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【共享】【自译】腹腔镜下缝合与打结

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这个帖子发布于8年零176天前，其中的信息可能已发生改变或有所发展。

选自《laparoscopic Surgery -Principles and Procedures》Second Edition一书，看到里面第一章第7节有关缝合打结的部分，忍不住手痒翻译了该章节，有什么错误望各位不吝指教。版主觉得不错的话望酌情给点分吧，呵呵。

对腔镜下缝合打结技术感兴趣的同学还可以参考我上传的胡三元教授《内镜外科缝合打结技术》（完整版）视频：
http://surgeon.dxy.cn/bbs/topic/22942813

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2012-05-08 19:12 浏览 : 34046 回复 : 84

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coolsquall 编辑于 2012-05-10 14:18

• 建立【基层普外常规手术交流专栏】

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Suturing and Knot Tying缝合与打结

Surgeons performing laparoscopic procedures should know several methods for ligating vessels, reapproximating tissue surfaces, and reconstructing organs. Developing suturing skills is no less important simply because stapling devices and clip appliers are available in the operating room. Sometimes the surgeon may want to tie an extracorporeal knot and advance the knot within the abdominal cavity. After suturing on delicate tissue, most surgeons prefer to instrument-tie intracorporeally.

外科医生实施腹腔镜手术时必须了解结扎血管、关闭组织表面、重建器官的数种方法。提高缝合技术的重要性并不因为吻合器、腔镜夹在手术室里的出现而有所减少。有时外科医生在体外打结再将结推入腹腔内。而在脆弱的组织上进行缝合后，许多外科医生更愿意使用腹腔内器械打结。

Throwing a square knot after an open incision requires a different set of skills than laparoscopic suturing and knot typing. The difficulty with tying knots arises from various factors. Laparoscopic instruments are long, restrict ease of movement, and diminish tactile feedback when compared to the open counterpart. Furthermore, most video systems currently under use cannot take advantage of the stereoscopic capabilities of human vision.Moreover, the 15-fold magnification requires a proportional adjustment in speed and enhanced efficiency in movement for completion of tasks in a reasonable period of time.However, technology is finding a solution, at least in part, to these difficulties. Robotassisted laparoscopic surgery using computer-controlled instrument motion and three dimensional (3-D) vision video systems, instead of limiting the surgeon's skills, actually can improve them.

开放手术中打一个方结所需的技巧与腹腔镜下缝合打结完全不同。打结的难度受几个因素影响。与同样的开放手术相比，腹腔镜器械较长、移动范围受限、触觉反馈减弱。而且，与人眼立体视觉相比，目前投入应用的绝大多数视频系统没有优势可言。此外，放大15倍的视野要求术者按比例调整移动速度及提高移动效率，以在合理时间内完成操作任务。当然，科技的发展已经找到或部分找到了解决这些困难的方法。机器人辅助腹腔镜外科使用了计算机控制器械移动，以及应用三维视频系统，它不再限制外科医生技术的发挥，而是更好的促进其发展。

As to the process of learning laparoscopic suturing and knot tying, only a serious dedication to practice will develop the necessary dexterity; fortunately, today residents acquire laparoscopic skills from the beginning of their training along with other surgical skills, making it part of the integral process of becoming a surgeon.

学习腹腔镜缝合与打结的过程中，只有严格的训练才能提高所需的灵敏度。幸运的是，今天的住院医师们从训练伊始便可同时学习腹腔镜操作技巧和其他手术技巧，这已经成为了培养外科医生的一个整体进程。

