胸椎结核手术入路的比较

目的：探讨胸椎结核手术入路的选择。方法：对1999年至2006年32例胸椎结核手术资料作回顾性分析，采用经肋横突切除、肋骨切除开胸、经胸膜外清除、植骨、内固定术等不同入路进行比较。结果：经肋横突切除、侧前方入路12例，手术暴露时间平均50分钟，入路时的出血量约200ml，术后2例肋间神经损伤，3例胸膜损伤，1例对侧病灶清除不彻底。肋骨切除开胸入路15例，手术暴露时间平均25分钟，入路时的出血量约50ml，术后无一例出现胸腔并发症。经胸胸膜外入路5例，手术暴露时间平均为35分钟，入路时的出血量约80ml，术后无一例出现胸腔并发症所有患者均经1年以上的随访，根据阮狄克标准，本组优良率92％，内固定组患者无内固定失败，植骨均融合。Frankrl分级均E级。结论：对胸椎结核根据病不同的病情，采用个体化设计前路手术，均能取得满意疗效。     

椎板侧方入路治疗极外侧腰椎间盘突出症的解剖及临床应用

[目的]通过对后正中经椎板侧方手术入路局部解剖结构的观测,探讨该入路治疗极外侧腰椎间盘突出症的临床疗效及注意事项。[方法]20具经防腐固定的成人尸体标本,观测横突间韧带厚度、前后方血管分布规律、腰神经前支与矢状面夹角、椎弓峡部侧缘及横突基底部副突处距腰神经前支距离。自2004年1月~2006年1月,收治极外侧腰椎间盘突出症12例,其中7例采用后正中经椎板侧方手术入路治疗,5例采用后正中经椎板侧方联合经椎管内手术入路治疗。[结果]L3~S1横突间韧带厚度为0.6~1.3 mm;腰节段动脉前支及其伴行静脉90%以上位于横突间韧带腹侧上1/2处,横突间韧带背侧中1/3内侧缘处有一恒定腰节段动脉分支穿出;腰神经前支出椎间孔后与矢状面夹角为18.9°~39.2°;副突及峡部侧缘距腰神经前支距离分别为5.6~8.0 mm、1.7~3.6 mm。12例病人均取得随访,随访时间3~20个月,平均10个月。根据Nakal分级:优8例,良3例,总优良率91.67%。[结论]横突间韧带为后正中经椎板侧方手术入路中重要的解剖学标志,熟悉其应用解剖对于手术治疗极外侧腰椎间盘突出症具有重要指导意义。应用后正中经椎板侧方手术入路治疗极外侧腰椎间盘突出症创伤小,术后效果好,是一种安全有效的手术方法。     

经横突间入路治疗单纯极外侧腰椎间盘突出症

目的探讨经横突间入路手术治疗单纯极外侧腰椎间盘突出症的疗效。方法对1996年5月至2005年10月25例接受经横突间入路手术治疗单纯极外侧腰椎间盘突出症的患者进行回顾性分析。结果所有患者接受术后1、6、12个月的随访，术后最终结果以12个月随访时为准，12例腰背部疼痛得到缓解，有3例患者肌力无明显提高，2例患者感觉缺失区域未恢复，所有患者的膝腱反射恢复正常，股神经牵拉试验阴性。结论经横突间手术入路治疗单纯极外侧腰椎间盘突出症最低限度破坏脊柱的稳定性，不需进行融合，效果良好。     

上腰椎爆裂型骨折外侧入路的手术方法

目的: 介绍上腰椎爆裂型骨折外侧入路的手术方法。方法: 沿骶棘肌外缘切口, 分离暴露L1、2、3横突, 切除横突、椎弓根、椎体后缘和突出的椎间盘, 减压硬膜管, 并同时作椎体间植骨骨水泥固定。结果: 50例患者均能达到脊髓前减压彻底和椎体间植骨融合稳定的目的。截瘫和下肢神经症状的恢复根据Frankel标准, 一般均能恢复 1~2个档次。结论: 上腰椎爆裂型骨折外侧入路的手术方法, 能达到脊髓前减压彻底和椎体间植骨融合稳定的目的。     

经皮椎体成形术手术入路研究进展

经皮椎体成形术（PVP）作为治疗骨质疏松性椎体压缩骨折（OVCF）的重要手段,研究其不同穿刺入路具有重要意义。双侧椎弓根入路可使骨水泥在椎体内弥散更加均匀;单侧椎弓根入路具有出血少、透视次数少、时间短等优点;弯角椎弓根入路以单侧椎弓根入路进针,骨水泥在椎体内多点注射,同时保留了单侧椎弓根入路与双侧椎弓根入路的优点;横突-椎弓根入路骨性标志定位明确,穿刺成功率高,关节突损伤风险低;单侧后外上方入路、横突上缘椎体外侧壁入路和横突-椎弓根极外侧入路穿刺不受椎弓根约束,有利于骨水泥在椎体内均匀分布,为PVP提供了更加灵活和安全的选择;肋横突间椎弓根入路和前外侧入路在胸椎和颈椎PVP治疗中具有明显优势;Kambin三角入路通过经典手术入路区域进行穿刺,具有较好的应用价值。该文就PVP手术入路研究进展进行综述。     

