胸腔镜%冠状动脉旁路移植手术,非体外循环%外科手术,微创性
胸腔鏡%冠狀動脈徬路移植手術,非體外循環%外科手術,微創性
흉강경%관상동맥방로이식수술,비체외순배%외과수술,미창성
Thoracoscopes%Coronary artery bypass,off-pump%Surgical procedures,minimally
目的 冠状动脉粥样硬化性心脏病(CAD)患者接受微创直视冠状动脉旁路移植术(MIDCAB)手术治疗时,采用两种入路进行非机器人辅助全胸腔镜下乳内动脉取材术(TIMAH),探讨该手术方式的术前准备、操作方式、主要特点、优势及不足,并观察短期疗效.方法 CAD男性患者7例,年龄52 ～ 75岁,平均(63.8±8.5)岁,均行TIMAH和左乳内动脉(LIMA)到前降支(LAD)的旁路移植手术.其中LAD单纯闭塞性病变3例,钙化性重度狭窄2例,支架术后支架内血栓再狭窄1例,此6例患者均试行介入治疗,未获成功.另1例为冠状动脉旁路移植术(CABG)后,LAD静脉桥路闭塞,回旋支病变加重,进行二次CABG手术的患者.7例患者均行全麻双腔气管插管,右侧单肺通气,采用两种入路进行TIMAH,其后完成MIDCAB手术.其中4例经左腋前线第3肋间打孔置入胸腔镜,经左侧第5肋间左前外侧小切口完成LIMA取材术,其后经小切口进行冠状动脉吻合(简称2切口手术)；3例经左腋前线第2或3肋间打孔置入胸腔镜,经左侧第4肋间腋前线和第5肋间锁骨中线打胸腔镜操作孔完成LIMA取材术,其后根据前降支位置扩大第5肋间操作孔进行冠状动脉吻合(简称3切口手术).冠状动脉血管吻合应用普通胸壁牵开器和压迫式心脏稳定装置.二次手术患者完成LIMA与LAD吻合后,以大隐静脉行LIMA到钝缘支的“Y”型桥.结果 全部患者均完成MIDCABG手术,无中转正中开胸.6例LIMA取材质量良好,1例LIMA床止血过程中误伤LIMA远端,导致长度不足,加用2 cm大隐静脉延长LIMA长度.6例对LAD单支手术的患者,左胸壁小切口长度(6.0±0.9)cm,TIMAH时间(112±18)min,手术时间(293±75) min,术中出血(233±52) ml,围手术期均未异体输血,术后气管插管(14.2±10.7)h,ICU停留(1.8±0.4)天,术后住院(10.1士6.7)天.患者术后恢复良好,顺利出院,短期随访,心绞痛症状消失.结论 2切口和3切口手术均可完成TIMAH,手术安全可行,无需为LIMA取材向正中方向延长切口,手术切口小,术后恢复顺利,短期随访效果良好.
目的 冠狀動脈粥樣硬化性心髒病(CAD)患者接受微創直視冠狀動脈徬路移植術(MIDCAB)手術治療時,採用兩種入路進行非機器人輔助全胸腔鏡下乳內動脈取材術(TIMAH),探討該手術方式的術前準備、操作方式、主要特點、優勢及不足,併觀察短期療效.方法 CAD男性患者7例,年齡52 ～ 75歲,平均(63.8±8.5)歲,均行TIMAH和左乳內動脈(LIMA)到前降支(LAD)的徬路移植手術.其中LAD單純閉塞性病變3例,鈣化性重度狹窄2例,支架術後支架內血栓再狹窄1例,此6例患者均試行介入治療,未穫成功.另1例為冠狀動脈徬路移植術(CABG)後,LAD靜脈橋路閉塞,迴鏇支病變加重,進行二次CABG手術的患者.7例患者均行全痳雙腔氣管插管,右側單肺通氣,採用兩種入路進行TIMAH,其後完成MIDCAB手術.其中4例經左腋前線第3肋間打孔置入胸腔鏡,經左側第5肋間左前外側小切口完成LIMA取材術,其後經小切口進行冠狀動脈吻閤(簡稱2切口手術)；3例經左腋前線第2或3肋間打孔置入胸腔鏡,經左側第4肋間腋前線和第5肋間鎖骨中線打胸腔鏡操作孔完成LIMA取材術,其後根據前降支位置擴大第5肋間操作孔進行冠狀動脈吻閤(簡稱3切口手術).冠狀動脈血管吻閤應用普通胸壁牽開器和壓迫式心髒穩定裝置.二次手術患者完成LIMA與LAD吻閤後,以大隱靜脈行LIMA到鈍緣支的“Y”型橋.結果 全部患者均完成MIDCABG手術,無中轉正中開胸.6例LIMA取材質量良好,1例LIMA床止血過程中誤傷LIMA遠耑,導緻長度不足,加用2 cm大隱靜脈延長LIMA長度.6例對LAD單支手術的患者,左胸壁小切口長度(6.0±0.9)cm,TIMAH時間(112±18)min,手術時間(293±75) min,術中齣血(233±52) ml,圍手術期均未異體輸血,術後氣管插管(14.2±10.7)h,ICU停留(1.8±0.4)天,術後住院(10.1士6.7)天.患者術後恢複良好,順利齣院,短期隨訪,心絞痛癥狀消失.結論 2切口和3切口手術均可完成TIMAH,手術安全可行,無需為LIMA取材嚮正中方嚮延長切口,手術切口小,術後恢複順利,短期隨訪效果良好.
