009兽医师外科手术基础esavs chinese proceeding

1、ESAVSTrainingOptimizingtheManagementofClinical Disorders in Companion AnimalsSmall Animal Softe ESAVSTrainingOptimizingtheManagementofClinical Disorders in Companion AnimalsSmall Animal Softe Shanghai 30November-4CourseProf.Dr.GillesDupr(A) Dr. Laurent Findji (UK) Dr. Armin Pirker (A)Dr.GabrieleGrad

2、nerEuropeanSchoolforAdvancedVeterinaryEuropeanSchoolforEuropeanSchoolforAdvancedVeterinaryEuropeanSchoolAdvancedVeterinaryFoundedin1991aspilotprojectofthe“CometII”EuropeanSchoolAdvancedVeterinaryFoundedin1991aspilotprojectofthe“CometII”programmeoftheEuropeanUnion.Since1996supportedby the EU“Leonardo

3、daVinci”Abranchof theEAVS, EUROPEAN (reg underVol 411,Folio100,Case4in List of“OptimizingtheManagementofClinicalDisordersin Companion Animals”Shanghai/30November-4December Wewouldliketoexpressourspe ESAVS course:lnkstothefollowingcompaniesforsupportingWebsite:Veterinary Information SponsorofthePrinc

4、ipalSponsorofthe第一天（200911 30 日）：腹部手术讲第二天(200912 1 日)：实践操作GDLFAPAPGGLFGD 8:00-LFGDAPGD 13:00-第三天(200912 2 日)：基础整形手术，手第四天(200912 3 日：实践操作GDGG 8:00-LF第一天（200911 30 日）：腹部手术讲第二天(200912 1 日)：实践操作GDLFAPAPGGLFGD 8:00-LFGDAPGD 13:00-第三天(200912 2 日)：基础整形手术，手第四天(200912 3 日：实践操作GDGG 8:00-LFAP 13:00-第五天(200912

5、4 日：上午为临床病例，计持续时间讲上午临床病例课程讲师GillesDupre 8:00-计持续时间讲GillesDupre 8:30-12:1515分钟)上午协助讲师 : Gabriele Gradner下午协助讲师 : Armin Pirker对计持续时间讲GillesDupre8:30-12:1515分钟)上午协助讲师 : Armin Pirker下午协助讲师 : Gabriele Gradner教育背景和 职教育背景和 职 其研切开和关闭腹安全切开和闭合消化如何闭合创Prof.Dr.Gilles1A consistent methodestinal tract肠道From duoden

6、um 十二指肠至降结肠LymphnodesProf.Dr.Gilles1A consistent methodestinal tract肠道From duodenum 十二指肠至降结肠Lymphnodes The gutters and 大肠和腹膜后Colon and duodenum 结肠和十二指肠牵拉部Kidney, adrenal, ureter, 肾，肾上腺Followthe GI Stomach Duodenum十二指 Jejunum空 Ileum Caecum Colon结 Rectumnksto Dr.A.Abdominlinspeion A conitent method Ca

7、udalpart 后部Colon,inguinal rings,bladder, pros e, uterus结肠环。Abdominlinspeion A conitent method CranialpartDiaphragm, 膈 esophagus,道 Biliarytree胆Stomach, 胃 pylorus 幽门, Pancreas, 胰腺Portal V, CanI use the Openandclosethe打开和关闭腹腔Univ.Prof.Dr. GillesDipl.DIUpologie erventionnelle, DIUthoracoscopieKle erchir

8、urgie, VE T E R I N R M E D IZ IN IS C H E U N IV E R S I T T W IE Prof.Dr.Gilles2Tighterisnotbetter过紧并不好！Before HeatedfluidsincreaseProf.Dr.Gilles2Tighterisnotbetter过紧并不好！Before Heatedfluidsincreasepatientstemperature加Antisepticsandantibioticsdonotprevent Aspirate the fluids and count the sponges B

