胸腔镜手术与开胸手术治疗先天性支气管囊肿的对比分析

目的总结传统开胸手术与胸腔镜手术治疗先天性支气管囊肿的经验,分析两种手术的可行性及优劣。方法回顾性分析本院自2013年1月至2叭5年11月收治的先天性支气管囊肿患儿临床资料。患儿均经产前超声检查获得初步诊断,经产前评估及出生后增强CT检查明确诊断,最后经手术确诊。手术方式分为传统开胸手术及胸腔镜手术,比较两组手术时间、术中出血量、住院时间及胸腔引流管留置情况,探讨小儿胸腔镜手术治疗支气管囊肿的可行性及风险。结果共13例确诊,12例手术,1例家属决定暂不手术。手术病例中,女性6例,男性6例,男:女=1:1。左右侧比为1:1,其中6例手术诊断为支气管囊肿,3例合并肺囊腺瘤,3例合并肺隔离症。5例术前准确诊断为支气管囊肿,7例诊断为肺囊腺瘤或肺隔离症。手术年龄最小5 d,最大1岁,平均手术年龄4.8个月。5例采取传统开胸手术;7例采取胸腔镜手术,其中1例2月龄患儿因术中须行肺叶切除而增加辅助切口。所有手术病例均治愈。结论先天性支气管囊肿属于少见疾病,由于存在感染以及占位的风险,建议早期手术。胸腔镜下操作,对于婴幼儿病例,不会增加手术风险,是一种可行的手术方式。     

机器人辅助胸腔镜技术治疗小儿先天性肺部疾病的单中心研究

目的探索应用机器人辅助胸腔镜下进行小儿先天性肺部疾病手术的安全性、有效性及在微创手术中的优势。方法 2020年5月至2021年3月,浙江大学医学院附属儿童医院应用机器人辅助胸腔镜对85例临床拟诊为先天性肺部疾病的患者行手术治疗,其中男54例,女31例,年龄6个月15天至12岁10个月,平均(17.56±7.35)个月。所有病例手术通过1个8 mm观察孔、2个8 mm操作孔和1个5 mm辅助切口完成,手术过程中不撑开肋骨。对患者围手术期资料进行分析,总结经验。结果 85例患者手术均获得成功,包括解剖性肺叶切除术、肺段切除术、锲形切除术、囊肿剥离术和叶外隔离肺切除术,其中中转开胸手术1例。无一例发生围术期并发症或死亡。胸腔引流管留置时间0～5 d,平均(1.38±0.87)d;住院时间4～10 d,平均(6.23±1.25)d;手术时间42～270 min,平均(74.76±30.21)min;术中出血量1～30 mL,平均(4.05±2.21)mL;住院总费用61 897～95 033元,平均(70 426.65±6 086.78)元。所有患者围术期未行输血治疗。结论机器人辅助胸腔镜行肺叶切除术安全有效,由于该技术具有更逼真的视野、更灵活稳定的操作而具备更宽泛的手术适应证,是胸部微创手术的新选择。     

先天性肺囊性病变28例的诊断与治疗

目的 探讨儿童先天性肺囊性病变的诊断、手术时机和方式.方法 对儿童先天性肺囊性病变28例的临床资料进行回顾性分析.男19例,女9例;年龄1～12岁,平均5.4岁,其中1～5岁11例.先天性肺囊肿21例,其中支气管源性囊肿13例;肺源性囊肿6例;混合型2例.肺隔离症7例.术前诊断主要依靠胸部X线片和CT,术前确诊21例,其中先天性肺囊肿17例,肺隔离症4例.术前误诊7例,误诊率25%,其中误诊为肺脓肿、纵隔占位各2例,气胸、肺大疱、支气管扩张症各1例.行肺囊肿摘除术 3例,肺段切除术2例,肺叶切除17例,其中2例为急诊手术,隔离肺切除4例,双肺叶、肺叶加肺段切除术各1例.结果 本组无死亡病例,术后恢复良好,均痊愈出院,随访1～5 a,患儿生长发育及活动正常.结论 儿童先天性肺囊性病变误诊率高,诊断主要依靠影像学检查,确诊后应尽早手术,手术疗效满意,预后良好.     

