腹部外科手术中英优质课件.ppt

1、腹部外科手腹部外科手术术中英中英 Introduction 前言前言 Exploratory celiotomy/laparotomy 剖腹探剖腹探查术查术 Gastrotomy&gastropexy for GDV 胃切开胃切开术术&胃固定胃固定术术治治疗疗胃扭胃扭转转 Enterotomy&resection&anastomosis 肠肠切开切开术术&切除切除术术&吻合吻合术术 Splenectomy 脾切除脾切除术术 Liver biopsy&liver lobectomy 肝肝脏脏活活检检&肝叶切除肝叶切除术术 Exploratory Celiotomy剖腹探剖腹探查术查术 Indic

2、ations 适适应应症症 Trauma 创伤创伤 Penetrating wounds 穿透穿透伤伤 Haemoabdomen 腹腔有血液腹腔有血液 Tumors 肿肿瘤瘤 Septic abdomen 腹部感染腹部感染 Ileus 肠肠梗阻梗阻 Midline Celiotomy中中线线剖腹剖腹术术 Most common approach 最常最常见见的方法的方法 Diagnostic procedures 诊诊断程序断程序e.g.biopsy,exploratory surgery 例如活例如活组织检查组织检查，探，探查术查术 Therapeutic surgery 治治疗疗手手术术e

3、.g.gastric dilatation volvulus,cystotomy 例如胃例如胃扩张肠扩张肠扭扭转转，膀胱切开，膀胱切开术术 Elective surgery 选择选择性外科手性外科手术术e.g.ovariectomy 例如卵巢切除例如卵巢切除术术 Midline Celiotomy中中线线剖腹剖腹术术 Preoperative aspects 术术前准前准备备 Correct anesthetic protocol(AB)恰当的麻醉方案恰当的麻醉方案 Clipping 剪毛剪毛 Dorsal recumbency 背背侧侧斜卧斜卧 Sterile preparation ope

4、ration site 无菌手无菌手术术操作操作 Draping 覆盖覆盖创创巾巾 Basic surgical instruments 基本的外科器械基本的外科器械 Midline Celiotomy中中线线剖腹剖腹术术 Midline Celiotomy中中线线剖腹剖腹术术 Midline Celiotomy中中线线剖腹剖腹术术 Midline Celiotomy中中线线剖腹剖腹术术 Midline Celiotomy中中线线剖腹剖腹术术 Midline Celiotomy中中线线剖腹剖腹术术Midline Celiotomy中中线线剖腹剖腹术术Good separation of sub

5、cutis and rectus sheath will make closing of the abdomen easier 良好的分离皮下良好的分离皮下组织组织及腹直肌会更容易地关及腹直肌会更容易地关闭闭腹腔腹腔Lift the abdominal wall with forceps when stab incision is made 用用镊镊子提起腹壁刺开切口子提起腹壁刺开切口Check for adhesions before cutting through the linea alba 切开腹白切开腹白线线之前之前检查检查是否有粘是否有粘连连Prevent enclosing ab

6、dominal fat in suture line 在在缝缝合合线处线处防止防止闭闭合腹部脂肪合腹部脂肪Midline Celiotomy中中线线剖腹剖腹术术 Exploratory Celiotomy剖腹探剖腹探查术查术 ALWAYS check the entire abdominal cavity in the SAME order 要以相同要以相同顺顺序序检查检查整个腹腔整个腹腔 Start with abdominal wall,peritoneum(free fluid)要从腹壁、腹膜（游离液体）开始要从腹壁、腹膜（游离液体）开始 Exploratory Celiotomy剖腹探

