A safe, new approach to establishing a pneumoperitoneum at laparoscopy.

The traditional method of establishing a pneumoperitoneum before laparoscopic surgery is via a Verres needle inserted in the midline below the umbilicus while tenting the abdominal wall with the hand. A new approach is described in which preliminary surgical exposure and tenting of the linea alba immediately above the umbilicus is achieved before needle insertion through the superior margin of the umbilical ring. The advantages of this new technique over the conventional method are discussed. Further technical features important in the safe formation of the pneumoperitoneum are emphasized.     

改良式腹腔镜下成人腹股沟斜疝修补术

目的 :报道改良式腹腔镜下成人腹股沟斜疝修补术。方法 :使用腹腔镜配合一次性腹腔闭合器及自制带线钩针行荷包内环口周边腹膜缝扎 ,配合使用巴德补片 (BardComposix)治疗成人斜疝 32例。结果 :32例手术均获成功 ,无 1例发生并发症 ,随访 3～ 4月 ,无 1例复发。结论 :此术式安全 ,手术时间短 ,操作简单 ,术后无需缝线 ,无并发症 ,无复发 ,术后疤痕少 ,美容效果好     

High-pressure trocar insertion technique.

BACKGROUND: The majority of laparoscopic complications occur at the time of Veress needle and trocar insertion. Although not very frequent, they increase the morbidity and mortality of both diagnostic and operative laparoscopic procedures. Alternative techniques of trocar insertion have been described but have not completely eliminated the risk of injury. TECHNIQUE: After Veress needle insertion and establishment of pneumoperitoneum to 25 to 30 mm Hg, insertion of a short trocar is performed in the deepest part of the umbilicus without elevation of the anterior abdominal wall. The result is a parietal peritoneal puncture directly beneath the umbilicus. The high-pressure setting used during initial insertion of the trocar is lowered as soon as safe abdominal entry is documented. EXPERIENCE: The trocar insertion technique described above was performed in 3041 procedures. No vascular injury occurred. There were two bowel perforations. No complications related to the increased intra-abdominal pressure were observed. CONCLUSION: The high-pressure abdominal entry technique has the advantage of reducing intra-abdominal trocar-related injuries without requiring additional instrumentation or additional training.     

Comparison of direct trocar and veress needle insertion in the performance of pneumoperitoneum in laparoscopic cholecystectomy

Veress needle insertion, direct trocar insertion and open technique are different methods of establishing pneumoperitoneum to perform a successful laparoscopic procedure. We conducted this study to compare the use of a Veress needle and direct trocar insertion to create pneumoperitoneum. 274 laparoscopic cholecystectomy operations were evaluated. There were no significant differences in the age and gender between Veress needle and direct trocar entry groups. In this study we have seen that the complication rate while performing pneumoperitoneum by direct trocar entrance was less than in Veress needle usage. Direct trocar entrance also reduces the operation time. In laparoscopic cholecystectomy the direct trocar entrance method is a more reliable and less time consuming method than Veress needle usage.     

Comparison of Direct Trocar and Veress Needle Insertion in the Performance of Pneumoperitoneum in Laparoscopic Cholecystectomy

Veress needle insertion, direct trocar insertion and open technique are different methods of establishing pneumoperitoneum to perform a successful laparoscopic procedure.

We conducted this study to compare the use of a Veress needle and direct trocar insertion to create pneumoperitoneum. 274 laparoscopic cholecystectomy operations were evaluated. There were no significant differences in the age and gender between Veress needle and direct trocar entry groups.

In this study we have seen that the complication rate while performing pneumoperitoneum by direct trocar entrance was less than in Veress needle usage. Direct trocar entrance also reduces the operation time. In laparoscopic cholecystectomy the direct trocar entrance method is a more reliable and less time consuming method than Veress needle usage.     

Improved technique for establishing pneumoperitoneum for laparoscopy.

