胸椎间盘突出症的手术治疗

目的：研究分析胸椎间盘突出症患者的手术治疗效果。方法：回顾性分析30例胸椎间盘突出症的临床表现、影像学特征和手术治疗方法。结果：后路全椎板切除减压5例,侧后方或侧前方入路摘除致压物14例,后路全椎板切除、侧后方入路摘除致压物11例。术后随访1－8年,手术优良率达83．4％。结论：胸椎侧后方或侧前方入路摘除椎间盘及后路全椎板切除侧后方入路摘除椎间盘是手术治疗胸椎间盘突出症的有效术式。     

胸椎间盘突出症的诊断和手术治疗

目的：回顾性研究３０例胸椎间盘突出症的临床表现、诊断及手术治疗效果。方法：分别对胸椎间盘突出症的临床表现、影像学特征和手术治疗方法进行描述。结果：后路全椎板切除减压５例,侧后方或侧前方入路摘除致压物１４例,后路全椎板切除侧后方入路摘除致压物１１例,术后随访１～８年,手术优良率达８３．４％,结论：胸椎侧后方或侧前方入路摘除椎间盘及后路全椎板切除侧后方入路摘除椎间盘是手术治疗胸椎间盘突出症的有效术式。     

胸椎间盘突出症的诊断和手术治疗(附15例报告)

目的：探讨胸椎间盘突出症的临床表现、诊断及手术效果。方法：回顾15例胸椎间盘突出症的临床特点及影像学改变、手术治疗方法。全椎板切除减压椎间盘摘除3例，侧前方或侧后方入路摘除椎间盘8例，全椎板切除侧后方入路摘除椎间盘4例，随访1－10年，手术优良率达80％。结论：理学、CT或MRI检查对确诊与定位有重要价值。根据椎间盘突出的大小、位置等情况可选择其入路。侧前方或侧后方入路及全椎板切除侧后方入路摘除椎间盘是治疗胸椎间盘突出症的有效、较安全术式。     

手术治疗胸腰段椎间盘突出症5例报告

胸腰段椎间盘突出症是临床较少见的一种病症,作者在多年的临床实践中确诊5例病人,均行侧前方入路椎间盘切除、肋骨植骨、V en trofix内固定,效果较好,汇报如下。1临床资料1.1一般资料我科自1997~2002年间手术治疗胸腰段椎间盘突出症5例,其中男4例,女1例;年龄在35~59岁,平均47岁     

胸腰段椎间盘突出症

目的：探讨胸腰段椎间盘突出症的发病机制、临床特点及治疗方法。方法：报告35例胸腰段椎间盘突出症。T11～12 26例，T12～L1 12例，L1～2 17例。均行侧前方椎间盘切除、植骨及内固定术。结果：术后随访10～41个月，疗效优良19例，良8例，可5例，差3例。结论：胸腰段椎间盘突出症发病率低，症状不典型，临床表现复杂，容易漏诊、误诊。侧前方椎间盘切除、植骨及内固定术对脊柱的损伤及其稳定性的影响较小，操作安全，疗效可靠。     

胸腰段椎间盘突出症的诊断与治疗

目的探讨胸腰段椎间盘突出症的临床诊断和治疗方法。方法4例病人分别为T11-12、T12-L1、L1-2、L2-3椎间盘突出症，均行手术治疗，下胸段2例采用半椎板和部分肋骨头及椎弓根切除，行椎管减压及胸椎问盘切除，极高位腰椎间盘突出症患者采用椎板大部分切除，椎管减压髓核切除术。结果4例瘫痪症状明显好转，随访6月～9年，2例下胸段手术患者，恢复正常工作，但踝震挛仍轻度存在，上腰段2例患者，1例全部恢复，1例瘫痪症状在恢复中。结论瘫痪为胸腰段椎间盘突出症的首发临床症状，而腰痛及自下而上的进行性双下肢无力是其突出物渐进性压迫脊髓的表现，胸腰段MRI检查可以确诊，有症状者早期手术，可免于瘫痪。     

