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1、手術室中的頸動脈內(nèi)膜切除術Carotid Endarterectomy(CEA)日照市人民醫(yī)院神經(jīng)外科張玉海國家遠程卒中中心、腦防委CEA培訓基地、北京市腦血管病中心外科治療相關問題 麻醉方式（GALA trial）術式介紹-標準CEA（傳統(tǒng)CEA）-翻轉(zhuǎn)式CEA 護士協(xié)作 并發(fā)癥的預防Operation room team position during CEA.S Surgeon,aS assisting surgeon,Ne neurophysiologist；A anaesthesiologist；N nurse；M microscope團隊配置及體位團隊配置及體位I.Supine p
2、osition;II.Head up:to reduce cervical venous pressure;III.Head is placed on a ring,with a sandbag under the shoulders;IV.Exposing the full length of the sternomastoid muscle;手術體位要求手術體位要求手術切口麻醉篇 麻醉平穩(wěn)及適時調(diào)整血壓至關重要麻醉方式 全麻：-General anaesthesia has several advantages,including easier surgical manoeuvres,ha
3、ndling of complications and easier patient monitoring.局麻：-local/regional anaesthesia decreases the number of medical complicationsat the expense of neurological complications.General anaesthesia versus local anaesthesia for carotid surgery(GALA):a multicentre,randomised controlled trialMethod:a para
4、llel group,multicentre,randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries.-general(n=1753)or local(n=1773)anaesthesia;-stroke(including retinal infarction),myocardial infarction,or death between randomisation and 30 days aft
5、er surgery;Conclusion:The two groups did not significantly differ for quality of life,length of hospital stay,or the primary outcome in the prespecified subgroups of age,contralateral carotid occlusion,and baseline surgical risk.兩個組在生活質(zhì)量、住院時間、預設不同年齡組的結果、雙側頸動脈閉塞和手術風險等方面均無顯著差異。麻醉的不可替代性 掌握術前有無心臟疾病，缺血性尤
6、為重要 術前的基礎血壓，要明確 麻醉平穩(wěn)后開始手術前的血壓，記錄定標 臨時阻斷后可能需要短時升壓至要求值 動脈縫合完畢后需要盡快降壓 結合TCCD定出出室后的血壓安全控制范圍麻醉深度監(jiān)測麻醉深度電極腦氧監(jiān)測麻醉協(xié)助TCCD術前定標 術中阻斷后短時升壓 血流再通后積極降壓，不建議用硝普鈉術后麻醉與TCCD定控制范圍麻醉機麻醉機TCCD監(jiān)測術中指導意義大 術前麻醉平穩(wěn)后定標主要參考。腦血流峰值、平均值、收縮期、舒張期 Baseline(before induction)Pre-clamp(at heparin injection)Clamping,shunt insertion(if requir
7、ed)Post-clamping(15 min after clamping)Clamp release 5-min post-release 10-min post-release術中監(jiān)測術中監(jiān)測手術護理篇 熟悉流程能減少動脈阻斷時間 器械準備要求高 巡回護士及時調(diào)整雙極電凝 阻斷前靜脈給肝素 腔內(nèi)操作持續(xù)肝素鹽水沖洗 術中沖洗準備 兩套吸引裝置操作流程 分離暴露動脈鞘 顯微操作階段：切開剝離斑塊、縫合動脈 關閉動脈鞘、分層縫合。顯微操作前器械顯微操作前器械顯微操作中器械顯微操作中器械顯微操作中器械術中特別注意的問題 術中對血管的保護尤為重要。器械對縫合線的損傷隱患最大。無損傷器械使用。肝素
8、鹽水的高頻率沖洗（1ml含10u肝素）。肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;CEA視頻剪輯.mp4粥樣斑塊（粥糜樣物）粥樣斑塊（粥糜樣物）狹窄處的真腔縫隙狹窄處的真腔縫隙狹窄真腔狹窄真腔不穩(wěn)定斑塊術式 標準CEA 翻轉(zhuǎn)式CEAStandard CEA technique.P Plaque,T superior thyroid artery,L longitudinal arteriotomyCEA technique with intraluminal shunt.IS I
9、ntraluminal shunt,R rubber band aroundthe CCA,C window aneurysm clip at the ICA,P plaque,T superior thyroid arterySelective shunting with eversion carotid endarterectomyModified Eversion Carotid EndarterectomyAnn Vasc Surg 2013;27:178185手術涉及的解剖結構 耳大神經(jīng)、頸外靜脈 頸闊肌、胸鎖乳突肌 頸內(nèi)靜脈、面靜脈 頸內(nèi)動脈 頸總動脈 頸袢、舌下神經(jīng)、迷走神經(jīng)、喉
10、上神經(jīng)、面神經(jīng)頸闊肌頸闊肌External jugular vein:vein is ligated and divided;Arteria branch of the great auricular nerve;Great auricular nerve（耳大神經(jīng)）External jugular vein頸動脈鞘The jugular vein is not dissected free;it is merely identifi ed and left untouched.觸及CCA，分離方向：向頭端，由CCA,ICA,ECA,superior thyroid arteries；向上：P
