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Applied Anatomy Study on Laparoscopic Surgery for Gastric Cancer

Author: WuTao
Tutor: ZhongShiZhen
School: First Military Medical University
Course: Clinical Anatomy
Keywords: laparoscopy gastric cancer radical gestrectomy surgical plane anatomy interfascia space dorsal mesogastrium
CLC: R322
Type: PhD thesis
Year: 2007
Downloads: 559
Quote: 1
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Laparoscopic surgery for gastric cancer is considered as a new technique in minimally invasive and radical resection. By separating in interfascial space and highly vessels ligation, laparoscopic radical gastrectomy can accomplish the "en-bloc" resection which is hard to perform in traditional opening operation. At the same time, minimally invasive surgery may lead to some distinguished clinical superiority in less suffering, less bleeding and batter postoperative quality of life. Today, laparoscopy can be applied in not only preoperative diagnosis of gastric cancer but also radical gastrectomy. The result of laparoscopic radical excision for early gastric cancer without lymph nod metastasis has been proved equal to that in open surgery. With the development of technique and surgical therapy mode, laparoscopic surgery is possible to substitute traditional open surgery step by step.Clinical experience proved that any development in surgery is based on the anatomic theory correspond. Surgical safety and radical resection of cancer depend on the reorganization of surgical plane and vessels in laparoscopic vision. Today, there are still many disputes in radical gestrectomy for developed gastric cancer because of its operative complexity and exposure difficulty. Mesogastrium is not considered as an important structure in open surgery for gastric cancer. Laparoscopic gastrectomy coincide to open surgery in surgical principle but quite different in the style of operation perform. The anatomic study of mesogastrium is so few that seldom people aware it can be used to locate the right surgical plane in narrow laparoscopic vision in laparoscopic surgery. To evaluate the function of mesogastrium in laparoscopic surgical plane localization, we observed the distribution of mesogastrium in both formalin fixed cadaver and fresh cadaver, performed laparoscopic gastrectomy and lymph nod dissection in fresh cadaver.Part. 1 Clinical anatomic observation on fascias and fascia space in radical gastrectomy for gastric cancer1 Objectives: To explore the anatomic relationship of fascias origin from dorsal mesogaster and fascia space formed in embryogeny. So as to provid anatomic basis for surgical approach for radical gastrectomy and lymphadenectomy.2 Methods: 8 formalin fixed cadavers were dissected and observed to elucidate the anatomic features of the layers, the spaces and the components of fascia and the interfascial space related on redical gastrectomy and lymphadenectomy.3 Results3.1 The anterior and posterior pancreatic fascia, the anterior lob of transverse mesocolon, gastrosplenic ligament and splenorenal ligament are derived from dorsal mesogastrium in embryogeny. The fascias were stretched each other though the anatomic appearance are different.3.2 Under the fascias there were potential fascial space scatter abroad, the fascial space were feed through from one to the other. (1) fascial space exit between the two lobs of transverse mesocolon; (2) There were anatomic diversity of fascial sapce from pancreatic margin to transverse colon. The fascial space in the side of transverse colon is much larger than which in the side of pancrease; (3) Transverse mesocolon were continued to the anterior pancreatic fascia and the posterior layers of greater omentum. (4) Vessels in transverse mesocolon near the transverse colon are from middle colic artery. They located in the posterior lob of transverse mesocolon. (5) There is fusion space between deep fascia of pancreas and capsula pancreatis. 5 Conclusion5.1 The lymphatic system follow the vessels is locate in fascia space. Lymphadenectomy in radical gastrectomy must dissect not only lymph nods but also the whole fascia relative.5.2 The fascial space between fascias or organs are the right approaches to surgical operation in radical gastrectomy.Part.2 Anatomy observations on surgical planes in laparoscopic surgery for gastric cancer1 Objective: To study the anatomic features of fascia and fascial space around stomach in laparoscopic vision. The research try to find a proper surgical approach and surgical plane in laparoscopic radical gastrectomy for distal gastric cancer. So as to locate the surgical plane in laparoscopic vision.2 Method: Routine anatomic observes in 8 formalin fixed cadavers, laplaparoscopic gastrectomy was performed in 6 fresh cadavers. Transverse mesocolon, capsula pancreatic and the potential interfascial space beneath were observed under laparoscopy. The anatomic features of surgical plane and mark point of vessels in laparoscopic vision were recorded to help surgical plane localization.3 Results: Fascia space between stomach, spleen, pancreas and renal is a safe surgical plane for laparoscopic operation in the surgical treatment of distal gastric cancer. Most of operations in laparoscopic gastrectomy were definite in this surgical plane. Liberate follow the interfascial space can affect the operation both in safety and radical dissection. Special vision of vessels in laparoscopy such as gastropancreatic fold and trifid structure can be marked to locate the root of vessels in operation.4 Conclusion: Fascia and interfascial space formed in embryonic development are very important to surgical plane localization and vessels identification in laparoscopic operation for gastric cancer. Full understanding of the laparoscopic anatomic features can provide a new research method and anatomic theoretical basis for laparoscopic operation design.Part.3 Localization and anatomic features of vessels in laparoscopic radical gastrectomy for