胸椎间盘突出症的外科治疗

目的 探讨胸椎间盘突出症的临床特点、手术与术后近期疗效的关系。方法 17例胸椎间盘突出症患者均行后方入路侧前方减压术，其中3例合并颈、腰椎间盘突出症患者先后或同时予以手术。结果 全部病例术后症状无加重，14例得到随访，平均4年2个月(6个月～6年)，优良率78．4％(11／14)。结论 临床表现以胸髓损害为主，侧前方减压摘除椎间盘是手术治疗胸椎间盘突出症的安全、有效方法，同时应注意勿忽视多发椎间盘突出症(颈、腰)等合并病变的处理。     

经后外侧入路减压椎弓根钉内固定治疗胸腰段椎间盘突出症

目的探讨采用经后外侧入路减压椎弓根钉内固定术治疗胸腰段椎间盘突出症的疗效和注意事项。方法自2005年1月~2010年1月收治胸腰段椎间盘突出症13例,发病节段:T11、124例,T12L15例,L1、24例。椎间盘突出类型:中央型2例,旁中央型4例,侧后方突出7例。症状:胸腰背痛13例,下肢无力9例,大小便障碍7例,性功能障碍3例,足下垂4例。所有患者均常规行X线、CT、MRI全脊柱扫描,确定责任节段后经后外侧入路行减压内固定术。通过JOA评分、并发症发生情况评估疗效。结果术后13例获得随访32.6(13～52)个月。根据JOA评分:优9例,良3例,可1例,优良率92.3%。无内固定断裂或松动现象、无胸腰椎后凸加重现象。结论经后外侧入路可以安全有效对胸腰椎间盘突出进行减压,内固定使减压后病变节段融合及维持生理曲度,是治疗胸腰段椎间盘突出症的有效手段。     

胸腰段椎间盘突出症（附6例临床报道）

目的：提出胸腰段椎间盘出突症概念,并探讨其诊治要点。方法：对近年来收治的6例胸腰段椎间盘突出症的临床资料进行分析。结果：6例中4例有外伤史,其临床表现多样,确诊靠MRI检查,侧后方或侧前方手术后效果良好。结论：早期诊断,及早手术是获得满意的手术效果的关键。     

“菱形”截骨切除脊髓前方致压物治疗硬化性胸及胸腰段椎间盘突出症

目的:探讨经后路"菱形"截骨切除脊髓前方致压物治疗硬化性胸及胸腰段椎间盘突出症的临床疗效。方法:2009年8月~2014年7月,共收治26例硬化性胸及胸腰段椎间盘突出症患者,男19例,女7例;年龄平均43.8±23.3岁(18~70岁)。19例为胸椎间盘突出,包括胸椎间盘突出并钙化14例,胸椎后缘骨赘5例;7例为胸腰段椎间盘突出并钙化。术前神经功能Frankel分级:B级3例,C级14例,D级9例。手术均采用经后路"菱形"截骨切除脊髓前方致压物。手术疗效评价参照改良Macnab疗效评定标准及Frankel分级,随访观察治疗效果。结果:手术均顺利完成,术后X线片显示内固定位置良好,CT显示突出物切除彻底。1例患者(T10/11)术后出现症状加重(Frankel分级由D级变为C级),经甲强龙、脱水剂、营养神经药物治疗后恢复至术前水平。随访5~36个月,平均19.8个月。24例患者术后神经功能获不同程度恢复(2例Frankel D级患者无变化)。根据改良Macnab疗效评定标准,本组优15例,良8例,可2例,差1例,优良率88.46%(23/26),总有效率96.15%(25/26)。所有患者均获得骨性融合,无内固定松动断裂等并发症发生。结论:经后路"菱形"截骨切除脊髓前方致压物治疗硬化性胸及胸腰段椎间盘突出症可获得满意疗效。     