腹腔镜治疗小儿肝囊肿的临床研究

目的 分析小儿肝囊肿腹腔镜治疗的可行性及效果.方法 回顾性分析自2010年12月至2013年12月收治肝囊肿7例患儿的临床资料.其中,男3例,女4例;年龄12 d～3岁7个月;全部为单发囊肿.全部患儿行腹腔镜手术(经脐部单切口腹腔镜5例),及术中胆道造影.1例患儿行腹腔囊肿切除术,4例患儿行腹腔镜囊肿开窗术,2例患儿行腹腔镜囊肿胆囊吻合术.结果 无术中中转开腹.手术时间90～150 min,平均(102.9±23.6)min.出血量2～5 ml.无死亡病例,无创面出血,腹腔感染,腹腔积液等并发症.患儿术后3～7 d出院.术后每3个月门诊复查超声及生化指标,全部患儿肝功能及胆红素正常.囊肿切除及开窗术患儿无囊肿复发,胆囊吻合术患儿囊肿明显减小,无不适症状;无胆道感染、腹腔感染积液等并发症.结论 小儿肝囊肿应用腹腔镜及经脐部单切口腹腔镜治疗是安全有效的,如果囊肿与肝内胆管相通可考虑行囊肿胆囊吻合术.     

175例小儿连续胸腔镜肺切除术回顾性研究

目的 探讨胸腔镜肺切除术在治疗婴幼儿和儿童肺部病变的安全性和有效性.方法 回顾性研究2014年9月至2016年6月间一组在北京儿童医院收治的需要肺切除的患儿,总结分析175例病例的临床资料、手术方法、手术效果及术后病理.结果 175例病例均顺利完成手术,无严重并发症及二次开胸的病例.175例中,男100例,女75例.年龄2个月至13岁10个月,平均(18.5±41.6)个月;手术时间15～120min,平均(75.0±37.9) min;出血量1～300ml,平均(5.0±26.9)ml.中转开胸7例,中转开腹1例,中转率4.6％.术后病理:先天性肺气道畸形即肺囊性腺瘤样畸形(CPAM) 105例、隔离肺47例、肺部肿瘤9例、肺气肿6例、肺囊肿4例、肺血管淋巴管畸形1例,肺动静脉瘘1例、肺寄生虫性肉芽肿1例.结论 婴幼儿和儿童的肺部病变可以经过胸腔镜治疗,且胸腔镜肺切除术是安全和有效的.腔镜的微创手术可以降低手术创伤,减轻术后疼痛,缩短住院时间,同时减小手术切口,伤口美观.     

不同手术方式治疗小儿肺隔离症的比较研究

目的比较胸腔镜手术与传统开胸手术治疗小儿肺隔离症的临床疗效,探讨胸腔镜手术治疗小儿肺隔离症的优势。方法收集2012年3月至2017年3月入住本院小儿外科并实施手术治疗的26例肺隔离症患儿临床资料,根据采用手术方式的不同分为胸腔镜手术组和传统开胸手术组。比较两组手术时间、术中出血量、术后胸腔引流时间及住院时间。结果 26例均顺利完成手术,无手术死亡病例。平均手术时间:胸腔镜手术组(118.36±7.61)min,传统开胸手术组(119.60±7.11)min,差异无统计学意义(t=-0.425,P=0.674)。平均术中出血量:胸腔镜手术组(2.18±0.40)mL,开胸手术组(4.47±0.64)m L,差异有统计学意义(t=-11.125,P=0.000)。胸腔引流管平均留置时间:胸腔镜手术组(3.54±0.69)d,开胸手术组(6.67±0.98)d,差异有统计学意义(t=-9.064,P=0.000)。术后平均住院时间:胸腔镜手术组(7.54±0.82)d,开胸手术组(8.80±0.77)d,差异有统计学意义(t=-3.981,P=0.001)。术后并发症:胸腔镜手术组3例,其中肺部感染2例,肺不张1例;开胸手术组6例,其中肺部感染4例,肺不张2例,差异无统计学意义(P0.05)。除4例失访以外,其余22例随访1～2年,其中2例发生肺炎,其余病例均恢复良好。结论胸腔镜手术治疗肺隔离症较传统开胸手术具有切口小、术中出血少、恢复快、术后住院时间短等优点,是一种安全可靠的手术方式。     