7、剖腹探查术查术 Diaphragm&liver 隔膜隔膜&肝肝 Exploratory Celiotomy剖腹探剖腹探查术查术 Liver&bile ducts 肝肝&胆管胆管Exploratory Celiotomy剖腹探剖腹探查术查术 Adrenal gland right 右右侧肾侧肾上腺上腺 Exploratory Celiotomy剖腹探剖腹探查术查术 Right kidney 右右侧肾脏侧肾脏 Exploratory Celiotomy剖腹探剖腹探查术查术 Female reproductive tract 雌性生雌性生殖系殖系统统 Exploratory Celiotomy剖腹探

8、剖腹探查术查术 Bladder&male reproductive tract 膀胱膀胱&雄性生殖系雄性生殖系统统 Exploratory Celiotomy剖腹探剖腹探查术查术 Left retroperitoneal area&adrenal 左左侧侧腹膜后区腹膜后区&肾肾上腺上腺 Exploratory Celiotomy剖腹探剖腹探查术查术 Gastro-intestinal tract&pancreas 胃胃肠肠道道&胰腺胰腺 Exploratory Celiotomy剖腹探剖腹探查术查术 Gastro-intestinal tract&pancreas 胃胃肠肠道道&胰腺胰腺 Ex

9、ploratory Celiotomy剖腹探剖腹探查术查术 Duodenum 十二指十二指肠肠 Exploratory Celiotomy剖腹探剖腹探查术查术 Jejunum 空空肠肠Exploratory Celiotomy剖腹探剖腹探查术查术 Ileum,caecum&colon 回回肠肠，盲，盲肠肠&结肠结肠 Exploratory Celiotomy剖腹探剖腹探查术查术 Spleen 脾脾脏脏 Exploratory Celiotomy剖腹探剖腹探查术查术 ALWAYS check all instruments&swabs are accounted for!经经常清点所有器械和棉常

10、清点所有器械和棉签签 Introduction;Gastric Surgery介介绍绍；胃外科学；胃外科学 Gastric foreign bodies 胃异物胃异物 induction of vomiting 诱导诱导呕吐呕吐 endoscopic removal 内内窥镜窥镜移除移除 gastrotomy 胃切开胃切开术术 Hypertrophic pyloric stenosis 肥厚性幽肥厚性幽门门狭狭窄窄 Gastric dilatation-volvulus 胃胃扩张肠扩张肠扭扭转转 Gastropexy 胃固定胃固定术术 Gastrotomy 胃切开胃切开术术 Incision

11、in gastric body 胃体的切开胃体的切开 Double layer closure 双双层层关关闭闭 simple continuous,all layers 全全层简单连续缝层简单连续缝合合 interrupted inverting(Lembert)伦伦伯特伯特缝缝合合 Gastrotomy 胃切开胃切开术术 Gastrotomy;closure胃切开胃切开术术；闭闭合合 Gastric Dilatation Volvulus胃胃扩张肠扩张肠扭扭转转 Clinical signs 临临床症状床症状 Algorithm for acute GDV 急性胃扭急性胃扭转转 Emerg

12、ency treatment 急急诊诊 Surgical treatment 外科治外科治疗疗 Radiography 放射放射线线照相照相术术 Results 结结果果 Clinical signs of GDV急性胃扭急性胃扭转转的的临临床症状床症状 Unproductive attempts to vomit 无呕吐物的呕吐无呕吐物的呕吐 Rapid distension of the abdomen 腹部迅速膨腹部迅速膨胀胀 Usually shortly after eating 通常通常发发生在生在进进食后不久食后不久Differential diagnosis:intestina

13、l volvulus 鉴别诊鉴别诊断：断：肠肠扭扭转转 more serious general signs than in GDV 比胃扭比胃扭转转更更严严重的症状重的症状 rapid progression,usually fatal 病情病情进进展快，通常是致命的展快，通常是致命的 very painful(ischemia)非常疼痛（局部缺血）非常疼痛（局部缺血）Intestinal volvulus小小肠肠扭扭转转 intubation gastrocentesis radiography surgery observationno no no yes no yes yes yes

