直视微创胆道手术367例临床研究

目的　探索直视微创胆道手术方法和技巧 ,以减小胆道手术创伤和加速术后康复。方法　应用普通手术器械和深部手术拉钩 ,完成微创直视胆道手术。结果　完成单纯胆囊切除术 3 2 0例 ,胆囊切除同时胆总管切开探查取石T型管引流术 3 9例 ,胆总管再次手术 8例。微创切口 :2 5cm 9例 ,3cm 3 3 5例 ,4cm 11例 ,扩大为小切口 4cm以上 12例。 3 67例患者无死亡 ,无感染 ,无胆道损伤和术后出血 ,治愈率 10 0 %。结论　此术式适应症广 ,手术时间短 ,出血少 ,恢复快 ,合并症发生率低 ,痛苦微小 ,成本低 ,安全可靠     

胃减容术3种机械通气对患者氧合情况的比较

目的：探讨病态肥胖患者行腹腔镜胃减容术时，3种机械通气参数对患者氧合情况的影响。方法：选择行腹腔镜胃减容术的病态肥胖24例，按手术时间顺序分为3组，每组8例。A组：潮气量12ml／kg，呼吸频率10次／min；B组：潮气量20ml／kg，呼吸频率10次／min；C组：潮气量12ml／kg，呼吸频率20次／min。分别于气腹前（T1）、气腹后（T2）抽取动脉血测量pH、PO2、PCO2、Plat（平台压）、Peak（峰压）、AaDO2（肺泡-动脉氧分压差）。结果：气腹后B组Plat（33．2±1．8）cmH2O、Peak（36．3±1．6）cmH2O显著高于A组Plat（29．5±3．9）cmH2O（q=3．053，P〈0．05）、Peak（33．0±2．9）cmH2O（q：2．823，P〈0．05）和C组Plat（28．0±4，1）cmH2O（q：4．290，P〈0．05）、Peak（31．8±2．8）cmH2O（q：4．704，P〈0．05）。其他观察指标无统计学差异。结论：病态肥胖患者在腹腔镜下施行胃减容术时，加大潮气量20ml／kg或加快呼吸频率20次／min不能改善患者的氧合情况。     

非单极电刀器械在腹腔镜胆囊切除术中的应用

目的:探讨非单极电刀器械在安装心脏起搏器、心脏支架或体内有其他金属物体的胆囊疾病患者行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中的应用。方法:总结2000年以来收治的安装心脏起搏器、心脏支架或体内有其他金属物体胆囊疾病患者48例,用超声刀、百克剪、LigaSure、双极电刀行LC,同时随机选取单极电刀下无心脏起搏器、心脏支架或体内其他金属物体LC 15例为对照组。病例分为超声刀组、百克剪组、LigaSure组、双极电刀组、单极电刀组。对4组的手术时间、出血量等进行统计学分析,比较非单极电刀器械在安装心脏起搏器、心脏支架或体内有其他金属物体胆囊疾病患者行LC中的应用优势。结果:超声刀组、百克剪组、LigaSure组、双极电刀组无一例患者术中出现心电监测异常或发生心脏严重并发症,手术时间、术中出血量等明显少于高频电刀组。结论:非单极电刀在安装心脏起搏器、心脏支架或体内有其他金属物体的胆囊疾病患者行LC是安全可行的,且超声刀、百克剪、LigaSure在手术时间、术中出血量等明显优于高频电刀组。     

Laparoscopic Versus Open Renal Procurement for Pediatric Recipients of Living Donor Renal Transplantation

Despite reports demonstrating the safety of laparoscopic donor nephrectomy (LDN) for pediatric recipients of renal transplants, recent evidence has challenged using LDN for recipients 5 years of age or younger. We retrospectively reviewed the records of all pediatric recipients of living donor renal transplants from September 2000 through August 2004. We compared those who received allografts recovered by LDN (n = 34) with those recovered by open donor nephrectomy (ODN, n = 26). Outcomes of interest included operative complications, postoperative renal function, the incidence of delayed graft function or episodes of acute rejection and long-term graft function. Donor and recipient demographic data were similar for the LDN and ODN groups. Serum creatinine and calculated creatinine clearance were not significantly different between groups both in the early postoperative period and at long-term follow-up (p > 0.142). Rates of delayed graft function and acute rejection did not differ between groups. Among recipients aged 5 years old or younger stratified by donor technique (9 LDN, 5 ODN recipients), no difference was noted in graft outcomes both early and long-term (p > 0.079). At our center, pediatric LDN recipients have graft outcomes comparable to those of ODN recipients. At experienced centers, we recommend continued use of LDN for pediatric recipients of all ages.     

