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

Objective To develop and evaluate a porcine model for training the single needle running suture method of laparoscopie urethrovesical anastomosis(LUA). Methods Twenty minipigs with mean weight of 30kg were general anaesthetized with Sumianxin solution 0. 1 ml/kg intramuscularly. Pneumoperitoneum was created by insufflation of carbon dioxide by a veress needle inserted through the umbilicus. One 10mm port and two 5mm ports were positioned after the establishment of pneumoperitoneum. The intestine was used as "bladder". The procedures were completed with the single needle running suture method of laparoscopic urethrovesical anastomosis. Six trainees performed the LUA procedure based on the models during a laparoscopic training course, following the technique used in the operation room. The learning curve was analyzed by operative time. Results The porcine model for laparoscopic training was established successfully and 3 LUAs could be performed on each pig. Each trainee performed 10 LUAs based on the models during the training course of laparoscopic urology. The operative time declined from (55.3±10. 4)min initially to (22.4±4.8)min (P＜0. 01) after the training course. At the end of training, all trainees could accomplish a watertight LUR procedure on the model. Conclusions The establishment of the training model is feasible. The trainees could acquire the skills necessary to perform LUA in vivo based on this model. The model provides a platform for training the basic techniques of LUA procedures.     

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.     

Assistant skill in gastric endoscopic submucosal dissection using a clutch cutter

BACKGROUND A clutch cutter is a scissor-type knife used in endoscopic submucosal dissection(ESD) for gastrointestinal tract tumors. The assistant during the ESD using a clutch cutter(ESD-C) needs to rotate the device and grasp the target tissue appropriately; therefore, the assistant's skill may affect the technical outcomes of ESD-C.AIM To determine how assistant skill level affected the technical outcomes of gastric ESD-C using an ex vivo porcine training model.METHODS In this pilot study, mock lesions of 15-30 mm in diameter were created in the middle or lower third of the porcine stomach. A total of 32 ESD-C procedures were performed by 16 trainees. Each trainee operator performed two ESD-C procedures; one ESD-C was assisted by an expert(ESD-C-E), and the other was assisted by a non-expert(ESD-C-NE). The total procedure time of the ESD was set as the primary outcome, and en bloc resection rate, complete procedure rate, perforation rate, and each procedure time/speed for mucosal incision or submucosal dissection were set as the secondary outcomes. In addition, we investigated factors associated with the difficulty of ESD including incompletion of ESD procedure, a long procedure time(≥ 20 min) or intraoperative perforation.RESULTS The median total procedure time of the ESD-C-E was significantly shorter than that of the ESD-C-NE(12.9 min vs 21.9 min, P = 0.001). The en bloc resection rate was 100% in both groups. Complete resection rates of the ESD-C-E and ESD-C-NE groups were 100% and 93.8%, respectively. No intraoperative perforation was observed in both groups. In the multivariate analysis, assistant skill was significantly associated with the difficulty of ESD, with the highest odds ratio of 16.5.CONCLUSION Assistance by an expert is an important factor when trainees perform ESD-C procedures.     

一种新型的经皮肾镜手术离体动物模型

目的 介绍一种新型的X线和B超定位下经皮肾镜手术(PCNL)培训的离体动物模型.方法 模型由带有输尿管的新鲜成年猪肾、2根肋骨的全层胸壁、2根长钉和1块木板组成.输尿管预置导管后,胸壁对折包裹猪肾,2根肋骨覆盖肾上极,用长钉将模型固定在木板上.可以切开肾盂预置石子以训练碎石操作.X线定位:经输尿管导管注入造影剂,逆行肾盂造影显示肾集合系统,确定目标肾盏后,C-臂探头向术者方向旋转30°,使穿刺针、目标肾盏长轴和C-臂长轴在同一平面上,穿刺针头和针尾呈牛眼征.穿刺针确定方向后,C-臂调整到垂直位,观察穿刺深度并按原方向穿人目标肾盏.B超定位:经输尿管导管注入生理盐水制造人工肾积水,B超引导下确定目标肾盏.穿刺完成后,进行扩张、碎石等训练.训练结束后,解剖猪肾,对穿刺针和扩张效果进行检测.结果 126名泌尿外科医生接受培训,其中104名(82.5 %)成功完成模型的经皮肾镜的穿刺、扩张、碎石等操作,114名(90.5%)医生认为该模型对临床手术有"帮助"或"非常有帮助".结论 该模型可以较好地模拟临床PCNL操作过程,为初学者提供一个轻松的学习环境,可反复检查操作训练,为临床手术积累经验.