14、successful?stomach empty?severe dilatation?position normal?Emergency treatment急急诊诊治治疗疗 Intubation of the stomach 胃插管胃插管 Percutaneous gastrocentesis 胃穿刺胃穿刺 Shock therapy 休克休克疗疗法法 Intubation of the stomach插胃管插胃管Tube:Lavacuator II Mallinckrodtmouth piece:InstruvetPO box 170,5430 AD Cuijckthe Netherland

15、s Percutaneous gastrocentesis经经皮肤的胃穿刺法皮肤的胃穿刺法 Surgical treatment外科治外科治疗疗 Repositioning of the stomach 胃的重新定位胃的重新定位 Assessment of gastric viability 胃的可行性胃的可行性评评估估 Removal of gastric contents(gastrotomy)除去胃内容物（胃切开除去胃内容物（胃切开术术）Fixation of the pyloric antrum(gastropexy)固定幽固定幽门窦门窦（胃固定（胃固定术术）Repositioning

16、 of the stomach胃的重新定位胃的重新定位rightpp Assessment of viability可行性可行性评评估估 Clinical assessment 临临床床评评价价 serosal coloration 浆浆膜的着色膜的着色 gastric wall texture 胃壁胃壁结结构构 vascular thrombosis or avulsion 血管血栓或撕血管血栓或撕裂裂 Intravenous fluorescein1 静脉内静脉内荧荧光素光素1 Wheaton LGJ.J Am Anim Hosp Assoc 1986;22:197-204 Gastric

17、 Necrosis胃坏死胃坏死 Uncommon:不常不常见见：30 of 285(11%)1;28 of 137(20%)2 fundus and corpus,greater curvature 胃底，胃体，胃大弯胃底，胃体，胃大弯 if resectable:partial gastrectomy 如果可切除：胃部分切除如果可切除：胃部分切除术术NB:significantly increased mortality 死亡率死亡率显显著增加著增加 13 of 28(46%)vs 24 of 137(18%)21 Matthiesen DT.Vet Surg 1985;14:185-193

18、2 Brourman JD et al.J Am Vet Med Assoc 1996;208:1855-58 Fixation of the pyloric antrum固定幽固定幽门窦门窦 Tube gastrostomy(1976)1 胃造口胃造口术术 Incisional gastropexy(1982)2 切口胃固定切口胃固定术术 Circumcostal gastropexy(1985)3 肋周肋周边边胃固定胃固定术术 Muscular flap gastropexy(1986)4 肌瓣胃固定肌瓣胃固定1 Parks JL et al.J Am Anim Hosp Assoc 19

19、76;12:168-1722 McCoy DM et al.J Am Anim Hosp Assoc 1982;18:763-683 Leib MS et al.J Am Vet Med Assoc 1985;187:245-484 Schulman A et al.J Anim Hosp Assoc 1986;22:339-46 Fixation of the pyloric antrum固定幽固定幽门窦门窦 Belt-loop gastropexy(1989)1 Belt环环胃固定胃固定术术 Incorporating gastropexy(1993)2 合并胃固定合并胃固定术术 Gast

20、rocolopexy(2001)3 胃胃结肠结肠固定固定术术1 Whitney WO et al.J Am Anim Hosp Assoc 1989;25:75-83 2 Meyer Lindenberg AJ et al.J Am Vet Med Assoc 1993;203:1303-73 Eggertsdottir AV et al.Vet Surg 2001;30:546-51 Incisional gastropexy切口胃固定切口胃固定术术McCoy D.M.,Sykes G.P.,Hoffer R.E.,Harvey H.J.A gastropexy technique for

21、permanent fixation of the pyloric antrumJ Am Anim Hosp Assoc 1982;18:736-738 Incisional gastropexy切口胃固定切口胃固定术术leftcranial Incisional gastropexy切口胃固定切口胃固定术术 Incisional gastropexy切口胃固定切口胃固定术术 Incisional gastropexy切口胃固定切口胃固定术术 Mortality 死亡率死亡率 43 of 148(29%)van Sluijs FJ.Tijdschr Diergeneesk 1991;116:1