The establishment of a pneumoperitoneum is essential for laparoscopy. Anatomical features of the umbilicus can be used to reduce associated complications and improve the ease of creating a pneumoperitoneum.     

A comparison of the effect of two anaesthetic techniques on surgical conditions during gynaecological laparoscopy

In a prospective, randomised, controlled trial, we compared the effects of two anaesthetic techniques on surgical conditions during day-case, gynaecological laparoscopic procedures in 40 female patients. Patients were allocated randomly to two groups, either to breathe spontaneously through a laryngeal mask airway or to receive a neuromuscular-blocking agent (NMB) and have the lungs ventilated via a tracheal tube. We then measured the number of attempts of Verres' needle insertion, initial intra-abdominal pressure, time to reach a steady 15 mmHg (1.97 kPa) of intra-abdominal pressure, adequacy of the pneumoperitoneum, operative view and duration of operation. We found that the initial intra-abdominal pressure was higher and the operation time shorter in the laryngeal mask group. The adequacy of the pneumoperitoneum for trocar placement was better in the NMB group. We conclude that the anaesthetic technique of spontaneously breathing through a laryngeal mask airway reduces total operation time. However surgeons should be aware of the different abdominal pressure patterns produced by each anaesthetic technique, and anaesthetists must consider the implications of the anaesthetic technique on surgical safety.     

Umbilical stalk technique for establishing pneumoperitoneum

The Veress needle technique for establishing pneumoperitoneum is widely used yet associated with slow insufflation and potentially life-threatening complications. The open or Hasson technique is relatively safer but considered cumbersome by many. We describe a mini-open technique that uses a 5-mm transumbilical incision and placement of a 5-mm blunt cannula without the trocar. We have employed this technique for 4 years in 600 patients without a midline laparotomy incision incorporating the umbilicus and have accessed the abdomen safely for laparoscopy without any complications. The time from skin incision to the start of the procedure is usually under 2 minutes. Our umbilical stalk technique provides rapid and safe access to the abdomen, eliminating the dangers of a blind sharp needle or trocar insertion and the need for a larger incision with placement of stay sutures. We recommend this simple technique for entry into the uncomplicated abdomen.     

Technical advantages of the paramedian approach for lumbar epidural puncture and catheter introduction

The lumbar epidural space of 14 autopsy subjects was examined by epiduroscopy. The aim was to compare the midline and paramedian approaches of locating the space, the estimated risk of accidental dural puncture, the course taken by the epidural catheter after introduction and with special attention to the influence of the dorsomedian connective tissue band. The paramedian needle passed a greater distance within the epidural space before contact with the dura mater and demonstrated a low risk of accidental dural puncture. The catheter passed by the paramedian approach did not cause any tenting of the dura and took a straight cephalad direction in all 14 cases. The midline catheter caused tenting of the dura in all 14 cases and the direction of travel was variable. Differences were statistically significant. Influence of the dorsomedian connective tissue band was greatest on the behaviour of the midline needle and catheter.     

Safe Veress needle insertion

Background/Purpose For laparoscopic surgery, the creation of pneumoperitoneum still remains a must. The insertion of a Veress needle or a trocar is never perfectly safe, and almost every kind of intraabdominal organ injury due to these insertions has been reported worldwide. Here, we describe a safe technique for creating pneumoperitoneum. Methods For the creation of pneumoperitoneum, under direct vision, the linea alba was elevated with two towel clips and then the Veress needle was inserted. We reviewed 368 patients operated on with this technique for complication rates. Ultrasound images were obtained before and during abdominal-wall lifting in 10 patients. Results There were no injuries due to the insertion of the Veress needle or trocars. In 90% of the patients, pneumoperitoneum was created successfully on the first attempt. Ultrasound examination demonstrated a mean extra safe area of 11.8 mm during abdominal-wall lifting with this technique. Conclusions Elevating the linea alba during Veress-needle insertion is safe.     

