优势等.

腹腔镜技术是近10年来外科研究和发展的热点之一,其手术视野清晰、创伤小,已逐步取代传统的开腹手术成为绝大部分腹部疾病的首选治疗方式,在胃癌和结直肠癌中亦被作为优先选择的根治性治疗手段.但胰腺解剖位置特殊,位于腹膜后,周围毗邻大血管,本身手术难度高,术后并发症多,使得微创技术在胰腺中的应用相对落后.近年来,随着微创技术的进一步成熟,对胰腺手术认识的加深,以及超声刀、腔镜下直线切割闭合器等器械的应用,越来越多的胰腺肿瘤中心开始开展腹腔镜胰腺手术,并进一步尝试在腹腔镜下行胰腺癌根治术,也取得了一定的成果.本文系统性回顾分析近年来腹腔镜下胰腺恶性肿瘤根治术的最新研究进展.

目的 采用kocher手法,分离十二指肠降部与下腔静脉之间间隙;分离胃结肠韧带,不保留大网膜,进入小网膜囊,小网膜囊后壁下面即为胰腺前缘;分离横结肠系膜前叶及胰腺背膜,于胰腺下缘找到肠系膜上静脉,分离钳顺着肠系膜上静脉在胰腺后侧打洞分离,直至门静脉;解剖肝十二指肠韧带,游离肝门三管;分别于胃大弯和胃小弯游离韧带,于固定处用直线切割闭合器切断胃;于预定切除处断胰;仔细分离钩突与SMV之间的小静脉、以及可能出现的胃结肠干、胃网膜右静脉等血管;施行胰肠吻合、胆肠吻合、胃肠吻合.

Objective To evaluate the short?term efficacy and cosmetic effect of dual?port laparoscopic distal gastrectomy (DPLDG) for gastric cancer. Methods Thirty consecutive patients underwent DPLDG at the Department of General Surgery,Nanfang Hospital from November 2016 to August 2018. Inclusion criteria:(1)age of 18 to 75 years;(2)primary gastric adenocarcinoma confirmed pathologically by endoscopic biopsy;(3)tumor located at middle?low stomach and planned for distal gastrectomy;(4)cT1b?2N0?1M0 at preoperative staging;(5)tumor diameter ≤3 cm;(6)US Eastern Cancer Cooperative Group(ECOG)score 0 to 1 points;(7)American Society of Anesthesiologists grade I to II;(8) perioperative management based on enhanced recovery after surgery (ERAS) principle. Exclusion criteria:previous upper abdominal surgery(except laparoscopic cholecystectomy),history of other malignant disease,and body mass index ≥30 kg/m2. A self?developed single?incision,multiport, laparoscopic surgery Trocar(Surgaid Medical,Xiamen,China,comprising 3 channels for observation, main surgeon and assistant surgeon)was placed through a 3?4 cm incision under or at the left side of the umbilicus. An additional 5 mm Trocar was inserted under the rib margin of the right clavicle to serve as the secondary operating hole and the position of the drainage tube. The liver was suspended to expose the surgical field clearly. Surgical procedure was as follows:conventional laparoscopic instruments were used. After entering the omental sac,dissection was performed along the transverse colon to the spleen flexure. Left gastroepiploic vessels were identified and then ligated at the root. No.4sb lymph nodes were dissected. The No.4d lymph nodes were dissected along the greater curvature of the stomach. Then the dissection was continued rightward to the hepatic flexure to separate mesogastrium and mesocolon. The right gastroepiploic artery was ligated at the root to allow the removal of No. 6 lymph nodes. The duodenal bulb was transacted by liner stapler,the right gastric artery was ligated at the root and the No. 5 lymph nodes were removed. Peritoneal trunk,common hepatic artery,splenic artery and left gastric artery and vein in posterior pancreatic space at upper pancreas were separated,then left gastric vessels were ligated,and No.9,No.8a,No.11p and No.7 lymph nodes were dissected. The left side wall of portal vein was exposed and No. 12a lymph nodes were removed. No. 1 and No. 3 lymph nodes were dissected along the lesser curvature. The stomach corpus was transacted by liner stapler at 4?5 cm proximal end of the tumor. Roux?en?Y anastomosis or Billroth II anastomosis was performed in the cavity. A drainage tube was placed near the gastrojejunal anastomosis through the right upper abdomen secondary operating hole. Postoperative short?term efficacy(operation time,blood loss,5?port conversion rate,open conversion rate,number of retrieved lymph nodes,time to postoperative first flatus,time to first soft diet intake, time to removal of drainage tube, postoperative hospital stay, postoperative analgesics use, and postoperative 30?day complication rate)and cosmetic scale(questionnaire:degree of satisfaction with scar,description of scar,grade of scar;total score ranged from the lowest 3 to the highest 24;the higher the better) were evaluated in all 30 patients. Results No serious complication and death were observed intraoperatively. The mean operative time was(197.8±46.9)minutes. The median blood loss was 30 ml(quartile 31.25 ml). The mean number of retrieved lymph node was 38.7±14.1. Five?port conversion rate was 3.3%(1/30),and no open conversion occurred. Mean time to postoperative first flatus,time to first soft diet intake,time to removal of drainage tube and postoperative hospital stay were(45.3±18.9) hours,(87.6±35.6)hours,(101.8±58.0)hours and(6.1±2.1)days,respectively. Twenty?four(80%) of patients had no additional analgesics use. The postoperative complication rate within 30 days was 16.7%(5/30). Postoperative overall cosmetic score was 22.1±1.3,and cosmetic score of 96.7%(29/30) of patients was 18 to 24. Conclusion DPLDG is safe and feasible with advantages of faster postoperative recovery,reducing pain and better cosmetic outcomes.

距幽门2 cm开始紧贴胃大弯壁用超声刀离断大网膜,同时充分游离胃后壁与胰腺之间粘连,直至胃底,显露出左侧膈肌脚及食道左侧.经口置入36 F粗胃管,沿胃小弯直至到达胃窦处,距幽门4～6 cm开始用成钉高度较高的内镜下直线切割闭合器进行袖状胃裁剪,然后换用为钉腿高度较低的内镜下直线闭合器切割,切割线距离胃管边缘1 cm,在胃底部离食道左侧缘1～2 cm处离断胃底.用倒刺缝合线连续浆肌层缝合加固胃切缘,可将大网膜一并缝合在胃切缘.移除胃管,清理腹腔,扩大主操作孔,取出切除的胃组织,在左侧膈肌脚放置引流管,用不可吸收线全层缝合10 mm及12 mm戳卡孔.

腹腔镜远端胰腺切除术因具有出血少、住院时间短等优点逐渐成为胰体尾良性肿瘤的标准术式[1]. 但术后胰瘘仍是胰腺手术的主要并发症,并且其与术后严重并发症(出血、腹腔感染等)密切相关. 很多研究表明,术后胰瘘与多种因素有关,如胰腺质地、胰腺厚度等. 其中,胰腺残端处理方法被认为是影响胰瘘的关键技术[2]. 研究表明,直线切割闭合器闭合残端与手工缝合残端是同样安全的,对胰瘘的影响差异并无统计学意义. 然而,关于不同钉仓处理胰腺残端对术后胰瘘影响的随机对照研究未见报道[3]. 本研究采用单盲、随机、平行对照的方法评估不同钉仓类型对术后胰瘘的影响.