经腹腔镜治疗新生儿先天性胆总管囊肿

目的 对经腹腔镜行囊肿彻底切除,肝管空肠Roux-en-Y吻合术治疗新生儿胆总管囊肿的可行性、安全性进行探讨.方法 自2003年4月至2007年4月本院收治罹患先天性胆总管囊肿新生儿9例,其中男2例,女7例;年龄13～28d(平均24d).9例转氨酶都升高,均为囊肿型,囊肿直径2.5～8cm(平均3.8cm),其中8例患儿合并黄疸,4例出现陶土样便.采用经腹腔镜行囊肿彻底切除,肝管空肠Roux-en-Y吻合术,监测术前和术后黄疸指标变化.结果 9例患儿均成功手术,手术时间为3.3～4.0h(平均3.6h),出血量约5～10ml;无中转开腹,无术中并发症发生.术后14～28h(平均18h)排气,1～3d(平均1.5d)排便,留置胃管14～30h(平均19h),术后进食时间16～30h(平均20h),腹腔引流放置时间57h(46～72h),术后3～9d(平均5d)黄疸消退,术后7d转氨酶及直接胆红素不同程度下降.术后住院时间4～9d(平均6.3d).随访3～45个月,肝功能正常,无胆管炎、吻合口狭窄、肠粘连梗阻等并发症.结论 由有丰富腹腔镜胆总管囊肿切除经验的医师实施手术,经腹腔镜行囊肿彻底切除,肝管空肠吻合术治疗新生儿先天性胆总管囊肿是一种安全、可靠的方法.     

电视胸腔镜与传统开胸手术在小儿肺叶切除中的比较

目的对比观察电视胸腔镜手术(video-assisted thoracospic surgery,VATS)与传统开胸手术在小儿肺叶切除术中的临床效果。方法 2012年6月至2015年12月本院共收治61例需行肺叶切除的患儿,依照患儿病变情况及家属意愿分别采取了电视胸腔镜手术(VATS组)和开胸手术(开胸组)。VATS组22例中,14例在电视胸腔镜辅助下行小切口肺叶切除术,8例在全胸腔镜下行肺叶切除术;开胸组39例接受传统开胸肺叶切除术。比较两组手术切口、手术时间、术中出血量、输血比例、术后使用呼吸机时间、引流量多于2 mL·kg~(-1)·d~(-1)的天数、术后重症监护室滞留时间、术后并发症的发生率,以及围手术期白细胞、C反应蛋白、降钙素原等指标。结果两组均顺利完成手术,无死亡及严重并发症。两组年龄、体重、发病部位以及病理改变无显著性差异(P0.05);术后并发症的发生率元显著性差异(P0.05);与传统开胸组相比,VATS组切口长度(2.87±1.04 cm vs 8.25±2.32 cm,t=-2.741,P=0.003)、手术时间(85.67±23.95 minuts vs 110.48±32.71 minuts,￡=-3.112,P=0.002)、术中出血量(80.00±45.40 mL vs 143.04±67.04 mL,t=-4.112,P=0.002)、输血比例(P=0.043)、引流量大于2 mL·kg~(-1)·d~(-1)的天数(3.66±1.74 d vs 6.26±3.59 d,t=-4.305,P=0.000)、术后重症监护室滞留时间大于24 h、呼吸机辅助通气时间大于12 h的例数均降低(P0.05);术后第1 d胸腔镜组中白细胞(5.68±1.59×10~9/L vs 13.99±1.74×10~9/L,t=-4.325,P=0.002)、CRP(16.68±2.55 mg/L vs 25.63±4.67 mg/L,t=-6.613,P=0.000)以及PCT(1.40±0.61 ng/mL vs 6.61±3.17 ng/mL,t=-7.372,P=0.002),均低于传统开胸组(P0.05)。结论与传统开胸组相比,VATS下行小儿肺叶切除术出血少,术后呼吸机使用时间、.ICU滞留时间短,应激性炎症反应弱,但对于降低并发症的发生率并元显著差异。     