Direct trocar insertion versus Veress needle insertion in laparoscopic cholecystectomy

BACKGROUND: Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. The safety of direct disposable shielded trocar insertion for the creation of pneumoperitoneum was assessed by comparing with Veress needle insertion during laparoscopic cholecystectomy (LC). METHODS: One thousand five hundred patients undergoing LC with pneumoperitoneum were included in this study. In 470 patients the Veress needle insertion technique was used, and in 1,030 patients direct trocar insertion technique was used. Patients having indications for open trocar insertion were excluded from the study. RESULTS: Complication rate was significantly higher in the Veress needle group (14% versus 0.9%; P <0.01), and the two major complications, gastric perforation and iliac artery laceration, were also encountered in this group. CONCLUSIONS: Our results suggest that with a lower complication rate, direct insertion of the disposable trocar is a safe alternative to Veress needle insertion technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost/instrumentation and rapid creation of pneumoperitoneum.     

吸引型喉导管与食管引流型喉罩在腹腔镜手术麻醉中的应用

目的：探讨吸引型喉导管与食管引流型喉罩用于腹腔镜手术麻醉通气的效果。方法：择期腹腔镜胆囊切除术患者32例,随机分为吸引型喉导管组（LTS组）与食管引流型喉罩组（PLMA组）,进行麻醉中通气。结果：LTS组与PLMA组气腹前后,放气腹前后pH、PaCO2各组内与本组间比较无明显差异（P〉0.05）。PETCO2、SpO2于气腹前后无明显差异（P〉0.05）。Ppeak、VT于气腹前后差异明显（P〈0.05）,Ppeak于放气腹前后也有明显差异（P〈0.05）。结论：LTS与PLMA用于全麻腹腔镜手术通气,气腹建立时VT由8mL/kg调整为10mL/kg,可避免CO2气腹引起的PaCO2升高,通气效果可维持稳定。     

Hybrid transvaginal cholecystectomy: a novel approach

Natural Orifice Transluminal Endoscopic Surgery (NOTES) allows cholecystectomy to be performed by means of a flexible scope introduced through the stomach, rectus, bladder, or vagina. However, available endoscopes have several limitations if used in the peritoneal cavity. The hybrid technique reported overcomes these limitations by using conventional 5-mm laparoscopic instruments through the umbilical scar and transabdominal sutures for retraction. After creating the pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the umbilicus followed by a 5-mm, 30° scope. A culdotomy then is performed under direct and laparoscopic views. The flexible endoscope is inserted into the pelvis through the vagina and advanced to expose the gallbladder. Three or more transabdominal sutures are placed through the gallbladder wall for retraction. Cholecystectomy then is performed using conventional 5-mm laparoscopic instruments through the 5-mm umbilical port. Finally, stay sutures are removed and the specimen is retrieved through the vagina. Six patients successfully have undergone this new procedure. In our opinion this hybrid approach increases safety, overcomes the limitation of the current instrumentation, and maintains most of the advantages of Natural Orifice Transluminal Endoscopic Surgery.     

Laparoscopic Transumbilical Cholecystectomy Without Visible Abdominal Scars

Introduction  We present a novel surgical technique for cholecystectomy utilizing three laparoscopic ports placed through the umbilicus. This new method is natural orifice transumbilical surgery (NOTUS) and describes a laparoscopic operation that can be performed with all incisions placed within the umbilicus obviating visible abdominal scars. Objectives  To develop a novel laparoscopic surgical technique for cholecystectomy utilizing only transumbilical incisions. Summary Background Data  Natural orifice translumenal endoscopic surgery (NOTES) has become an exciting area of surgical development. Significant limitations to this surgical concept, however, are lack of surgical expertise and appropriate flexible instrumentation. An alternative and competing technology to NOTES is NOTUS. Methods  We describe a patient in whom a laparoscopic surgical technique for cholecystectomy utilized incisions all placed entirely within the umbilicus. This new technique is called NOTUS and describes a laparoscopic operation that can be performed without visible abdominal scar. Results  The operative time was 70 min. There were no intraoperative complications. The patient did well postoperatively and was discharged on the same operative day. There were no postoperative complications at 2 months follow-up. Conclusion  Cholecystectomy performed through laparoscopic incisions placed within the umbilicus was technically feasible and safe in our patient. Development of advanced flexible instrumentation and visualization platforms may facilitate this new operative approach. Further advantages of NOTUS cholecystectomy compared to conventional laparoscopic cholecystectomy will ultimately require a randomized clinical trial.     