9、efore Specimen 标本采Histology组织学检Bacteriology细菌学检 Tubes ?Prof.Dr.Gilles3Suture type and dehiscence Poole (Am. Surg.1984), Freeman (Vet. Surg 1984) ): Polyglactin910 = Polyglycollic A. = Monofilament Polydioxanon= Non resorbable MonofilamentSuture type and dehiscence Le r(Eur. Surg.Prof.Dr.Gilles3Sutur

10、e type and dehiscence Poole (Am. Surg.1984), Freeman (Vet. Surg 1984) ): Polyglactin910 = Polyglycollic A. = Monofilament Polydioxanon= Non resorbable MonofilamentSuture type and dehiscence Le r(Eur. Surg. Res.-1976),Leese, Ellis - (Surg. Suture the tsit Whereistheer缝合在什么部位强度高？Rosin(Vet.Surg.Suturin

11、gtheexternalismandatorybutsufficient缝合外面筋膜是必须和充分的。Karpieni (Surg. Gynecol. Obst. 1976) Kapur (Am. J. Surg. 1979)Suturingthedoesnotincrease缝合腹膜并不增加抗力。Archibald Suturing all the planes, including perito dehiscence缝合全层，包括腹膜，防止裂开外腹直肌内腹直腹外斜腹内斜腹腹横Theclosureobjective 闭合目的： 防止裂开 Which layers 哪层 What suture

12、material Which technique Patient Prof.Dr.Gilles4Suture/ woundlength 缝合长度率LangenbecksArchSurg.2001 Suture length to woundlength ratio 4/1 to 缝合长度比伤口长度率Prof.Dr.Gilles4Suture/ woundlength 缝合长度率LangenbecksArchSurg.2001 Suture length to woundlength ratio 4/1 to 缝合长度比伤口长度率4/1 到High tensutureleads to weake

13、r scar !高张力缝合导致较弱的瘢Suture/ wound length 缝合长度率Tighterisweaker越紧强度越小！errupted and mutifilament create more 简单结节和炎Hoer J, EurSurgRes. 2000;32(6):359-Influence of suture material and suture technique on idline laparotomies.Inflammation issignificantlyhigherwith errupted sutures and withPolyglactin 910/P

14、olypropyleneSuture technique and dehiscence 缝合技术和裂开Simple continuous bsorbableandnonabsorbable简单连续缝合通常使用吸收或是不可吸收线Suture type and dehiscence Crowe(Vet. Surg. 1978) 550 cases, contiuou ture withPolyproplene = 1 Looysen (Vet. Surg 1988) No bet n simple errupted and simple continousProf.Dr.Gilles5 Monof

15、ilamentneed more 需要多打For simple Start with Prof.Dr.Gilles5 Monofilamentneed more 需要多打For simple Start with Finish with Suture in risky Abdominal 腹腔积 Hypoproteinemia 低蛋白血 Chemotherapy Cushing库兴Suture in risky Abdominal 低蛋白血 Chemotherapy CushingMonofilament 单纤Slowlyabsorbable or 吸收缓慢或不可吸NoSuturesfrom5

16、to10mmfrom从切线510mm处开始无张力缝合Newabsorbablesuturesare新的吸收线被应Prof.Dr.Gilles6s结论 Can I Prof.Dr.Gilles6s结论 Can I use smaller Can I use a r needle CouldI make a simple ture Could it beless tight 能不能松一些ESAVSSofteSurgeryBasic(CourseMaster:Univ.Prof.Dr.GillesESAVS 软组织手术基础(Univ.ProfDrGillesOpenandclosesafelythe

17、安全的开腹和关腹Univ.Prof.Dr.GillesPreoperative Preoperative management of most animals undergoing exploratory laparotomy is dic ed by the underlying abdominaldisease. GeneralESAVSSofteSurgeryBasic(CourseMaster:Univ.Prof.Dr.GillesESAVS 软组织手术基础(Univ.ProfDrGillesOpenandclosesafelythe安全的开腹和关腹Univ.Prof.Dr.Gille

