即刻剖宫产新生儿入重症监护病房的危险因素

目的 探讨自决定手术到新生儿剖出时间（DDI）＜15 min的即刻剖宫产新生儿入新生儿重症监护病房（NICU）的危险因素。
方法 选择2019年3月至2021年3月行即刻剖宫产的产妇130例,ASA Ⅰ—Ⅲ级。根据新生儿结局分为两组：新生儿入NICU（N组）和新生儿未入NICU（C组）。采用单因素和多因素Logistic回归分析DDI＜15 min的即刻剖宫产新生儿入NICU的危险因素,并采用受试者工作特征曲线(ROC)评价预测效能。
结果 术后转入NICU的新生儿28例(21.5%)。多因素Logistic回归分析显示：产妇合并症增加（OR=1.59,95%CI 1.04～2.43,P=0.03）、新生儿早产（OR=37.38, 95%CI 10.26～139.05, P＜0.01）、新生儿出生后1 min Apgar评分＜8分（OR=11.90, 95%CI 2.81～50.47, P＜0.01）是DDI＜15 min的即刻剖宫产新生儿进入NICU的独立危险因素。根据多因素Logistic回归模型得出ROC曲线,曲线下面积(AUC)为0.84（95%CI 0.77～0.97）,敏感性82.1%,特异性93.1%。
结论 在DDI＜15 min的即刻剖宫产中,产妇合并症数量增加,新生儿早产、出生后1 min Apgar评分＜8分是新生儿进入NICU的危险因素。     

腹腔镜胆总管一期缝合与内镜取石治疗继发性胆总管结石的临床疗效比较

背景与目的 腹腔镜胆总管探查术与内镜下取石术在治疗继发性胆总管结石方面仍存在争议,但文献报道多倾向于腹腔镜胆总管探查术一期缝合术联合胆囊切除术的单阶段治疗策略。因此,本研究比较腹腔镜胆总管一期缝合与内镜取石治疗继发性胆总管结石的临床疗效。方法 回顾性分析2019年1月—2020年2月天津市南开医院肝胆胰第二外科治疗的183例继发性胆总管结石患者临床资料,其中,60例行腹腔镜胆总管探查术+胆总管一期缝合+胆囊切除术（一期缝合组）,123例行内镜逆行胰胆管造影术/内窥镜括约肌切开术+腹腔镜胆囊切除术（内镜取石组）。采用倾向性评分匹配（PSM）方法对两组病例进行1∶1匹配,共59对匹配成功,比较匹配后两组患者手术疗效、术后并发症、住院时间等指标,并分析术后住院时间及术后相关并发症的影响因素。结果 PSM前,两组患者性别差异有统计学意义（P=0.007）,经PSM后两组基线数据差异均无统计学意义（均P>0.05）。内镜取石组术后总体并发症发生率高于一期缝合组（P<0.05）,主要原因是前者较高的术后高淀粉酶血症发生率（20.3% vs. 0）,其他并发症发生率两组间差异均无统计学意义（均P>0.05）;一期缝合组术后住院时间明显短于内镜取石组,住院费用也明显低于内镜取石组（均P<0.05）。高龄（OR=0.396,95% CI=0.182~0.864,P=0.020）、高淀粉血症（OR=0.057,95% CI=0.007~0.468,P=0.008）、内镜取石术（OR=0.084,95% CI=0.040~0.179,P=0.000）是术后住院时间延长的危险因素;手术方式是术后高淀粉酶血症的影响因素（P<0.05）。两组患者获至少1年随访,均无发生结石复发及胆道狭窄。结论 腹腔镜胆总管一期缝合治疗继发性胆总管结石相较内镜取石住院时间更短、费用更低,且不破坏Oddi括约肌正常生理结构。     

腹腔镜超声用于复杂肝胆管结石病腹腔镜术

目的 观察腹腔镜超声(LUS)用于复杂肝胆管结石病腹腔镜术中的价值。方法 回顾性分析43例接受腹腔镜手术治疗的复杂肝胆管结石病患者,根据术中是否应用LUS将其分为LUS组(n=18)和未应用LVS(non LVS, NLVS)组(n=25),对比组间一般资料、术中及术后相关情况。结果 组间患者性别、既往史、合并症,以及具体术式、中转开腹、手术时间及术中失血量差异均无统计学意义(P均＞0.05)。LUS组术后胆道残石率为44.44%(8/18),NLUS组为80.00%(20/25),组间差异有统计学意义(P＜0.05)。术中应用LUS是术后胆道残石率较低的独立影响因素[OR=0.20,95%CI(0.05,0.77),P＜0.05]。结论 在复杂肝胆管结石病腹腔镜术中应用LUS可降低术后胆道残石率。     