목적 관상동맥죽양경화성심장병(CAD)환자접수미창직시관상동맥방로이식술(MIDCAB)수술치료시,채용량충입로진행비궤기인보조전흉강경하유내동맥취재술(TIMAH),탐토해수술방식적술전준비、조작방식、주요특점、우세급불족,병관찰단기료효.방법 CAD남성환자7례,년령52 ～ 75세,평균(63.8±8.5)세,균행TIMAH화좌유내동맥(LIMA)도전강지(LAD)적방로이식수술.기중LAD단순폐새성병변3례,개화성중도협착2례,지가술후지가내혈전재협착1례,차6례환자균시행개입치료,미획성공.령1례위관상동맥방로이식술(CABG)후,LAD정맥교로폐새,회선지병변가중,진행이차CABG수술적환자.7례환자균행전마쌍강기관삽관,우측단폐통기,채용량충입로진행TIMAH,기후완성MIDCAB수술.기중4례경좌액전선제3륵간타공치입흉강경,경좌측제5륵간좌전외측소절구완성LIMA취재술,기후경소절구진행관상동맥문합(간칭2절구수술)；3례경좌액전선제2혹3륵간타공치입흉강경,경좌측제4륵간액전선화제5륵간쇄골중선타흉강경조작공완성LIMA취재술,기후근거전강지위치확대제5륵간조작공진행관상동맥문합(간칭3절구수술).관상동맥혈관문합응용보통흉벽견개기화압박식심장은정장치.이차수술환자완성LIMA여LAD문합후,이대은정맥행LIMA도둔연지적“Y”형교.결과 전부환자균완성MIDCABG수술,무중전정중개흉.6례LIMA취재질량량호,1례LIMA상지혈과정중오상LIMA원단,도치장도불족,가용2 cm대은정맥연장LIMA장도.6례대LAD단지수술적환자,좌흉벽소절구장도(6.0±0.9)cm,TIMAH시간(112±18)min,수술시간(293±75) min,술중출혈(233±52) ml,위수술기균미이체수혈,술후기관삽관(14.2±10.7)h,ICU정류(1.8±0.4)천,술후주원(10.1사6.7)천.환자술후회복량호,순리출원,단기수방,심교통증상소실.결론 2절구화3절구수술균가완성TIMAH,수술안전가행,무수위LIMA취재향정중방향연장절구,수술절구소,술후회복순리,단기수방효과량호.
Objective To analysis of preoperative preparation,operation,character,advantage and deficiency of two non-robotic TIMAH approach in MIDCAB,and to observe the short-term follow up result.Methods 7 male CAD patients with classic unstable angina pectoris,the age ranged from 52 to 75 years,average (63.8 ± 8.5) years,underwent TIMAH and MIDCAB,in which 6 single LAD disease patients and one patient for reoperation with saphenous vein graft (SVG) graft failure to LAD and progressive obtuse marginal(OM) coronary artery disease.These patients were intubated with a double-lumen endotracheal tube,and one-lung ventilation were used to facilitate the procedure.In the approach of two incisions TIMAH for 4 patients,the thoracoscope was placed at the third intercostals space(ICS) on the anterior axillary line,and LIMA was dissected with endo-instruments placed from the two angles of mini-thoracotomy at fifth ICS on the midclavicular line.In the approach of three incisions TIMAH for 3 patients,LIMA was dissected with endo-instruments placed from two ports at the fourth ICS on the anterior axillary line and at the fifth ICS on the midclavicular line,and the thoracoscope was placed at the second or third intercostals space (ICS) on the anterior axillary line.Anastomosis of LIMA and LAD followed through mini-thoracotomy at fifth ICS with the heart stabilizer after TIMAH.SVG graft was used from LIMA to OM in the reoperation patient.Results All patients underwent TIMAH and MIDCAB safely without transferece to stenotomy,only one LIMA was extended with 2 cm SVG for injure at the distal.In 6 single vessel disease patients the length of mini-thoracotomy incision was (6.0 ± 0.9) cm,TIMAH time was (112 ±18) min,operation time was (293 ± 75) min,bleeding volume was (233 ± 52) ml,endotracheal tube time was (14.2 ± 10.7) h,ICU time was (1.8 ±0.4) d and hospital stay time was (10.1 ±6.7) d.All patients were uneventful discharged and with no recurrence of cardiac symptoms in short-term follow up.Conclusion TIMAH can perform safely in both approaches for LIMA prepare to MIDCAB as described before.The minimally invasive procedure need not enlarge incision for LIMA harvesting with good short term results.
