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微创胸腔镜肺段切除术目前主要应用于早期肺癌、肺功能较差的病人、良性深部病变、多发结节以及二次手术等情况,其具有在最大程度切除病变基础上最大程度保留余肺功能的优点,同时胸腔镜使用减少了创伤。单孔胸腔镜技术在目前的肺外科已应用比较成熟,但对于复杂肺段切除,有时因为角度因素,导致直线切割缝合器的放置困难,靶段肺动、静脉及气管尚可通过结扎或者血管夹的方式处理,但段间平面的处理有时较为困难。膨胀萎陷法是目前应用较多的寻找段间交界的方法,简单方便,缺点主要为等待时间较长。为了尽量减少以上缺点,本研究对立体的段间平面进行降低维度处理,采用超声刀或者电钩对段间平面进行分离,在膨胀萎陷法产生的界限尚未显示时,通过保留的段间静脉进行段间平面分离,将立体维度降低后使用直线切割缝合器处理,取得良好的效果。现作报道。
胸腔镜下膨胀萎陷联合立体降维法处理肺段间平面的临床应用
Clinical application value of thoracoscopic inflation-deflation and dimensionality reduction method in the treatment of intersegmental plane of lung
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摘要:
目的探讨胸腔镜肺段切除膨胀萎陷法确定肺段间平面,将立体段间平面进行降维后裁剪的手术方法的临床应用效果。 方法回顾性分析2018年12月至2019年12月收治的微创胸腔镜肺段切除术,应用膨胀萎陷立体降维法处理段间平面的28例病人临床资料。全部病人术前胸部薄层CT明确肺部病变,在胸腔镜三维重建引导下完成肺段切除,部分多发结节病人联合肺楔形切除;肺段动、静脉及气管处理完成后,应用膨胀萎陷法显示出段间交界后,通过超声刀或者电钩等能量器械对立体的段间平面进行分离,降低段间平面的立体维度,段间静脉作为重要的段间平面标志引导降低维度,将降维后的段间平面应用切割缝合器处理。 结果全组均顺利完成手术,无中转开胸病例,胸腔镜下解剖清晰,操作顺利;单肺段切除9例,联合肺段或肺亚段切除11例,肺段联合肺楔形切除8例;共切除病变数37个。膨胀萎陷等待约15 min段间交界清晰可见;超声刀或者电钩分离段间平面无明显出血,保留段间静脉,术毕膨肺,余肺舒展度良好,无严重压榨。术后肺轻度漏气5例经引流愈合,复查胸片肺复张良好;总引流量(494.64±332.45)mL;引流时间(4.04±1.50)d;住院时间(6.79±2.46)d。围术期无严重并发症及死亡病例。 结论微创胸腔镜下可安全施行肺段切除,膨胀萎陷法可以清晰显示肺段间平面,立体的段间平面进行降维后裁剪更简单易操作,减轻压榨,术后余肺舒展性更好。 Abstract:ObjectiveTo determine the intersegmental plane of lung by thoracoscopic pulmonary segmental resection with inflatio-deflation method, and investigate the clinical effects of cutting out the three-dimensional intersegmental plane after dimensionality reduction. MethodsThe clinical data of 28 patients treated with minimally invasive thoracoscopic pulmonary segmentectomy by the dimensionality reduction handling intersegmental plane from December 2018 to December 2019 were retrospectively analyzed.The lung lesions in all patients were identified uisng the thin-layer CT of chest before operation, the pulmonary segmentectomy was implemented under the guidance of three-dimensional reconstruction of thoracoscopy, and some patients with multiple nodules were treated with pulmonary wedge resection additionally.After the pulmonary artery, vein and trachea were treated, the intersegment junction was shown by the inflation-deflation method, the three-dimensional intersegmental plane was separated by ultrasonic knife or electric hook and other energy instruments to reduce the three-dimensional dimension of the intersegmental plane.The intersegmental vein was used as an important intersegmental plane symbol to guide the reduction of the dimension, and the intersegmental plane after the dimensionality reduction was processed by cutting stapler. ResultsThe operation was successfully completed in all groups, and no cases were transferred to thoracotomy.Thoracoscopic anatomy was clear, and the operation was smooth.Nine patients were treated with single pulmonary segmentectomy, 11 patients were treated with pulmonary segmentectomy combined with pulmonary segmentectomy or subpulmonary segmentectomy, and 8 patients were treated with pulmonary segmentectomy combined with pulmonary wedge resection.A total of 37 lesions were resected.The boundary between sections was clearly visible for about 15 minutes