11、osterior belly of the digastric muscle（二腹肌）;向下：Further exposure:Inferiorly the middle thyroid vein（甲狀腺中靜脈）may require ligation and the omohyoid muscle（肩胛舌骨?。?需耐心處理的：淋巴結淋巴結需注意的：觀察心率，必要時應用局麻藥物；不要急于升壓提升心率Posterior belly of the digastric muscle;Hypoglossal nerve 重要標記：The hypoglossal nerve:crosses the in
12、ternal and external carotid arteries;頸袢：Ansa cervicalis;調(diào)整方向及深度：Self-retaining retractor；此過程輕提血管外膜，分離過程盡量不觸及分叉部或斑塊處；減少斑塊脫落的風險；分離是為臨時阻斷做準備，不要過分游離血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后關系時，則需將分叉部盡可能分離；肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;阻斷順序：-The first cl
13、ip is applied to the ICA,then one each to the ECA and the superior thyroid artery and finally to the CCA.（試阻斷）-Clamps were applied sequentially to the superior thyroid artery,the common carotid artery,internal carotid artery,and the external carotid artery.（持續(xù)阻斷）-返血：分別提起ECA，ICA阻斷帶；或源于咽升A，使用較大的阻斷夾完全阻
14、斷ECA；重要標記：The hypoglossal nerve:crosses the internal and external carotid arteries;頸袢：Ansa cervicalis;調(diào)整方向及深度：Self-retaining retractor；此過程輕提血管外膜，分離過程盡量不觸及分叉部或斑塊處；減少斑塊脫落的風險；分離是為臨時阻斷做準備，不要過分游離血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后關系時，則需將分叉部盡可能分離；動脈切開：longitudinal arteriotomy注意刀片方向：Cutting edge ou
15、twards so that once the lumen is entered,the blade can be drawn outwards to commence a longitudinal arteriotomy.技巧：切開動脈壁時：可標記切口，以確保方向；The arteriotomy is slightly lateral to the midline(from the surgeons point of vision);especially at the bifurcation it runs some 3 mm lateral from the upper aspect of
16、 the bifurcation;Potts angle scissors近端:the vessel is palpated to find a target area of lesser disease where the endarterectomy can be stopped;遠端:the arteriotomy on the anterolateral aspect of the internal carotid is taken beyond the severe disease,this being usually within 12 centimeters of its ori
17、gin;Dissector（剝離子的使用）（剝離子的使用）The inner is a thickened,irregular longitudinal length of atheroma with the intima that may be ulcerated and covered with thrombus.The outer layer is yellow and uniform in thickness:it is a layer of thickened intimomedial fibers that may peel off easily as a circular str
18、ip,but which can also be left in situif firmly adherent to the wall.特殊斑塊處理 Care is necessary when dissecting hard,calcified plaques.Firmer attachments to the outer vessel layers;處置方式：Cut through the plaque to the lumen,cutting it longitudinally until the healthy ICA is reached;The inner core of athe
19、roma is gently mobilized along its length until an end point is reached in the internal carotid artery;It thins down to a transparent thin layer of intima無殘渣：無殘渣：without residual frills.移形處的處理：移形處的處理：clean end point must be seen；PIN；The absence of any residual frills is tested by flushing and carefu
20、l excision.Proximally,obtaining a satisfactory end point may be more difficult.Distally,it is advisable to follow the atheroma until it reaches its thin end point;斑塊切斷順序：斑塊切斷順序：-The plaque is transversally cut in the most caudal aspect of the arteriotomy.-the arteriotomy proceeds cranially stepwise