对比腔内微波消融与大隐静脉高位结扎及剥脱术治疗下肢静脉曲张效果

目的 对比分析腔内微波消融（EMA）与大隐静脉高位结扎及剥脱术（简称传统剥脱术）治疗下肢静脉曲张的效果。方法 回顾性分析94例单侧下肢静脉曲张患者,其中45例接受超声引导下EMA治疗（EMA组）、49例接受传统剥脱术（传统组）;记录并比较2组手术时间、术中出血量、手术切口数量、住院时间及术后并发症,并于术后6及12个月行临床严重程度评分（VCSS）和阿伯丁静脉曲张问卷（AVVQ）评分以评估疗效。结果 94例均治疗成功。EMA组手术时间及住院时间较传统组短,术中失血量及切口数量均少于传统组（P均<0.05）。组间术后并发症皮下淤血、皮下血肿及皮肤灼伤发生率差异均有统计学意义（P均<0.05）,局部感觉异常及切口感染发生率差异均无统计学意义（P均>0.05）。术前及术后组间VCSS、AVVQ评分差异均无统计学意义（P均>0.05）。术后6及12个月,2组VCSS及AVVQ评分均较术前降低（P均<0.05）。结论 EMA与传统剥脱术治疗下肢静脉曲张效果相当,前者安全性更高。     

微创经椎间孔入路腰椎椎间融合术治疗连续双节段腰椎退行性疾病

目的比较微创经椎间孔入路腰椎椎间融合术(MIS-TLIF)及传统开放TLIF治疗双节段腰椎退行性疾病的临床疗效。方法 2015年1月-2019年9月收治双节段腰椎退行性疾病患者56例,采用MIS-TLIF治疗26例(MIS-TLIF组)、采用传统开放TLIF治疗30例(TLIF组)。记录2组手术时间、术中透视次数、术中出血量、术后引流量、术后卧床时间、术后肌酸激酶(CK)等指标及并发症发生情况。术前及术后1周、3个月、12个月时采用疼痛视觉模拟量表(VAS)评分和Oswestry功能障碍指数(ODI)评估腰腿痛程度及腰椎功能。采用Bridwell分级评估术后椎间融合情况。在术后腰椎CT上采用Rao分级评价螺钉位置。结果所有手术顺利完成,所有患者随访(14.7±2.1)个月。MIS-TLIF组较TLIF组手术时间长,术中透视次数多,但术后卧床时间短,差异均有统计学意义(P < 0.05);2组术中出血量、术后引流量及术后CK水平差异无统计学意义(P > 0.05)。2组术后各时间点腰腿痛VAS评分及ODI较术前均显著改善,差异有统计学意义(P < 0.05);MIS-TLIF组术后1周腰痛VAS评分较TLIF组更低,差异有统计学意义(P < 0.05),2组术后3、12个月时腰腿痛VAS评分差异无统计学意义(P > 0.05);各随访时间点2组ODI差异无统计学意义(P > 0.05)。2组患者均未发生内固定松动或融合器移位等并发症。2组椎间融合率组间差异无统计学意义(P > 0.05)。2组A型螺钉分布差异无统计学意义(P > 0.05),B型螺钉分布差异有统计学意义(P < 0.05)。术后共发生硬膜撕裂4例、下肢麻木加重4例、切口愈合不良1例,2组并发症发生率差异无统计学意义(P > 0.05)。结论 MIS-TLIF与传统开放TLIF临床疗效类似,且在手术时间、术中辐射暴露情况及椎旁肌肉损伤等方面并无明显优势,双节段腰椎退行性疾病患者建议选择传统开放TLIF治疗。     

