鏡面人胸腔鏡肺癌根治術(shù)

1、整理課件,1,“鏡面人”胸腔鏡手術(shù)經(jīng)驗分享,整理課件,2,“鏡面人”,“鏡面人”又稱“鏡子人”或“鏡像人”，即心臟、肝臟、脾臟、膽等器官的位置與正常人相反，心臟、脾臟在右邊，肝臟位于左邊，心、肝、脾的位置好像是正常臟器的鏡中像。,整理課件,3,左肺位于右側(cè)，左肺門形態(tài)同正常右肺門，右肺及右肺門則相反。心臟大部分位于右側(cè)胸腔，主動脈、心尖、胃泡軸線同在右側(cè)。升主動脈、右心房、肝臟軸線在左側(cè)，右肺低于左膈，形如“鏡像”。,整理課件,4,“鏡面人”雖然內(nèi)臟全部錯位，但只是位置發(fā)生變化，相互間的關(guān)系并未改變，因此生理功能與正常人一樣，對健康與生活都沒有太大影響。但值得注意的是，“鏡面人”一旦患病，醫(yī)生

2、如果照常規(guī)判斷極有可能發(fā)生誤診。,整理課件,5,“鏡面人”雖然內(nèi)臟全部錯位，但只是位置發(fā)生變化，相互間的關(guān)系并未改變，因此生理功能與正常人一樣，對健康與生活都沒有太大影響。但值得注意的是，“鏡面人”一旦患病，醫(yī)生如果照常規(guī)判斷極有可能發(fā)生誤診。,整理課件,6,全內(nèi)臟反位是人體胚胎發(fā)育過程中由于內(nèi)臟發(fā)生旋轉(zhuǎn)障礙而使全部內(nèi)臟器官形成解剖結(jié)構(gòu)的變異，發(fā)病率為120 00014 000，男女比例為3：2，患者通常無癥狀，與普通人壽命差異無統(tǒng)計學意義，確切的病因未知。它本身沒有臨床意義，但可能影響手術(shù)部位。目前，國內(nèi)已有“鏡面人”患者行肝臟、心臟、腎上腺手術(shù)的多例報道，關(guān)于全內(nèi)臟反位同時合并肺癌的報道不

3、多。,整理課件,7,醫(yī)療特點,為“鏡面人”做手術(shù)，極大地考驗了術(shù)者的逆向思維能力，臟器的反位使手術(shù)難度和手術(shù)風險都增大。醫(yī)生的手術(shù)習慣、技巧等也都要跟著一起“轉(zhuǎn)位”。原本技術(shù)越熟練的醫(yī)生可能越會犯錯。對病人來說，風險也在增大。,整理課件,8,給“鏡面人”做手術(shù)，花費的時間遠比正常人多，而且，有些內(nèi)臟手術(shù)還可能需要重新準備手術(shù)器械。許多醫(yī)生在為“鏡面人”做手術(shù)之前，還要經(jīng)過模擬演習。,整理課件,9,病例介紹,患者男，64歲，2017年5月就診，體檢發(fā)現(xiàn)左肺腫物2周，行胸部PET-CT示：全內(nèi)臟反位，鏡面右位心；左中葉占位性病變，代謝增高，周圍型肺癌可能雙側(cè)頸部、雙側(cè)肺門、4、5、6淋巴結(jié)，腹腔及

4、雙側(cè)腹股溝多發(fā)淋巴結(jié)，考慮炎性；患者為行進一步診治，就診于天津一中心醫(yī)院。否認家族中有類似病患者，否認兩系三代家庭性疾病遺傳史。,整理課件,10,病例,查體：體溫36.4，心率70次分，呼吸16次分，血壓12080 mmHg，體重70 kg，發(fā)育正常，營養(yǎng)中等，自主體位，神清合作，頸軟，無頸靜脈怒張，心律齊，無雜音，胸廓對稱無畸形，呼吸運動自如，兩側(cè)語顫基本正常，胸壁無壓痛，叩診呈清音，雙肺呼吸音清，未聞及干濕羅音，雙下肢無水腫。 纖維支氣管鏡示：隆突銳利、黏膜光滑、活動度好、位置正常；總氣管、左右主支氣管、左上中下支氣管、右上下支氣管黏膜光滑，色澤正常，管腔通暢，無新生物及分泌物。（麻醉前氣

5、管插管前細鏡） 心電圖示：I導聯(lián)、avL導聯(lián)P波倒置，QRS波以向下波為主，avR導聯(lián)P波直立，V。一V，導聯(lián)R波逐漸減小，s波逐漸增深，RS比例逐漸減小。將左右手反接，胸導聯(lián)V，V。置于右胸對應部位的心電圖示：V，V。導聯(lián)R波逐漸增高，s波逐漸減少，RS比逐漸增大。,整理課件,11,病例,整理課件,12,病例,整理課件,13,病例,整理課件,14,手術(shù)記錄,雙腔插管全麻成功后，取右側(cè)臥位，分別取第7肋間腋中線、第4肋間腋前線，第8肋間肩胛下角線分別做小切口，置入胸腔鏡及操作器械，探查見腫物位于左肺中葉外側(cè)段肺實質(zhì)內(nèi)，直徑約1.5cm，質(zhì)地韌，邊界清楚，不光滑，不活動，表面臟層胸膜凹陷，肺門周

