同侧复发性腹股沟疝腹腔镜腹膜前修补术93例分析

目的探讨腹腔镜腹膜前修补术治疗同侧复发性腹股沟疝的可行性。方法我院2012年12月～2017年12月我科对93例复发性腹股沟疝(单侧90例,双侧3例;复发性斜疝51例,复发性直疝42例)行全腹膜外(total extraperitoneal,TEP)或经腹腹膜前(transabdominal preperitoneal,TAPP)腹腔镜修补术,Bogros间隙或髂窝间隙内粘连分离较困难时,使用防粘连涂层补片经腹部分腹膜外补片植入术(transabdominal partial extraperitoneal,TAPE)或经腹腹腔内补片植入术(intraperitoneal onlay mesh,IPOM)。结果 93例手术均顺利,无中转开放手术。TEP 63例,手术时间25～60 min,平均37. 4min,术中出血量5～20 ml,平均9. 6 ml。TAPP 30例,1例改行TAPE,1例改行IPOM,30例手术时间35～90 min,平均49. 1min,术中出血量5～30 ml,平均15. 6 ml。93例术后住院时间1～3 d,平均1. 3 d。5例术后出现腹股沟区或阴囊局部血肿或血清肿,多次穿刺抽吸后均好转。93例术后随访6～60个月,无切口感染、腹股沟区顽固性疼痛及疝再复发等。结论腹腔镜腹膜前修补术是治疗复发性腹股沟疝安全可行的方式。选择合适的病例和术式,注意术中的操作要点是再手术成功的关键。     

腹腔镜成人腹股沟疝修补术的临床应用

目的：探讨腹腔镜成人腹股沟疝修补术的手术方法和应用价值。方法：回顾分析行腹腔镜腹股沟疝修补术32例患者的临床资料,其中斜疝27例,直疝4例,复合疝1例。行腹膜前补片修补术（transabdominal preperitoneal prosthesis,TAPP）19例,行腹腔内补片植入术（intraperitoneal onlay mesh,IPOM）12例,行完全腹膜外补片植入术（total extraperirtoneal pros-thesis,TEP）1例。结果：32例手术均获成功,无中转开腹,手术时间35～90min,平均55min,术后3～5d出院,随访1～29个月无一例复发。结论：腹腔镜腹股沟疝修补术安全可行,具有并发症少、术后患者疼痛轻、康复快、复发率低等优点,并可同时发现复合疝和隐性疝。     

腹腔镜经腹腹膜前疝修补术的围手术期护理

正腹股沟疝临床常见,传统疝修补术后复发率高。近年,腹腔镜无张力疝修补技术日渐成熟,应用广泛。腹腔镜腹股沟疝修补术(laparoscopic inguinal hernia repair,LIHR)主要包括经腹腹膜前疝修补术(transabdominal preperitoneal,TAPP)、全腹膜外疝修补术(totally extraperitoneal,TEP)及腹腔内补片植入术(intraperitoneal onlay mesh,IPOM)~[1]。TAPP操作方便,术后康复快,复发率低,并发症少,临床应用较广泛。现结合2010年1月至2013年12月行TAPP治疗的42例腹     

腹腔镜腹股沟疝修补术64例的临床应用

目的 探讨腹腔镜在腹股沟疝修补术中应用的可行性和优缺点.方法 64例成人腹股沟疝采用不同的腹腔镜疝修补术式完成,随访观察临床疗效,对临床资料进行回顾性总结分析.结果 所有患者均成功完成腹腔镜腹股沟疝修补术,包括腹腔镜腹股沟疝腹腔内网片植入术(intraperitoneal onlay mesh,IPOM)术式34例,腹腔镜经腹腹膜外腹股沟疝修补术(transabdominal preperitoneal prosthetic, TAPP)术式7例,腹腔镜全腹膜外腹股沟疝修补术(totally extraperitoneal prosthetic, TEP)术式20例,IPOM同时对侧行TAPP者2例,IPOM同时对侧行TEP者1例.单侧平均手术时间为25～160 min,平均66 min;双侧手术时间为60～187 min,平均76 min.术中出血量为 5～100 ml, ,术后平均住院时间4.8 d.总体疗效满意,并发症发生率14.06%,全组复发率为3.12% .结论 腹腔镜腹股沟疝修补术安全可行,具有微创优势,但仍需积极防治并发症.     

三种不同腹腔镜术式治疗老年复发性腹股沟疝的临床效果比较

目的:比较腹腔镜腹腔内补片植入术(intraperitoneal onlay mesh,IPOM)、腹腔镜经腹腹膜前疝修补术(transabdominal preperitoneal,TAPP)与腹腔镜全腹膜外疝修补术(totally extraperitoneal,TEP)3种手术方式治疗老年复发性腹股沟疝的临床效果。方法:回顾分析为156例老年复发性腹股沟疝患者行腹腔镜手术的临床资料,其中23例行IPOM,106例行TAPP,27例行TEP,术后随访1个月,对比3种术式的手术时间、术后住院时间、术后下床活动时间、术后第1天疼痛VAS评分等情况。结果:IPOM、TAPP、TEP 3组患者平均手术时间为(53.2±13.8)min、(52.6±18.6)min、(56.5±16.8)min;术后住院时间平均(4.2±2.1)d、(3.5±2.8)d、(3.7±1.9)d;术后下床活动时间平均(14.2±3.8)h、(15.5±3.1)h、(15.3±2.9)h;术后第1天疼痛VAS评分平均(2.3±0.3)分、(2.5±0.6)分、(2.6±0.9)分;术后并发症发生率分别为13.04%、16.98%与14.81%,上述指标差异均无统计学意义(P>0.05)。结论:3种腹腔镜疝修补术均适于老年复发性腹股沟疝患者,具体手术方式主要根据上次手术入路及补片层次进行个性化选择。     