血管内治疗不同分期动脉粥样硬化性椎基底动脉闭塞性脑梗死

目的 观察血管内治疗不同分期动脉粥样硬化性椎基底动脉闭塞性脑梗死(ASVBOCI)的效果。方法 回顾性分析77例接受血管内治疗的ASVBOCI患者,包括急性期组(发病≤24 h,AP组)23例、亚急性早期组(发病>24 h且≤14 d,SAEP组)23例、亚急性晚期及慢性期组(发病>14 d,SALCP组)31例,对比观察3组术中情况、围手术期不良事件及预后。结果 AP组、SAEP组及SALCP组血管再通率分别为78.26%(18/23)、95.65%(22/23)及93.55%(29/31),差异无统计学意义(P>0.05);AP组、SAEP组术中机械取栓率均高于SALCP组(P均<0.05),AP组球囊扩张及支架植入均低于SAEP组和SALCP组(P均<0.05)。围手术期AP组1例、SAEP组2例颅内出血,SALCP组无出血。术后3个月SALCP组预后良好率高于、死亡率低于AP组及SAEP组(P均<0.05),后二者差异均无统计学意义(P均>0.05)。结论 血管内治疗不同分期ASVBOCI安全、有效。     

经皮微创钢板内固定与切开复位内固定治疗成人胫骨远端骨折的Meta分析

目的:对经皮微创钢板内固定术(MIPPO)与切开复位内固定术(ORIF)治疗成人胫骨远端骨折的疗效进行Meta分析。方法:通过计算机检索Pubmed(1968年至2014年3月),Cochrane图书馆、中国知网数据库(1998年至2014年3月),手工检索相关的中英文骨科杂志。收集MIPPO与ORIF治疗成人胫骨远端骨折的病例对照研究,选择术后感染率、手术时间、术中出血量、骨折不愈合率、骨折延迟愈合、骨折畸形愈合率作为Meta分析的评价指标,按Cochrane协作网推荐的方法进行系统评价。结果:共纳入5项研究366例患者。Meta分析结果显示:MIPPO组感染率低于ORIF组[OR=0.23,95%CI(0.06,0.92),P=0.04];MIPPO组骨折不愈合率低于ORIF组[OR=0.16,95%CI(0.03,0.76),P=0.02];ORIF组骨折畸形愈合率低于MIPPO组[OR=7.46,95%CI(1.68,33.10),P=0.008];MIPPO组手术时间短于ORIF组[MD=-14.42,95%CI(-27.79,-1.05),P <0.05];MIPPO组术中出血量少于ORIF组[MD=-87.17,95%CI(-99.20,-75.15),P <0.05];两组骨折延迟愈合率比较差异无统计学意义。结论:对于成人胫骨远端骨折,与切开复位内固定治疗相比,经皮微创钢板内固定治疗手术时间短、出血量较少、术后感染率和骨折不愈合率低,但骨折畸形愈合率高。总体来看MIPPO较ORIF治疗成人胫骨远端骨折更有优势,但最佳治疗方案的选择应结合患者的病情进行综合考虑。     

内窥镜与开放手术治疗复发性腰椎间盘突出症的比较

目的: 比较内窥镜手术与开放手术治疗复发性腰椎间盘突出症(RLDH)的临床效果及优缺点. 方法: 对2008年8月至2010年12月手术治疗的35例复发性腰椎间盘突出症患者进行回顾性研究. 按手术方式分为两组,内窥镜组14例,行椎间盘镜(MED)下经椎间孔减压椎间融合(TLIF);开放手术组21例,行后路全椎板减压椎间融合(PLIF).两组患者均同时采用了椎弓根螺钉内固定. 分别比较两组患者的手术时间、出血量、术后引流量、镇痛药剂量、术后卧床时间. 采用视觉模拟疼痛评分(VAS)、JOA评分(15分法)和汉化版Oswestry下腰痛功能障碍指数(CODI)对患者术前、术后及末次随访时的临床症状体征以及功能状态进行评价,对结果进行统计分析. 结果: 两组患者手术时间无差异(P>0.05),内窥镜组术中出血量、术后引流量、术后所需镇痛药剂量和卧床时间以及术后腰痛VAS评分均明显少于开放手术组(P<0.01).35例患者均获1年随访,两组患者术前术后JOA评分比较差异无统计学意义(P>0.05),内窥镜组CODI指数优于开放手术组(P<0.05).结论: 两种术式均能获得满意的临床效果;椎间盘镜下TLIF手术创伤小、术后疼痛少、功能恢复较好,是目前治疗RLDH的首选方法.     

