复杂性后尿道狭窄的手术径路探讨

目的：总结各种复杂性后尿道狭窄手术径路的应用经验,提高复杂性后尿道狭窄的治疗效果。方法：对72例复杂性后尿道狭窄患者的手术径路进行回顾性分析。结果：64例（89％）一次手术成功,经会阴径路中采用单纯经会阴径路34例中治愈31例（91％）,经会阴耻骨下缘径路14例中治愈13例（93％）,经耻骨径路中采用单纯经耻骨径路6例中治愈4例（67％）,经耻骨联合会阴径路18例中治愈16例（89％0,41例长段后尿道狭窄（＞3cm)者治愈35例（85％）,18例有合并症者治愈17例（94％例）。结论：复杂性后尿道狭窄的各种手术径路均存在一定的优缺点,选择合适的手术径路应综合多种因素考虑,经会阴径路因操作简单,创伤小,并发症少,仍是目前首选的手术径路。     

Thoracolaparoscopic repair of diaphragmatic hernias

Complex long-standing diaphragmatic hernia presenting in adults is often managed through an open approach. Minimal invasive approach by either laparoscopy or thoracoscopy is limited by its ability to tackle these complex hernias with large defects and thoraco-mediastinal adhesions. Thus, standard laparoscopic or thoracoscopic approach is associated with high conversion to open approach. We herein describe a novel combined thoraco-laparoscopic approach to repair complex diaphragmatic hernias in a series of three adults.     

Transcondylar fossa approach to treat ventral foramen magnum meningioma--case report

A 41-year-old female presented with a meningioma of the craniocervical junction manifesting as tetraparesis and vesicourethral dysfunction. Neuroradiological examinations showed a homogeneous enhanced mass lesion extending from the foramen magnum to the upper aspect of the second vertebral body. The tumor was totally removed via the transcondylar fossa approach, which is one type of the lateral approach. She was discharged without neurological deficits. The transcondylar approach is often utilized for lesions that occupy the ventral portion around the foramen magnum. The transcondylar fossa approach, a variation of the transcondylar approach, is a refined technique which obtains a closely similar surgical working field. Use of the transcondylar fossa approach remains controversial when treating patients with little brain stem dislocation, a small condylar fossa, and a protruding occipital condyle, but the approach can easily be converted to the transcondylar approach. The transcondylar fossa approach could become a standard method to access the craniocervical junction.     

Anterior muscle sparing approach for total hip arthroplasty

The purpose of this review is to examine the validity of positive claims regarding the direct anterior approach (DAA) with a fracture table for total hip arthroplasty. Recent literature regarding the DAA was searched and specific claims investigated including improved early outcomes, speed of recovery, component placement, dislocation rates, and complication rates. Recent literature is positive regarding the effects of total hip arthroplasty with the anterior approach. While the data is not definitive at present, patients receiving the anterior approach for total hip arthroplasty tend to recover more quickly and have improved early outcomes. Component placement with the anterior approach is more often in the “safe zone” than with other approaches. Dislocation rates tend to be less than 1% with the anterior approach. Complication rates vary widely in the published literature. A possible explanation is that the variance is due to surgeon and institutional experience with the anterior approach procedure. Concerns remain regarding the “learning curve” for both surgeons and institutions. In conclusion, it is not a matter of should this approach be used, but how should it be implemented.     

Less-invasive sublabial unilateral transseptal approach for transsphenoidal surgery

A less-invasive sublabial approach was developed to overcome the disadvantages associated with the conventional sublabial approach. The basic differences between this modified sublabial approach and the conventional approach are: a smaller incision (1-1.5 cm long) and almost midline vertical skin incision underneath the upper lip; minimal development of an inferior tunnel; no widening of the maxillary rim of the piriform aperture; and a strictly unilateral approach. This less-invasive approach uses a slim and small nasal speculum originally designed for the transnasal approach. This modified sublabial approach was applied to 41 of 133 patients who underwent transsphenoidal surgery between August 1998 and the end of 2000. These cases confirmed that this approach is a simple, rapid, and less-invasive technique with significantly fewer mucosal complications compared to the conventional approach. We conclude that this modified sublabial approach offers a good alternative to the conventional standard sublabial approach.     

