Education Campus
Level 4 Surgery
Six Sample Cases
[Editor’s Comments] This part of Education Campus is where the six representative cases of high clinical difficulty are presented, with detailed operation records. They are: 1. Extended total gastrectomy; 2. Simulated radical surgery for thyroid cancer; 3. Simulated Berne surgery for duodenal rupture; 4. Left lateral hepatectomy, intrahepatic lithotomy and hepatobiliary basin internal drainage; 5. Focal clearance and drainage for acute pancreatitis; 6. Radical surgery for rectal cancer.
Case 1. Extended total gastrectomy
Single operation record of Wuhu Changhang Hospital for Surgery Case 1
Name: Yao XX
Gender: Female
Age: 74
Bed No.: 34
Hospitalization No.: 19052
Operation Date: 1995/4/21
Pre-operation Diagnosis: gastric cardia cancer and esophagus invasion
Post-operation Diagnosis: gastric fundus and cardia and esophagus cancer
Surgery operated: total gastrectomy + splenectomy, esophagojejunostomy (Schlatter’s style).
Operation Time: started at 9am, ended at 4pm
Blood transfusion volume: 1200ml
Surgeon: Mingle Li
Assistant 1: Yang, Zonghua
Assistant 2: Wu, Maowang
Surgical nurse: Qian, Weilin
Anesthesia: continuous epidural block
Anesthesiologist: Chen, Qibin and Wang, Yisen
The gross examination of the specimens after operation showed that the primary cancer focus was located in the posterior wall of small bend near the cardia, involving 1cm at the lower end of the cardia and esophagus and invading the whole layer. Name of pathological specimen sent for examination: whole stomach, distal esophagus, and spleen. Procedure: Supine, chest and abdomen disinfection cloth, sword navel longitudinal incision 25cm long, bite in addition to the xiphoid process. Laparotomy was performed layer by layer and the incision was isolated. There was no ascites in the abdominal cavity and no space-occupying lesion in the liver. There was a little adhesion between pancreas and spleen and the lesion. The mass was located at the small bend of the posterior wall of the gastric fundus and involved the serosal layer, with the size of 10x7x5cm. There was still space between the mass and the liver. No metastasis was found at the pelvic floor and other parts of the abdominal cavity. A total gastrectomy and splenectomy were performed with a double-tube jejunum anterior to the colon and side-to-side anastomosis of the esophagus, plus a Bauwn short circuit between the jejunal afferent and afferent loops. The stomach was free, and the origin of the left gastric artery was cut off by the root of the vena cava. The omentum and the anterior layer of transverse mesocolon were excised, and the duodenum was severed 3cm below the pylorus, sealing the stump. Pancreas-stomach adhesion was separated from under the pancreatic capsule, and the spleen was excised. Acute severance was performed in the space between normal tissues outside the pericardial mass. The peritoneum at the part where the esophageal hiatus was incised was reversely folded, and the left and right vagus nerve trunks were severed. Then the esophagus was bluntly separated and 7cm was dragged down. At this point, the whole stomach has been free. The cancer focus was wrapped and placed for traction. Thus, group (1) (2) (3) (4) (5) (6) (7) (10) (11) (15) of lymph nodes were removed and radical 2 surgery was performed. Jejunum proximal to 20cm was anastomosed with esophagus at 5cm above cardia via anterior ascending colon for lateral end anastomosis. Five needles in seromuscular layer were intermittently sutured and fixed at posterior wall. Jejunum opposite mesangial margin was cut for 3cm and was intermittently sutured with whole layer of posterior wall of esophagus. The feeding channel was cut off at 4cm above cardia, and whole stomach and spleen sent out the operation field. Then whole-layer suture of anterior wall was performed for one week. Esophageal inflammation was fragile and it was easy to avulsion. Tension-reduction suture was conducted carefully, and the anastomosis was sleeved into jejunum a little with two-layer suture without leakage. Jejunum slightly distant from the anastomosis was sutured onto the septal muscle near the hiatus to reduce the tension, and the hiatus was slightly repaired to prevent internal hernia without narrowing. A Braun short-circuit anastomosis between the double loops of jejunum (8cm) was performed 7cm below the anastomosis, and a gastric tube was inserted into the proximal jejunum to facilitate postoperative suction and decompression. The abdominal cavity was washed thoroughly, and the fields were carefully examined without bleeding or leakage. There was no torsional compression of the intestinal loop in place of stomach. The abdominal cavity was immersed in distilled water to destroy the tumor, and after the abdominal cavity was wiped clean, a double cannula was placed under the septum to poke the wound and then led out for fixation. The abdomen was closed in sequence conventionally. The procedure was uneventful and 400ml of blood was lost.
Conclusion of the operation: The advanced gastric cardia cancer involves extra-gastric pancreas, spleen and distal esophagus, and the inflammation of esophagus is fragile. Although the whole stomach, distal esophagus and spleen are resected, and the large and small omentum are removed, as well as the anterior lobe of transverse mesocolon are removed, and the removal range reaches the second lymph node. Although the root 2 operation is achieved, the short-term and long-term prognosis is still not optimistic. Operator, record Li Mingjie 95，4，21
Note: 1 Postoperative pathology (952343) reported poorly differentiated adenocarcinoma of the lateral aspect of the lesser curvature of the cardia, partially mucinous adenocarcinoma, with a lesion of 10 × 7 cm involving the esophagus, cardia, fundus of the stomach, and body of the stomach and penetrating the whole layer. There were seven lymph nodes at the lesser curvature, six metastatic carcinomas, and none of the five lymph nodes at the greater curvature had metastatic carcinomas. Focal mild acute inflammation of spleen. He has survived for half a year and his constitution is relatively thin.