2012-05-08 19:13

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• 博导不闻不问

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I. PORT PLACEMENT 戳孔位置

Port placement will either impede or simplify laparoscopic suturing. Ideally, the shaft of the needle holder should be placed parallel to the line of incision being reapproximated. The tip of the needle driver should easily reach the working area with only half (15 cm) of the instrument's length within the abdominal cavity. The assisting grasping forceps should also comfortably reach the line of incision from the opposite side, and together the two instruments should form a 60-90 degree angle from the axis of the laparoscope (Fig. 1). At a minimum, three port sites are necessary. The most "natural" video projection occurs with the camera positioned between and behind the grasper and needle driver. This ideal positioning is sometimes impractical, and an acceptable alternative position is for the laparoscope to approach the operative field from one side of the two working instruments. The camera should never approach the operative field opposite the vector of the working instruments, because the video image will be reversed (mirror image), and it becomes virtually impossible to precisely manipulate the instruments. Also, ports inserted too close together ( < 7 em) will result in "sword fighting" of instruments and obscured camera visualization.

不同戳孔位置可能利于也可能妨碍腹腔镜下缝合。理想情况下，持针器纵轴应平行于拟缝合关闭的切口。持针器末端应很容易抵达术野，腹腔内的器械长度应只有其总长一半（15cm）。辅助抓钳能很舒适的从对侧移至切口。两器械与镜头的夹角应在60-90度（图1）。最少也应有三个戳孔。镜头位于抓钳与持针器之间的后方时得到的视野是最“自然”的。这种理想位置有时是不切实际的，那么另一种可接受的位置就是镜头从两器械的一侧观察术野。任何时候都不要把镜头摆在两器械的对面来观察术野，因为这时得到的画面是反的（镜像），而且不利于精确操作器械。此外，戳孔距离太近的话（<7cm）将导致器械之间互相打架，并且使阻挡镜头视野。

Figure 1 Correct arrangement of laparoscopic ports for suturing. Laparoscope is behind and between suturing instruments, which enter operative field from oblique angles. (From McDougall and Soper, 1994.)

图1 腹腔镜缝合时戳孔的正确位置。镜头在后方，位于两缝合器械之间，后两者以斜角进入术野。

The ideal trocar for laparoscopic suturing must allow the passage of large (10 or 12 mm) as well as small (5 mm) instruments through the same reducer, and it must be sturdy enough to tolerate multiple needle passes without loosening the gas seal. There are many disposable trocars available in the market with these characteristics. In a nondisposable trocar is used, usually the needle must be backloaded into a reducer before insertion into the abdominal cavity.

用于腹腔镜下缝合的理想戳卡应该既允许粗器械（直径10或12mm）也允许细器械（直径5cm）通过同一个接口，而且它应该足够坚韧，可以耐受缝针多次进出而不损害密封圈导致漏气。市场上有许多一次性戳卡具有以上特性。而当使用非一次性戳卡时，缝针应该反折着通过接口进入腹腔。

Suturing requires both hands. Securing working ports with screw threads, balloons, or suture will help prevent the port from becoming accidentally dislodged as the surgeon withdraws instruments from the abdominal cavity during suturing. A skilled first assistant an simplify laparoscopic suturing by presenting tissue to the tip of the needle at right angles whenever possible. Atraumatic instruments should be used to prevent inadvertent tissue injury. If the surgeon is struggling with a particular angle, an additional port may be inserted. Careful port placement at the beginning of the operation is especially important when a considerable amount of suturing is anticipated during a case.

缝合时双手都需要派上用场。螺纹、气囊或者缝合的方法都可以固定戳卡，以防止缝合过程中术者拔出腹腔内器械时不小心带出了戳卡。训练有素的第一助手应该在任何时候都能以正确的角度将组织递给针尖，使缝合操作变得更为简单。使用无损伤器械有助于防止组织意外损伤。如果术者为达到某个特定角度而苦苦奋斗，那么最好是再增加一个戳孔。预计术中需用到大量缝合操作时，开始阶段仔细的设计戳孔位置尤为重要。

2012-05-08 19:16

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coolsquall 编辑于 2012-05-08 19:25