22、12-21 29 of 193(15%)Brockman DJJ.Am Vet Med Assoc 1995;270:460-64 24 of 137(18%)Brourman JD et al.J Am Vet Med Assoc 1996;208:1855-58 33 of 136(24%)Glickman LT et al.J Am Anim Hosp Assoc 1998;34:253-59 Complications并并发发症症 Cardiac arrhythmias 心律失常心律失常78 of 193(40%)151 of 118(43%)2 Wound infection 创创口

23、感染口感染13 of 118(11%)21 Brockman DJ.J Am Vet Med Assoc 1995;207:460-642 Sluijs FJ van.Tijdschr Diergeneesk 1991;116:112-21 Recurrence复复发发Gastropexy 胃固定胃固定术术 4 of 61(7%)1 9 of 85(11%)2 14 of 97(15%)4No fixation 未固定未固定 39 of 55(71%)3 25 of 33(76%)11 Meyer Lindenberg A et al.J Am Vet Med Assoc 1993;203:1

24、303-72 Glickman LT et al.J Am Anim Hosp Assoc 1998;34:253-593 Egertsdottir AV et al.Act Vet Scand 1995;36:175-844 Sluijs FJ van.Tijdschr Diergeneesk 1991;116:112-21 Prophylactic Gastropexy预预防性胃固定防性胃固定术术 laparoscopic-assisted gastropexy(2002)1 腹腔腹腔镜检查辅镜检查辅助胃固定助胃固定术术 grid-laparotomy gastropexy(2003)2

25、电电网开腹胃固定网开腹胃固定术术 Cost-effective?成本合算？成本合算？1 Rawlings CA et al.J Am Vet Med Assoc 2002;221:1576-812 Steelman-Szymeczek SM et al.J Am Anim Hosp Assoc 2003;39:397-402 Laparoscopic Gastropexy 腹腔腹腔镜检查辅镜检查辅助胃固定助胃固定术术 laparoscopic-assisted gastropexy(2002)1 grid-laparotomy gastropexy(2003)2 Cost-effective?

26、1 Rawlings CA et al.J Am Vet Med Assoc 2002;221:1576-812 Steelman-Szymeczek SM et al.J Am Anim Hosp Assoc 2003;39:397-402 Introduction;Intestinal Surgery介介绍绍；肠肠外科外科 Indications 适适应应症症 Foreign Bodies 异物异物 Intussusception 肠肠套叠套叠 Tumor 肿肿瘤瘤 Ulcera 溃疡溃疡 Trauma 创伤创伤 Enterotomy 肠肠切开切开术术 Resection&end-to-e

27、nd anastomosis 切除切除术术&端端对对端吻合端吻合术术 Enterotomy 肠肠切开切开术术 Anti-mesenteric side 反反肠肠系膜系膜侧侧 Isolate intestines 隔离隔离肠肠子子 Incise healthy part 切割健康的部分切割健康的部分 Remove FB 去除去除FB Appositional suture 同位同位缝缝合，合，4-0缝线缝线pattern,4-0 monocryl Omental patch 网膜的修网膜的修补补 Enterotomy 肠肠切开切开术术 Enterotomy 肠肠切开切开术术 Enterotomy

28、 肠肠切开切开术术 Resection 切除切除术术 Indications 适适应应症症 Irreducible intussusception 不可复性不可复性肠肠套叠套叠 Narrowing of intestinal lumen 肠肠腔腔变变窄窄e.g.scar tissue or adhesions 例如例如结结痂痂组织组织或粘或粘连连 Severe damage of intestinal wall 严严重的重的肠肠壁壁损损坏坏e.g.trauma,foreign body or strangulation 例如例如创伤创伤，异物或，异物或绞绞窄窄 Intestinal neopl