手术后标本肉眼检查所见: 原发癌灶位于贲门附近小弯后壁累及贲门食道下端1cm侵犯全层。
送出检查病理标本名称: 全胃、食道远端、脾。
手术经过:
仰卧、胸腹部消毒铺巾，剑脐间纵切口长25cm，咬除剑突。逐层开腹，切口隔离。
腹腔无腹水，肝无占位灶，胰脾与病灶粘连少许，肿块位于胃底后壁小弯处，侵及浆膜层，大小为10x7x5cm，与肝尚有间隙，盆底及腹腔他处未见转移灶。拟行全胃切除，脾切除，双管空肠结肠前与食道作侧端吻合，加空肠输入出袢间Bauwn短路术。
游离胃周，腔动脉根部切断胃左动脉起始部。切除大小网膜、横结肠系膜前层，幽门下3cm断离十二指肠，封闭其残端。从胰包膜下，分离胰胃粘连，切除脾脏。贲门周围肿块外正常组织间隙作锐性断离。切开食道裂孔处腹膜反折，断离左右迷走神经干，钝性分离食道，拖下7cm。至此，全胃已游离。癌灶予包裹搁置牵引。至此，清除了(1) (2) (3) (4) (5) (6) (7) (10)(11) (15) 组淋巴结，根2手术。
空肠近侧20cm处经结肠前上提与食道在贲门上5cm处作侧端吻合，后壁5针浆肌层间断缝合固定，切开空肠对系膜缘3cm，作与食道后壁全层间断缝合，于贲门上4cm处断食道，全胃+脾送出术野，继而作前壁全层缝合一周，食道炎症脆弱，极易撕脱，仔细减张缝合，二层缝合将吻合口套入空肠少许，无泄漏。再将吻合口稍远处空肠缝于食道裂孔附近隔肌上以减张，略加修补食道裂孔以防内疝，未致缩窄。
吻合口下7cm作双袢空肠间Braun短路吻合8cm，并将胃管置入近端空肠，以利术后吸引减压。
彻底冲洗腹腔，仔细检查创野，无出血及渗漏。代胃之肠袢无扭转压迫，蒸馏水浸泡腹腔灭瘤，拭净腹腔后隔下置双套管戳创引出固定。常规依次关腹。 手术经过平顺，失血400ml. 安返病房。
手术结论: 晚期胃底贲门癌累及胃外胰脾及食道远端，食道炎症脆弱，虽作全胃、食道远侧、脾切除，并清除大小网膜，横结肠系膜前叶，清除范围达第二站淋巴结，虽然达到根2手术，但近远期预后仍不乐观。
术者、记录 李名杰
95，4，21
注:
1 术后病理 (952343) 报告为贲门小弯侧差分化腺癌，部分为粘液腺癌，病灶10x7cm累及食道贲门、胃底、胃体并穿透全层，小弯处7枚淋巴结，6枚转移癌，大弯5枚淋巴结均无转移癌。脾脏局灶性轻度急性炎。
2 至今半年存活，体质较瘦弱。
Case 2. Simulated radical surgery for thyroid cancer
Single operation record of Wuhu Changhang Hospital for Surgery Case 2
Name: Gao XX
Gender: Female
Age: 47
Bed No.: 34
Hospitalization No.: 18639
Operation Date: 1994/8/30
Pre-operation Diagnosis: metastatic carcinoma of the right thyroid gland
Post-operation Diagnosis: metastatic follicular adenocarcinoma of the right thyroid gland
Surgery operated: modified right cervical lymph node dissection + isthmus resection and left thyroidectomy
Operation Time: started at 9am, ended at 2pm
Blood transfusion volume: 400ml
Surgeon: Mingle Li
Assistant 1: Yang, Zonghua
Assistant 2: Shi, Lianghui
Surgical nurse: Gao, Qingjie
Anesthesia: cervical plexus block
Anesthesiologist: Chen Qibin
Gross examination of the post-surgical specimen revealed a resected mass necropsy showing a typical enlarged lymph node. Pathological report of rapid section of lymph nodes during the operation (Pathology No.944346, Second Municipal Hospital): metastatic thyroid cancer and follicular adenocarcinoma, and the possibility of papillary adenocarcinoma cannot be ruled out. Name of pathological specimen sent for examination: 9 superficial and deep lymph nodes in right neck, thyroid. Procedure: 1 The patient was supine under cervical plexus anesthesia with left head and neck hyperextension. For routine skin sterilization and towel spreading, an “in” incision was made in the anterior region of the right neck, which began 2cm below the right mastoid and ended on the sternum and extended left to the outer margin of the left sternocleidomastoid muscle, 18cm in length. The other incision extended to the right reached the right supraclavicular recess, and the original surgical scar was excised. All the flaps were secretly separated to reach the outer margin of the right trapezius muscle, and the outer margin of the left sternocleidomastoid muscle went up to the lower margin of the mandible and abutted against the sternal notch. 2 The platysma muscle was incised, and the bilateral anterior cervical muscle groups were separated from the cervical midline and transected to expose various lumps and thyroid. No residual remains were observed in the right thyroid lobe. The right common carotid artery, vagus nerve, and internal jugular vein were pushed to the superficial layer by the mass. Nine visible lymph nodes of different sizes were located in the right inferior cervical trigone, the right sternocleidomastoid muscle area, the right supraclavicular fossa, and the anterior cervical trigone, respectively. The largest one was 5cm in diameter, and the smaller one was about 1cm. The lymph nodes were hard in texture, smooth in surface, and not densely adhered. The trachea was moved to the left, but not associated with a mass, and the left thyroid lobe was slightly larger and no obvious nodules were palpable. 