• 北京很多医院都装了安检机，大家认为有必要吗？

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II. MATERIALS 材料

A. Suture 缝线

Selection of suture materials (catgut, silk or synthetics, monofilament or braided, permanent or absorbable) is no different from that for open surgery. Catgut suture may catch and get caught up in the port as the surgeon advances a throw. This problem is usually avoided by the use of synthetic sutures (2-0 or 3-0 polydioxanone), which slide easily during knot advancement. Although newer synthetic fibers have greater tensile strength, monofilament sutures may be difficult to manipulate due to the "memory" of the tail hindering effective knotting. Consequently, synthetics require more throws to prevent an individual knot from unraveling. Intracorporeal knotting uses only 8-15 cm of suture material, thereby minimizing the amount of suture dragged through tissues. During extracorporeal knot tying, longer suture lengths (60-90 cm) are required to reach the operative field and return out of the same port.

缝线的选择（肠线、丝线或合成线，单股线或编织线，可吸收线或非可吸收线）与开放手术没什么区别。打结过程中肠线容易卡在戳孔里。这个问题可以通过使用合成线来解决（2-0或3-0聚二恶烷酮线），它在打结时很容易滑动。尽管新的合成纤维有较高的抗张强度，但单股线很难操作，因为尾部的“记忆效应”不利于有效打结。因此，合成线需要打更多的结以防止结头散开。体内打结只需要留8-15cm长的缝线，以减少穿过组织拖拉缝线的次数。在体外打结时则需要较长的缝线（60-90 cm），以便能抵达术野后再从同一戳孔拉到体外。

B. Needle Types 缝针

There are three basic types of needle curvatures: straight, ski tip, or curved (Fig. 2). Straight needles are easiest to position and hold within the jaws of the needle driver but are difficult to drive in an arc through tissue. When using a straight needle, the assisting grasper must position adjacent tissue to include an appropriate purchase by the needle. Ski-tip needles (straight in the shaft, curved near the tip) load like straight needles, but with the added advantage of the curve near the tip, allowing it to arc through tissues with minimal damage. The curved needle is the most difficult to position properly within the jaws of the needle driver. The benefit of the curved needle is that the bite of tissue is the same as that the surgeon is accustomed to during open surgery. By supinating the wrist, the needle cleanly passes through tissues without tearing. Thanks to the progressive improvement of laparoscopic instruments, most needle drivers now have an excellent grasping strength comparable to that of those used in open surgery, making the laparoscopic handling of curved needles easier and their use widespread.

共有三种不同曲率的缝针：直针、雪橇针、弯针（图2）。直针很容易放好位置并被持针器抓持，但很难沿弧线缝合组织。使用直针时，辅助抓钳必须将邻近组织抓起去包裹针尖。雪橇针（针体为直，针尖弯曲）像直针一样抓持，但其优势在于弯曲的针尖可以沿弧线穿过组织以减少损伤。弯针是最难摆好位置并被持针器正确抓持的。弯针的优点在于缝合组织时与开放手术时的习惯相同。通过旋转手腕，弯针可以很明确穿过组织而不造成撕裂。随着腹腔镜器械的发展，现在越来越多的持针器有着远胜于开放手术器械的抓持强度，这使腹腔镜下操作弯针更为容易并促使其得到广泛应用。

Figure 2 Types of needles: (A) straight; (8) ski tip; (C) curved.

图2 缝针类型：(A) 直针； (8) 雪橇针； (C) 弯针

Suture and needle may be passed directly through the port or backloaded to ensure that the port's valve is not torn by the needle. To backload suture into a reducing sheath (Fig. 3), the suture should be grasped at least 5 mm behind the needle. Obviously, pop-off needles are avoided for laparoscopic procedures because they may detach prematurely. Large curved needles may not fit through a 10 mm port; if a large needle is necessary, either the port size can be enlarged or the part can be removed temporarily and the needle introduced directly through the skin incision.

