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1、LigaSureTM 的临床应用,Energy Based Tissue and Vessel Fusion,Vessel ligation is a critical component of all surgical dissection.血管的结扎是所有外科手术分离中的关键部分,Vessel and Tissue LigationWhat are your choices?,Ligation Techniques,Manufacturers Recommended Range of Vessel Size for Application(mm),0.5,1.0,1.5,2.0,2.5,3
2、.0,3.5,4.0,4.5,5.0,5.5,6.0,6.5,7.0,7.5,8.0,8.5,9.0,9.5,10.0,Suture,Clips,Staples,Monopolar ES,Bipolar ES,Ultrasonic Coag,Vessel Sealing,*,*,3 sizes of clips and appliers,Vascular Staples,Vessel and Tissue Fusion脉管和组织融合技术,Electrosurgical Technology That Combines,Pressure and Energy压力和能量,To Create a F
3、usion Zone产生一个融合带,Tissue and Vessel Fusion,an advance in a unique electrosurgical technology that combines pressure and energy to create a fusion zone一种先进电外科技术将压力和能量结合从而产生融合带,Developed in response to surgeon requests for an additional option to current vessel ligation methods根据外科医生的需求发展的技术，从而提供目前血管结
4、扎手段以外的方法。,Vessel Fusion System脉管闭合系统,Generator 主机Bipolar instrument configuration 双极工作模式Low Voltage-180V 低电压180V High Current-4A 高电压4A Tissue Response 组织反馈技术Instruments 器械High pressure 高钳口压力Open(reposable and single use)开放器械（可重新组装的和一次性使用的）Laparoscopic(single use)腔镜器械（一次性使用）,System Operation,Applies
5、optimal pressure to vessel/tissue bundle 在血管/组织束上施加最佳的压力Energy delivery cycle:能量输送周期：Measures initial resistance of tissue and chooses appropriate energy settings 测量组织的最初电阻并选择适当的能量设定Delivers pulsed energy with continuous feedback control 输送能量脉冲同时进行持续的反馈控制Pulses adapt as the cycle progresses随循环周期的进行调
6、整能量脉冲Senses that tissue response is complete and stops the cycle 监测组织反馈当闭合完成时停止能量输送,Fusion Characteristics融合带的特性,Intimal layers of vessel walls fused 融合血管壁的内膜Does not rely on a proximal thrombus 不依赖于近端血栓Permanent 永久性闭合,Tissue Effects of Coagulation Versus Vessel Fusion凝血和脉管闭合技术的组织效果的比较,Coagulation r
7、elies on vessel shrinkage and a proximal thrombus for vessel occlusion.凝血依赖于血管的收缩和近端血栓堵塞血管,Vessel fusion fuses the intimal walls of the vessel,completely obliterating the lumen.脉管闭合技术融合了血管壁的内膜，从而完全封闭管腔。,*Porcine Model,Fusion Characteristics,Plastic-like consistencydue to collagen remodeling 由于胶原蛋白的重
8、塑，闭合带均一而且富有弹性。Distinctive,possibly translucent fusion zone 独特的透明闭合带Withstands greater than three times normal systolic pressure 可承受3倍以上的正常收缩压,Tissue Selection Criteria选择组织的标准,Veins and arteries up to and including 7mm 达到并包括7mm的静脉和动脉Tissue bundles containing vessel(s)or lymphatics 包含有血管或淋巴管的组织束Lympha
9、tics up to and including 7 mm 达到并包括7mm的淋巴管,Results,High burst strength seals exhibited the following properties:高破裂压的闭合带具有以下特性：Thin,translucent,plastic-like seal site 薄的透明弹性闭合带seal zone significantly compressed 被压缩的扁平闭合带intimal layers of vessel walls fused 融合血管壁内膜lateral thermal damage 2mm 外侧热损伤2mm,
10、H&E stained longitudinal section of sealed porcinerenal arteryH&E染色的猪肾动脉闭合带的纵切面,The seal zone.Note the fused lumen of the vessel walls.闭合带；注意血管壁已被融合在一起，内腔消失。,Burst Strength Study ResultsPercent success of fusion zone withstanding 3 times normal systolic pressure(360mmHg),Comparison Study Results,Pro
11、bability of seal failure below 400 mmHg:在400mmHg压力下闭合带破裂的概率：Ultrasonic coagulator 超声凝血95.0%Standard bipolar 标准双极 28.0%Clips*金属夹 0.4%Vessel sealer*脉管闭合技术 0.2%Ligatures*缝线 0.0%Probability of failure for ultrasonics and standard bipolar is significantly higher than other methods 超声刀和标准双极的闭合失败概率明显高于其他方法
12、。Other methods(*)not statistically different from each other 其他的方法（*）之间没有明显区别。,Healing process,A comparison*of the healing process following ligation with sutures and vessel sealing system have been studied at 7,14 and 28 days.缝线结扎和血管闭合技术的愈合过程中第7、14和28天比较At 7 days,both LigaSure and suture sites exhi