3 The right sternocleidomastoid muscle was transected at the middle and lower 1/3 point to improve exposure. First, a lymph node 2cm in diameter was cut from the upper extremely shallow part of a series of lumps and sent for rapid section. The pathological report was thyroid cancer metastasis and follicular adenocarcinoma. The modified right neck lymph node dissection was performed. A total of nine lymph nodes large and small visible to the naked eye were removed during the operation. The intact general A and internal V nerves of the neck, vagus nerve and right accessory nerve were carefully protected. 4 The anatomy of the thyroid gland was continued, and the isthmus and most of the left thyroid lobe were removed, with the size of the posterior medial glandular finger retained. Suture the residual thyroid. 5 The wound cavity was rinsed to perfect hemostasis. One skin tube was inserted and another was poked out of the wound. The anterior cervical muscle group and the severed right sternocleidomastoid muscle were sutured, and the wound was sutured layer by layer and intermittently. 6 Patients were anesthetized satisfactorily during the operation, with clear anatomy, no important vascular and neural damage, less bleeding, silent hoarseness and cough, and were returned to the ward. 7 Although it is a well-differentiated adenocarcinoma, reoperation for cervical lymph node metastasis has occurred, which makes the long-term prognosis difficult to be optimistic.
Performer and Record Li Mingjie 94, 8, 9
Note: 1 Pathological report with regular section on 94/9/2 after operation (Medical record No.944355 of the Second Municipal Hospital): (1) Papillary-follicular adenocarcinoma of thyroid. (2) There are small focal metastases in the “normal” thyroid tissue and (3) most lymph node metastases. 2 The follow-up visit has lasted for more than one year. The patient showed no signs of recurrence or symptoms.
手术后标本肉眼检查所见: 切除之肿块剖检为典型肿大之淋巴结。术中淋巴结快速切片病理报告 (市二院病理号944346): 转移性甲状腺癌、滤泡状腺癌，不排除乳头状腺癌可能。送出检查病理标本名称: 右颈浅深淋巴结计9枚，甲状腺。
手术经过:
1 颈丛麻醉下患者仰卧，头颈部过伸偏左。常规皮肤灭菌、铺巾，右侧颈前区作一“入”形切口，始于右乳突下止于胸骨上2cm左延至左胸锁乳突肌外缘，长18cm，另向右延伸切口达右锁骨上凹，切除原手术疤痕，潜行剥离诸皮瓣达右斜方肌外缘，左胸锁乳突肌外缘，上至下颔下缘，下抵胸骨切迹。
2 切开颈阔肌，从颈中线分离两侧颈前肌群并予横断，显露诸肿块及甲状腺。右甲状腺叶未见残留遗迹，右颈总动脉、迷走神经、颈内静脉被肿块推向浅层，9枚可见之大小不等之淋巴结分别位于右颈下三角区，右胸锁乳突肌区、右锁骨上窝及颈前三角区内，其中最大者为直径5cm，小的为1cm左右，质硬，表面光滑，粘连不致密。气管左移，但与肿块不关联，左甲状腺叶略大，无明显结节可扪及。
3 从右胸锁乳突肌中下1/3分处横断该肌，以改善显露，在一串包块的上极浅处先切取一枚淋巴结直径2cm送快速切片，病理报告为甲癌转移灶，滤泡状腺癌，遂行改良式右颈淋巴清扫术，术中共切除肉眼所见有9枚大小淋巴结，仔细保护颈总A、颈内V，迷走神经、右付神经等未受损伤。
4 继续解剖甲状腺，切除其峡部及左甲状腺叶大部，保留其后内侧腺体指头大小。缝合残余甲状腺。
5 冲洗创腔，完善止血，置皮管一根另戳创引出，缝合颈前肌群及断离之右胸锁乳突肌，分层间断缝合创口。
6 术中麻醉满意，解剖清晰，无重要血管神经损伤，出血少，无声嘶哑及呛咳发生，安返病房。
7 虽为高分化腺癌，但已发生颈淋巴结转移再手术，惜根治过晚，远期预后难以乐观。
术者、记录 李名杰
94，8，9
注:
1 术后于 94/9/2 常规切片病理报告 (市二院病检号 944355):
(1) 甲状腺乳头状一滤泡型腺癌。(2) “正常”甲状腺组织内有小灶性转移及 (3) 多数淋巴结转移。
2 术后随访至今已一年余，患者无复发征象，无症状。
Case 3. Simulated Berne surgery for duodenal rupture
Single operation record of Wuhu Changhang Hospital for Surgery Case 3
Name: Li XX
Gender: Male
Age: 29
Bed No.: 22
Hospitalization No.: 18158
Operation Date: 1993/10/7
Pre-operation Diagnosis: duodenal rupture, peritonitis
Post-operation Diagnosis: duodenal descending retroperitoneal injury, peritonitis
Surgery operated: Berne-like operation (intestinal repair, external drainage of common bile duct, gastric antrum resection, gastrojejunostomy, duodenal fistulization, abdominal cavity drainage)
Operation Time: started at 7pm, ended at 11pm
Blood transfusion volume: 400ml
Surgeon: Mingle Li
Assistant 1: Shen, Yaping
Assistant 2: Wu, Maowang
Surgical nurse: Qian, Wailing
Anesthesia: Continuous epidural block
Anesthesiologist: Chen Qibin
样液体，肝十二指肠韧带区及十二指肠降部到右肾周围后腹膜大片水肿、增厚绿染，作Kocher切口，游离十二指降部，该处腹膜后大片疏松组织坏死，充斥胆汁样液体，清理后查出十二指肠降部右后侧破裂1.5cm粘膜外翻，继续寻找其他腹腔后器官未见损伤。
Procedure:
In supine position, routine disinfection was applied to the abdomen. The right longitudinal incision through the rectus abdominis muscle, 18cm in length, was performed subcutaneous hemostasis, and laparotomy was performed in sequence using a shawl.