不同横突定位臂丛神经阻滞在肩上肢手术中的临床应用

目的评价不同横突入路肌间沟臂丛阻滞在肩上肢手术中的应用价值。方法采用三种不同横突入路肌间沟臂丛阻滞实施上肢手术200例,C5、C6、C7横突入路分别为72、70和52例。评价阻滞后30min各感觉和运动神经阻滞效果,并记录并发症情况。结果总的优良率为94.5%,C5、C6、C7入路分别为94.8%、92.9%和96.1%。其中C5入路对腋神经和C4神经阻滞率较C6、C7入路高(P<0.05),而C7入路对尺神经阻滞率明显提高(P<0.05)。结论根据手术部位选择不同横突入路的肌间沟臂丛阻滞,定位简单,成功率高,可满足整个肩部上肢手术的要求。     

双侧入路与经上关节突横突单侧入路PVP手术治疗腰椎骨质疏松性椎体压缩骨折的疗效比较

目的 分析经上关节突横突基底单侧入路与传统双侧入路注射骨水泥经皮椎体成形术治疗腰椎骨质疏松性椎体压缩骨折(osteoporosis vertebral compression fracture,OVCF)的疗效.方法 自2018年1月～2018年12月采用PVP手术治疗52例腰椎OVCF患者,根据手术入路分为两组:单侧组30例,经上关节突横突基底单侧入路;双侧组22例,采用传统双侧入路.术后随访12～18个月,对两组患者的手术疗效进行比较.结果 两组患者受伤后至手术时间,以及术前、术后1 d、术后1个月及末次随访时的伤椎前缘高度、Cobb角和VAS评分、骨水泥渗漏率差异均无统计学意义(P>0.05);两组患者手术时间、骨水泥用量差异有统计学意义(P<0.05).结论 两种入路穿刺行PVP手术治疗腰椎OVCF均安全有效,但上关节突横突基底单侧入路穿刺的手术时间短、骨水泥注入量少,是一种理想的替代方法.     

胸椎后纵韧带骨化症的诊断与治疗

报告９例胸椎后纵韧带骨化症，年龄自４７～６８岁，平均５５岁。除１例位于Ｔ１０～１１水平外均发生在上、中胸椎。本文讨论了本症的发病率、临床表现、影像学特征以及手术方法。指出经肋横突椎弓根入路、前入路骨化韧带切除为本病的主要术式     

肱骨髁间骨折手术入路的探讨

目的：探讨肱骨髁间骨折手术的入路方式。方法：18例肱骨髁间骨折的病人分别采用经鹰嘴截骨入路、经肱三头肌舌型瓣显露入路、经肱三头肌两侧入路的方式手术治疗。结果：随访平均1年5月，骨折全部愈合，无肘内翻畸形及骨化性肌炎的发生，优良率83％。结论：经鹰嘴截骨入路的手术方法是治疗肱骨髁间骨折相对较好的手术入路，应值得临床推广应用。     

髋臼前柱骨折与前壁骨折的诊断和治疗

目的：探讨髋臼前柱骨折与前壁骨折的诊断和治疗方法。方法：自1994年5月-2003年12月共收治髋臼前柱骨折和前壁骨折(A3型)31例，其中A3—1型5例，A3—2型9例，A3—3型17例。其中13例采用非手术治疗，18采用手术治疗。手术入路：髂腹股沟入路13例，髂股入路5例。结果：随访1～4年，平均2年。结果手术治疗组关节功能表现优良者17例，可1例。非手术治疗组关节功能表现优良者10例，可2例，差1例。结论：骨折块较大、移位比较严重且伴有髋关节前脱位的髋臼前壁骨折需要手术治疗。高位型前柱骨折多数需要行手术治疗。低位型前柱骨折多数行非手术治疗，少数移化非常严重的骨折需要行手术治疗。     

颈椎横突前结节解剖观测和术中定位的应用

目的：探讨应用颈椎横突前结节解剖特点行术中触摸定位的可靠性。方法：对30具成人颈椎标本行横突前结节形态观察和测量。经1100例颈椎前路手术应用颈椎横突前结节触摸定位法进行术中定位。结果：颈椎横突前结节位置和走向较为恒定,C6横突前结节最高。术中触摸C6横突前结节定位,经术中透视或术后拍片证实术中定位无一例错误。结论：术中触摸颈椎横突前结节是一较准确、简单的定位方法。     