29、asm 肠肿肠肿瘤瘤 Resection 切除切除术术 Preoperative aspects 术术前准前准备备 Correct anaesthetic protocol:适当的麻醉方案：适当的麻醉方案：Antimicrobial prophylaxis shortly before surgery 手手术术前抗菌前抗菌药药物物预预防防 Appropriate analgesia(no NSAIDs)适当适当镇镇痛（没有痛（没有类类固醇消炎固醇消炎药药的）的）Consider urinary catheter 考考虑导虑导尿管尿管 Extensive clipping 大面大面积积切除切除

30、Dorsal recumbency 背背侧侧斜卧斜卧 Sterile preparation operation site 无菌手无菌手术术操作操作 Draping 覆盖覆盖创创巾巾 Resection 切除切除术术 Technical aspects 技技术术方面方面 Basic surgical instruments 基基础础外科器械外科器械 Specific surgical instruments:特定的外科器械：特定的外科器械：Self retaining abdominal retractor 自自动牵动牵开器开器 Non crushing forceps 组织钳组织钳 Suct

31、ion 抽吸抽吸 Surgical sponges with radiopaque marker 外科外科纱纱布布 Wound protector 保保护伤护伤口口 Clean gloves and instruments for closure 清清洁洁手套和关手套和关闭闭的器械的器械 Resection 切除切除术术 Technical aspects 技技术术方面方面 Suture materials 缝缝合材料合材料 Anastomosis 吻合吻合术术 2-0,3-0 or 4-0 synthetic monofilament absorbable(Biosyn/Maxon,Mono

32、cryl)2-0，3-0或或4-0人造可吸收人造可吸收缝线缝线 Case 病例病例 Labrador retriever,male,5 months 拉布拉多，雌性，拉布拉多，雌性，5个月个月 Bloody diarrhoea,vomiting 便血，呕吐便血，呕吐 Palpable abdominal mass 明明显显的腹部的腹部肿块肿块 Intussusception肠肠套叠套叠 Manual reduction 手手动动复位复位 Intestinal resection 肠肠切除切除术术 One layer end-to-end anastomosis 单层单层端端对对端吻合端吻合术术

33、 Simple interrupted approximating suture 简单间简单间断断缝缝合合 Resection&anastomosis切除切除术术&吻合吻合术术 Resection&anastomosis切除切除术术&吻合吻合术术 Resection&anastomosis切除切除术术&吻合吻合术术 Resection&anastomosis切除切除术术&吻合吻合术术 Tips 要点要点Use stay sutures on mesenteric and anti-mesenteric side 在在肠肠系膜和反系膜和反肠肠系膜系膜侧侧使用固定使用固定缝线缝线Place sut

34、ures approximately 2-3 mm apart and 1-2 mm from incision 离切口离切口1-2mm处设处设置固定置固定缝缝合合线线，缝线间缝线间距距2-3mmPrevent eversion of mucosa 防止黏膜外翻防止黏膜外翻Mesenteric side is most difficult to suture 肠肠系膜系膜侧侧最最难缝难缝合合Use omental patch or serosal patch 使用网膜和使用网膜和浆浆膜膜贴贴Staplers 钉钉 Postoperative aspects术术后后护护理理Post-operat

35、ive care depends patient 术术后后护护理取决于患病理取决于患病动动物物Discontinue antibiotics within 2-6 hours,unless peritonitis is present 在在2-6小小时时内停止使用抗生素，除非内停止使用抗生素，除非发发生腹膜炎生腹膜炎Offer water as soon as patient is good awake 一旦患者完全清醒就提供水一旦患者完全清醒就提供水Encourage early ambulation and feeding 鼓励早日活鼓励早日活动动和喂养和喂养If peritonitis

