結(jié)扎速血管閉合系統(tǒng).ppt

1、Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder Key Steps to Success,Huang Jian The 2nd Affiliated Hospital Sun Yat-Sen University, Guangzhou China,Introduction,Laparoscopic radical cystectomy with orthotopic neobladder (LRC-OIN) is increasingly accepted by urologists. It is no more

2、 the issue of feasibility but the issue of improvement for this procedure. Discuss the techniques of key steps in LRC-OIN,Haemostatic Instruments,Harmonic scalpel PK system Bipolar forceps LigaSure vessel sealing system Electric hook Hem-O-Lok,Hem-o-lok,PK System,LigaSureTM Vessel Sealing System,圖1-

3、2-10 結(jié)扎速血管閉合系統(tǒng),Ultracision-Harmonic Scalpel,Patiens position and trocar site,The Major Steps of the Procedure,Step 1: Pelvic lymphadenectomy Step 2:Dissection of seminal vesicle and Denonvelias fascia to expose the posterior aspect of prostate Step 3: Exposing the anterior aspect of bladder and pros

4、tate Step 4:Dividing the lateral pedicles of the bladder and the prostate Step 5: Dividing the apex of the prostate and urethra Step 6: Extracorporeal construction of Ileal neobladder Step 7:Intracorporeal neobladder-urethra anastomosis,Step 1: Pelvic Lymphadenectomy with electric hook and LigaSure,

5、Techniques of Pelvic Lymphadenectomy,Sequence: Lymphadenectomy before or after cystectomy extent: standard or extented Using instrument: harmonic scalpel, PK system bipolar clamp and electric scissors, or electric hook and LigaSure Attention: blood vessel and obturator nerve injury lymphatic leakage

6、 tumor cell seeding,Step 2: Dissection of seminal vesicle opening Denonvelias fascia,Step 3: Exposing the anterior aspect of bladder and prostate,Step 4: Dividing the lateral pedicles of the bladder and the prostate,Nerve sparing Non nerve sparing,How to protect the neurovalscular bundle,Nerve spari

7、ng techniques,Non nerve sparing techniques,Step 5: Dividing the urethra,Step 2 to step 5: Cystectomy,Posterior aspect Anterior aspect Bilateral pedicles Prostate apex and urethra,How to avoid rectum injury,Correctly localized seminal vesicle Opening the Denonvelias fascia and separating rectum from

8、prostate Dividing lateral peadicle close to the prostate Transecting the urethra while pulling up the prostate apex,How to deal with the DVC,Clearly exposing the prostate apex Suture ligating and transected with scissors Different techniques : Ligasure, PK forceps, Hem-o-lock, Endo-GIA,Different met

9、hods in dividing the lateral paedicles,LigaSure PK Forceps Endo-GIA Harmonic scalpel,How to avoid the tumor seeding,Avoidingbladder wall perforation Dont transgressing the tumor boundaries, Blocking up the bladder neck before transecting uretha,Step 6: Removal the spacimen and neobladder constructio

10、n,The technique of Extracorporeal formation of neobladder,5 cm of midline subumbilical skin incision M shape ileal pouch Implantation of ureters directly to the posterior wall of the pouch by means of ureteral half nipple.,Different techniques in formation of neobladder,Intracorporeally or extracorp

11、oreally Reconstruction: Studer pouch, hemi-kock pouch, T pouch, M pouch, Implantation of ureters: ileal chimney, ileal nipple, extramural serous-lined tunnels, mucosal sulcus, ureteral nipple,Studer pouch T pouch Hemi-kock pouch,ileal chimney,ileal nipple,extramural serous-lined tunnels,Mucosal sulcus,Ureteral nipple,Step 7: Neobladder- urethra anastomosis Two running sutures technique,Tips and tricks in Neobladder- urethra anastomosis,A traction stitch to relieve the tension Changing to head-up position Two running suture technique better than interrupted, or running suture technique.