A small amount of pale green fluid in the abdominal cavity was about 100ml. His stomach and duodenal bulb were normal, his liver looked normal in color and texture, smooth and nodular-free, and his spleen was roughly 500gm in hardness. A small amount of bile-like fluid was accumulated in the omental foramen, and a large area of edema and thickening green stain appeared in the retroperitoneum from the hepatoduodenal ligament area and descending part of duodenum to the periphery of right kidney. A Kocher incision was made to free the descending part of duodenum, where a large area of loose tissue behind peritoneum was necrotic and filled with bile-like fluid. After cleaning, 1.5cm mucosal eversion due to rupture in the right posterior part of descending part of duodenum was found, and no damage was seen in continuing to find other organs after abdominal cavity.
Incision of the common bile duct was performed for decompression, the nipple part was explored. The site of the injury was determined to be 1.5cm above the front of the nipple under direct vision. Under the guidance of biliary tract investigators, the ruptured bowel was trimmed and repaired carefully with double-layer suture and omentum covering. No tension was detected. The repair was satisfactory and the opening of the common bile duct was not affected.
The common bile duct was rinsed, and no leakage was found at the repaired part. The T-tube was used for external drainage, and the repaired common bile duct was rinsed under pressure without leakage.
Gastric antrum resection was performed, followed by decompression by duodenostomy, and gastrojejunostomy was performed before the colon. The anastomosis length was 4.5cm along the peristalsis opening.
As mentioned above, all procedures were in accordance with Berne’s procedure except for non-transection of the gastric vagus nerve, turning the damaged part into a duodenal diverticulum to facilitate the successful repair.
The abdominal cavity was thoroughly washed again, and tubes were placed for drainage from the Venturi orifice and the pelvic floor, followed by a duodenal fistula and T-tube insertion to lead out of the abdomen.
The abdomen was closed according to the layers and the operation was completed. The operation was uneventful and there was no accidental bleeding or collateral damage during the operation.
Conclusion of the operation:
Retroperitoneal injury and extensive inflammatory edema in the descending part of duodenum. The operation was conducted 28 hours after the injury, and the patient was in a critical condition. However, thorough diverticularization treatment was performed at the repair part, and healing was expected.
Performer and Record: Mingjie Li, 1993/10/7
Note: No postoperative complications occurred and the patient recovered smoothly. The patient was hospitalized for 34 days and then discharged from hospital. The patient was followed up for two years after operation and he had lived and worked normally. No doctor visit was required after operation.