New approach to the splenic vessels

The transperitoneal approach is used systematically for an arterial or a venous splenorenal anastomosis. However, this approach is associated with high morbidity and mortality rates. Because of our anatomical and surgical findings we have used the retroperitoneal approach to the splenic hilus by means of the lumbar region. The first splenorenal arterial anastomosis with this approach was done in 1972. The approach has proved to be less aggressive since it avoids the danger of damaging the pancreas, it is a more direct approach to the splenic vessels and it provides better exposure and facilitates the anastomosis. In addition, the loss or infection of ascitic fluid in cirrhotic patients is avoided with this approach, as well as intraoperative hemorrhaging caused by the great surplus circulation. There has been neither mortality nor complications in the 13 cases of arterial and venous splenorenal anastomoses that we have done with this method.     

Trans-cerebellomedullary fissure approach with special reference to lateral route

The trans-cerebellomedullary fissure (CMF) approach provides good exposure of the fourth ventricle without splitting the inferior vermis. The popularly utilized trans-CMF approach is performed in the midline suboccipital approach. However, the trans-CMF approach actually has two routes: medial and lateral. The lateral route is the trans-CMF approach through a lateral foramen magnum approach such as the transcondylar approach, opening the CMF from the lower unilateral side. We studied the surgical anatomy of the CMF and fourth ventricle. Based on the anatomic findings, we adopted the lateral route of the trans-CMF approach for four patients, each with a tumor near the jugular tubercle extending into the fourth ventricle through the CMF. Our study demonstrated that the lateral route of the trans-CMF approach enables sufficient exposure of not only unilateral cerebellopontine cistern but also of the lateral part of the fourth ventricle. A tumor is safely removed by this approach with easy feeder or tumor bed controls, especially if it is anchored at the lateral part of the CMF as is the jugular tubercle meningioma.     

Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study

Intramedullary nailing is one viable option for treating fractures of the tibia with a short, proximal segment. For a procedure being carried out with the knee in a semi-extended position, either a suprapatellar or parapatellar approach may be used. The objective of this study is to demonstrate whether the entry point for tibia nails is obtainable through suprapatellar or parapatellar approaches and to evaluate the most frequent injuries of the knee with these two approaches.Materials and methodsPaired legs from 10 fresh frozen cadavers were used. An arthroscopy was performed in each knee, documenting the status of the knee prior to the insertion of the tibia nail. In a random manner, the left or right leg underwent nailing with a suprapatellar or parapatellar approach in a semi-extended position. Fluoroscopy was utilized in each case to localize the entry point, and a tibia nail was inserted in all cases. A knee arthrotomy was then performed and the status of the following structures was assessed: patella and trochlea cartilage, tibia plateau cartilage, inter-meniscal ligament, lateral and medial meniscus, and the ACL.ResultsThe correct fluoroscopy entry point was achieved in all of the specimens (20). Three legs (3/10) with parapatellar approach had intra-articular disruption. In legs with a suprapatellar approach, patellar cartilage and trochlea cartilage damage was found in two of the specimens, respectively. There was one specimen with cartilage damage in the parapatellar approach. There were no meniscal injuries. Partial laceration of the intermeniscal ligament was found in three of the knees for each approach. One ACL injury was found in the suprapatellar group. Mean distance from the entry point to major structures is not significantly different with either approach. (p = 0.45).ConclusionsA good fluoroscopic entry point can be achieved using either the parapatellar or suprapatellar approach. The parapatellar approach for tibia nailing has similar rate of soft tissue damage compared to the suprapatellar approach. The suprapatellar approach damaged the cartilage in one-third of the cases and if cartilage injury occurs with the parapatellar approach, this is located in a low risk area.     

Current status of the hybrid approach for the treatment of hypoplastic left heart syndrome

The hybrid approach for hypoplastic left heart syndrome (HLHS), consisting of bilateral pulmonary artery banding and ductal stenting, has emerged as an alternative to the traditional Norwood approach. This approach defers open heart surgery to beyond the neonatal period, which is believed to reduce postoperative mortality and morbidity and improve neurological development as compared with the conventional approach. However, there have been no scientific studies supporting these hypotheses. Recently, there seems to be a tendency that many centers recommend the hybrid approach as an interim procedure to rescue preoperative high-risk patients. Currently, the decision to adopt the hybrid approach or the Norwood approach seemed to be based on the preference of congenital heart surgeons and cardiologists. Further investigation including a randomized multi-center study would allow a scientific decision as to which approach is more appropriate for the patient with HLHS.     