13、bited gross signs of inflammation.第7天：“LigaSure 和缝线的部位都有炎症的表现”At 14 days,numerous adhesions were noted at the suture sites whereas the LigaSure seals did not affect any of the surrounding tissue第14天：“在缝线部位有许多的粘连，而LigaSure闭合带与周围组织没有粘连”At 28 days:“numerous evolved adhesions were present at the suture
14、sites.The LigaSure sites were difficult to locate.”第28天：“缝线部位有许多粘连形成，而LigaSure 闭合部位已经难以确认”The potential for seals composed of the patients native tissue reduce the inflammatory response and improves healing process.闭合带由患者自身的组织构成，从而减少了炎症反应，促进了愈合过程。,*Comparison of Healing Process Following Ligation wi
15、th Sutures and Bipolar Vessel Sealing PETERSON,STRANAHAN,SCHMALTZ,MIHAICHUK,COSGRIFF Surgical Technology International,Sutures at 28 days,LigaSure at 28 days,Vessel Fusion Technology,Ensures:Fusion strengths higher than other energy based techniques 闭合强度高于其他的能量技术Fusion strengths comparable to existi
16、ng mechanical based techniques 闭合强度与现存的机械闭合技术相当,Vessel Fusion Technology,Ensures:Reliable,consistent,permanent vessel wall fusion 可靠的、一致的、永久性血管壁融合Minimal thermal spread 最小的热传导Reduced sticking and charring 较少的粘连和焦痂,Surgical specialties with experience in vessel fusion technology,Surgical Applications
17、,LigaSureTM Clinical Applications,General surgery普外科Gynaecological surgery妇产科Urological surgery泌尿外科Thyroid surgery甲状腺手术,General Surgery,Gastrectomy 胃切除术Gastrojejunostomy 胃空肠吻合术Gastric Bypass 胃旁路手术Mastectomy 乳房切除术Axillary Dissection 腋窝淋巴结清扫Liver Resection 肝切除Living Door Liver Transplant 活体肝移植手术Splene
18、ctomy 脾切除术Thyroidectomy 甲状腺切除术Lap Nissen 腔镜Nissen手术Esophagectomy 食道切除术,Bowel Resection 小肠切除术Abdominal Perineal Resection 经腹会阴联合切除术Low Anterior Resection 低位前切除Colectomy 结肠切除术Hemorrhoidectomy 痔切除术Whipple 胰十二指肠切除术Omentectomy 网膜切除术Ileo-anal Pull-through 拖出式回肠肛管吻合术Rectal Prolapse 直肠脱垂手术Adrenalectomy 肾上腺切
19、除术Lap Colectomy 腔镜结肠切除术,Gynaecology妇产科,LigaSureTM Use in GYN ProceduresLigaSureTM 在妇产科手术中的使用,Anatomy解剖Vaginal Hysterectomy经阴道子宫切除术 TAH经腹子宫切除术 LAVH腔镜辅助的经阴道子宫切除术 Supracervical Hysterectomy子宫颈上子宫切除术,子宫解剖,腹腔镜子宫切除术,Study by:Barbara Levy,MDClinical Assistant Professor of OB/GYN,U of WA Seattle,WA,Vaginal
20、Hysterectomy经阴道的子宫切除术,84 patients 共84例患者Blood loss decreased in all cases compared to average expected loss 所有病例的失血量均少于平均预期失血量5 cases suture used on one side,vessel fusion used on the other 5例在一侧使用缝线，另一侧使用脉管闭合技术Operative time consistently decreased 10-20 minutes 手术时间平均下降1020min,Study by:Robert McLel
21、lan,MDDepartment of GynecologyLahey Clinic,Burlington,MA,Total Abdominal Hysterectomy,50 patients(randomized vessel fusion/suture)50例患者（随机使用血管闭合技术/缝线）Procedure time(abdominal incision to closure of vaginal cuff with satisfactory hemostasis 手术时间（从做腹部切口到关闭阴道袖并得到满意的止血效果）Vessel fusion 30.6 min.(18-62)使用
22、血管闭合技术：30.6min(1862)Suture 48.2 min.(30-109)使用缝线：48.2min(30109)Blood loss 失血量 Vessel fusion 32-50ccSuture 25-250cc,结肠解剖,Colon Anatomy结肠的解剖,Right Hemicolectomy右半结肠切除术,Transverse Colectomy横结肠切除术,Left Colectomy左半结肠切除术,Sigmoid Colectomy乙状结肠切除术,Low Anterior Resection低位前切除,Laparoscopic Assisted Colectomy腔
23、镜辅助的结肠切除术,IndicationsColon carcinoma 结肠癌 Rectosigmoid cancers 直乙结肠癌Rectal cancer直肠癌 Benign colon polyps良性结肠息肉 Diverticulitis憩室 Volvulus肠扭转 Crohns disease of the bowel克隆氏病Squamous cell carcinoma of the anus肛管鳞状上皮细胞癌,Anal or rectal sarcomas肛门或直肠肉瘤 Crohns disease of the rectum 直肠克隆氏病Anal or rectal mela
24、noma肛门或直肠黑色素瘤,Laparoscopic Surgery,Less pain 较少的疼痛Faster recovery 更快的恢复Earlier discharge 住院时间短Earlier return to work 更快的恢复工作?Better survival from cancer？肿瘤患者的生存率更高MASSIVE PATIENT DEMAND,Down Sides of Laparoscopy,More difficult 操作更困难Learning curve(20-30 cases)学习曲线（2030例）Longer operating time,initially 更长的手术时间（最开始时）Technology dependant 依赖于医生的技术,Contraindications禁忌症,Inadequately trained surgeon/surgical team 未经充分训练的外科医生/手术组Large,locally advanced cancers 大的局部进展期肿瘤Multiple previous surgeries 多次手术史Heart failure,chronic lung disease 心脏衰竭、慢性肺部疾病,Questions,
