力学原理在胰十二指肠切除术中的应用:“1管2针3缝”式胰肠吻合术(附视频)
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浙江大学医学院附属邵逸夫医院 普通外科,浙江 杭州310016

作者简介:

张津鸣,浙江大学医学院附属邵逸夫医院实习医师,主要从事肝胆胰外科方面的研究。

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国家自然科学基金资助项目(82473007)。


Application of mechanical principles in pancreaticoduodenectomy: "1-tube, 2-needle, 3-suture" pancreaticojejunostomy (with video)
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Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou 310016, China

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    摘要:

    胰肠吻合是胰腺重建手术中最具挑战性的步骤之一,其影响患者的预后。胰腺具有形态上窄下宽、组织脆弱、富含消化酶以及肠道持续蠕动等特点,这些因素易导致胰肠吻合口的松动和术后胰瘘的发生。通过力学建模分析及临床实践总结,笔者提出了一种基于力学原理的胰肠吻合方法。该方法概括为“1管2针3缝”,即1根胰管支撑管、2种和2根不同缝线以及3种不同的缝合方法。本文将详细介绍这一操作方法,并深入解析其技术原理。此外,对笔者中心病例进行回顾性分析总结发现,该方法可有效降低术后胰瘘的发生率。

    Abstract:

    The pancreatojejunostomy is one of the most challenging steps in pancreatic reconstruction surgery, and its success directly impacts the patient's prognosis. The pancreas has characteristics such as being narrow at the top and wide at the bottom, fragile in texture, rich in digestive enzymes, and subject to constant intestinal peristalsis. These factors can easily lead to the loosening of the pancreatojejunostomy site and the occurrence of postoperative pancreatic fistula. Through mechanical modeling analysis and a summary of clinical practice, the authors propose a pancreatojejunostomy method based on mechanical principles. This method is summarized as "1-tube, 2-needle, 3-suture" method, which refers to one pancreatic duct stent tube, two types and two strands of different sutures, and three different suturing techniques. This article will provide a detailed introduction to this operative method and deeply analyze its technical principles. Additionally, a retrospective analysis of cases from the authors' center found that this method can effectively reduce the incidence of postoperative pancreatic fistula.

    图1 2种和2根不同缝线的区别和目的 A-B:使用2根可吸收缝线固定胰管支撑管,缝线被吸收后支撑管可自行脱落;C-D:使用2根不可吸收缝线进行前后壁的吻合,1根缝线脱落时另1根不受影响,保证吻合的牢固性Fig.1 Differences and purposes of two types of sutures and two sutures A-B: Using two absorbable sutures to secure the pancreatic duct support tube; once the sutures are absorbed, the support tube can detach on its own; C-D: Using two non-absorbable sutures for the anastomosis of the anterior and posterior walls; when one suture detaches, the other remains unaffected, ensuring the stability of the anastomosis
    图2 胰肠吻合手术步骤拆解 A:固定胰腺端支撑管;B:胰腺上缘8字缝合止血;C:全程贯穿缝合;D:空肠开孔;E:“U”型缝合固定肠端支撑管;F:半程后壁缝合;G:胰腺下缘8字缝合止血;H:半程前壁宽基底缝合Fig.2 Detailed steps of pancreaticojejunostomy procedure A: Fixing the pancreatic end support stent; B: Hemostasis with 8-shaped suture on the upper edge of the pancreas; C: Continuous through-and-through suturing; D: Opening in the jejunum; E: U-shaped suturing to fix the intestinal end support stent; F: Partial posterior wall suturing; G: Hemostasis with 8-shaped suture on the lower edge of the pancreas; H: Partial anterior wall wide-base suturing with a wide base
    Fig.
    图3 采用与不采用宽基底连续缝合后吻合口的变化 A:普通缝合,胰腺残端未被小肠包裹;B:宽基底连续缝合,胰腺残端被小肠包裹Fig.3 Changes in anastomosis with and without wide base continuous suturing A: Standard suturing, pancreatic stump not covered by the small intestine; B: Wide base continuous suturing, pancreatic stump covered by the small intestine
    图4 胰肠吻合后的空肠环形肌受力分析(F表示环形肌的收缩力,→表示收缩力方向) A:普通吻合完毕后环形肌的张力状态;B:宽基底连续缝合后空肠环形肌的张力状态Fig.4 Analysis of force on the jejunal circular muscle after pancreaticojejunostomy (F representing the contraction force of the circular muscle, and → indicating the contraction force direction) A: Tension state of the circular muscle after standard anastomosis; B: Tension state of the jejunal circular muscle after wide base continuous suturing
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张津鸣,沙洪存,陈鸣宇.力学原理在胰十二指肠切除术中的应用:“1管2针3缝”式胰肠吻合术(附视频)[J].中国普通外科杂志,2024,33(9):1422-1429.
DOI:10.7659/j. issn.1005-6947.2024.09.009

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  • 收稿日期:2024-07-09
  • 最后修改日期:2024-08-25
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  • 在线发布日期: 2024-10-12