18、sPreoperative Preoperative management of most animals undergoing exploratory laparotomy is dic ed by the underlying abdominaldisease. Generalobservations include: notingtheanimalsattitude and ture, temperature, respiratory rate and effort, and heart rate and rhythm. Abdominal auscul , and palpation

19、plus rectal examination are indicated. ravenous catheter should placedfor fluid and drugadministration, and blood lesshould be drawn. Useful initial blood shall be performed, depending on the animals condition and ed underlying Electrolyteandhydrationabnormalitiesshouldbecorrectedbeforesurgery.Minim

20、aldataincludePCV, BUN and Albumin.的况和可能的疾病。电解质和脱水异常应该在术前被纠正。最少的数据应该包括 PCV、BUN 和白蛋白。Surgical 术部解剖The rectus sheath is ed of an external ernal leaf . The external leaf is formed by aponeurosisof theexternal abdominal oblique muscle and aportion of theaponeurosis of abdominal oblique muscle. The aponeu

21、rosis of the transversus abdominis muscle joins the leaf near the pubis. ernal leaf consists of aportion of the aponeurosis of ernaloblique muscle, the aponeurosis of the transversus abdominis muscle, and the transversalis .ernal leaf disappears in the third of the abdomen where the of ernal abdomin

22、alobliquemusclethe external leaf, leaving the caudal abdominis muscle covered only by a thin sheet .和一部分腹内鞘斜膜和腹横筋膜组成。内层在腹腔后部消，20091130日-1247Openingthe打开腹腔The abdomen generally is explored by means of a ventral midline .ost animals the abdomen, including the inguinal areas and caudal thorax, should b

23、e prepared for aseptic surgery allowof the o thoracic or pelviccavities if sary. Preparing toosmall an Openingthe打开腹腔The abdomen generally is explored by means of a ventral midline .ost animals the abdomen, including the inguinal areas and caudal thorax, should be prepared for aseptic surgery allowo

24、f the o thoracic or pelviccavities if sary. Preparing toosmall an is a common mistake, particularly for abdominal exploration in trauma patients. Using electroscalpels is adequate to open every single layer of the . However er should be setr in order not to fulgurate es. After opening with an electr

25、oscalpel, suturesremovalisusuallydelayedby2to3腹部通常在腹正中线做切口。在大多数动物，整个腹部从胸腔后方到骨盆使用高频电刀切开，皮肤缝合拆线通常需要延期 2-3 天。 腹腔探查Tovisualize allabdominal structures y, the must extend from the xiphoid s the pubis. If only a specific abdominal structure will be examined, a shorter can be made. caudal abdominal extendi

26、ng from umbilicus to pubis is adequate for bladder similarly, a cranial abdominal (i.e., umbilicus to xiphoid s) allows evaluation of the and stomach. ally the midline is extended laterally at the xiphoid s (1 caudal to the last rib) to e ure of the liver, biliary system, and diaphragm. A (paralumba

27、r) celiotomy can be used to ex used for unilateral adrenalectomy.e the kidneys and adrenal glands; it is most Exploration of the suggestiononhowt1. ExplorethecranialExaminethediaphragm(includingtheesophagealhiatus)andtheentireliver(palpatetheInspectthegallbladderandbiliarytree;expressthegallbladdert

28、odetermineits Examinebothpancreaticlimbs(palpategently),theportalvein,hepaticarteries,andcaudalvena ExplorethecaudalInspectthedescendingcolon,urinarybladder,urethra,andeoruterineInspecttheinguinal。3. Explore-Palpateestinaltractfromtheduodenumtothedescendingcolonandobservethevasculatureand，20091130日-

29、12484. Exploretheguttersandretroperitnoneal-Usethemesoduodenumtoretractestinetotheleft,andexaminetheright-Palpatethekidneyandexaminetheadrenalgland,ureter,and- Use the descending colon to retract4. Exploretheguttersandretroperitnoneal-Usethemesoduodenumtoretractestinetotheleft,andexaminetheright-Pal

