体位对纵隔淋巴结的影响-谭黎杰

胸、腹腔镜的食管癌根治术的淋巴结清扫问题体位和插管对纵隔淋巴结清扫的影响,复旦大学附属中山医院胸外科谭黎杰,MIE经过20年的临床应用，虽然仍有争议，但已被多数的食管外科医师所接受如同食管癌开放手术，MIE存在多种手术方式的共存目前为止，不同MIE的手术方式其临床结果无显著差异,由于病理形式和综合治疗模式的不同，多数西方国家的文献并无食管癌手术中上纵隔淋巴结清扫的报道迄今，食管鳞癌的手术标准仍以日本“扩大二野及三野淋巴结清扫”为较高标准因此，胸腔镜下上纵隔尤其左侧喉返神经淋巴结清扫是这一技术不可绕过的问题,2010新版分期中N的重新定义,2010版分期中食管癌淋巴结引流区域,胸腔镜下如何做到纵隔淋巴结清扫？,Advantages of radical VAE,the magnifying effect of the surgical field and alteration of the viewpoint of the surgeonVAE is performed using common visual information shared by all of the surgical staff.,Udagawa et al. Rationale for video-assisted radical esophagectomy Gen Thorac Cardiovasc Surg (2009) 57:127131,Disadvantages of video-assisted surgery,loss of three-dimensional recognition limited tactile sensationThe alteration of the viewpoint requires technically more sophisticated handeye coordination.,Udagawa et al. Rationale for video-assisted radical esophagectomy Gen Thorac Cardiovasc Surg (2009) 57:127131,Advantage of using VATS (example 1),The right recurrent laryngeal nerve can be observed in more detailed fashion with VATS. Identifi cation of its small branches and dissection of the nerve are more accurate,Corresponding operative field under conventional thoracotomy. rrln, right recurrent laryngeal nerve; rv, right vagus nerve; rsc, right subclavian artery,Advantage of using VATS (example 2),Left recurrent laryngeal nerve can be observed in more detailed fashion withVATS. Identification of its small branches and dissection of the nerve are more accurate,Corresponding operative field under conventional thoracotomy. lrln, left recurrent laryngeal nerve; tr, trachea; sn, sympathetic nerve branch; ln, dissectedlymph nodes,胸腔镜和开发手术纵隔淋巴结清扫的比较,胸腔镜下食管旁淋巴结清扫不存在争议,胸腔镜隆突下淋巴结清扫,规范的左上纵隔（喉返神经旁）淋巴结清扫,质量控制？每一例都能清晰显露左侧喉返神经？将淋巴结清扫导致的神经损伤降至最小？手术时间和Ergonomics?,理论上气管、左总支气管与主动脉弓距离越大，越能清晰暴露左侧喉返神经手术野污染物越少越好给手术器械留下的操作空间越大越好,左侧卧位时如何做到,向患者腹侧、上方牵拉气管需要拉钩和优秀的助手减少术野的污染：吸引器和优秀的助手困难双腔管尤其左侧双腔管使助手必须用一定的力量牵拉原本狭小的空间放置多种器械，手术操作空间更为狭小,Thoracoscopic port site placement for MIO: left lateraldecubitus position. A, B 5-mm ports. C, D 10-mm ports,俯卧位的优势,重力作用本身使后纵隔间隙增大污染物不易影响术野普通气管导管的应用，气管下段和左总支气管内无导管通过，轻压上述结构及可获得较大的操作空间外科医生的Ergonomics好，手术时间缩短！,Thoracoscopic port site placement for MIO: prone position. A,C 5-mm ports. B 10-mm port,俯卧位右侧喉返神经的显露,俯卧位左侧喉返神经的显露,Thoracoscopic oesophagectomy in prone position improves the quality of dissection,The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harms way. Small to moderate bleeding will not obscure the operative field.Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon.,G. B. Cadie Surg Endosc (2006) 20:13081309,以在主动脉弓上暴露左侧颈总动脉为标准评价不同体位下左喉返神经的显露Noshiro等认为俯卧位有助于左侧喉返神经的显露，减少损伤的几率.,Noshiro Surg Endosc. 2010; 24: 2965-2973.,中山医院胸外科的临床结果,临床资料,2009.1 2010.12 回顾性分析156例TLE患者淋巴结清扫结果Group A：71例 常规二野清扫Gro