Lessons learned at sea--ocean sailing as a metaphor for surgical training

Surgical education is in the process of tumultuous change. Mastering this change will require a new set of competencies and a new understanding of the medical education process. While accreditation agencies are rapidly working to define the new criteria and benchmarks, training programs are quickly pulling together curricula, objectives, and evaluation tools. Yet much has already been learned in other complex, high-risk activities. Blue water sailing, ocean racing, and trans-Atlantic crossing are all activities that require a renewed form of leadership and an understanding of how knowledge, skill, and behavior come together to define the competent sailor. Ideas learned in such endeavors may assist the surgical educator in defining the horizons and the hazards of this uncharted voyage.     

Fundamentals of laparoscopic surgery: a surgical skills assessment tool in gynecology

Objective:

To describe our experience with the Fundamentals of Laparoscopic Surgery (FLS) program as a teaching and assessment tool for basic laparoscopic competency among gynecology residents.

Methods:

A prospective observational study was conducted at a single academic institution. Before the FLS program was introduced, baseline FLS testing was offered to residents and gynecology division directors. Test scores were analyzed by training level and self-reported surgical experience. After implementing a minimally invasive gynecologic surgical curriculum, third-year residents were retested.

Results:

The pass rates for baseline FLS skills testing were 0% for first-year residents, 50% for second-year residents, and 75% for third- and fourth-year residents. The pass rates for baseline cognitive testing were 60% for first- and second-year residents, 67% for third-year residents, and 40% for fourth-year residents. When comparing junior and senior residents, there was a significant difference in pass rates for the skills test (P=.007) but not the cognitive test (P=.068). Self-reported surgical experience strongly correlated with skills scores (r-value=0.97, P=.0048), but not cognitive scores (r-value=0.20, P=.6265). After implementing a curriculum, 100% of the third-year residents passed the skills test, and 92% passed the cognitive examination.

Conclusions:

The FLS skills test may be a valuable assessment tool for gynecology residents. The cognitive test may need further adaptation for applicability to gynecologists.     

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patient's recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English‐only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at‐risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.     

Midwest Surgical Association research in the next 50 years: Newton, Bacon, or Jefferson approach?

In addition to serving as your president this past year, I have the significant honor and challenge of addressing you at the 50th Anniversary of the Midwest Surgical Association. Milestones like this allow us the opportunity to reflect on past joys and ponder future opportunities. The three powers possessed by a guild/profession are: control over association; control over the workplace; and control over the market. We have experienced loss of power in each area, beginning with the passage of the Medicare-Medicaid Act in 1965. There are opportunities for a response, and efforts should be made to save our profession. To thrive in the future and regain our status in the debate over how health care will be delivered will require a more expansive view of research and the skills required. As I hope I have demonstrated, to regain our position as the true advocates for our patients we will need to develop the requisite skills and knowledge to convey our medical care successes. This must be done within a context that will be acceptable to our patients, our hospitals, our payers, and our government watch dogs. The buzz word for the foreseeable future will be quality.     

COVID-19 and surgery: A thematic analysis of unintended consequences on performance,practice and surgical training

PurposeThe shift in the national focus and allocation of resources to the management of COVID19 has led to significant changes to surgical practice including the delay of elective surgery. The aim of this study was to explore the implications of such changes on surgeons.MethodUsing a qualitative study design, semi-structured interviews were conducted with general surgery consultants and non-consultant hospital doctors from a major tertiary hospital in the Dublin region between March–May 2020. Data collection proceeded iteratively using a thematic analysis approach with quality controls such as memoing and collaborative analysis.ResultsFourteen surgeons (8 male, 6 female) were interviewed. The majority (n = 11, 78.6%) were NCHDs. Significant themes determined included ‘impacts’ on a variety of constructs such as performance, self-reported fatigue and wellbeing. Training themes elucidated included the effects of the cancellation of elective admissions on reduced operative exposure for trainees. Senior surgical staff were particularly focused on increased complexity in patient management. New policy requirements such as personal protective equipment use and novel rotas have had implications for aspects of work engagement. The pandemic and subsequent national restrictions imposed has afforded opportunities for improved well-being but also resulted in greater solitude in surgeons.ConclusionsRhetoric surrounding fatigue management and virus control dominates the conversation on the relationship between COVID-19 and surgery. Tipping the balance back to parity of fatigue management with service delivery in surgery will be key for sustainability of the surgical workforce.     