Case 4. Left lateral hepatectomy, intrahepatic lithotomy and hepatobiliary basin internal drainage
Single operation record of Wuhu Changhang Hospital for Surgery Case 4
Name: Shui XX
Gender: Male
Age: 46
Bed No.: 10
Hospitalization No.: 16502
Operation Date: 1991/4/18
Pre-operation Diagnosis: hepatobiliary stones
Post-operation Diagnosis: hepatobiliary stones
Surgery operated: resection of most of the left external lobe of the liver + hepatobiliary stones removal + residual cholecystectomy + liver tube jejunum pelvic internal drainage
Operation Time: started at 2pm, ended at 8:40pm
Blood transfusion volume: 1200ml
Surgeon: Mingle Li
Assistant 1: Yang, Zonghua
Assistant 2: Shi, Lianghui
Surgical nurse: Gao, Jieqing
Anesthesia: intravenous compound intubation general anesthesia
Anesthesiologist: Chen Qibin
Macroscopic examination of surgical specimens revealed left intrahepatic stones, common hepatic duct, common bile duct, and residual gallbladder stones Name of pathological specimen sent for examination: left extrahepatic lobe Procedure: If epidural anesthesia was not effective, intravenous combined with tracheal intubation general anesthesia was adopted. Supine position, chest and abdomen routine iodine tincture, alcohol disinfection, disinfection shop single three layers. An arc-shaped incision was made under the right upper abdominal costal image to dry the left side of the xiphoid process first, and then the tip of the right 11 rib reached the right anterior axillary line, 30cm in length. The original surgical scar was excised, subcutaneous hemostasis was performed, and a skin towel was used. The incision was made layer by layer into the abdomen, and there was extensive intra-abdominal adhesion. After separation, the peritoneal cutting edge was sutured to the skin towel to isolate the incision. Blunt and sharp adhesion was separated along the hepatic margin, revealing the common bile duct, and its expansion reached 2.5cm, touching multiple stones. The gallbladder remained from the original operation, which was 2.0cm in diameter and contained stones. Stones were palpated in the transverse portion of the left hepatic duct. The liver was normal in color and soft without space-occupying lesions or fibrous atrophy. Stomach intestine pancreas spleen normal. We decided to perform hepatobiliary incision and stone removal, partial resection of the left outer lobe of the liver, residual cholecystectomy, and hepatic duct plastic basin-type enterohepatic drainage. The common hepatic duct was cut at a high position for stone removal and exploration of the biliary tract therefrom. The common bile duct and grade I and II hepatic ducts in the liver were all filled with stones, and the left hepatic duct still had a narrow ring, so the deep stones were difficult to be taken out. Hence, they were shelved and left lateral lobectomy was performed instead. Cut off the ligament of liver garden, falciform ligament, left coronary ligament, left and right trigonal ligament, make the liver down loose. A needle was inserted through the suture 1.5cm left of the second hepatic gate to pre-ligate the left hepatic vein. In turn, the hepatic pedicle was blocked (25 minutes) and most of the left outer lobe was excised so as to expose the transitional part of the transverse part of the left hepatic duct. The vessels on their sections were clamped, ligated and stopped bleeding respectively, the hepatic pedicle tourniquet was released, and the transverse part of the left hepatic duct was opened. Three grams of pigment stone in the inner bladder was removed. After the hepatic portal Glisson’s sheath was cut, the first-grade branch of the hepatic duct was separated upward along the hepatic door panel, and 4–5 g of calculi were removed from the confluence area of the hepatic ducts, and the calculi in the liver were removed by realignment and washing at the cross-section of the left hepatic duct. Then the “small gallbladder” was excised to dredge the entire distal common bile duct. The cystic duct was sutured and repaired without leakage by using the Oddis probe No.9. The common hepatic duct together with the left and right primary hepatic ducts were all unfolded, and they were sutured and ligated while being towed to expose the openings of the secondary hepatic ducts in the liver under direct vision, to remove the stones therein and expand the stenosis, which was then rinsed with hydrogen peroxide. The basin edge of the hepatic duct was trimmed with a basin diameter of 4.5cm. The jejunum was cut off 15cm below the initial position, and the abdominal vascular arch of the intestinal system was cut so that the distal jejunum tube was lifted to the brim of the basin without tension. A layer of mucosa-to-mucosa whole-layer suture was made with the mouth of the basin at an interval of 3mm with a new suture circle. No leakage was found after examination and extrusion. The periphery of the anastomosis was further reinforced by covering with paddle membrane, and several needles were suspended from the intestinal end slightly distal to the anastomosis and the liver bed to reduce tension. The ascending bowel was routed through the anterior colon without causing compression. The cross-section of the liver was reexamined and compressed with hot saline gauze to stop bleeding. After there was no bleeding or bleeding, the liver was left open and uncovered, so that a small amount of postoperative bleeding could be absorbed into the peritoneum. A lateral end anastomosis was performed at the distal 40cm part of the enteric loop for gallbladder transportation with the proximal section of jejunum. The entire inner layer was intermittently sutured, and the external reinforcement suture was performed, together with synchronous suture for 5cm, to make it Y-shaped, so as to resist reflux. After the surgical field was completely removed and wiped, both anastomoses were found to be satisfactory without distortion or compression. Double cannulae were placed under the liver, and the wound from the right abdomen was poked out of the abdomen. One needle was fixed and sutured. The abdomen was routinely closed according to the layers, and the wound was covered with dressings after operation, which was smooth during the operation and satisfactory in anesthesia. The patient was sent back to the ward. Surgical conclusion: 1 The hepatolith was removed completely, and the residual gall bladder was excised. There was no stenosis in the distal common bile duct through No.9 probe. 2 Partial resection of the left outer lobe of the liver is performed to eliminate left hepatic duct stones and stenosis. Its section is perfect for hemostasis. 3 The common hepatic duct and the left and right primary hepatic ducts were trimmed together into a “basin”, with the diameter of 4.5cm. All the secondary hepatic ducts were expanded, and stones were removed for washing. 4 Hepato-intestinal-pelvic anastomosis, with a diameter of 4.0cm, resistant to reflux. 5 The two anastomoses were sutured orderly without leakage, tension, distortion or compression.
Operator, record Li Mingjie 1991, 4, 19
Note: No residual stone or recurrence was found after reexamination by B ultrasound and follow-up for 4 years.