21、always after the segment of the plaque is dissected free.頸外動脈斑塊處理：頸外動脈斑塊處理：-Atheromatous core extends into the external carotid artery,usually for 510 mm.-Y型切開：型切開：ICA斑塊殘端的處理：Technique to secure the distal end of the plaque.In case it is not possible to remove all remnants of plaque in the distal en
22、d of ICA and the intima is loose,tacking sutures are used.The stitches are positioned at 6,9 and 12 hours“l(fā)ooking into ICA lumen”.The 4th firm point is the first stitch starting the closure(at 3 hours).RP Residual plaque6/0 tacking sutures縫合前的要求：縫合前的要求：-good end points:all three carotid vessels;-Res
23、idual clot is flushed away.I.Closure starts:above the endarterectomy at the upper extreme of the incision.II.6/0 running suture;III.Before its completion,the ICA is shortly opened and flushed.The artery is flushed with heparin solution;IV.More knots are used usually 7 and the ends of the stitches ar
24、e cut longer,some 56 mm from the knots.肝素鹽水沖洗：As the suture line is almost complete,further flooding of the segment with heparinized saline solution is undertaken to remove any residual debris and to fill the segment with fluid,removing any air bubbles.短暫松開甲狀腺上A：The loop may be released around the s
25、uperior thyroid artery to allow blood to fill thesegment,flushing out any remaining bubbles.The internal carotid artery clamp is removed first to ensure that there are no leaks,then the external.I.After the arteriotomy is closed,the ICA clip is briefly(1 sec)opened.II.The clips are then removed from
26、 the ECA,the superior thyroid artery and the CCA.III.The last to remove is the clip from the ICA.IV.Direct dopplerometry is used to check the patency and disclose any irregularities in the vessels;臨時阻斷夾釋放順序臨時阻斷夾釋放順序The arteriotomy usually leaks a small amount and sometimes even a small jet of blood
27、may be encountered.-Add extra stitches?-Leaking arteriotomy is covered for some 35 min by muslin soaked in warm Ringer solution;-Covered by a small strip of oxycellulose;suction drainCarotid sheath;Closed in two layers(platysma,skin)縫合后滲血的處理縫合后滲血的處理局部出血的觀察 Hemorrhage:dressing,neck swelling,with or w
28、ithout tracheal compression,and blood collected in the drainage bottle Continued hemorrhage of greater than 100 ml/h and/or tracheal compression may require reexploration,evacuation of the hematoma and securing hemostasis.相關并發(fā)癥Carrdiac issues:The two possible serious complications likely to occur ar
29、e myocardial infarction or cardiac failure during the perioperative period and a decrease in blood pressure during the perioperative period.Ipsilateral stroke:drop in blood pressure,vessel thrombosis or by embolisation,from the endarterectomised vessel.Hyperperfusion syndromeCranial nerve injury:XII
30、th,VIIth,recurrent nerveWound:wound haematoma and excessive wound swellingHOW TO AVOID COMPLICATIONSPATIENT SELECTIONANAESTHESIA(gentle and smooth anaesthesia)MONITORING(諸多方面：BP，術中轉(zhuǎn)流的監(jiān)測，血管縫合后的即刻監(jiān)測，術后切口的觀察等)DISSECTION AND ENDARTERECTOMYCROSS CLAMPING（Proper sequence of clip application and removal decreases the risk of perioperative embolisation.）HAEMOSTASIS（meticulous haemostasis）HEPARIN NON-REVERSALPOST-OPERATIVE CARE作為術者參與手術術中解剖演示術中解剖演示W(wǎng)e areA Team Believe me,I can.We are sure,we can您的聆聽
cea手術室篇 ppt課件數(shù)學