gastric cancer1 Objective: To study the anatomic features of celiac trunk, superior mesenteric artery, superior mesenteric vein and their branches in laparoscopic vision. So as to find out a proper way to locate and expose the vessels from laparoscopic vision in laparoscopic radical gastrectomy and lymph nods dissection for distal gastric cancer. Study the surgical skill of vessels skeletonization base on the anatomic features of vaginae vasorum. Try to reduce the probability of vessel injury in laparoscopic surgical operation.2 Method:2.1 Anatomic studies: Routine anatomic observations and laparoscopic observations were performed in 8 10% formalin fixed cadavers and 6 fresh cadavers. Vessels localization and disposal in laparoscopic vision were strictly imitated to the real course which in laparoscopic gastrectomy. Vessels in transverse mesocolon, capsula pancreatic, lesser omentum, posterior abdominal wall and potential interfascial space around the stomach were observed on the topographic natures and the location landmarks which in laparoscopic vision.2.2 Clinical studies: Vessels location and disposals courses of 30 patients in which laparoscopic gastrectomy were performed from 2005 to 2006 were analyzed. The surgical plane that locate the vessels courser, anatomic distribution of vessels and its branches, vessels location in laparoscopic vision and skills of vessels skeletonization were observed and recorded by photo and video. Try to find some significant anatomic landmarks of target vessels which can be located easily in laparoscopic gastroectomy. Summarize proper methods to liberate the vessels and avoid vessels injury by mistake in vague vision at the same time.3 Results: (1) The courser and anatomic feature of vessels in laparoscopic vision are significant different from that in gross anatomy in both observation mode and observation angle. (2) The coursers of most target vessels which must be skeletonized were located in the same surgical plane. (3) The target vessels in laparoscopic gastrectomy distribute around pancreas especially in the position: superior to dorsal pancreas, inferior to the neck of pancreas and above pancreaticoduodenal fascia. (4) Fascia that cover splenic artery, left gastric artery and common hepatic artery form such special structure named plica lienalis, plica gastropancreation and plica hepatopancreation that can be located in laparoscopic vision. (5) A special structure similar to the mark of "Benz" form by the junction of common hepatic artery, proper hepatic artery and gastroduoden artery can be identified easily in laparoscopic vision. (6) There was space form by loose connective tissue between vessels and vaginae vasorum. Liberation in the space can totally expose the whole course of vessels easily. (7) The skeletonization of vessels makes it easy to observe the vessels distribution in narrow space.4 Conclusion:4.1 The intraficial space between anterior lob and posterior lob of dorsal mesogastrium is a permanent surgical plane to procedure vessels skeletonization and ligation in laparoscopic surgery for gastric cancer.4.2 Most operations for vessels disposals were around pancreas. Pancreas can be seemed as a permanent land mark in laparoscopic vision to conduct vessels location and skeletonization.4.3 Special facial structure above vessels may be identified easily in laparoscopic vision which can be seem as the land mark to locate the vessels precisely in laparoscopic surgery.4.4 Liberations in the space beneath vaginae vasorum may be easier to handle and safer than the liberation out side vaginae vasorum.4.5 Vessels disposals following the vaginae vasorum can make it more safety for the operator to justify the direction of vessels in narrow space. So that the vessels mistaken injury due to vague surgical vision can be avoid. On the other hand, vessels skeletonization inside vaginae vasorum may coincident to "en bloc" dissection in radical operation for gastric cancer.Part.4 Imageological studies of fascial space and vessels relevant to laparoscopic radical gastrectomy for gastric cancer1 Objective: (1) To study the imageological features of fascial space before laparoscopic surgery. Provide preoperative individualized anatomic features of fascial space for surgical plane localization. (2) To observe celiac trunk, superior mesenteric artery, superior mesenteric vein and their branches in Imageology. So as to locate the vessels before laparoscopic operation.2 Method: CT and MRI image in cross section, vertical plane and coronal plane were analyzed to locate the fascia and fascial space. The imaging features and adjacent structure of fascial space and relevant organs were identified and described in detail. Vessels relevant to lymph nod dissection were identified before operation to mark the anatomic variation and assist intraoperative vessels localization.3 Results: (1) fascia and fascial space around pancreas can be identified clearly in MRI image. (2) The continues of fascia and adjacent structure can be proved and localized in imageological studies. (3) CT imaging can display the anatomic features of vessels and prove the variation possible before operation but can not identify the fascia and fascial space. (4) MRI imaging is the best choice for fascia and fascial space observation.4 Conclusion: (1) Gastric wall and fascial space around stomach can be well identified in MRI image, and it can be used to judge the infiltration condition and anatomic features of surgical plane before operation. (2) The imaging of pancreas and vessels around it can help to localize the vessels and observe the anatomic variation before surgical operation. (3) The course and distributions of vessels can be identified in CT or MRI image to assess the safety in laparoscopic lymph nod dissection. (4) Preoperation imageological study associate to apply anatomy is helpful to surgical operation design and intraoperative localization of surgical plane.

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