36、is suspected perform abdominocentesis,chemistry profile and complete blood cell count 如果如果怀怀疑是腹膜炎疑是腹膜炎进进行腹腔穿刺、全血行腹腔穿刺、全血细细胞胞计计数数 Introduction;Splenectomy介介绍绍；脾切除；脾切除术术 Indications 适适应应症症 Tumor 肿肿瘤瘤 Trauma(haemo)创伤创伤 Torsion 扭扭转转 Immune-mediated 免疫介免疫介导导 Partial vs total 局部和整体局部和整体 Anatomy Spleen脾解剖脾

37、解剖stomachspleengastrosplenic ligamentShort gastric vesselsleft gastroepiploicsplenic a+vbranch to pancreas Functions of the Spleen脾功能脾功能Red blood cell maintenance,iron metabolism维持红细胞，铁代谢Blood reservoir储血Immune functions免疫功能Haematopoiesis造血 Splenectomy 脾切除脾切除术术 Preoperative considerations 术术前注意事前注意事

38、项项 Dogs with splenic masses have a high risk of cardiac arrythmias(especially those with anaemia,haeomoabdomen)脾有脾有肿块肿块的犬有高的犬有高风险风险的心律失常（特的心律失常（特别别是患有是患有贫贫血血时时）Treat hypovolaemic shock 治治疗疗低血容量休克低血容量休克 Antidysrhythmic drug if still severe enough to cause hypotension or pulse deficits 如果疾病仍然如果疾病仍然较较重

39、重低血低血压压或脉冲赤字，那么要或脉冲赤字，那么要使用抗使用抗节节律不律不齐药齐药 Splenectomy 脾切除脾切除术术 Preoperative considerations 术术前注意事前注意事项项 Animals with splenic neoplasia or torsion are at risk of DIC:有脾有脾肿肿瘤或扭瘤或扭转转的的动动物有弥散性血管内凝血的物有弥散性血管内凝血的风险风险：Perform PT/APTT tests,blood type,PCV/TP 进进行行PT/APTT检测检测、血型、血型、PCV/TP Be ready to provide e

40、xtra stabilisation/postop care 随随时时提供提供额额外外稳稳定的定的术术后后护护理理 Prophylactic antibiotics are given if there is a torsion or a long surgery is expected 如果是扭如果是扭转转或或预计预计手手术时间过长术时间过长要使用要使用预预防性抗生素防性抗生素?Longer term antibiotics to immunosuppressed animals following splenectomy(routinely done in human medicine)？

41、长长期期给给非免疫抑制非免疫抑制动动物使用抗生素物使用抗生素时时要要实实施脾切除施脾切除 Splenectomy 脾切除脾切除术术 Hilar approach(many ligatures)门门式方法式方法 Quick splenectomy 快速的脾切除快速的脾切除术术 Lots of forceps!许许多的多的镊镊子子 Ligate specific vessels 结结扎特定的血管扎特定的血管 Double ligation splenic artery+vein 双双结结扎脾扎脾动动脉和静脉脉和静脉 Stapling devices(also for partial)装装订设备订设

42、备（局部也适用）（局部也适用）Bipolar electrosurgical device(ligasure)双双击电击电装置（装置（结结扎束）扎束）Splenectomystomachspleengastrosplenic ligamentShort gastric vesselsleft gastroepiploicsplenic a+vbranch to pancreasHosgood et al 1989Hard to do if anatomy is distorted by mass/adhesions如果解剖由如果解剖由肿肿物或粘物或粘连连而扭曲，那么而扭曲，那么实实施施难难度更

43、大度更大Splenectomy 脾切除脾切除术术 Intraoperative considerations 术术前注意事前注意事项项 Use abdominal retractors,suction,waterproof drape,swabs with radio-opaque marker 使用腹部拉使用腹部拉钩钩，吸痰，防水性，吸痰，防水性创创巾，无巾，无线电线电不透明不透明标记标记的棉的棉签签 Examine entire abdomen;count swabs in and out;weigh swabs and measure fluid in suction bottles 检