30、patethekidneyandexaminetheadrenalgland,ureter,and- Use the descending colon to retract the abdominal contents to the right. Examine the left kidney, adrenal gland, ureter, and ovary.Before关腹之前Take采Specimen should be harvested as soon as include : Pathologic and bacteriologic ssible after the explora

31、tion is completed. They les if needed. e les are usually more andiveasliquidAbdominallavage:Isitsary腹腔冲洗：这是必须的吗？Historically, many different antiseptics (i.e., povidone-iodine and chlorhexidine) and antibiotics have beenaddedtolavagefluids.Povidone-iodineisthemostwidelyusedantiseptic;however,thishas

32、 notshowna leffectinrepeatedexperimentalandclinicaltrials andmaybedetrimentalanimals with established peritonitis because the olyvinylpyrrolidone-inhibits chemotaxis. Similarly, there is no substantial t adding antibiotics to lavage fluid patients treated ppropriate systemic antibiotics. Room temper

33、ature lavage fluids should not used in anesthetized patients. Heated lavage fluids have been proven to be effective in increasing the temperature in dogs.剂（聚维酮碘和氯己定）SpongesandmaterialBeforeclosureisattempted,allfluidsshouldbeaspiratedandspongesshouldbe是否需要插饲管In cases of major abdominal surgery, when

34、 peritonitis, pancreatitis or long standing anorexia ipated,toplaceafeeding tubeshouldbedone atthisverymoment.t are to be placed directly jejunostomy tubes.o the include : Gastrostomy, gastro-jejunostomy ，20091130日-1249Closureofthe关闭腹腔Suturematerialand缝合材料和缝合方法The linea alba may be closed with errup

35、ted sutures or a simple ture The simple continuous technique does not increase the risk of dehiscence when properly (i.e., secure knots and appropriate suture material), and it allows for Closureofthe关闭腹腔Suturematerialand缝合材料和缝合方法The linea alba may be closed with errupted sutures or a simple ture Th

36、e simple continuous technique does not increase the risk of dehiscence when properly (i.e., secure knots and appropriate suture material), and it allows for closure. Preferably absorbable suture material er631, polydioxanone, polyglyconate, and poliglecaprone should be used for continuou ture patter

37、ns, and six to eight knots should be placed at each end of the inci line. Monofilament, nonabsorbable suture material (i.e., nylon and polypropylene) has been asso ted with suture sinus formation and should be avoided.连续缝合不会增加开裂风险且缝合速度快，节约时间。连续缝合时选用抗张力好的可吸收材料（如 er 63125）6-8 个结。单股非Suturethenadequates

38、uturelengthtowoundlengthratio缝合腹膜合适的缝合线长度与切口长度比The is the holding layer of the . In order to R of 4.1 to 8.1, erruptedincorporate 4 to 10 mm on each side of the in each suture. 5 mm apart, depending on the animals size. Tighten fficiently to e but not enough strangulate e because overly tight suture

39、s adversely affect wound healing. Incorporate thickness bites of the abdominal wall in the sutures if the inci alba). Do not incorporate the falciform ligament betnthefasis midline (i.e., through the l edges. If the is lateral the linea alba and if muscular ti sheathwithoutincludinge is ed (i.e., pa

40、ramedian ), close the external hesutures.Dotempttoincludehe 膜。间断缝合间距 5mm，这取决于动物的大小。拉紧缝合线但不要勒到组织，因为缝合过紧不利于伤口愈合。如果切口在正中（如通过腹白线）（如旁切口），Subcutisandskin皮下组织和皮肤的缝合Close subcutaneous e with a simple continuous pattern of absorbable suture material, and e the preputialis muscle fibers. Use nonabsorbable sut