脊神经后支阻滞在老年人腰椎后路椎间融合术多模式镇痛方案中的应用

目的 探讨联合罗哌卡因脊神经后支阻滞多模式镇痛方案在老年人后路腰椎椎间融合术(PLIF)围手术期镇痛中的应用。方法 行PLIF的老年患者(年龄 ≥ 65岁)60例,随机分为对照组(A组,n=20)、常规多模式镇痛组(B组,n=20)和脊神经后支阻滞多模式镇痛组(C组,n=20),记录3组患者术前6 h及术后6、12、24、48、72 h及1周时疼痛视觉模拟量表(VAS)评分,术后1、3、7 d及出院时的运动阻滞(Bromage)评分;统计不良反应发生率和额外使用镇痛药物的例数。结果 术前6 h,VAS评分B、C组低于A组,差异有统计学意义(P<0.05);术后6、12、24 h,C组低于A、B组,差异有统计学意义(P<0.05);术后48 h,各组间差异无统计学意义(P>0.05);术后72 h及1周,B、C组低于A组,差异有统计学意义(P<0.05)。术后1 d,Bromage评分C组低于A、B组,差异有统计学意义(P<0.05);术后3、7 d及出院时,各组间差异无统计学意义(P>0.05)。B、C组不良反应发生率低于A组,差异有统计学意义(P<0.05);额外使用镇痛药物例数C组 < B组 < A组,各组间差异均有统计学意义(P<0.05)。结论 联合应用罗哌卡因脊神经后支阻滞的多模式镇痛方案能有效缓解老年人PLIF围手术期疼痛,且不影响运动功能。     

侧卧位与俯卧位下经椎间孔入路经皮内窥镜下腰椎椎间盘切除术治疗腰椎椎间盘突出症

目的 比较侧卧位与俯卧位下经椎间孔入路经皮内窥镜下腰椎椎间盘切除术（PETD）治疗腰椎椎间盘突出症（LDH）的疗效。方法 2018年1月—2019年12月采用PETD治疗LDH患者90例,按照术中采取体位的不同分成侧卧位组（47例）和俯卧位组（43例）。比较2组手术时间、术中出血量、住院时间、术中发生极度不舒适和不耐受手术体位例数、术中不适Likert量表评分、疼痛视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）及术后复发率。采用改良MacNab标准评价手术疗效。结果 侧卧位组手术时间、住院时间与俯卧位组比较,差异无统计学意义（P>0.05）;侧卧位组术中出血量较俯卧位组少,差异有统计学意义（P<0.05）。侧卧位组术中极度不舒适患者比例及术中不适Likert量表评分均低于俯卧位组,差异有统计学意义（P<0.05）;不耐受手术体位患者比例组间差异无统计学意义（P>0.05）。2组术后VAS评分、ODI与术前相比均明显降低,差异有统计学意义（P<0.05）,组间差异无统计学意义（P>0.05）。侧卧位组疗效优良率为91.49%（43/47）,术后复发率为4.26%（2/47）;俯卧位组疗效优良率为86.05%（37/43）,术后复发率为9.30%（4/43）;组间差异均无统计学意义（P>0.05）。结论 LDH患者在侧卧位下行PETD,其疗效与俯卧位相当,且有助于降低术中出血量,减少术中极度不适情况的发生,可确保手术平稳、安全开展。     

Reduction of post-operative opioid use in neonates following open congenital diaphragmatic hernia repairs: A quality improvement initiative

BackgroundA limited number of post-operative opioid reduction strategies have been implemented in the neonatal population. Given the potential neurodevelopment effects of prolonged opioid use, we created a quality improvement initiative to reduce opioids in our NICU and evaluated the intervention in our CDH population.MethodsOur opioid reduction intervention was based on standing post-operative IV acetaminophen, standardizing post-surgical sign-out between the surgical, anesthesia and NICU teams and a series of education seminars with NICU providers on post-operative pain control management. A historical control was used to perform a retrospective cohort analysis of opioid prescribing patterns in addition to a utilizing process control charts to investigate time trends in prescribing patterns.ResultsForty-five children with CDH underwent an operation were included in our investigation- 18 in our pre-intervention cohort, 6 in a roll-out cohort and 21 in our post-intervention cohort. Each cohort was clinically similar. The intervention reduced total post-operative opioid use (morphine equivalents) from 82.2 (mg/kg) to 2.9 (mg/kg) in our post-intervention group (p < 0.0001). Our maximum Neonatal Pain and Agitation Sedation Score over the first 48 post-operative hours were equivalent (p = 0.827). Safety profiles were statistically equivalent. The opioid reduction intervention reduced post-operative intubation length from 156 to 44 h (p = 0.021).ConclusionA multi-tiered intervention can decrease opioid use in post-surgical neonates with complex surgical pathology including CDH. The intervention proposed in this investigation is safe and does not increase pain or sedation scores in neonates, while lessening post-operative intubation length.Evidence levelLevel II     