Carpal alignment after different surgical approaches to the scaphoid: a comparative study

Thirty-seven patients with inlay bone grafting for scaphoid nonunion were evaluated before and after operation for wrist function and carpal alignment. There were 26 in whom a palmar approach had been used. The remaining 11 had been treated with a dorsal approach. The two procedures showed a similar union rate (around 80%). The palmar approach, however, caused a significant increase in the scapholunate angle (p less than 0.001) and in the lunocapitate angle (p less than 0.05) and consequently augmented carpal collapse. The dorsal approach did not affect carpal alignment. The surgical division of the palmar radiocarpal ligaments, which is necessary when using a palmar approach, may be responsible for these findings. Accordingly, a dorsal approach should be preferable to a palmar approach when a graft is used for treatment of a scaphoid nonunion.     

Differential dynamic programming technique for optimal control

Continuous- and discrete-time differential dynamic programming (DDP) approaches to solve general optimal control problems are described and analysed. A comparison of the two approaches shows the continuous-time approach to be more general and flexible compared with the discrete-time approach, since it is not tied to any discretization scheme. A comparison of DDP with the non-linear programming (NLP) approach is also given. Three structural control problems — a linear model of a space structure, a single degree of freedom non-linear impact absorber and a non-linear flexible beam subjected to an impulsive load — are used to numerically evaluate the continuous- and discrete-time DDP approaches. Several grid sizes are used to show that the continuous-time approach with a reasonable number of grid points is more accurate and efficient (in most cases) than the discrete-time approach. It is therefore recommended to fully develop and evaluate the technique for the optimal control of large-scale systems.     

The anterior approach to the adrenal gland.

The traditional approach to the adrenal gland is via a loin incision. While this is frequently the ideal approach for unilateral disease if both adrenals are to be examined or removed the surgeon must choose between bilateral loin incisions and a transabdominal approach. A bilateral posterior approach may be made with the patient is a prone, semi-jacknife position. This, however, is often unsuitable for sick patients, and of course does not permit the surgeon to perform a laparotomy or simultaneous oophorectomy if this is considered necessary. We feel, therefore, that an anterior approach merits serious consideration.     

Intradural anterior transpetrosal approach

The standard anterior transpetrosal approach (ATPA) for petroclival lesions is fundamentally an epidural approach and has been practiced for many decades quite successfully. However, this approach has some disadvantages, such as epidural venous bleeding around foramen ovale. We describe here our experience with a modified technique for anterior petrosectomy via an intradural approach that overcomes these disadvantages. Five patients with petroclival lesions underwent surgery via the intradural ATPA. The intraoperative hallmarks are detailed, and surgical results are reported. Total removal of the lesions was achieved in two patients with petroclival meningioma and two patients with pontine cavernoma, whereas subtotal removal was achieved in one patient with petroclival meningioma without significant morbidity. No patient experienced cerebrospinal fluid leakage. The intradural approach is allowed to tailor the extent of anterior petrosectomy to the individually required exposure, and the surgical procedure appeared to be more straightforward than via the epidural route. Caveats encountered with the approach were the temporal basal veins that could be spared as well as identification of the petrous apex due to the lack of familial epidural landmarks. The risk of injury to the temporal bridging veins is higher in this approach than in the epidural approach. Intradural approach is recommended in patients with a large epidural venous route, such as sphenobasal and sphenopetrosal vein. Navigation via bone-window computed tomography is useful to identify the petrous apex.     

THE ANTERIOR APPROACH TO THE ADRENAL GLAND

The traditional approach to the adrenal gland is via a loin incision. While this is frequently the ideal approach for unilateral disease if both adrenals are to be examined or removed the surgeon must choose between bilateral loin incisions and a transabdominal approach. A bilateral posterior approach may be made with the patient in a prone, semi-jacknife position. This, however, is often unsuitable for sick patients, and of course does not permit the surgeon to perform a laparotomy or simultaneous oophorectomy if this is considered necessary. We feel, therefore, that an anterior approach merits serious consideration.     

Anterior approach in THA improves outcomes: opposes

Total hip arthroplasty (THA) can be performed through multiple surgical approaches, including anterior, anterolateral, lateral, transtrochanteric, posterolateral, posterior, and the 2-incision technique. The overwhelming majority of THAs today are performed through a posterolateral approach, which has many advantages: it can be extended without difficulty, it is expeditious, it results in reduced blood loss and little muscle damage, and recovery is rapid. The major disadvantage of the approach is its increased dislocation rate, which has become less of a problem with the advent of larger femoral heads and dual-mobility acetabular components. The anterior approach is another hip approach with advantages and disadvantages. One disadvantage is the need for a special table on which to perform the procedure, which can cost ≥$100,000. Many surgeons also recommend the use of intraoperative fluoroscopy with this approach, which prolongs surgery and adds possible draping contamination during the fluoroscopy. Exposure of the femur may be difficult with this approach, especially in patients with increased body mass index. The operative time also tends to be longer with this approach, as exposure may be more tedious. The published data report significant complications with this procedure.     