Arndt支气管内阻塞管在小儿肺囊肿切除术中的应用

小儿肺囊肿是一种常见的支气管、肺发育异常。近年来，随着小儿胸腔镜和开胸手术的增多，对实行单肺通气的麻醉技术提出了更高的要求。Arndt支气管内阻塞管是近年用于单肺通气的新技术，在国内使用报告较少。我科自2006年12月～2007年3月采用支气管内阻塞管行单肺通气和肺叶隔离技术完成3例肺囊肿切除术，均获得满意效果。     

全胸腔镜手术与传统开胸手术治疗儿童肺隔离症的对比研究

目的比较电视胸腔镜手术与传统开胸手术治疗儿童先天性肺隔离症的安全性与有效性,探讨全胸腔镜手术治疗儿童先天性肺隔离症的临床价值。方法选择2010年5月至2018年1月于南京医科大学附属儿童医院心胸外科接受手术治疗的66例先天性肺隔离症患儿作为研究对象,其中27例采取全胸腔镜手术,为全胸腔镜手术组; 39例采取传统开胸手术,为开胸手术组。对比两组手术时间、术中出血量、术后引流量与引流管留置时间以及术后住院时间的差异。结果全胸腔镜手术组中有1例中转开胸手术,无一例手术中死亡,手术后均恢复顺利,无严重并发症发生。全胸腔镜手术组和开胸手术组中位随访时间分别为0. 7年、4. 1年。全胸腔镜手术组手术时间(80±5. 6) min,术中出血(20±9. 2) m L,术后住院时间(5. 1±2. 1) d、术后引流量(50±9. 6) m L,术后引流管留置时间(4±1. 3) d,均明显优于传统手术组(P 0. 05)。结论与开放手术相比,全胸腔镜下手术治疗儿童先天性肺隔离症具有手术时间短、出血少、恢复快、切口美观等优点,对患儿心肺功能影响小,临床效果基本满意。     

Congenital cystic disease of the lung in infants and children (experience with 57 cases).

A retrospective analysis of 57 consecutive cases with congenital cystic disease of the lung admitted to King Faisal Specialist Hospital and Research Center and King Khalid University Hospital, Riyadh, between 1985-1995 is presented. There were 37 congenital lobar emphysema (CLE), 7 cystic adenomatoid malformation (CAM), 8 bronchogenic cyst (BC) and 5 pulmonary sequestrations (PS). There were 39 males and 18 females with ages ranging from 1 day to 5 years. All patients were symptomatic except three. Respiratory distress, repeated chest infections, and cystic changes noted in chest x-ray were the commonest presentation. Five of eight patients with BC presented with symptoms related to pressure effect of the cyst on the surrounding structures, these included bronchiectasis in two patients, bronchopleural fistula in one, pulmonary artery stenosis and bronchomalacia in one, airway obstruction mimicking bronchial asthma in one. Seven patients (12.2%) were treated conservatively, the remaining underwent surgery. Surgery included excision of the bronchogenic cyst and lobectomy for CLE, CAM, and intralobar sequestration. The post-operative course in most cases was uneventful. There were no deaths in this series, and the majority of patients had a satisfactory outcome with follow-up ranging from 1-72 months (mean 24 months). It appears that lobectomy for symptomatic CLE, CAM, and intralobar sequestration and excision for bronchogenic cyst offer the best treatment modality and is well tolerated by pediatric patients. Careful search for associated anomalies is important to obtain better outcome.     