44、查检查整个腹部；整个腹部；计计算外部和内部的棉算外部和内部的棉签签数量；称重棉数量；称重棉签签并并测测量吸量吸滤滤 瓶中的液体瓶中的液体1ml blood=1.3g Splenectomy 脾切除脾切除术术 Intraoperative considerations 术术前注意事前注意事项项 LDS,vascular clips and vessel sealant devices can all speed up surgery and have been used safely to remove spleens LDS、血管、血管钳钳和血管填充和血管填充剂剂等装置都会加速手等装置都会加速

45、手术过术过程，而且都能程，而且都能够够保保证证安全安全实实施脾摘除施脾摘除 Hilar splenectomy 肝肝门门部脾切除部脾切除术术 Ligation splenic A+V结结扎脾扎脾动动脉和静脉脉和静脉 Complications Splenectomy脾切除脾切除术术并并发发症症 Haemorrhage 出血出血 Technical failure 技技术术故障故障 DIC 弥散性血管内凝血弥散性血管内凝血 Cardiac arrhythmias 心律失常心律失常 Gastritis or pancreatitis 胃炎或胰腺炎胃炎或胰腺炎?Increased risk of i

46、nfection？增加感染的？增加感染的风险风险 Potentiation of subclinical disease with RBC parasites 红细红细胞寄生虫的胞寄生虫的亚临亚临床疾病床疾病 Introduction;Hepatic lobectomy介介绍绍；肝叶切除；肝叶切除术术 Indications 适适应应症症 Trauma 创伤创伤 Neoplasia 肿肿瘤瘤 Focal abscess 病灶病灶脓肿脓肿 Hepatic arteriovenous fistula 肝肝动动静脉瘘静脉瘘 Volvulus of liver lobe 肝叶的肝叶的肠肠扭扭转转 He

47、patic lobectomy肝叶切除肝叶切除术术 Six lobes(papillary process)六叶六叶 Efferent bloodflow(portal vein and hepatic arterie)输输出的血流（出的血流（门门静脉和肝静脉和肝动动脉）脉）Afferent bloodflow(hepatic veins)输输入的血流（肝静脉）入的血流（肝静脉）Gall bladder 胆囊胆囊 Hepatic ducts;cystic duct;ductus choledochus 肝胆管；胆囊管；胆肝胆管；胆囊管；胆总总管管 Interlobular fibrous ti

48、ssue 小叶小叶间间的的纤维组织纤维组织 Preoperative aspects术术前准前准备备 Correct anesthetic protocol 适当的麻醉方案适当的麻醉方案 Cave coagulopathies;serum albumin level;decreased hepatic function 凝血障碍；血清白蛋白水平；肝功能下降凝血障碍；血清白蛋白水平；肝功能下降 Prophylactic antibiotics 预预防性抗生素防性抗生素 Dorsal recumbency 背背侧侧斜卧斜卧 Clipping ventral abdomen from xiphoid

49、 to umbilicus 切口从腹部的切口从腹部的剑剑状状软软骨到骨到脐脐部部 Sterile preparation operation site 无菌手无菌手术术操作操作 Technical aspects技技术术方面方面 Basic surgical instruments 基本的外科器械基本的外科器械 Specific surgical instruments:特殊的外科器械：特殊的外科器械：Large curved haemostatic or mixter forceps 大号弯止血大号弯止血钳钳或或mixter式式钳钳 Self retaining Balfour retrac

50、tor 自自动牵动牵拉器拉器 Stapling device/Ligasure 装装订订装置装置/结结扎扎术术 Finger fracture method,guillotine technique 手指骨折方法、剪断技手指骨折方法、剪断技术术 Counted gauze sponges with radiopaque markers 可可计计数的数的带带有不透有不透X线线的的标标志物的志物的纱纱布海布海绵绵 Finger fracture technique手指撕裂技手指撕裂技术术 Hepatic lobectomy肝叶切除肝叶切除术术 Hepatic lobectomy肝叶切除肝叶切除术术