缝针和缝线需要反折着通过戳卡，以防止损伤气阀。为了反折缝线进入戳卡鞘，需距针尾至少5mm抓线。显然，腹腔镜手术中不宜用普通不带线缝针，因为它们需要反复过早的取出。大弯针可能无法通过10mm戳卡，如果一定要用大弯针，可以换大直径戳卡，也可以临时拔除戳卡，将缝针直接经切口送入体内。

Figure 3 Backloading needle driver. (A) Instrument is inserted in reducer sheath; (B) the suture is held at least 5 mm behind the needle base; (C) the instrument and needle are withdrawn into the sheath.

图3 持针器反折 (A) 器械插入戳卡鞘; (B) 距针尾至少5mm抓线; (C) 器械和针退入鞘中

c. Needle Holders 持针器

Surgeons develop their own preferences for needle holders. In general, needle holders should be capable of grasping the needle firmly, positioning the needle at a 90 degree angle, releasing the needle smoothly, and grasping suture without destroying the braid. Pistol grip needle holders allow for a more physiological resting wrist position but at the same time are awkward to manipulate and may cause digital cutaneous nerve injury; therefore, for the most part these have been placed by needle drivers with in-line shafts (coaxial), which rotate easily. The in-line position allows the surgeon to perform precise surgical maneuvers and operate unencumbered. Many surgeons prefer needle holders with two moveable serrated, diamond-shaped jaws that provide more grasping strength. Springoperated needle holders are available with predetermined angles (45 degrees right, 45 degrees left, or 90 degrees), but fixed angles limit suturing flexibility and are not suited for intracorporeal knot tying.

外科医师对持针器各有所好。一般说来持针器应该能稳固的抓持缝针，能将针固定在90度位置，释放缝针时动作平滑，并且抓线时不会损伤缝线。*式持针器使手腕处于生理休息位，但同时操作笨拙，可能导致皮神经损伤，因此很多时候都被同轴的持针器所代替，后者旋转更为方便。同轴持针器使术者能毫无阻碍的进行更为精细的操作。许多外科医生喜欢持针器上带两个均可活动的菱形带齿钳嘴，它们可提供更好的抓持强度。而弹簧式持针器能提供预设的钳嘴角度（右侧弯曲45度，左侧弯曲45度，或90度），但固定的角度会限制缝合的灵活性并且不适于体内打结。

A well-designed complementary assisting forceps facilitates intracorporeal suturing and knot tying. Assisting instruments with curved tips aid looping the suture and do not obscure vision of the operative field during intracorporeal knot tying. The smooth tapered end of the forceps prevents the loop from catching on the instrument's shaft. A pointed tip warrants caution, though, because it may puncture the liver or spleen, and sharp jaws may fray suture. Control of the instrument tips under constant camera visualization prevents iatrogenic injury.

良好设计的辅助抓钳有助于体内缝合与打结。辅助器械的弯曲尖端有利于体内打结时绕线圈，且不会阻碍术区视野。逐渐平滑变细的钳尖可以防止线圈卡在钳杆上。当然，锐利的钳尖需要引起警惕，因为它可能刺伤肝脏和脾脏，锋利的钳嘴也可能损伤缝线。将器械尖端一直放在视野范围内有助于预防医源性损伤。

The surgeon should be relaxed while operating. During laparoscopic suturing the arms will quickly tire if the elbows or shoulders are abducted and neck muscles tensed. Most surgeons will palm their instruments at waist level. For more delicate suturing control, the instruments may be held at shoulder level and manipulated with the fingertips. Operating table height and position is adjusted to keep the surgeon as comfortable as possible. For example, during procedures involving upper abdominal organs it is often convenient for the surgeon to stand or sit between the abducted legs of a patient in the lithotomy position.

术者在操作中需要放松。在腹腔镜缝合过程中，肘部和肩部外展以及颈部肌肉紧张将导致手臂迅速疲劳。许多外科医生都在腰际水平抓持器械。进行精细缝合操作时，器械需在肩水平抓持并以指尖操作。手术台的高度和位置应该调整到术者最舒适的程度。例如，进行上腹部器官手术时，术者最方便的位置是站或坐在截石位患者外展的两腿之间。

2012-05-08 19:21

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