四、芜湖长航医院手术记录单 例4
手术后标本肉眼检查所见: 左肝内结石，肝总管、胆总管、残余胆囊结石
送出检查病理标本名称: 左肝外叶
手术经过:
硬脊膜外麻醉无效改行静脉复合气管插管全麻。仰卧位，胸腹部常规碘酊、酒精消毒，铺消毒单三层。择右上腹肋像下弧形切口，始干剑突左旁，终于右11肋尖抵右前腋线，长30cm，切除原手术疤痕，皮下止血，披皮巾，逐层进腹，腹内广泛粘连，分离后，将腹膜切缘缝于皮巾以隔离切口。
沿肝缘钝性、锐性分离粘连，显露胆总管，见其扩张达 2.5cm，扪及多处结石，原手术残余胆囊，直径2.0cm，内含结石。左肝管横部扪及结石。肝色泽正常，质软，无占位病变，无纤维萎缩。胃肠胰脾正常。决定行肝胆管切开取石，肝左外叶部分切除，残余胆囊切除，肝管整形盆式肝肠内引流术。
高位切开总肝管，取石并由此探查胆道，胆总管、肝内 I、Ⅱ级肝管均充斥结石，左肝管尚有狭窄环，其深部结石不易取出，乃就此搁置，转而作左外叶肝切除。
切断肝园韧带、 镰状韧带，左冠状韧带，左右三角韧带，使肝下降松动。于肝二门之左1.5cm处贯穿缝扎一针以预扎肝左静脉。转而阻断肝蒂 (25分钟) 切除左外叶大部，以显露左肝管横部移行部为度，其断面脉管分别钳夹结扎止血，松开肝蒂止血带，开放左肝管横部，取出其内胆色素性结石3克。
切开肝门Glisson氏鞘，沿肝门板向上分离出肝管一级分支，在肝管汇合区取出结石4-5克，并于左肝管断面会师冲洗取净肝内结石。继而切除“小胆囊”，疏通远端胆总管全程，Oddis括约可通过9号探子，缝合修补胆囊管无漏。
将肝总管连同左右一级肝管全部展开，边缝扎边牵引，直视显露肝内诸二级肝管开口，清除其内结石并扩张狭窄，双氧水冲洗。
修整肝管盆缘，盆径4.5cm。
空肠起始下15cm切断，剪裁其肠系腹血管弓，使远断肠管上提至盆缘无张力，与盆口作一层粘膜对粘膜全层缝合，针距3mm，间新缝合一圈，检查、挤压无泄漏，吻合口周边再以桨膜复盖加固，复在吻合口稍远侧肠端与肝床悬吊数针以减张力。上提之肠管由结肠前途径，未致压迫。
复查肝断面，热盐水纱布敷压止血，待无出血渗血后，任其敞开未加复盖，以期术后少量渗液利于腹膜吸收。
输胆肠袢远侧40cm处与空肠近端断面作侧端吻合，内全层间断缝合，外加固缝合，并作同步缝合5cm，使其呈y形，以抗返流。
彻底清除手术野，拭净，检查两吻合口满意，无扭曲及压迫，肝下置双套管，右腹戳创引出腹外，并于固定缝合一针。
常规依层关腹，术毕敷料复盖伤口，术中平顺，麻醉满意，送返病房。
手术结论:
1 肝内胆石已取净，残余胆囊切除，胆总管远端通过9号探子无狭窄。
2 肝左外叶部分切除，消除左肝管结石及狭窄。其断面止血完善。
3 肝总管与左右一级肝管共修整成“盆”，盆径4.5cm，诸二级肝管均已扩张，取石冲洗。
4 肝管肠盆式吻合，口径达4.0cm，抗返流。
5 两吻合口缝合有序，无漏、无张力、无扭曲及压迫。
术者、记录 李名杰
1991，4，19
注: 术后B超复查及随访4年无残石及复发。
Case 5. Focal clearance and drainage for acute pancreatitis
手术后标本肉眼所见: 胰腺弥漫性水肿出血、局灶性坏死、腹腔大量血性渗出液、广泛皂化斑、胆囊结石水肿充血。送出检查病理标本名称: 胰腺、网膜、胆囊。
手术经过:
硬脊膜外麻醉有效。取仰卧位，腹部常规碘酊洒精消毒，铺无菌单三层。择右腹直肌纵切口长20cm，上抵剑突，下达脐下3cm，皮下止血，披皮巾，逐层开腹。
腹腔大量血性混浊液体涌出，量约2000ml，吸引之。腹腔广泛水肿充血、出血及遍布皂化斑，大网膜炎性团块状，全胰腺高度水肿伴出血坏死，小网膜腔积液500ml，胆囊充血水肿，其内结石多枚，最大一枚3.5cm及众多不成形胆泥，胆总管及肝内未扪及结石。肝质地色泽正常，脾正常，阑尾正常。
作胰包膜上下缘切开减压引流，清除少量坏死胰灶，再行Kocher切开松动胰头。胆囊切除，胆总管切开，其内径
0.8cm，未见结石及蛔虫等，下端可通过8号探子，置T管外引流。团块网膜部分切除，敞开小网腹腔，以利引流。
反复彻底冲洗腹腔、拭净。盆底Douglas窝双套管、胰床后下及网膜孔各置单管引流，连同T管分别戳创引出腹外并予以固定。
术中血压波动较大，麻醉深浅不定，手术进行颇为艰难，但无意外损伤、出血，术中补液3000ml、全血400ml，5% S.B. 500ml。
清点纱布器械无误，按层关腹，术毕安返病房。
手术结论:
1 急性重症胰腺炎，病性重，死亡率高，预后莫测。
2 手术已充分松动胰床、减压引流，胆总管减压引流，对抑转病情有利; 然胰腺有继续坏死可能。
3 胆囊已切除，消除了并存胆囊病灶。
Single operation record of Wuhu Changhang Hospital for Surgery Case 5
Name: Tang XX
Gender: Male
Age: 60
Bed No.: 38
Hospitalization No.: 15539
Operation Date: 1989/11/20
Pre-operation Diagnosis: Acute Severe Pancreatitis, Peritonitis, and Gall Bladder Stones
Post-operation Diagnosis: Pancreas Focus Clearance, Pancreas Bed Drainage, Cholecystectomy, Choledochal
T-tube External Drainage, Abdominal Cavity Drainage
Operation Time: started at 9pm, ended at 21, 开始于9Pm，完毕于21，1.30/Am ??? 1.30/Am
Blood transfusion volume: 400ml
Surgeon: Mingle Li
Assistant 1: Huang, Hongcheng
Assistant 2: Shi, Lianghui
Surgical nurse: Gao, Qingsheng
Anesthesia: continuous epidural block
Anesthesiologist: Wang Yisen