腹腔镜下膀胱尿道单针连续吻合法动物模型的建立和应用

目的 建立模拟膀胱尿道单针连续吻合法训练的动物模型.方法 体质量30 kg左右的巴马小型猪20只,速眠新10 mg/kg诱导麻醉,3.5%戊巴比妥钠0.25 g/kg术中维持.取仰卧位经脐点穿刺导入CO2制备气腹,放置3个工作套管.游离出尿道蒂,取末端小肠作为代膀胱.按照腹腔镜下膀胱尿道单针连续吻合法步骤完成吻合.6名具有腹腔镜体外模拟训练经验的学员参加培训,根据手术时间评估学员的学习曲线.结果 6名学员在该模型上均成功完成腹腔镜下膀胱尿道单针连续吻合法的各项操作技术.每只模型猪可行3次手术,学员平均接受10次膀胱尿道单针连续吻合法训练,平均手术时间第1次(55.5±10.4)min,第10次(22.4±4.8)min,2次手术时间比较差异有统计学意义(P＜0.01).结论 小猪模型末端小肠替代膀胱,反复利用游离尿道蒂可提供多次训练机会,能够使学员尽快掌握腹腔镜下膀胱尿道单针连续吻合法的操作技术.     

Abdominal wall lifting with subcutaneous wiring: An experience of 50 cases of laparoscopic cholecystectomy without pneumoperitoneum

Abdominal wall lifting is a method to produce operative space between the anterior abdominal wall and the intra-abdominal organs during laparoscopic surgery. We devised a hanger lifting procedure for the anterior abdominal wall to avoid complications as well as reduce the costs related to the pneumoperitoneum. In our series, we performed 50 cases of laparoscopic cholecystectomy with this abdominal wall-lifting procedure. Though at the beginning we performed laparoscopic cholecystectomy by the pneumoperitoneum, we discarded the insufflator for this operation since starting the new procedure. There was no incidence of conversion to pneumoperitoneum and a fairly good operative view was achieved enabling a smooth laparoscopic cholecystectomy.     

机器人保留脾血管胰体尾切除术治疗儿童胰岛素瘤报道

目的报道国内外首例儿童机器人保留脾血管胰体尾切除术,探讨该方法治疗儿童胰腺良性疾病的可行性和安全性。 方法2016年7月收治1例儿童胰体尾胰岛素瘤病例,患儿女性,9岁,体质量24 kg,身高1.20 m。行机器人保留脾血管的胰体尾切除术。机器人操作时采用4孔法：自脐下缘微小切口置入气腹针建立气腹后缝合该切口,观察孔位于下腹正中脐下5 cm(10 mm),1臂位于左侧平脐水平与腋前线的交点(8 mm),2臂位于右侧脐水平下2 cm与腋前线交点(8 mm),辅助孔位于左侧锁骨中线脐水平下3 cm(12 mm)。用超声刀切开胃结肠韧带,显露胰腺,腹腔镜超声探查证实病灶位于胰尾,直径约2 cm;切断脾结肠韧带,结肠脾曲向下游离;用电凝沿胰腺下缘分离胰后间隙,向脾门进行,将胰尾与脾脏之间的粘连分开,于胰腺后方分离出脾静脉,胰腺上缘分离出脾动脉,逐一分离夹闭或缝合动静脉与胰腺之间的分支,使胰尾完全游离,距离肿瘤右侧约1 cm以直线切割闭合器蓝色钉仓切断胰体尾,胰腺断端以4-0 Prolene线连续缝合。标本装入一次性标本袋自辅助孔取出,胰腺断端放置乳胶引流管1根自腹壁右侧孔引出。 结果手术时间155 min,气腹时间120 min,术中出血量约10 ml,围手术期恢复顺利,无胰瘘、出血及腹腔感染等并发症。术后血糖恢复正常,空腹胰岛素及血糖比值小于0.4,胰腺MRI平扫及增强扫描显示胰腺无肿瘤残留。 结论机器人与传统腹腔镜相比,具有三维视野、操作灵活等优点,该病例的成功经验初步显示机器人保留脾血管的胰体尾切除术治疗儿童胰岛素瘤是安全、可行的。     