41、ures or stainless steel staples to theskin. kinsutureswithout.，20091130日-124Key要ClosetheTightersuturesleadtoweakerscarsProf.Dr.Gilles1Thesubmucosa 粘膜下 The The submucosaprovidesplexusprovidesthe most of the strengthProf.Dr.Gilles1Thesubmucosa 粘膜下 The The submucosaprovidesplexusprovidesthe most of the

42、 strengthfor the GI tractbloodsupply to the 粘膜下层是消化道强度最大tract TheSerosa,alwaysthe浆膜，总是浆膜当前知BasicscienceStructure and healing结构和愈合Suture technique缝合技Suturematerial 合材Operativeenvironment手术环Specifictechniques 裂开以现the digestive tract安全切开和闭合消化道Univ.Prof. Dr. GillesDIUp ologie erventionnelle,DIUthoracosc

43、opie Kle ierchirurgie,VUWV ET E R I N RM E D I Z I N I S C H E U NI V E R S IT T W IE Prof.Dr.Gilles2Everting, 外翻，内4060管腔狭Everting, Prof.Dr.Gilles2Everting, 外翻，内4060管腔狭Everting, 外翻，内Current 当前知BasicscienceStructure and healing结构和愈合Suture technique缝合技材Operativeenvironment手术环Specifictechniques prolong

44、s thelagphaseDigestive tract消化道愈Lagphase延滞: 0-4 : 3-14 : 10-180Digestive tract消化道愈Lagphase延滞:0-4 : 3-14 : 10-180Prof.Dr.Gilles3 One layer apsimple continuousis the techniqueof单层简单连续缝合Includethe包括Prof.Dr.Gilles3 One layer apsimple continuousis the techniqueof单层简单连续缝合Includethe包括粘erruptedor结节缝合或连续缝合El

45、lison et al, JAAHA, 1982 Weisman et al, JAVMA, Asecondlayeritional适合做二层胃，食道Whatdoesasecondlayer第二层缝合能带来什么？itional leads to lebetter ap对位良好可is et al Surg. Gynecol. Obstet., 1968 Ellison et al, JAAHA, 1982Bellenger Aust. Vet. J Prof.Dr.Gilles4Surgeons 外科医生Patients病患影Prof.Dr.Gilles4Surgeons 外科医生Patient

46、s病患影Peritonitis, 腹膜炎Foreign body, 异物Alb 75 Isitviable 是否能存Onelargeresectionorseveral Isitviable 是否能存 Other其它技Fluorescein 95 % accurate for non viable 95确定不能存活肠58% accuratefor viable 58 确定能够存活Doppler flowPulse oxymetryMost common error : 常犯的错Resection of viable segments切除可存活肠Isitviable 是否能存 Adapt 使直径

47、适Prof.Dr.Gilles8Current 当前知BasicscienceStructure and healingSuture techniqueSuturematerial缝合 料Operative environmentProf.Dr.Gilles8Current 当前知BasicscienceStructure and healingSuture techniqueSuturematerial缝合 料Operative environmentSpecifictechniques Gastricclosure胃闭合Onelayer SITwolayersMucosa(1)- Sero

48、musculosa 粘膜（1浆膜肌层itional / Inverting ?同一位置/Particularitiesof 特殊胃闭Low bacteriacountLow No Serosal 浆膜Prof.Dr.Gilles9Openandclose safelythedigestive 3FeedProf.Dr.Gilles9Openandclose safelythedigestive 3Feed喂他Openandclose safelythe digestive 2Youaretheho 只有你自己了解情Openand closesafelythedigestiveThink V s

49、l 考Howtobe estinal surgery 肠道手术如何成Theywonteat Sticka tube in ESAVSSofteSurgeryBasic(CourseMaster:Univ.Prof.Dr.GillesESAVS 软组织手术基础(Univ.ProfDrGillesOpenandclosesafelythedigestive安全的切开和闭合消化Univ.Prof.Dr.GillesDehiscence used to be a major complication estinal surgery. In ESAVSSofteSurgeryBasic(CourseMa