Retroperitoneoscopic adrenalectomy: lateral versus posterior approach

PURPOSE: We used a lateral or posterior approach to perform retroperitoneoscopic adrenalectomy for adrenal tumors and compared the results to determine which approach is more advantageous. PATIENTS AND METHODS: We removed 42 adrenal tumors from 42 patients by retroperitoneoscopic surgery. We used the posterior approach in 17 cases and the lateral approach in 25 cases. We compared the operating time, complications, and surgical advantages for the two approaches. RESULTS: The mean operating time was significantly shorter with the lateral approach, 141 +/- 64 minutes v 225 +/- 88 minutes for the posterior approach (P = 0.0019), which we believe reflects the technical advantages of the lateral approach. Complications included one case of pneumothorax and an instance of pulmonary edema in a patient with chronic renal failure using the lateral approach and one occurrence each of pneumothorax and bleeding using the posterior approach. Retroperitoneoscopic adrenalectomy could not be performed in 1 of 25 cases (4.0%) using the lateral approach and in 3 of 17 cases (17.6%) using the posterior approach. CONCLUSION: Our series suggests that the lateral approach is preferable to the posterior approach for retroperitoneoscopic adrenalectomy.     

Infrarenal aortic aneurysm repair by retroperitoneal approach combined with laparoscopic cholecystectomy: two case reports

Simultaneous repair of abdominal aortic aneurysm and treatment of cholelithiasis by the transperitoneal approach is controversial because of the risk of prosthesis infection. We report two patients who underwent a successful combined procedure using a retroperitoneal approach for the aortic aneurysm repair and a laparoscopic approach to the cholecystectomy. This combined approach reduces the risk of infection of the aortic prosthesis and is associated with a rapid return of normal peristalsis.     

An analysis of video-assisted thoracoscopic resection for mediastinal masses in 150 cases

BACKGROUND: To clarify the usefulness of the diagnosis and treatment of mediastinal masses, by video-assisted thoracoscopic surgery (VATS), we performed a retrospective multi-institutional study to delineate the type of approach, histopathology, and complications associated with these entities. METHODS: We analyzed 150 patients who underwent the VATS procedure at several institutions between 1991 and 1999. RESULTS: VATS resections were performed using various combinations of the "pansternal approach." The unilateral thorax approach was applied in 135 patients, the bilateral thorax approach combined with the suprasternum approach in seven patients, the unilateral thoracic approach combined with the supraclavicular approach in three patients, the infrasternal approach in three patients, and the bilateral thoracic approach combined with both the infrasternal and the suprasternal approaches in two patients. Thoracoscopic resections or biopsies diagnosed 140 benign and 10 malignant mediastinal masses. There were operative complications in nine patients (6%). Eight patients (5.3%) were converted to conventional thoracotomy. CONCLUSION: VATS is a safe, effective, minimally invasive technique that can facilitate the resection of mediastinal masses when the pansternal approach is applied as appropriate for the location of the tumor.     

Transmastoid Repair of Superior Semicircular Canal Dehiscence

Objective/Hypothesis Superior semicircular canal (Sup SC) dehiscence syndrome is a rare condition, causing a variety of auditory and vestibular symptoms. The traditional surgical management is a middle cranial fossa, extradural approach to resurface the Sup SC. Recently, a transmastoid approach for plugging of the Sup SC has been developed. We present further data supporting the use of the transmastoid approach in preference to the middle fossa approach.Design This is a retrospective multi-institutional case series.Method We included 10 patients in this case series from two tertiary otology institutions. Sup SC dehiscence was confirmed by correlation of clinical symptoms with positive audiometric, vestibular evoked myogenic potential, and computed tomography findings. A transmastoid approach was used for plugging of the Sup SC. Either a single fenestration was created at the site of dehiscence or separate fenestrations sited ampullopetal and ampullofugal to the dehiscence.Results All patients who underwent this procedure had good symptom control and hearing preservation postoperatively.Conclusion In patients with adequate temporal bone pneumatization, the transmastoid approach provides a safe and effective alternative to the middle cranial fossa approach. This series has demonstrated excellent symptom control and preservation of hearing with the transmastoid approach.     

Arthroscopic assisted mini-open biceps tenodesis: surgical technique

We describe a safe and simple approach for performing biceps tenodesis. This is performed in conjunction with arthroscopic inspection and debridement. This approach is less invasive than a deltopectoral approach and has been tested and proven secure.