三维重建及吲哚菁绿辅助下开展腹腔镜保留十二指肠胰头切除术1例报道

Laparoscopic duodenum-preserving pancreatic head resection assisted by threedimensional reconstruction and indocyanine green:a case report

目的总结术前CT三维重建及术中吲哚菁绿辅助下开展腹腔镜保留十二指肠胰头切除术(laparoscopic duodenum-preserving pancreatic head resection,LDPPHR)过程中吲哚菁绿的给药方式及显影情况。方法回顾性分析2022年4月四川大学华西医院胆道外科收治的1例56岁女性患者因“体检发现胰腺占位”考虑胰头良性肿瘤可能性拟行LDPPHR患者的临床病理资料。患者于术前行CT三维重建,尝试术前及术中分别多次予以静脉注射吲哚菁绿5 mg,完成LDPPHR手术。结果患者手术过程顺利。术前CT三维重建可以辅助判断胰十二指肠前后动脉弓以及周围主要血管的走行及关系。术前24 h静脉注射5 mg吲哚菁绿后在术中可明确显示胰腺上缘的胆总管,并且判断囊性占位与胆管和胰管不相通,但发现胰腺段胆总管显影效果较差,于是术中追加静脉注射5 mg吲哚菁绿后确切显示了胆总管后完整切除胰头;在切除胰头后,术中再次静脉注射5 mg吲哚菁绿后1 min内即可见十二指肠起始部、球部及降段肠壁荧光增强,提示十二指肠血供良好。本病例手术时间280 min,术中出血量约200 mL,术后第10天时患者出现一过性消化道出血伴胆汁漏,对症治疗后好转,术后第19天出院。术后病理检查结果诊断为胰腺浆液性囊腺瘤。结论开展LDPPHR采用术前CT三维重建及术中吲哚菁绿静脉注射辅助显影辨识手术区域的血管及胆管走行以及检查十二指肠血供,让手术变得更加精准化、可视化,是安全、有效地开展LDPPHR的有力保障。

Objective To summarize the preoperative CT three-dimensional reconstruction,and administration and visualization of indocyanine green(ICG)during ICG-assisted laparoscopic duodenum-preserving pancreatic head resection(LDPPHR).Methods A 56-year-old female patient admitted to the Department of Biliary Surgery in West China Hospital in April 2022 was retrospectively analyzed.The patient was considered the possibility of benign tumor of pancreatic head,and underwent LDPPHR.Three-dimensional CT reconstruction was performed before operation,and ICG(5 mg)was injected intravenously preoperative and intraoperative to complete LDPPHR.Results Preoperative three-dimensional CT reconstruction can assist in judging the course and relationship of anterior and posterior pancreaticoduodenal arterial arch and surrounding main blood vessels.After intravenous injection of 5 mg ICG 24 hours before operation,the common bile duct at the upper edge of pancreas was clearly visualized,and the cystic mass was judged not to communicate with bile duct and pancreatic duct.But it was difficult to identify the pancreatic segment of the common bile duct in fluorescence mode,ICG 5 mg was injected intravenously during the resection stage,and then the common bile duct was obviously visualized.After the resection stage,injected ICG(5 mg)intravenously again.Within1 min,the fluorescence of the duodenum was enhanced,which suggested that the blood perfusion of duodenum was well.The operative time was 280 min,the blood loss was about 200 mL.On the 10th day after operation,the patient developed transient gastrointestinal bleeding with bile leakage,which improved after symptomatic treatment and was discharged on the 19th day.Postoperative pathological examination diagnosed pancreatic serous cystadenoma.Conclusions Threedimensional reconstruction and ICG assisted LPDDHR can successfully visualize and identify the blood vessels and bile ducts,and check the duodenal blood perfusion.Which can making the operation more accurate and visual is a powerful guarantee for LDPPHR to be carried out safely and effectively.