Bedside laparotomy in newborns -A single institute experience

Background/purpose: Intra hospital transfer of sick newborns is known to cause adverse events with potential morbidity. Interventions at the bedside in a sick neonate can reduce the need for transport and in turn, potential hazards of transfer. Our single institute experience of performing bedside laparotomies in unstable newborns is reported here.Materials and methods: Seven-year data was collected from electronic medical records. This was a retrospective comparative study with level III evidence. Twenty-eight neonates operated at bedside for intraabdominal sepsis due to Necrotising Enterocolitis (NEC), Spontaneous Intestinal Perforation (SIP), complicated meconium ileus and perforation secondary to atresias were included Group A. Group B had 60 neonates operated for similar indications in the conventional operation theatres.Results: The average corrected gestational age at surgery, associated co-morbidities, average volume of blood loss and duration of surgery were compared between the groups. Group A had lower weight at surgery (1098 vs 1872 gs), greater percentage of neonates on inotropic support (78% vs 20%) with requirement of High Frequency Ventilation (HFO) (50% vs none). A quarter of neonates (7 of 28) in Group A had NEC Totalis as against only one case in group B. There was 25% survival in group A and 76.67% in group B. The lower survival in group A can be attributed to lower weight at surgery, higher inotrope requirement and need for unconventional modes of ventilation.Conclusion: Bedside laparotomy is a feasible option in unstable neonates deemed unsuitable for transport.     

Evaluation of Cellular and Biochemical Parameters of Blood and Peritoneal Fluid Following Exploratory Laparotomy in the Goat

To evaluate the effects of exploratory laparotomy on cellular and biochemical parameters of blood and peritoneal fluid, an experiment was conducted using 10 Iranian cross‐bred male goats. Approximately 10 ml of blood and 1–1.5 ml of peritoneal fluid were collected from all animals prior to operation for estimation of control values. Exploratory laparotomy was performed under local analgesia. Blood and peritoneal fluid samples were collected at 24, 48, 72 and 96 h after exploratory laparotomy. The results revealed that after exploratory laparotomy, the number of white blood cells and the percentage and absolute number of neutrophils and band neutrophils significantly increased (P < 0.05). However, the percentage of lymphocytes decreased significantly (P < 0.05). The concentrations of blood urea nitrogen significantly increased (P lt; 0.05). Furthermore, following the operation, the percentage and absolute number of neutrophils in the peritoneal fluid significantly increased (P < 0.05). In contrast, the percentage of lymphocytes in the peritoneal fluid decreased significantly (P < 0.05). The concentration of protein in the peritoneal fluid increased significantly (P < 0.05).     

The effect of prophylactic mesh implantation on the development of incisional hernias in patients with elevated BMI: a systematic review and meta-analysis

Background

Incisional hernia is a common complication after midline laparotomy. In certain risk profiles incidences can reach up to 70%. Large RCTs showed a positive effect of prophylactic mesh reinforcement (PMR) in high-risk populations.

Objectives

The aim was to evaluate the effect of prophylactic mesh reinforcement on incisional hernia reduction in obese patients after midline laparotomies.

Methods

Following the PRISMA guidelines, a systematic literature search in Medline, Web of Science and CENTRAL was conducted. RCTs investigating PMR in patients with a BMI ≥ 27 reporting incisional hernia as primary outcome were included. Study quality was assessed using the Cochrane risk-of-bias tool and certainty of evidence was rated according to the GRADE Working Group grading of evidence. A random-effects model was used for the meta-analysis. Secondary outcomes included postoperative complications.

Results

Out of 2298 articles found by a systematic literature search, five RCTs with 1136 patients were included. There was no significant difference in the incidence of incisional hernia when comparing PMR with primary suture (odds ratio (OR) 0.59, 95% CI 0.34–1.01, p = 0.06, GRADE: low). Meta-analyses of seroma formation (OR 1.62, 95% CI 0.72–3.65; p = 0.24, GRADE: low) and surgical site infections (OR 1.52, 95% CI 0.72–3.22, p = 0.28, GRADE: moderate) showed no significant differences as well as subgroup analyses for BMI ≥ 40 and length of stay.