Macroscopic findings of the specimen after surgery included diffuse edematous hemorrhage of the pancreas, focal necrosis, massive hemorrhagic exudate from the abdominal cavity, extensive saponifying plaques, and edematous and hyperemic cholecystolithiasis. Name of pathological specimen sent for examination: pancreas, omentum and gall bladder. Procedure: Epidural anesthesia is effective. In the supine position, the abdomen was routinely disinfected with iodine tincture and covered with three sterile sheets. A longitudinal incision with a length of 20cm was made in the right rectus abdominis muscle, reaching up to the xiphoid process and down to 3cm below the umbilicus. The incision was stopped by subcutaneous hemostasis, covered with a skin towel and laparotomized layer by layer. A large amount of bloody and turbid fluid gushed out from the abdominal cavity, measuring about 2000ml, and it was attracted. There were extensive edema, congestion, hemorrhage in the abdominal cavity and saponifying plaques, large omental inflammatory lumps, high-level edema of the whole pancreas with hemorrhage and necrosis, 500ml of fluid in the small omental cavity, and congestion and edema of the gallbladder. There were many stones therein, the largest one was 3.5cm and many unformed biliary muds, and there were no stones palpable in the common bile duct and liver. The liver is normal in color, the spleen is normal, and the appendix is normal. An incision was made at the upper and lower margins of the pancreatic capsule for decompression and drainage, to remove a small amount of necrotic pancreatic lesions. Then a Kocher incision was performed to loosen the pancreatic head. Cholecystectomy and common bile duct incision were performed. The inner diameter was
0.8cm, and no stones or ascaris lumbricoides was found. The lower end could be drained through a T-tube through a No.8 probe. Partial resection of the omentum of the mass was performed, and the small omental cavity was opened for drainage. Repeatedly and thoroughly wash the abdominal cavity and wipe it clean. Single drainage tubes were respectively placed in the double sleeves of Douglas fossa at the pelvic floor, the posterior lower part of the pancreatic bed, and the omental foramen, and then they were separately wound-poked and led out of the abdomen together with the T-tube and fixed. Blood pressure fluctuated greatly during the operation, and the degree of anesthesia was variable. The operation was quite difficult, but there was no accidental injury or bleeding. During the operation, 3000ml of fluid replacement, 400ml of whole blood, and 5% S.B. 500ml were administered. Count gauze equipment and correct, according to the layer of abdominal, BiAn return ward. Surgical conclusion: 1 Severe acute pancreatitis is characterized by severe illness, high mortality and unpredictable prognosis. 2 The operation has fully loosened the pancreatic bed, decompressed drainage and decompressed drainage of the common bile duct, which are beneficial to the disease inhibition and metastasis. However, there is a possibility of continue pancreatic necrosis. 3 The gallbladder has been excised, and the coexisting gallbladder lesions have been eliminated.