after the inflation-deflation.There was no obvious bleeding in the plane of the separation segment with ultrasonic scalpel or electric hook, and the veins between segments were retained.The lung was expanded after the operation, with good lung stretch and no severe pressing.After operation, 5 cases with mild pulmonary air leakage were healed by drainage, and the pulmonary reexamination showed good lung expansion.The total drainage volume was (494.64±332.45)mL, the drainage time was (4.04±1.50)d, and the length of hospital stay was (6.79±2.46)d.There were no serious complications and death in perioperative period. ConclusionsThe pulmonary segmentectomy can be safely operated under the minimally invasive thoracoscopy, the inflation-deflation method can clearly show the intersegmental plane of lung, the three-dimensional intersegmental plane can be easier to cut after dimensionality reduction, relieve squeezing and achieve better stretch of the rest lungs. -
[1] FREDDIE B, JACQUES F, ISABELLE S, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2018, 68(6): 394. doi: 10.3322/caac.21492 [2] 宋勇, 袁冬梅. 肺部结节处理中的几点思考[J]. 中华医学杂志, 2019, 99(2): 81. [3] 王群, 蒋伟, 奚俊杰. 肺部多发磨玻璃影的外科治疗[J]. 中国肺癌杂志, 2016, 19(6): 355. [4] 刘瀚, 陈亮, 朱全, 等. 完全胸腔镜下解剖性肺段切除术与肺叶切除术治疗肺部小结节的近期疗效比较[J/CD]. 中华临床医师杂志(电子版), 2012, 6(13): 103. [5] SCHUCHERT MJ, ABBAS G, AWAIS O, et al. Anatomic segmentectomy for the solitary pulmonary nodule and early stage lung cancer[J]. Ann Thorac Surg, 2012, 93(6): 1780. doi: 10.1016/j.athoracsur.2011.11.074 [6] 张云嵩, 杨晨露, 陈建, 等. 单孔胸腔镜解剖性肺段切除治疗肺部小病变395例临床分析[J]. 第二军医大学学报, 2019, 40(8): 827. [7] WANG J, XU X, WEN W, et al. Modified method for distinguishing the intersegmental border for lung segmentectomy[J]. Thorac Cancer, 2018, 9(2): 330. doi: 10.1111/1759-7714.12540 [8] 陈醒狮, 金润森, 李鹤成, 等. 肺段切除术中段间平面处理方式的研究进展[J]. 中国微创外科杂志, 2019, 19(2): 190. [9] XIE D, WANG H, FEI K, et al. Single-port video-assisted thoracic surgery in 1063 cases: a single-institution experience[J]. Eur J Cardiothorac Surg, 2016, 49: i31. doi: 10.1093/ejcts/ezv408 [10] GONZALEZ-RIVAS D, FIEIRA E, MENDEZ L, et al. Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy[J]. Eur J Cardiothorc Surg, 2012, 42(6): e169. doi: 10.1093/ejcts/ezs482 [11] 翟荣, 徐心峰, 王俊, 等. 肺段切除术中改良膨胀萎陷法影响因素研究[J]. 南京医科大学学报(自然科学版), 2018, 38(8): 1136. [12] TAKAGI K, HATA Y, SASAMOTO S, et al. Late onset postoperative pulmonary fistula following a pulmonary segmentectomy using electrocautery or a harmonic scalpel[J]. Ann Thorac Cardiovasc Surg, 2010, 16(1): 21. [13] KURODA H, DEJIMA H, MIZUMO T, et al. A new Liga Sure technique for the formation of segmental plane by intravenous indocyanine green fluorescence during thoracoscopic anatomical segmentectomy[J]. J Thorac Dis, 2016, 8(6): 1210. doi: 10.21037/jtd.2016.04.61 [14] 陈亮, 王俊, 吴卫兵, 等. 胸腔镜精准肺段切除术技术流程和质量控制[J]. 中国胸心血管外科临床杂志, 2019, 26(1): 21. [15] ASAKURA K, IZUMI Y, KOHNO M, et al. Effect of cutting technique at the intersegmental plane during segmentectomy on expansion of the preserved segment: comparison between staplers and scissors in exvivo pig lung[J]. Eur J Cardiothorac Surg, 2011, 40(1): e34. doi: 10.1016/j.ejcts.2011.02.021