Conclusions

We did not observe a significant reduction of the incidence of incisional hernia with prophylactic mesh reinforcement used in patients with elevated BMI. These results stand in contrast to the current recommendation for hernia prevention in obese patients.

     

Outcomes Following Laparoscopic Versus Open Repair of Incisional Hernia

Aim The purpose of this study was to compare short- and long-term outcomes for patients undergoing laparoscopic or open surgery for incisional hernia repair using meta-analytical techniques. Methods A literature search was performed to identify comparative studies reporting outcomes on laparoscopic versus open surgery for incisional hernia repair. A random-effect meta-analytical model was used and subgroup analysis performed on high-quality studies, those reporting on more than 30 patients, and those published since 2000. Results Five studies, with a total of 351 patients, satisfied the inclusion criteria. Laparoscopic surgery was attempted in 148 (42.2%) patients. Overall, in the laparoscopic group, operative time was significantly longer—by 12.0 minutes (P = 0.03) and length of stay reduced by 3.3 days (P < 0.003) although this finding was associated with significant heterogeneity between studies (P < 0.001). There was no difference in the short-term adverse events between the groups, but there were fewer wound infections for laparoscopic patients in high-quality studies [odds ratio (OR) = 0.22, 95% confidence interval (CI): 0.05, 0.85, P = 0.03] and those reporting on more than 30 patients (OR = 0.19, 95% CI: 0.04, 0.84, P = 0.03). No difference in hernia recurrence was shown in the overall or subgroup analysis. Conclusions Laparoscopic incisional hernia repair was associated with a reduced length of stay and lower wound infection rate. The impact on post-operative quality of life and financial implications needs further prospective, validated evaluation.     

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Introduction

The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects.

Methods

We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study.

Results

Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair.

Conclusion

We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.     

“对位对线”补片固定法在腹腔镜切口疝修补术中的应用

背景与目的 切口疝的微创修补理念在疝外科界已经形成共识，腹腔镜下切口疝修补在临床上的应用越来越普及，但腔镜下的补片固定技术仍然是一个难点。本研究旨在介绍一种新式的切口疝补片固定方法并探讨其临床应用效果。方法 回顾性分析2018年1月—2019年12月中山大学附属第六医院胃肠、疝和腹壁外科120例行腹腔镜切口疝修补手术（IPOM）患者的临床资料，其中60例的补片固定方式采用“对位对线”补片固定法（观察组），另60例采用传统疝钉双圈固定方法（对照组），比较两组患者相关临床指标以及经济学指标。结果 两组患者性别、年龄、BMI、病程以及疝环最大缺损指标差异均无统计学意义（均P>0.05）。观察组的平均补片固定时间短于对照组（35.5 min vs. 47.7 min，P<0.05），平均疝钉固定数量少于对照组（36.6枚 vs. 44.2枚，P<0.05），平均术后疼痛VAS评分低于对照组（3.2分 vs. 4.6分，P<0.05），住院费用低于对照组（3.9万元 vs. 4.8万元，P<0.05）。两组患者在血清肿、补片感染发生率，术后住院时间的差异均无统计学意义（均P>0.05）。观察组和对照组平均随访26.3个月与25.8个月，观察组和对照组的切口疝复发率（1.7% vs. 5.0%，P=0.61）及术后慢性疼痛的发生率差异均无统计学意义（6.7% vs. 8.3%，P=1.00）。结论 “对位对线”补片固定法可缩短补片固定时间，减少疝钉使用数量，节约住院费用，并且可降低切口疝术后早期疼痛的发生，该方法在腹腔镜切口疝修补术中的应用是安全有效的，可在临床进行推广使用。     

Transverse Versus Midline Incision for Upper Abdominal Surgery

Purpose Transverse and midline abdominal incisions are both commonly used for laparotomy to perform surgery on the pancreas and stomach, but comparative data are limited, especially from prospective randomized trials.Methods During a predefined 2-year recruitment period, 94 patients undergoing an elective major laparotomy for disorders of the pancreas or stomach were enrolled in this study. The outcome measures were pulmonary function, incisional pain, and wound characteristics.Results The operation groups were equally divided according to the type of incision used. The patients who underwent transverse incision laparotomy had significantly better postoperative pulmonary function and significantly less postoperative incisional pain than those who underwent midline incision laparotomy (P < 0.05), but there were no differences in morbidity and the incidence of wound complications.Conclusion Performing a transverse incision for surgery on the pancreas or stomach results in better postoperative pulmonary function and less incisional pain than a midline incision, without affecting postoperative morbidity.     

