强生Scienceofstapling

1、section 1:the origins of surgical stapling吻合口原则吻合口原则 anastomotic principles无组织张力 no tissue tension无吻合口漏 leak-proof anastomosis止血效果好 good hemostasis足够的吻合口血供 adequate blood supply足够的吻合口内径 adequate lumenthese tenets are the basis of modern surgical craftsmanship.吻合器起源吻合器起源 the origins of surgical stapl

2、ing1,2病患的预后推动了器械的革新病患的预后推动了器械的革新 innovation driven by patient outcome避免组织污染 prevent contamination缩短手术时间 shorten operations用最简单可靠的方法关闭组织close the tissue in a simple, reliable manner1. baker rs, et al. obes surg. 2004;14:1290-1298.2. hardy kj. aust n z j surg. 1990;60(8):625-633.1909first instrument w

3、as invented by humer hltl in hungary1921aladr von petz produced a simpler device; considered the forerunner of modern open mechanical staplersthe origins of surgical stapling1,2早期所有成功的器械及缝合器均遵循同一条思路组织处理早期所有成功的器械及缝合器均遵循同一条思路组织处理all successful early devices and staplers are linked by a common thread t

4、issue management:基本原则基本原则 these fundamental principles:用特定的压力使组织闭合压力使组织闭合coapt tissue with a given amount of compression同时在两排缝钉间进行切割 simultaneous cutting between opposed staple lines along a sturdy anvil使金属缝钉缝钉b字成形字成形以稳固组织 hold tissue immobile while driving metal staples with precision (b-shaped)1.

5、astafiev gv. surgical staplers (chirurgicheskiey shivayushiye apparaty). 1967;7 translated from the russian.2. baker rs, et al. obes surg. 2004;14:1290-1298. 1950srussians develop modern open staplersthe origins of surgical stapling1,2 重大里程碑重大里程碑 significant milestones - 1950s - 1990s:1958after obse

6、rving russian devices, an american surgeon, dr. mark ravitch introduces several key functional innovations including different length staple lines, a reusable stapler, sterile, preloaded cartridges, and the first circular stapler with a double row of staples1976ethicon, inc. introduces the first com

7、pletely disposable, single patient use mechanical stapler1980the dawn of minimally invasive procedures (mip). surgeons request laparoscopic adaptation of transecting linear cutter (tlc) device1989titanium replaces stainless steel as the key component for staplessection 2:the surgical stapler:endosco

8、pic vs. open platforms1. baker rs, et al. obes surg. 2004;14:1290-1298.吻合器的功能吻合器的功能 the function of surgical stapling1主要目的：利用最佳的压榨力以达到止血和防止吻合口漏的目的primary objective: hemostasis and leak prevention with optimal compression applied引起出血及漏的潜在因素 causes of potential leaks/hemorrhage from surgical stapling:

9、机械性因素 mechanical/tissue缝合线不完整 secondary to staple line failure引起漏的最常见因素 most common cause of leaks通常在术后2天 usually within 2 days post-op组织缺血 ischemic通常在术后57天 usually 5-7 days post-op较少见 rare开放器械开放器械 open surgical stapler platforms11. data on file, ethicon endo-surgery, inc.腔镜器械腔镜器械endoscopic surgical

10、 stapler platforms1* endogia is a trademark of covidien.1. data on file, ethicon endo-surgery, inc.组织压力组织压力 surgical stapler platforms compression直线形 linear弧形 curved圆形 circular直线型 linearopenezetsechelonendoscopicendogiasection 3: the staple缝钉规格缝钉规格 staple specifications11. ifus, ethicon endo-surgery

11、, inc.吻合钉吻合钉 the stapleliving tissue compressed to adequate thickness for stapling.living tissue before compression.living tissue after stapling. the material composition of the staple should avoid spring back to keep the tissue compressed.吻合钉的成形吻合钉的成形 the staplebadgood成钉形态成钉形态 staple formation cont

12、inuum缝钉材质缝钉材质staple material 钛钛 titanium原子结构atomic structureatomic structureafter deformation force缝钉材质缝钉材质 staple material 钛合金钛合金titanium alloyatomic structureafter deformation force缝钉材质缝钉材质 staple material 钛合金钛合金titanium alloysection 4: tissue dynamics组织特性组织特性 tissue characteristics1-41. baker rs,

13、 et al. obes surg. 2004;14:1290-1298.2. bischoff je. ann biomed eng. 2006;34(7):1164-1172.3. bischoff je, et al. biomech model mechanobiol. 2004;3(1):56-65.4. gu wy, yao h. ann biomed eng. 2003;31(10):1162-1170.压缩力学压缩力学 compression dynamics不同材料收压后的反应：钢材不同材料收压后的反应：钢材 reaction of different materials u

14、nder pressure: steel压缩力学压缩力学 compression dynamics不同材料收压后的反应：橡胶不同材料收压后的反应：橡胶 reaction of different materials under pressure: rubber压缩力学压缩力学 compression dynamics不同材料受压后的反应：生物组织不同材料受压后的反应：生物组织 reaction of different materials under pressure: tissue组织压缩与时间的关系组织压缩与时间的关系tissue compression dynamics over tim

15、efthickness1time1time2thickness215秒的压榨过程使组织达到最佳的缝合厚度秒的压榨过程使组织达到最佳的缝合厚度15 seconds of compression will compress thick tissue to an optimum thickness for stapling. 5 seconds15 seconds厚组织受压的时间因素厚组织受压的时间因素thick tissue compression over timesample: ets45 bluevideosection 5:tissue compressiondemonstrationtraining无压力击发无压力击发 without compression 缝合不完整缝合不完整缝合不完整缝合不完整 组织溢出组织溢出 钉砧变形钉砧变形video w/o compression有压力击发（等待有压力击发（等待15秒）秒）with compression等待等待15s后击发后击发等待等待15s后缓慢击发后缓慢击发等待等待15s后击发后击发surgical stapling 2009 ethicon endo-surgery, inc.fo