Abstract：

Objective To lessen the learning curve of percutaneous renal lithotripsy(PCNL),we introduced a novel ex-vivo learning and training model for PCNL under fluoroscopy and ultrasonography-guided access. Methods The model was set up nailing an adult porcine kidney with＞3 cm ureter (freshly removed from the slaughtering factory),with a full thickness flap of the thoracic wall or abdomen wall with two ribs,to a board.The porcine kidney was placed within the flap with the catheterized ureter outside.The kidney was enclosed by the flap so as to create a roodel for percutaneous renal surgery;with the ribs overlying the upper portion of the kidney.The model was fixed to the board by two nails.Artificial stone material was implanted in the renal pelvis.Fluoroscopy guidance access:Retrograde pyelography via injection of contrast medium into the ureteral catheter images the collecting system. After the long axis of the target calyx is identified,the C-arm is rotated 30 degrees toward the surgeon,placing the C-arm axis in the same posterior plane of the kidney.The needle is advanced in the plane of the fluoroscopic beam,and the appropriate needle placement is determined by obtaining a "bull's-eye sign" on the fluoroscope screen. Rotating the C-arm to a vertical position monitors the depth of the needle penetration. Ultrasonography guidance access:The renal pelvis can he filled with normal saline through a catheter to simulate hydronephrosis and the target calyx is identified under ultrasonography guidance.The tract dilation and stone disintegration were followed.After training,the kidney can be opened to examine the target calyx and the complication of dilation. Results Altogether,126 urologists attended a urologic endoscopic technique training course.Of the 126 trainees,104 (82.5%) successfully performed the whole percutaneous procedure.At the end of training,114 (90.5 %) of the 126 attendees rated the porcine kidney model for simulation of percutaneous renal surgery as "very helpful" or "helpful".Conclusions This biological training model simulates realistically the clinical procedure of PCNL with respect to trainee experience in a low stress environment that provides an opportunity for repetitive performances in order to learn basic technical skills for the clinical procedure of PCNL in the future.     

Open versus laparoscopic right hemicolectomy in the elderly population

AIM:To compare short term outcomes of elective laparoscopic and open right hemicolectomy(RH) in an elderly population.METHODS:All patients over the age of 70 undergoing elective RH at Ninewells Hospital and Perth Royal Infirmary between January 2006 and May 2011 were included in our analysis.Operative details,hospital length of stay,morbidity and mortality was collected by way of proforma from a dedicated prospective database.An extracorporeal anastomosis was performed routinely in the laparoscopic group.The primary endpoints for analysis were morbidity and mortality.Our secondary endpoints were operative duration,length of hospital stay and discharge destination.RESULTS:Two hundred and six patients were included in our analysis.One hundred and twenty-five patients underwent an open resection and 81 patients had a laparoscopic resection.The mean operating time was significantly longer in the laparoscopic group(139 ± 36 min vs 197 ± 53 min,P = 0.001).The mean length of hospital stay was similar in both groups(11.2 ± 7.8 d vs 9.6 ± 10.7 d,P = 0.28).The incidence of postoperative morbidities was 27% in the open group and 38% in the laparoscopic group(P = 0.12).Overall inhospital mortality was 0.8% in open procedures vs 1% in laparoscopic.CONCLUSION:Laparoscopic RH was associated with a significantly longer operative time compared to open RH.In our study,laparoscopic RH was not associated with reduced post-operative morbidity or significantly shorter length of hospital stay.     

Hepatic portal venous gas after endoscopy in a patient with anastomotic obstruction

A 72-year-old male underwent a laparoscopic low anterior resection for advanced rectal cancer.A diverting loop ileostomy was constructed due to an anastomotic leak five days postoperatively.Nine months later,colonoscopy performed through the stoma showed complete anastomotic obstruction.The mucosa of the proximal sigmoid colon was atrophic and whitish.Ten days after the colonoscopy,the patient presented in shock with abdominal pain.Abdominal computed tomography scan showed hepatic portal venous gas(HPVG) and a dilated left colon.HPVG induced by obstructive colitis was diagnosed and a transverse colostomy performed emergently.His subsequent hospital course was unremarkable.Rectal anastomosis with diverting ileostomy is often performed in patients with low rectal cancers.In patients with anastomotic obstruction or severe stenosis,colonoscopy through diverting stoma should be avoided.Emergent operation to decompress the obstructed proximal colon is necessary in patients with a blind intestinal loop accompanied by HPVG.     

The efficacy of a first aid training course for drivers: an experience from northern Iran

Objective：To evaluate the efficacy of a first aid training course for a group of drivers.Methods：This study comprised 500 drivers,randomly selected from the road transport companies.They underwent a course of first aid training and the results were evaluated at 0-3 and 4-6 months after training.Results：Both quantitative and qualitative improvements were observed in the drivers＇ efficacy in giving first aid.Also the rate of correct interventions was higher at 4-6 months than at 0-3 months.The exception was airway management which was not favorably improved after training.Conclusion：The first aid training course for drivers is beneficial and helpful for prehospital care system in road traffic accidents.     