Operator, record: Mingjie Li, 1989/11/21
Note: stress ulcer bleeding and shock occurred 14 days after operation, and the patient was rescued without second operation. Recovered and discharged. Followed up for 6 years with no recurrence. Case 6. Radical surgery for rectal cancer
手术后标本肉眼检查所见: 菜花样癌块6cm，侵犯肠管一圈，累及肠壁全层。
送出检查病理标本名称: 直肠癌肿连同其上25cm、其下5cm肠管，肠系膜下动脉根部淋巴结。
手术经过:
仰卧，头向低15，臀部抬高体位。会阴消毒，预置导尿管开放于床边挂并内。
腹部常规消毒，铺单三层，择经左腹直肌纵切口长25cm，脐上二指至耻骨上缘，皮下止血，披皮巾，逐层开腹。切口全层予以隔离。
无腹水，腹膜无结节，肝正常，无转移灶，胃胰脾无异，肠系膜下动脉根部及主动脉旁无肿大之淋巴结，全结肠无病变，腹内无粘连，小肠系膜多发黄豆大淋巴结。腹膜反折上1cm直乙交界处肿块6cm侵及该段肠管一圈及全层，但未梗阻，结肠空虚。
决定作直肠前切除术，Dixon术式。阻断癌肿上、下肠腔，病灶部肠内注入 5-Fu 500mg。作肠系膜下动脉根部淋巴结活切。结扎切断左结肠动脉降支，保留其与升支边缘动脉网，病灶上10cm结肠血动良好。
左侧腹膜后解剖，直视左输尿管全程，离断乙状肠系膜，远离病灶外3cm切开腹膜反折，游离达肿块下7cm直肠。
盆腔内生殖器无病复，子宫略大 (经后期)，附件(一)，与癌肿无关联，术终时应求顺予扎管绝育 (各缝扎一针)。
切除病灶上25cm及下5cm之乙直肠，消毒后作对端吻合，两层间断缝合，无泄漏，血运良好，无张力。
分别以蒸馏水、0.1%新吉尔灭、5-Fu 500mg 及生理盐水浸泡、清洗腹、盆腔、仔细止血。
修复后腹膜及重建盆底、将吻合口置于腹膜外，其附近置双套管负压引流戳创引出。腹腔Douglas后窝烟卷引流。
清点纱布器械无误，分层关腹，术中失血少，经过平顺，术毕，安返房。
Single operation record of Wuhu Changhang Hospital for Surgery Case 6
Name: XXX
Gender: Female
Age: 44
Bed No.: 38
Hospitalization No.: 13533
Operation Date: 1987/4/2
Pre-operation Diagnosis: rectal adenocarcinoma
Post-operation Diagnosis: DukesB1 stage of rectal adenocarcinoma
Surgery operated: anterior rectal resection (Dixon’s technique)
Operation Time: started at 9am, ended at 1:30pm
Blood transfusion volume: 800ml
Surgeon: Mingle Li
Assistant 1: Cai, Yalun
Assistant 2: Shen, Yaping
Surgical nurse: Gao, Jieqing
Anesthesia: continuous epidural block
Anesthesiologist: Chen Qibin
Macroscopic examination of the specimen after surgery showed that the cauliflower-like carcinoma was 6cm in size and involved one circle of the intestinal canal and the entire intestinal wall. Name of pathological specimen sent for examination: rectal cancer swelling together with its upper 25cm and lower 5cm intestinal tubes, and lymph node at the root of inferior mesenteric artery. Procedure: Supine, head down 15, hip up position. Perineum disinfection, preset catheter open in the bed hanging and inside. The abdomen was routinely sterilized and spread in three layers. The longitudinal incision through the left rectus abdominis muscle, 25cm in length, and the two upper navel fingers to the upper margin of pubic bone were selected for subcutaneous hemostasis, and the abdomen was opened layer by layer with a skin towel. The entire lay of that incision is isolated. No ascites, no nodule in peritoneum, normal liver, no metastasis, no difference in stomach, pancreas and spleen, no enlarged lymph nodes at the root of inferior mesenteric artery and paraaortic, no lesion in the whole colon, no intra-abdominal adhesion, and multiple soybean and large lymph nodes in mesentery. The mass at the junction of straight B and 1cm in retroperitoneal fold invaded one circle and the whole layer of this segment of intestine by 6cm, but it was not obstructed and the colon was empty. It was decided to perform anterior resection of the rectum using the Dixon procedure. The upper and lower intestinal cavities of the cancer were blocked, and 5-Fu 500mg was injected into the intestine of the lesion. A lymph node biopsy of the root of the inferior mesenteric artery was performed. The descending branch of the left colonic artery was cut off by ligation, and its marginal arterial network with the ascending branch was preserved. The blood movement of the colon 10cm above the lesion was good. The left retroperitoneum was dissected, and the whole process of the left ureter was observed under direct vision. The B-shaped mesentery was separated, and the peritoneum was incised and reversely folded 3cm away from the outside of the lesion and free to the rectum 7cm below the mass. There was no recovery of pelvic internal genitalia, and the uterus was slightly larger (in the later stage), Appendix (1), which had no connection with cancer. Therefore, ligation and sterilization (one needle for each suture) should be performed smoothly at the end of the operation. The second rectum 25cm above and 5cm below the lesion was excised. After disinfection, it was anastomosed to the right end with two layers of intermittent suture without leakage, good blood supply and no tension. Rats were immersed in distilled water, 0.1% neomycin, 5-Fu 500mg and normal saline, respectively, for abdominal and pelvic cleaning and careful hemostasis. The retroperitoneum was repaired and the pelvic floor was reconstructed. The anastomosis was placed outside the peritoneum, and a double-tube negative pressure drainage puncture wound was placed nearby for extraction. Abdominal Douglas posterior fossa cigarette drainage. The gauze devices were counted without error, and the abdomen was closed in layers. The blood loss during the operation was small. After the operation was smooth and completed, the gauze was returned to the room.
Conclusion of the operation:
The adenocarcinoma of upper rectum has a good differentiation. Although it has invaded 肠管 and the whole layer of intestine one week, and the disease stage is fairly long, no extra-intestinal metastasis is found. The prognosis is estimated to be better following the standard Dixon radical resection.
There is no tension at the anastomosis, the blood supply is good, and the suture is satisfactory, so the complication risk of leakage should be small. The operation has been conducted in accordance with the principle of sterility and no tumor, hence iatrogenic implantation dissemination will be rare. Postoperative chemotherapy should be supplemented to enhance the curative effect.
Operator, record: Mingjie Li, 87/4/2
Note: Patient recovered well without any complications. She had been hospitalized for 26 days and discharged after recovery. The patient was followed up for 8 years without recurrence or symptoms, and her quality of life was normal. Digital rectal examination showed soft mucosa at anastomosis, with intestinal cavity free and wide.