6、圍可見多發(fā)明顯腫大淋巴結(jié)。腫物深在，無法行肺楔形切除術(shù)，遂按術(shù)前預案決定直接行胸腔鏡下肺葉切除術(shù)。鏡下游離肺門周圍縱隔胸膜，切斷下肺韌帶。游離左側(cè)中葉靜脈，以內(nèi)鏡血管縫合切開器切斷。打開斜裂，游離左肺中葉動脈外側(cè)段分支，以內(nèi)鏡血管縫合切開器切斷。游離左肺中葉支氣管，以內(nèi)鏡直線縫合切開器閉合后，通氣見左肺上下葉可充分復張，遂切斷中葉支氣管。游離中葉動脈內(nèi)側(cè)段分支，以內(nèi)鏡血管縫合切開器切斷。以內(nèi)鏡直線縫合切開器切開分化不全的水平裂后將左肺中葉完整切除。清掃2、4、7-10組淋巴結(jié),整理課件,15,對全內(nèi)臟轉(zhuǎn)位伴肺癌患者進行肺外科手術(shù)時，麻醉醫(yī)師及手術(shù)醫(yī)師均應重視并理解異常的胸腔解剖。全內(nèi)臟轉(zhuǎn)位患者

7、心臟及主動脈弓、食管位于右側(cè)，右肺只有兩葉，支氣管及動靜脈血供情況類似正常人左肺情況；左側(cè)胸腔沒有心臟及主動脈弓，有臍靜脈弓、上腔靜脈等結(jié)構(gòu)，左肺有三葉，支氣管及動靜脈血供情況類似正常人右肺情況。術(shù)前氣管鏡檢查、胸部CT掃描及心臟肺大血管三維重建可以顯示支氣管樹及肺門結(jié)構(gòu)異常，協(xié)助評估異常的胸腔解剖對肺癌手術(shù)的影響。,整理課件,16,病理-腺癌,整理課件,17,Lobectomy for lung cancer by video-assisted thoracic surgery in situs inversus.湘雅醫(yī)院中南大學 胸腔鏡右下葉 2017,A 62-year-old man

8、with situs inversus totalis and non-small-cell lung cancer underwent a right lower lobectomy by video-assisted thoracoscopic surgery. Lobectomy in a situs inversus totalis patient can be performed safely using this minimally invasive procedure. Preoperative evaluation of the pulmonary artery and vei

9、ns by three-dimensional computed tomography and the bronchial tree by bronchoscopy, is essential to avoid unanticipated complications during the procedure. Asian Cardiovasc Thorac Ann. 2017 Mar;25(3):219-221,整理課件,18,Abstract：Lung cancer and situs inversus totalis are two completely irrelevant condit

10、ions. The likelihood of both conditions occurring simultaneously in one person is very rare. We report here a case of a 50yearold man who presented with intermittent chest pain. Enhanced computed tomography of the chest showed situs inversus totalis and a round mediastinal mass embracing the thoraci

11、c aorta. The primary diagnosis was suggested as pseudo aortic dissecting aneurysm. However, a tumor in the right lower lung was discovered during surgery, which enclosed and invaded the thoracic aorta. Finally, the patient successfully underwent right lower lobectomy accompanied by lymph node excisi

12、on and partial replacement of the thoracic aorta with an artificial vascular graft under cardiopulmonary bypass.,Lung cancer mimicking aortic dissecting aneurysm in a patient with situs inversus totalis 2016 華西 右下葉切除,整理課件,19,Lung cancer mimicking aortic dissecting aneurysm in a patient with situs in

13、versus totalis 2016 華西,Thorac Cancer. 2016 Mar; 7(2): 254256.,整理課件,20,A patient with situs inversus totalis and lung cancer-a rare combination胸腔鏡左下葉 2016,Situs inversus totalis (SIT) is a rare clinical entity which is characterized by a complete reverse anatomy of the thoracic cage and abdomen. Ther

14、e are a few reports of patients with SIT and lung cancer. The number of the cases that have been treated surgically is also very small. We report a case of an 80 years old patient who underwent left lower lobectomy after staging with uniportal video-assisted thoracoscopic surgery (VATS) and mediasti

15、noscopy. Ann Transl Med. 2016 Nov;4(22):450.,整理課件,21,A patient with situs inversus totalis and lung cancer-a rare combination.Ann Transl Med. 2016 Nov;4(22):450.,整理課件,22,A patient with situs inversus totalis and lung cancer-a rare combination.Ann Transl Med. 2016 Nov;4(22):450.,整理課件,23,A patient wit