β_2-微球蛋白、彩色多普勒超声在腹腔镜手术中评估肾功能的应用

目的:比较腹腔镜手术术前、术中、术后β2-微球蛋白、肾脏彩色多普勒超声的变化,探讨β2-微球蛋白、彩色多普勒超声在腹腔镜术中评估肾功能的应用价值。方法:腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)患者83例,分别在术前和气腹后30min、90min、术后第1天、第3天抽取空腹静脉血送检及行彩色多普勒超声检查,检查项目为BUN、Scr、β2-微球蛋白及肾脏的血流指数。结果:与气腹前相比,β2-微球蛋白在气腹后30min、90min均升高,差异有统计学意义,术后第1天、第3天差异无统计学意义;主肾动脉阻力指数在气腹后30min、90min均升高,差异有统计学意义,术后第1天、第3天差异无统计学意义;BUN、Scr在气腹后90min均升高,差异有统计学意义,气腹后30min、术后第1天、第3天差异无统计学意义。结论:腹腔镜术中β2-微球蛋白、彩色多普勒超声可用于早期评估肾功能。     

腹腔镜胆囊切除术中患者肾血流量的变化

目的 探讨腹腔镜胆囊切除术中患者肾血流量的变化.方法 择期行腹腔镜胆囊切除术患者32例,年龄18～64岁.气管插管后经口置入食管超声探头,采用经食管超声心动图分别于气腹前(基础状态)、气腹1、5、10、15、20、30 min、气腹停止后1、5 min时测量左肾动脉主干内径、主动脉内径、左肾动脉主干血流速度时间积分和降主动脉血流速度时间积分,计算左肾血流量(LRAF)、降主动脉血流量(DAF)和LRAF与DAF的比值(LRAF/DAF).分析LRAF和DAF的最大下降时点、最大下降量和最大下降百分比.结果 与基础值比较,气腹中各时点LRAF和DAF下降(P＜0.05),气腹停止后差异无统计学意义(P＞0.05);气腹中和气腹停止后各时点LRAF/DAF差异无统计学意义(P＞0.05).气腹中LRAF和DAF最大下降时间点分别为8.9 min[95%可信区间(95%CI)5.5～12.4 min]和6.7 min(95%CI4.0～9.5 min),最大下降量分别为130 ml/min(95%CI 96～163 ml/min)和1.57 L/min(95%CI1.20～1.95 L/min),最大下降百分比分别为40%(95%CI 31%～49%)和38%(95%CI 31%～44%).结论 腹腔镜胆囊切除术中气腹1～30 min时肾血流量下降,下降的最大程度约40%,时间在气腹9 min左右,其下降的原因与心输出量下降有关.     

RECONSTRUCTION OF A NATURAL-LOOKING UMBILICUS

Based on the assumption that the umbilicus is a wound that has healed by second intention, we describe a method of reconstruction. The procedure consists of complete resection of the umbilical scar and its reconstruction by a linear incision at the site of the new umbilicus and inversion of the skin hedges, which are sutured to the linea alba leaving a 1 cm space between the skin borders to cause secondary wound healing. This procedure provides a natural-looking umbilicus. It is easy and quick to do, and can be used for reconstruction after abdominoplasty, excision of a naevus, or when the umbilicus has been removed during a previous xiphopubic incision.