“双向识别”理念在解剖性肺段切除术段门结构处理中的应用

Application of “Two-way Identification”Concept in Video-assisted Thoracoscopic Anatomic Segmentectomy

目的探讨“双向识别”理念处理段门解剖结构的安全性。方法2017年4月~2018年12月我们对95例单孔胸腔镜意向性肺段切除术采用“双向识别”理念对段门解剖结构进行处理,即术中充分镂空段门结构后,根据病灶所在靶段的段门结构的走向来初步判断其血管与支气管,通过显露、识别要保留的邻近肺段结构,反过来确认先前判断的靶段血管与支气管是否正确,显露邻近肺段结构后再离断靶段结构。结果1例因术中出血转为肺叶切除术,无因段门结构误断中转肺叶切除,无中转开胸。手术时间30~170 min,平均85 min;术中出血20~150 ml,平均56.8 ml;术后引流时间2~7 d,平均3.5 d;术后住院时间3~13 d,中位数5 d。术后并发症:咳血2例、漏气5例、肺不张10例、肺部感染5例、胸腔积液9例、心律失常3例,均通过保守治疗得到控制。无围术期死亡。结论在单孔胸腔镜肺段切除术中应用“双向识别”理念能够准确地识别处理段门结构,避免段门解剖结构的误断,操作简单易行,使整个手术过程条理化、程序化。

Objective To evaluate the safety and technical feasibility of“two-way identification”concept as a method to recognize the segmental anatomical structures(including veins,arteries and bronchus)in video-assisted thoracoscopic anatomic segmentectomy.Methods Clinical data of 95 patients with pulmonary diseases who received the concept of“two-way identification”in video-assisted thoracoscopic anatomic segmentectomy during April 2017 to December 2018 were retrospectively analyzed.After the segmental portal structure was fully exposed during the operation,the blood vessels and bronchi of the target segment of the lesion were preliminarily determined according to the direction of the segmental portal structure of the target segment.By exposing and identifying the adjacent pulmonary segment structure to be preserved,in turn,the target segment blood vessels and bronchi previously determined were confirmed to be correct.After exposing the adjacent pulmonary segment structure,the target segment structure was disconnected.Results Of the 95 patients,1 patient was converted to lobectomy for bleeding by technical faux pas while there was no conversion to thoracotomy or lobectomy for misjudging the segmental anatomical structures.The operation time was 30-170 min(mean,85 min),and the intraoperative blood loss was 20-150 ml(mean,56.8 ml).The postoperative thoracic drainage time was 2-7 d(mean,3.5 d),and the postoperative hospital stay was 3-13 d(median,5 d).Postoperative complications included hemoptysis in 2 cases,air leakage in 5 cases,atelectasis in 10 cases,pulmonary infection in 5 cases,pleural effusion in 9 cases,and arrhythmia in 3 cases,all of which were controlled by conservative treatment.There was no perioperative death.Conclusion The application of"two-way identification"concept in video-assisted thoracoscopic anatomic segmentectomy can accurately identify and deal with the segmental structures,avoid the accidental disconnection of the anatomic structures,make the operation simple and easy,and make the whole operation process organized and programmed.