后侧半椎体切除治疗先天性角状脊柱后凸

[目的]介绍先天性后侧半椎体切除术的适应证和手术方法.[方法]经后路暴露双侧的椎板,自双侧分离暴露关节突外侧和横突,切除横突沿椎弓根自骨膜下向前分离,暴露多余的后侧半椎体,切除多余的一节椎弓和后侧半椎体,自后路行双侧椎弓根螺钉加压棒固定.[结果]手术治疗先天性后侧半椎体畸形35例,取得优异的治疗效果,但手术操作比较复杂,相当于全脊柱截骨术的难度.[结论]先天性后侧半椎体切除术的年龄范围:8～25岁,年龄越大越趋向于作全脊柱截骨术.     

髋臼骨折手术并发症分析

目的探讨髋臼骨折手术并发症,提高髋臼骨折手术疗效。方法1998年6月~2006年12月手术治疗髋臼骨折95例,按Letounel-Judet分型,其中后壁骨折22例,后柱骨折8例,前壁骨折5例,前柱骨折6例,横形骨折15例,后柱伴后壁骨折8例,横形伴后壁骨折12例,"T"形骨折5例,前柱伴后半横形骨折3例,双柱骨折11例。根据不同骨折类型,手术分别采用Kocher-Langenbeck(K-L)入路52例,髂腹股沟入路35例,前后联合入路6例,髂股入路2例。对术后患者关节功能和主要并发症进行分析。结果所有病例平均随访26.8(6~48)个月。术后发生创伤性关节炎10例、股骨头坏死7例、异位骨化15例、坐骨神经损伤8例。结论正确选择手术时机、切口入路和内固定植入位置是减少髋臼骨折手术并发症的关键。     

改良胸骨前入路在腔镜甲状腺手术中的应用体会

目的:探讨腔镜甲状腺切除术中改良手术入路的操作方法。方法:将28例甲状腺手术患者随机分为两组,分别采用改良胸骨前入路与传统胸乳入路。结果:改良组中1例快速病理提示乳头状癌,中转开放手术;传统组中1例于穿刺过程中出血120 ml,中转开放手术;余者均顺利完成腔镜手术。改良入路在入路游离时间、出血量、术后疼痛及并发症方面均具有明显优势。术区皮瓣术后无明显手术痕迹,除1例术后胸前出现瘀斑,余均较满意。结论:改良胸骨前入路优于胸乳入路,术中可减少游离出血及游离中的副损伤,缩短手术时间,减少手术并发症,且不影响美容效果;手术安全有效,值得推广应用。     

Modified Kocher-Langenbeck approach in combined surgical exposures for acetabular fractures management

Background:

Displaced fractures of the acetabulum are best treated with anatomical reduction and rigid internal fixation. Adequate visualization of some acetabular fracture types may necessitate extensile or combined anterior and posterior approaches. Simultaneous anterior iliofemoral and posterior Kocher-Langenbeck (K-L) exposures with two surgical teams have also been described. To assess whether modified Kocher-Langenbeck (K-L) approach can substitute standard K-L approach in the management of elementary acetabular fractures other than the anterior wall and anterior column fractures and complement anterior surgical approaches in the management of complex acetabular fractures.

Materials and Methods:

20 patients with transverse and associated acetabular fractures requiring posterior exposure were included in this prospective study. In 9 cases (7 transverse, 1 transverse with posterior wall, and 1 posterior column with posterior wall), stabilization was done through modified K-L approach. In 11 cases (3 transverse and 8 associated fractures), initial stabilization through iliofemoral approach was followed by modified K-L approach.

Results:

The average operative time was 183 min for combined approach and 84 min for modified K-L approach. The postoperative reduction was anatomical in 17 patients and imperfect in 3 patients. The radiological outcome was excellent in 15, good in 4, and poor in one patient. The clinical outcome was excellent in 15, good in 3 and fair and poor in 1 each according to modified Merle d’Aubigne and Postel scoring system.

Conclusion:

We believe that modified K-L approach may be a good alternative for the standard K-L approach in the management of elementary fractures and associated fractures of the acetabulum when combined with an anterior surgical approach. It makes the procedure less invasive, shortens the operative time, minimizes blood loss and overcomes the exhaustion and fatigue of the surgical team.     

Treatment of avulsed clavicle and recurrent subluxations of the ipsilateral shoulder by dynamic fixation

A new operative approach is presented for treatment of fractured distal end of clavicle associated with recurrent anterior shoulder subluxations. One case is presented in which open reduction of the fractured clavicle and stabilizing the anterior shoulder joint were accomplished by transfer of the coracoid process with its attached muscles under the subcapularis muscle onto the clavicle. The operation was followed by complete reduction of the fracture and a stable shoulder joint.     