Transfer of microsurgical flaps without an anoxic period at the time of vascular anastomoses

Summary Technical advances in microsurgery have made frequent use of free flaps possible. One of the concerns of the microsurgeons has been the role of ischemia in flap failure. In five patients, the rectus abdominis myocutaneous flap and the radial forearm flap each having with two dominant pedicles were used employing microsurgical vascular anastomoses before section of the second pedicle. This procedure eliminates the ischemic period of the flap and consequent accumulation of free radicals and development of microthrombi, ensuring vascular perfusion during the entire operation.     

The opportunity cost of arthroplasty training in orthopaedic surgery

IntroductionTraining the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees.Materials and methodsA prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis.Results394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group.DiscussionAt our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.     

腓肠神经营养血管皮瓣修复跟部小腿下段软组织缺损

自1999年,应用带腓肠神经营养血管蒂逆行岛状皮瓣修复足跟小腿下段软组织缺损6例,取得良好效果,介绍如下.……     

Determinants of surgical decision making: a national survey

Background

We conducted a national survey of general surgeons to address the association between surgeon characteristics and the tendency to recommend surgery.

Methods

We used a web-based survey with 25 hypothetical clinical scenarios with clinical equipoise regarding the decision to operate. The respondent-level tendency to operate (TTO) score was calculated as the average score over the 25 scenarios. Surgical volume was based on self-report. Linear regression models were used to evaluate the associations between TTO, other covariates of interest, and surgical volume.

Results

There were 907 respondents. The mean surgical TTO was 3.05 ± .43. Surgeons had significantly lower TTO scores when responding to questions within their area of practice (P < .0001). There was no association between TTO and malpractice concerns, financial incentives, or compensation structure.

Conclusions

Surgeons recommend intervention far less frequently within their area of specialization. Malpractice concerns, volume, and financial compensation do not significantly affect surgical decision making.     

Needs Assessment for Electrosurgery Training of Residents and Faculty in Obstetrics and Gynecology

Background and Objectives:

Effective application of electrosurgical techniques requires knowledge of energy sources and electric circuits to produce desired tissue effects. A lack of electrosurgery knowledge may negatively affect patient outcomes and safety. Our objective was to survey obstetrics-gynecology trainees and faculty to assess their basic knowledge of electrosurgery concepts as a needs assessment for formal electrosurgery training.

Methods:

We performed an observational study with a sample of convenience at 2 academic hospitals (Beth Israel Deaconess Medical Center and Mount Auburn Hospital). Grand rounds dedicated to electrosurgery teaching were conducted at each department of obstetrics and gynecology, where a short electrosurgery multiple-choice examination was administered to attendees.

Results:

The face validity of the test content was obtained from a gynecologic electrosurgery specialist. Forty-four individuals completed the examination. Test scores were analyzed by level of training to investigate whether scores positively correlated with more advanced career stages. The median test score was 45.5% among all participants (interquartile range, 36.4%–54.5%). Senior residents scored the highest (median score, 54.5%), followed by attendings (median score, 45.5%), junior residents and fellows (median score in both groups, 36.4%), and medical students (median score, 27.3%).

Conclusion:

Although surgeons have used electrosurgery for nearly a century, it remains poorly understood by most obstetrician-gynecologists. Senior residents, attendings, junior residents, and medical students all show a general deficiency in electrosurgery comprehension. This study suggests that there is a need for formal electrosurgery training. A standardized electrosurgery curriculum with a workshop component demonstrating clinically useful concepts essential for safe surgical practice is advised.