16、h situs inversus totalis and lung cancer-a rare combination.Ann Transl Med. 2016 Nov;4(22):450.,Lymph node (LN) 4L that were accessed with mediastinoscopy,整理課件,24,Lung Segmentectomy Using Video-assisted Thoracic Surgery for Lung Cancer in a Patient with Situs Inversus Totalis胸腔鏡左上 S3段切 2016,The case

17、 was 83-year-old man who had complete situs inversus, and was pointed out to have peripheral adenocarcinoma with the size of 1.8 cm at the left upper lobe( S3). Because of severe emphysema and other multiple comorbidities, left S3 segmentectomy with hilar lymph node sampling was performed using vide

18、o-assisted thoracic surgery (VATS). Preoperatively, the simulation of operation was performed using the 3 dimension computed tomography images of pulmonary arteriovenous and bronchus (3DCTAB). Postoperative course was uneventful. 3DCTAB was thought to be useful in understanding the anatomical locati

19、on of pulmonary arteriovenous and bronchus directly, and in performing segmentectomy in the case of situs inversus like this. Kyobu Geka. 2016 Jul;69(7):521-4.,整理課件,25,PET-CT診斷鏡面人伴肺動脈發(fā)育異常1例 2010 廣東醫(yī)學,整理課件,26,Lung resection for lung cancer in patient with situs inversus totalis胸腔鏡左中葉切除+左上葉部分切除 2013,S

20、itus inversus, which occurs in 1-2 of every 10,000 births, is a congenital malformation in which the thoracic and abdominal viscera are arranged in partial on complete mirror image of the normal anatomy. In the case of situs inversus, special attention must be taken in performing surgery. We present

21、 a surgical case of primary lung cancer in an 81-year-old patient with situs inversus totalis. During surgery, we used the Univent bronchial tube for one-lung ventilation. The appearance of the right lung and the arrangement of the pulmonary vessels and the bronchi corresponded to those normally fou

22、nd on the right side was noted at left thoracotomy. Left middle lobectomy and partial resection of left upper lung were successfully performed. In lung resection for situs inversus, it is important to be aware the mirrorimage anatomy. The three dimensional computed tomography (3D-CT) images were use

23、ful for preoperative evaluation of vessel variation. Masuda Y1, Kyobu Geka. 2013 Jun;66(6):481-4.,整理課件,27,Adenosquamous carcinoma of the lung in a patient with complete situs inversus.左下葉切除2011,We present a rare case of adenosquamous carcinoma of the lung in a patient with complete situs inversus. T

24、he patient was a 76-year-old woman with the chief complaint of hemosputum. Chest X-ray and computed tomography (CT) scans of the thorax showed a mirror image of the organs and vessels and revealed a tumor 3.5 cm in diameter, in the left lower lung field. She was referred and admitted to KKR Hokuriku

25、 Hospital, Kanazawa, Japan to undergo surgery. Bronchoscopy showed a mirror image of the usual arrangement of the bronchi, and 5 segmental branches in the left lower bronchi. During surgery, care was exercised when intubation with the Univent bronchial tube for one-lung ventilation. On thoracotomy,

26、the gross appearance of the left lung and the arrangement of the pulmonary vessels and the bronchi corresponded to those normally found on the right side. We were successful in performing a left lower lobectomy. Postoperative diagnosis confirmed an adenosquamous carcinoma with localized pleural diss

27、emination as p-t4n1m0, stage IIIa. Preoperative imaging, including CT, bronchoscopy, and angiographic examination of the patient, will be useful for prevention of vascular or bronchial injury during surgery in patients with complete situs inversus undergoing lung resection. Possible vascular or bron

28、chial anomalies should always be taken into consideration while operating on these patients. Ann Thorac Cardiovasc Surg. 2011;17(2):178-81.,整理課件,28,Right bronchial intubation using a left-sided double-lumen tube in a patient with situs inversus左上葉切除 2007,A 74-year-old man was scheduled for resection

29、 of a pulmonary tumor in the left upper lobe. He had asymptomatic complete situs inversus, and therefore his left lung had three lobes whereas his right lung had two. Since the tumor had been growing through the left upper bronchus into the left main bronchus, it seemed that the use of a bronchial b

30、locker in the left bronchus should be avoided. A 37-Fr left-sided double-lumen tube was rotated in the opposite direction (clockwise) and advanced easily into the right (anatomically left) main bronchus under fiberoptic guidance. One lung ventilation during the operation was performed successfully a

31、nd there was no postoperative airway complication. Several ways of achieving one lung ventilation in patients with situs inversus are discussed in this report. The use of a bronchial blocker should be considered first-choice, but sometimes its use is inappropriate as in this case. Commercially avail

32、able double-lumen tubes are not intended for use in cases of situs inversus. If a double-lumen tube is desired, intentional right bronchial insertion of a left-sided double-lumen tube seems to be an easy and reliable option. Masui. 2007 Dec;56(12):1411-3.,整理課件,29,Lung resection for primary bronchial carcinoma in a pa