后侧入路重建脊柱前中柱技术的安全性及疗效分析

目的：探讨在腰椎爆裂骨折的治疗中应用经单一后侧入路植入钛网重建椎体前中柱技术的安全性及疗效。方法：自2005年7月至2007年1月,对22例腰椎爆裂骨折患者（男18例,女4例,年龄28-57岁,平均42．7岁）,采用单一后侧入路截除骨折椎一侧横突,从侧方对前中柱骨折碎块进行清理,行椎管扩大减压成形,然后置入填塞自体松质骨的钛网重建椎体前中柱。同时,采用后路短节段椎弓根螺钉系统固定骨折椎邻近上下节段椎体。记录手术时间、术中出血量、手术前后骨折椎椎体部位高度、脊柱后凸畸形程度、椎管内占位情况等。结果：手术时间平均3．5h（2．8—5．8h）,术中出血量平均820ml（650～2100ml）。所有患者均获随访,随访时间12-28个月,平均17．2个月。术后,骨折椎椎体高度由术前平均压缩至（23．70±9．31）％恢复至正常高度的（95．77±1．93）％（P〈0．05）,脊柱生理曲度恢复,椎管内压迫完全解除。术后3例发生短暂的神经根牵拉伤,1例术后3个月时发生椎弓根螺钉系统连接杆松动。结论：通过单一的后侧入路向前侧植入钛网重建腰椎爆裂骨折的前中柱技术安全性可靠,应用于腰椎爆裂骨折的治疗有良好的疗效。     

Robot-assisted whipple’s operation for solid pseudopapillary tumour of pancreas

Solid pseudopapillary tumor is a rare tumor of the pancreas. They are slow growing with low malignant potential. The prognosis is excellent after surgical resection. Here we report a case of solid pseudopapillary tumor of the pancreas at the uncinate process. There are increasing interests about minimal access surgery for pancreatic lesion. However conventional laparoscopic Whipple’s operation is technically difficult. With the benign characteristic of this tumor, as well as the advance in robotic surgery, robot assisted approach is an ideal alternative for this case. The operation was performed with a five-port approach with the use of da Vinci S Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The operative time was 420 min and operative blood loss was 100 ml. The post operative course was uneventful and the patient was discharged on post operative day 10. This case demonstrates the feasibility of robot assisted Whipple’s operation, which has not been extensively reported in the literature.     

下颈椎脱位早期前路手术复位疗效分析

目的观察下颈椎小关节脱位早期治疗选择前路手术复位、植骨融合内固定术的临床效果。方法早期前路切开颅骨牵引下旋转撬拨复位,一期椎间植骨融合内固定41例。结果一期复位成功36例,失败5例,成功率87.8%。33例获6～24个月随访,植骨均融合,无内固定松动及滑脱。神经损伤均有不同程度恢复。结论早期前路手术复位植骨融合内固定术优于手法复位及颅骨牵引复位,手术可早期进行,术后并发症少,康复良好,并可减轻护理难度。     

Hand-assisted laparoscopic low anterior resection

Background: Laparoscopic low anterior resection for rectal cancer has never gained wide acceptance among general surgeons, mainly due to the technical difficulties encountered during pelvic dissection. It has therefore been stated that these patients should undergo open rather than laparoscopic surgery. Hand-assisted laparoscopic surgery (HALS) is a new technique that has the potential to overcome many of the existing limitations of pure laparoscopy. In the treatment of rectal cancer, HALS could reproduce an operative setting similar to that of the open approach. Methods: To assess the technical feasibility of hand-assisted laparoscopic low anterior resection for rectal cancer and evaluate potential benefits and drawbacks of this new procedure, a pilot study was conducted at a university hospital on 16 consecutive patients during a 12-month period. Only patients with extraperitoneal rectal cancer were included in this series. Patients' clinical data, operative time, conversion rate, complications, and early outcome measures were prospectively examined. Results: There were 9 men and 7 women. The average ± SD operation time was 238 ± 38 min. Conversion to open surgery was never required. Ten of 16 patients were off pain medication on the third postoperative day. Eight were able to walk the day after surgery. Three minor postoperative complications were recorded. Mean postoperative stay for patients without complications was 5.6 ± 1.4 days. Conclusion: From a technical standpoint, the reported hand-assisted procedure makes pelvic dissection during laparoscopic low anterior resection almost equivalent to the laparotomic operation. The incision for hand access that is needed with this technique does not seem to compromise the quick recovery of patients undergoing purely laparoscopic procedures.