无张力修补术后腹股沟复发疝再手术的探讨

目的探讨腹股沟疝无张力修补术后复发的原因及再手术治疗的原则。方法对2007年1月至2009年6月间31例腹股沟疝无张力修补术后复发患者的资料进行回顾性分析。复发时间为前次术后3个月至10年,平均(32±10)个月。既往手术方式:疝环填充式修补术14例,平片修补术10例,腹腔镜无张力疝修补术5例(TAPP、TEP、IPOM术后分别有2例、2例、1例),开放式腹膜前修补术2例。结果手术时间28～86 min,平均(38±6)min。首次复发行开放式全腹膜外无张力修补12例,平片修补6例,腹腔镜下修补4例(TEP2例、TAPP2例),巨大补片加强内脏囊(GPRVS)3例。多次复发者中2例行腹腔镜下修补(包括1例TEP和1例IPOM),2例行开放式完全腹膜外无张力修补,2例GPRVS。随访时间8～52个月,平均(29±8)个月,再复发1例。结论无张力腹股沟疝修补术后复发的原因主要是术中操作不当或患者复发的高危因素处理不当。应根据复发疝的类型和性质,选择个体化的治疗方案和手术路径。     

腹腔镜经腹腹膜前补片植入术治疗复发性腹股沟疝技术探讨

复发性腹股沟疝尤其是无张力疝修补术后复发疝的治疗依然是疝外科医师必须面对的难题。腹腔镜疝修补术凭借其“后入路”的手术特点和直视下操作的技术优势逐渐成为处理开放手术后复发疝的优选术式而被外科医师所接受和应用。因为复发疝情况复杂多变,目前尚无规范化的复发疝腹腔镜手术操作规范和指南。应用腹腔镜经腹腹膜前修补术（TAPP）治疗复发疝时绝大多数病人可以完整游离腹膜前间隙,部分病人须选择梭形或“T”形切口切开腹膜。原有补片一般不建议去除,在补片固定方面建议适当放宽指征,在特殊情况下可以选择局部修补法、腹腔内补片植入术（IPOM）或经腹部分腹膜外修补术（TAPE）修补缺损。     

腹腔镜腹膜前补片植入法腹股沟疝修补术50例报告

目的探讨腹腔镜腹膜前补片植入腹股沟疝修补术(transabdominalprepenritoneallaparoscopicherniarepair,TAPP)的临床疗效。方法从脐及两侧旁开10cm穿刺,置入摄像头及内镜器械,自疝内环上约5cm处近脐外侧壁打开壁腹膜,游离疝囊,后置入补片,覆盖整个缺损区,将补片用钉合器固定在耻骨梳韧带及联合腱上。结果50例腹腔镜手术均成功,手术时间20~70min,(39.8±10.5)min。术后腹股沟区疼痛1例,尿潴留2例。术后住院1~4d,平均2d。50例随访1~11个月,平均7个月,无复发。结论TAPP是安全有效的无张力疝修补术。     

应用腹腔镜技术诊治复发性腹股沟疝

目的探讨应用腹腔镜技术在复发性腹股沟疝诊断及治疗中的价值。方法回顾性分析1999年3月至2008年3月应用腹腔镜技术明确诊断并行腹腔镜疝修补术治疗的45例复发性腹股沟疝患者的临床资料。结果45例手术全部成功,无中转开放手术。应用腹腔镜经腹腹膜前补片修补术（TAPP）38例,腹腔镜完全腹膜外补片修补术（TEP）6例,腹腔镜腹腔内补片贴置术（IPOM）1例。术中明确诊断真性复发疝25例,新发疝16例,遗留疝4例。术中发现对侧隐匿疝5例,一并行腹腔镜疝修补术。手术时间30～120rain,平均（60．0±22．5）min,术后住院2～7d,平均3d。45例随访1—10年,平均（4．5±3．3）年,无1例再复发。结论应用腹腔镜可以明确复发性腹股沟疝的类型,有助于病因分析及减少再复发率。腹腔镜疝修补术创伤小、恢复快、再复发率低,可作为诊断和治疗复发性腹股沟疝的首选方法。     

3DMax补片在腹腔镜腹股沟疝修补术中的应用（附68例报告）

目的 评价3DMax补片在腹腔镜腹股沟疝修补术中的应用价值。 方法 回顾性分析2006年10月至2008年7月第二军医大学附属长海医院微创外科应用3DMax补片行腹腔镜腹股沟疝修补术的临床资料。 结果 68例病人中Ⅰ型疝4例,Ⅱ型疝45例,Ⅲ型疝16例,Ⅳ型疝3例;斜疝53例,直疝13例,股疝2例。67例完成腔镜下修补,经腹腹膜前网片疝修补术（TAPP）19例,腹腔镜下全腹膜外修补术（TEP） 48例;1例因疝囊过大疝内容物无法还纳中转开放修补。手术时间30~65min,平均40min。术后排气时间1~2d,术后平均住院2d。术后发生阴囊血清肿2例,小肠梗阻再手术1例。随访3~24个月,无复发病例。 结论 腹腔镜腹股沟疝修补术具有创伤小、恢复快及复发率低等优点,采用预先成型的3DMax补片使手术操作更加简便、并发症发生率更低。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.