Laparoscopic total colectomy: Does the indication influence the outcome?

AIM: To assess and compare outcomes of laparoscopic total colectomy performed for a variety of indications. METHODS: Sixty six patients underwent laparoscopic total colectomy for inflammatory bowel disease (IBD) (13) and other diseases (53). Data on demographics, pre and post-operative outcomes were collected prospectively.RESULTS: Mean operative time was 4.5 h. Conversion rate was 13.6%. Total colectomy performed for IBD was associated with a signifi cantly higher anastomotic leak rate (23.1% vs 1.9%, P < 0.05). On univariate analysis, hand sewn anastomosis and treatment with more than 20 mg of prednisolone for at least 3 mo was associated with a higher anastomotic leak rate (P < 0.05). No signifi cant difference was found in return of gut function and overall morbidity between disease groups. CONCLUSION: Laparoscopic total colectomy is feasible and outcomes are equivalent whatever the indica- tion, except for anastomotic leak rate which is higher for patients with IBD.     

组配式人工半骨盆假体重建的生物力学分析

Objective To analysis the biomechanical characteristics of the reconstructed pelvis with modular hemi-pelvie prosthesis by finite element (FE) method. Methods A subject-specific finite element model of pelvis was established. Th experiment was performed on the same cadaveric pelvis. Eight points on the surface of cortical bone was determined. Both the same load and boundary conditions were applied on the FE model and experiment. The stress by experiment (σ EXP) was calculated based on the data collected from the strain discs. Linear regression was performed with the stress predicted by FE model (σFEM) and experi-ment data to validate the FE model. A defect pelvic (with zone Ⅱ +Ⅲ in left hemi-pelvis) FE model was con-structed and assembled with the prosthesis. The stress distribution on the eontra lateral hemi-pelvis was cal-culated by the reconstructed pelvic FE model (σRS), and the results were compared with that of the normal pelvis (σNS). Also the comparison was clone at the resection level of the affected hemi-pelvis between normal pelvic FE model (σNR) and reconstructed model (σRR) both on medial and lateral cortical bone of the pelvis. Structural analysis was performed on the whole set of implant. Results FE predictions were strongly correlated with experimental results (R2=0.87). No significant difference was found between the σRS and σNS (t=1.81, P=0.08). Regarding to the stress distribution at lilac resection level, no difference was found between σNR and σRR on the medial side (t=0.47, P=0.65). However, on the lateral side, σRR were signifi-cantly higher than the σNR (t=2.78, P=0.02). The peak stress of the prosthesis was about 183 MPa located at the conjunction of the acetabulum and the iliac fixation part. The main load conduction path on the prosthe-sis was at the posterior side of column portion part of the iliac fixation. Conclusion Reconstruction with modular hemi-pelvic prosthesis could recover the pelvic biomechanics with rational mechanical design.     

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries

Purpose: To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees’ performance for emergent and urgent thoracic surgeries. Methods: With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coe...     

Faculty of Anaesthetists of the Royal College of Surgeons of Ireland

The Faculty of Anaesthetists of the Royal College of Surgeons of England, 35–43 Lincoln's Inn Fields, London WC2A 3PN. Telephone: 01-405 3474.     

深圳市某两所小学流行性腮腺炎突发疫情的流行病学分析

目的：通过对深圳市某两所小学发生的流行性腮腺炎突发疫情的流行病学特点及差异性进行分析,为制定科学、高效的防控策略提供科学依据。方法2013年5～7月深圳市大鹏新区某两所小学爆发流行性腮腺炎,以学校为整体研究对象,分别标记为学校A（24个班,学生1210例）和学校B（27个班,学生1274例）,对比两所小学的疫情流行病学差异性。结果分析发现,学校A流行性腮腺炎发病率为4.30%,发病班级所占比54.17%,均较学校B1.73%和29.63%高,对比差异有统计学意义（P＜0.05）;分析显示学校A学生出现疫病平均年龄为（11.2±1.1）岁,较学校B（9.34±1.0）岁,对比差异明显（P＜0.05）;且两组疫病患儿在接种疫苗率对比上差异无统计学意义（P＞0.05）;但疫情发生时,学校B疫苗紧急接种率明显高于学校A,对比差异有统计学意义（P＜0.05）。结论小学作为流行性腮腺炎爆发的主要场所之一,疫病爆发高峰季节前,针对易感染人群给予相应的疫苗接种等预防控制措施,同时加强流行性腮腺炎的监测,对于降低感染人群数量,减轻、遏制疫情有着积极的意义,值得相关防控部门重视。