[General Surgery Laparoscopy] Vascular skeletonization under 4K ultra-high definition laparoscopy

Skeletalization of blood vessels can significantly improve the complete tumor resection rate, but it also carries great risks, requiring solid basic skills in vascular surgery and techniques for dealing with vascular injuries. Laparoscopic vascular skeletonization is an advanced blood vessel separation technique performed during laparoscopic surgery. It is mainly used in tumor resection surgery, especially when dealing with tumors that are tightly adherent to or wrap around blood vessels.

Laparoscopic vascular skeletonization refers to the thorough separation of blood vessels from surrounding tumor tissue, lymph nodes, fibrous connective tissue, etc. through precise operations in the minimally invasive environment of laparoscopic surgery, while retaining the integrity and function of blood vessels. , while achieving the goal of complete tumor resection.

Technical points:

1. Operating environment: Performed under direct vision of a 4k laparoscope, utilizing the magnification and minimally invasive advantages of the 4k laparoscope to achieve precise operations.

2. Separation level: Separation along the level between the vascular adventitia and the vascular sheath is the key to vascular skeletonization. This layer is relatively loose, easy to separate, and can protect blood vessels from damage to the greatest extent.

3. Auxiliary tools: surgical instruments such as dissecting scissors, ultrasonic scalpels, and bipolar electrocoagulation are commonly used for separation and hemostasis. Ultrasound is particularly useful in breaking up and aspirating perivascular tumor tissue, leaving the integrity of the blood vessels undamaged.

4. Operation steps: First find easily exposed blood vessels, such as iliac blood vessels, inferior vena cava, renal vein, etc., and then gradually expand and separate them along the outer membrane of the blood vessels until the blood vessels are completely separated from the surrounding tumor tissue.

For surgeries with severe infiltration of tumor tissue, in view of the widespread and tight distribution of tumor tissue along important retroperitoneal blood vessels, in order to increase the surgical resection rate and reduce the risk of vessel damage, the vascular region can be further applied on the basis of "vascular skeletonization" "Gridding", that is, inferior vena cava, abdominal aorta, renal blood The tubes and iliac blood vessels can be regarded as a grid. Tumor tissue blocks located in this vascular network can be resected in pieces after the blood vessels at this site are skeletonized. Similar vascular networks also include the subdiaphragmatic celiac trunk (left stomach, common liver, spleen). artery, etc.) area, as well as the superior mesenteric blood vessel area, inferior mesenteric blood vessel area, iliac blood vessel area, etc.

According to the vascular network, the blood vessels in the network are skeletonized in sequence, and the tumors, enlarged lymph nodes, fibrous connective tissue, etc. that may exist in each network are sequentially removed to break them into parts and finally completely remove the tumor tissue.

For patients with tightly packed tumors, important but relatively small blood vessels, and an inconspicuous gap between the vascular sheath and adventitia, ultrasonic scalpel can be used to break up and aspirate the perivascular tumor tissue, leaving the integrity of the blood vessels undamaged.

Since the introduction of the standard surgical procedures of neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME), the 5-year local recurrence (LR) rate of locally advanced rectal cancer has been 5% to 10%. For locally advanced rectal cancer below peritoneal reflection, the incidence of lateral lymph node (LPN) metastasis is 16% to 23%, which is beyond the scope of routine TME dissection. In addition, increasing evidence shows that LPN transfer is an important cause of postoperative LR. Lateral pelvic lymph node dissection (LPND) remains controversial worldwide as a procedure to prevent and potentially cure lateral pelvic recurrence.In particular, surgeons in Western countries regard LPN metastasis as a systemic disease (except internal iliac lymph nodes) and tend to simply perform TME. The Japanese guidelines believe that LPN metastasis is regional metastasis, mainly occurs in middle and low cT3-T4 rectal cancer, and LPND has good therapeutic effect. Therefore, the Japanese Society of Colorectal Cancer (JSCCR) recommends TME plus central D3 resection and preventive LPND. As a standard treatment for advanced low rectal cancer.

Advantages

Improve the integrity and safety of tumor resection.

Reduce the risk of organ resection or postoperative organ atrophy associated with vascular injury.

Shorten the operation time, reduce intraoperative bleeding and postoperative complications.

Risk

It is technically difficult and requires the operator to have solid basic skills in vascular surgery and techniques for dealing with vascular injuries.

Unexpected situations such as blood vessel damage may occur during the separation process, which need to be dealt with in time.

Summarize

Laparoscopic vascular skeletonization is an advanced vascular separation technique that plays an important role in complex surgeries such as tumor resection. Through careful operation and appropriate auxiliary tools, this technology can achieve complete tumor resection while protecting the integrity of blood vessels, improving the safety and success rate of surgery. However, because this technique is difficult and risky, it requires operators to have extensive experience and superb skills.