腹腔镜辅助下大隐静脉隔绝术治疗大隐静脉曲张60例

目的探讨腹腔镜辅助下大隐静脉隔绝术的疗效。方法2000年1月～2004年1月对60例66条大隐静脉曲张腹腔镜辅助下行大隐静脉隔绝术,腹腔镜辅助下高位结扎、电灼大腿段大隐静脉,阻断其小腿段所有属支及交通支,使大隐静脉与体循环隔绝。结果手术时间30～60min,(50±9)min;术后住院时间3～5d,(3.5±0.6)d。60例随访1～36个月,平均28个月,无复发。结论腹腔镜辅助下大隐静脉隔绝术创伤小,疗效好,复发率低,是治疗大隐静脉曲张的理想术式。     

腹腔镜胆囊切除术前超声内镜检查胆总管必要性的探讨

目的 探讨腹腔镜胆囊切除（laparoscopic cholecystectomy,LC）术前超声内镜（endoscopic ultrasonography,EUS）检查胆总管的临床价值。方法 对25例术前经腹超声检查诊断胆囊结石,胆总管内径〉0.7 cm可疑胆总管梗阻的患者进行EUS检查,并与手术结果或内镜十二指肠乳头切开术（endoscopic sphincterotomy,EST）取石结果进行比较。结果 EUS对于胆总管病变诊断的敏感性、准确性和阴性预测值[100%（17/17）、92%（23/25）、100%（6/6）]均优于经腹超声[35%（6/17）、56%（14/25）、42%（8/19）]（P=0.000,0.008,0.020）。结论EUS对胆总管病变诊断优于经腹超声检查,可作为术前常规检查,特别是当胆总管内径〉1.0 cm时,EUS应作为术前必检项目。     

An inexpensive ex-vivo porcine laparoscopic Nissen fundoplication training model.

BACKGROUND: We recently implemented the use of an ex-vivo porcine model to teach residents the fundamentals of performing a laparoscopic Nissen fundoplication. METHODS: Residents were trained using intact porcine esophagus, stomach, and spleen placed in a standard video-trainer. They were later asked to complete a survey containing a course evaluation. RESULTS: Sixteen residents (R1-R4) completed the survey. They agreed that (1) the exercise was a valuable use of their limited time, (2) repeating the exercise will be of additional benefit, (3) it will improve their ability to perform or assist in an actual case in the OR, and (4) the surgical principles learned using the model will transfer to other laparoscopic cases. Significant subjective improvements were reported in resident comfort level in assisting in or performing a laparoscopic Nissen fundoplication. CONCLUSIONS: The use of an inexpensive ex-vivo porcine training model increases resident comfort level in performing a Nissen fundoplication in the operating room.     

腹腔镜胆囊切除联合手术117例临床报告

目的探讨腹腔镜联合手术的可行性及安全性。方法回顾分析1992年3月至2006年12月间117例腹腔镜联合手术的临床资料;男性39例,女性78例,年龄为25~74岁,其中行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC) 腹腔镜阑尾切除术(laparascopic appendectomy,LA)46例;LC 肝囊肿去顶减压术15例;LC 肾囊肿去顶减压术6例;LC 肝、肾囊肿去顶减压术3例;LC 腹腔镜脾切除、门奇静脉联合断流术7例;LC 腹腔镜胃肠间质瘤切除术6例;LC 腹股沟疝修补术3例;LC 结直肠癌根治术8例;LC 粘连松解术6例;LC 子宫肌瘤剔除术6例;LC 卵巢囊肿剥除术10例;LC 肾脏错构瘤切除术1例。结果手术均顺利完成,中转开腹1例,胆漏1例,无感染、出血和胆道损伤等并发症;术后住院日平均为5.7 d。结论只要严格掌握各自疾病的手术治疗原则及联合手术的适应证,对两种或两种以上腹部病变的腹腔镜联合处理是安全有效的,具有创伤小、痛苦少、恢复快、灵活方便和多病联治的优点。     

腹腔镜胆囊切除术后残株胆囊及胆囊管结石

目的探讨腹腔镜胆囊切除术后残株胆囊／胆囊管结石的原因、诊断、处理及预防方法。方法回顾总结我院 1992-2005年间收治的8例腹腔镜胆囊切除术后残株胆囊／胆囊管结石病例的临床资料。结果 8例病人术前经B超、MRI、 ERCP检查确诊后,均经再次手术治愈。残株胆囊结石2例;残株胆囊管结石6例,其中2例合并胆总管结石;2例行残余胆囊切除术,6例行残株胆囊管切除、其中4例附加胆总管切开探查和／或取石、T型管引流。随访1．1-13年,效果良好。结论判断失误是腹腔镜胆囊切除术后残株胆囊结石的主要原因,过长的炎性及畸形的胆囊管残留是腹腔镜胆囊切除术后残株胆囊管结石的主要原因;其症状和体征类似于结石性胆囊炎、合并胆管结石时可有黄疸;B超、CT、ERCP等检查可确诊;再次手术切除(或取出)残株胆囊／胆囊管(结石)是有效可靠的治疗方法;娴熟的腹腔镜技术、术中胆道造影、正确掌握中转开腹指征以及丰富的胆道外科经验是预防其发生的关键。