基于数据分析与计算的模型化布孔法在腹腔镜腹壁切口疝修补术中的应用

背景与目的 随着微创理念及技术的发展,经腹腔镜完成腹壁切口疝手术已成为趋势,但由于腹壁切口疝位置大小不定,暂无成熟的布孔方法供术者参考,使得手术术式的学习难度较大,不合理的布孔还易导致手术难度加大。笔者在此介绍一种基于数据分析与计算的模型化布孔方法,并通过与传统经验性布孔法进行比较,探讨其优势和临床效果。方法 选择2017年1月—2018年5月中山大学附属第六医院收治并拟行腹腔内补片植入术（IPOM）的44例腹壁切口疝患者,用随机数字表法将患者分为对照组（21例）和研究组（23例）,对照组采用术中放置观察孔后以手术经验放置操作孔的布孔方法,研究组采用术前腹部轮廓分析,并按照步骤划定限制条件,根据操作器械尺寸计算合理距离的方法指导穿刺孔放置位置的方法。比较两组患者术中及术后的相关临床指标。结果 两组患者一般资料差异无统计学意义（均P>0.05）。与对照组比较,研究组的平均布孔时间（7.28 min vs. 9.93 min）、平均手术时间（67.62 min vs. 79.10 min）、术中加孔率（17% vs. 48%）均明显减少（均P<0.05）。研究组与对照组患者的术后并发症发生率（4.3% vs. 19.0%）,术后住院时间（5.13 d vs. 5.76 d）及术后复发率（4.3% vs. 4.8%）差异均无统计学意义（均P>0.05）。结论 在腹腔镜腹壁切口疝IPOM手术采用模型化布孔法可以缩短布孔时间,合理的操作孔布置可以降低腹腔镜下粘连分离、缺损缝合及补片固定的难度,降低手术总时间及术中增加操作孔的几率,并不增加术后并发症发生率,住院时间及复发疝的几率。模型化布孔法以客观数据+定量计算代替传统布孔法的经验决策,在方法步骤上更明晰,并可以在使用中不断更新改进,将有助于腹腔镜腹壁切口疝手术的规范与推广。     

Comparing Surgical Outcomes in Obese Women Undergoing Laparotomy,Laparoscopy, or Laparotomy With Panniculectomy for the Staging of Uterine Malignancy

Background Limiting surgical morbidity while maintaining staging adequacy is a primary concern in obese patients with uterine malignancy. The goal of this study was to compare the surgical adequacy and postoperative morbidity of three surgical approaches to staging the disease of obese women with uterine cancer. Methods The records of all patients with a body mass index (BMI) of ≥35 undergoing primary surgery for uterine corpus cancer at our institution from January 1993 to May 2006 were reviewed. Patients were assigned to three groups on the basis of planned surgical approach—standard laparotomy, laparoscopy, or laparotomy with panniculectomy. Standard statistical tests appropriate to group size were used to compare the three groups. Results In all, 206 patients with a BMI of ≥35 were grouped as follows: laparotomy, 154 patients; laparoscopy, 25 patients; and laparotomy with panniculectomy, 27 patients. Median BMI was 41 (range, 35–84). Regional lymph nodes were removed in 45% of the laparotomy patients, 40% of the laparoscopy patients, and 70% of the panniculectomy patients (P = .04). Compared with laparotomy, both laparoscopy and panniculectomy yielded higher median pelvic and total lymph node counts (P = .001). Operative time was shortest after standard laparotomy, and blood loss was greatest after panniculectomy. The incidence of all incisional complications was lower for panniculectomy (11%) and laparoscopy (8%) compared with standard laparotomy (35%) (P = .002). On multivariate analysis, a significantly lower risk of total incisional complications was seen for patients undergoing panniculectomy (risk ratio, .25; 95% confidence interval, .071–.88) and laparoscopy (risk ratio, .19; 95% confidence interval, .04–.94). Conclusions Both laparoscopic staging and panniculectomy in a standardized fashion were associated with an improved lymph node count and a lower rate of incisional complications than laparotomy alone. Although definitive conclusions are limited by low patient numbers, the substantial decrease in wound complications suggests that these two approaches should be considered for obese patients undergoing uterine cancer staging. Presented in part at the Society of Gynecologic Oncologists Winter Meeting; Beaver Creek, CO; February 1–3, 2007.