50、ster:Univ.Prof.Dr.GillesESAVS 软组织手术基础(Univ.ProfDrGillesOpenandclosesafelythedigestive安全的切开和闭合消化Univ.Prof.Dr.GillesDehiscence used to be a major complication estinal surgery. In one study in the dog, Smeak and observed 15,7 % estinal wound dehiscence.Thehis group 73,3 % against 6,9 he non dehiscent g

51、roup. Another study by andHosgood showeda dehiscence group mortality of 80 % against 7,2 he non dehiscent. Given these other retrospective studies have been conducted more recently and show a dehiscence rate n1to2%.Thesearethe teverysingleveterinarysurgeonshould Hosgood 6.9%。Wy率为 80%，而非开裂犬7%7.2%明开裂发

52、生率在 Basic surgical techniques基本手术技estinal wall structureThe sub mucossa is rich in elastin and collagen fibers; also the majority of s o submucosa. Then it is the most solid layer of the penetrate the sub-mucosa.estine and any suture of estinal tract Healing of the digestive tract消化道的愈合During the la

53、g phase (from day 1 to 3) most of the er of the anastomosis is due to sutures. During the proliferation phase (day 3 to 14) the fibroblasts product collagen and the must erfere with collagen production. During the maturation phase (day 15 to 180) the anizes;duringthisperiod the sutureshaveno 细胞产生胶原和

54、缝合线必须不能干扰胶原的产生。在成熟阶段（第 15-180 天）胶Effect of suture patterns缝合方法的作用Theylook proofas soon astheyare done.Also,their tensile strength is n atternsto the fifth day, but they carry major cons. Thi effective only after 2ks. Finally,ture pattern is stenosing and mucosal bridging an, the mucosal seems to be

55、painful tendstoalterestinal成狭窄且粘膜桥在 2 周后才能有效。最后，至少在人，粘膜内翻会造成疼痛和改变肠管的运动性。，20091130日-124 Although he past e the disadvantages of inverting pattern they are stenosing create a huge local inflammation. During the lag phase their tensile strength is low whi this type of anastomosis more prone to dehiscen

56、ce.ay EffectsofThispatternallowsdirectitionofthearterio-venousplexuses,theliasationandformation.Howevermucosalisstilla Although he past e the disadvantages of inverting pattern they are stenosing create a huge local inflammation. During the lag phase their tensile strength is low whi this type of an

57、astomosis more prone to dehiscence.ay EffectsofThispatternallowsdirectitionofthearterio-venousplexuses,theliasationandformation.Howevermucosalisstilla 哪种缝合材料、哪种缝合针、哪种直径Everything has been he past: from Catgut to stainless steel. Today two ypes of materialmeet ourrequestedcriteria: Holdingduringthela

58、gphaseandavoidingaviolent reaction- the synthetic braided absorbable as Polyglactin 910 and polyglycolic acid or the absorbable monofilament as Polydioxanone, Polyglyconate, Polyglecaprone etc However because of longer half-life, their very small e drag and local reaction, absorbable monofilament is

59、 preferred. Decimal 1 to 1,5 (4/0 or 5/0) on a round needle is preferred use decimal 1,5 to 2 (4/0 or 3/0)he he dog we 如聚二氧六环酮、葡聚糖酸酯、Polyglecaprone 等。但由于可吸收单纤丝半衰期长、组织牵拉小和局部0.1-0.15（4/0or5/0）0.15-0.2（4/0or3/0） 间断结节、简单连续或库兴氏缝合？Fluorescein study has been conducted to compare histologically the suture l

60、ine of simple continuous or crushing sutures. It t crushing techniques generate many trauma, necrosis, hemorrage andmucocleformation. They should be avoided. Asimple suture promotes a better vascularisation of the wound up to day 20. Adhe are less frequent.s and mucosal 20 ，20091130日-124Enterotomy肠切