伴有并发症的儿童胆总管囊肿的临床处理

目的 讨论合伴有各类并发症的儿童胆总管囊肿的临床处理及手术时机和方法.方法 回顾性分析2013年1月至2015年12月上海新华医院小儿外科收治的45例合伴有各类并发症的儿童胆总管囊肿患儿的临床资料.其中,胆道穿孔7例,胆源性胰腺炎9例,胆管炎、阻塞性黄疸、肝功能受损29例,保守治疗效果不佳.7例胆道穿孔中,5例胆汁性腹膜炎行囊肿外引流和二期根治术;2例隐匿性胆道穿孔一期行根治术.9例胆源性胰腺炎给予内镜下鼻胆管引流,待淀粉酶正常后一期行根治术.29例阻塞性黄疸伴肝功能受损的患儿中,17例发病年龄小于3个月行一期根治手术;12例发病年龄大于6个月患儿先行ERCP置鼻胆管引流,待黄疸消退、转氨酶正常后一期行根治性手术.结果 伴胆道穿孔的7例胆总管囊肿患儿中,2例在外引流期间出现水电解质紊乱,1例T管脱落,1例隐匿性穿孔在根治术后出血再次手术,余者术后均痊愈出院.9例胆源性胰腺炎患儿置鼻胆管引流后淀粉酶均恢复正常,根治术后均痊愈出院.并发急性胆管炎、伴有梗阻性黄疸、肝功能受损29例中,12例发病年龄大于6个月,其中11例行内镜下置鼻胆管引流后并发症改善行根治手术,1例ERCP失败后改行外引流和二期根治术;小于3月龄婴儿直接行一期根治性手术,术后均痊愈出院.所有患儿保持随访,术后随访时间1～3年.1例术后慢性胰腺炎史,1例胆管炎史,均通过药物治疗缓解症状.结论 对合伴有各类并发症的儿童胆总管囊肿选择合理的处理手段和合适的手术方式将有效减少并发症所造成的危害.     

传统方法与胸腔镜处理小儿脓胸的比较分析

目的：评价不同治疗方法对小儿脓胸的治疗价值。方法：将9年中43例小儿脓胸分为用传统方法(A组)和电视胸腔镜手术(B组)处理两组,对其术后各种参数进行回顾性分析。结果：两组并发症的发生率和死亡率差异无显著性(P> 0.05),但术后发热时间、抗生素应用时间、胸管留置时间和住院时间B组均短于A组［(2.8±1.7) d vs (5.7±2.1) d, (7.6±2.5) d vs (13.8±4.7) d, (3.8±1.6) d vs (5.8±2.4) d, (10.4±3.0) d vs (17.8±5.6) d］(P<0.01)。结论：电视胸腔镜处理小儿脓胸创伤小,疗效好,疗程短,但应尽早施行。     

Denis Browne切口在小儿普胸手术中的应用

目的 探讨Ｄｅｎｉｓ Ｂｒｏｗｎｅ切口即腋下直切口在小儿普胸手术中的临床应用价值。方法 ９年中应用腋下直口进行普胸手术１６９例,胸膜外途径６５例,胸膜内途径１０４例。其中动导管未闭１４５例,先天性食管闭锁７例,先天性肺囊肿５例,大气性肺气肿６例,隔离肺１例,纵卫肿瘤５例。结果 全组手术顺利,术野显露良好,无手术并发症。结论该切口隐蔽美观,组织损伤小,明显减轻术后胸痛及肩关节活动障碍。特别适合于婴幼     

Thoracotomies in children

Thoracotomies in children have been less extensively studied, as the incidence of diseases necessitating thoracotomies is low in the pediatric age group. This study reviews childhood thoracic diseases, thoracotomy approaches, indications, and complications. Surgical procedures and complications of a total of 196 children below 16 years of age who underwent thoracotomy for various reasons at the Department of Thoracic Surgery, Ataturk Chest Diseases and Chest Surgery Training and Research Hospital, between January 2000 and December 2004, were reviewed in this study. Out of the 196 patients, 77 were female (39%) and 119 (61%) were male. The most commonly encountered indications for surgery were hydatid cyst (35%), bronchiectasis (25%), chronic nonspecific pleuritis (13%), chest wall deformities (10%), and mediastinal cystic formations and masses (10%). The other indications included tuberculosis (3%), aspergilloma (0.5%), fibrohyalinized cyst (0.5%), resection of trachea (0.5%), bronchogenic cyst (0.5%), inflammatory pseudo-tumor (0.5%), sequestration (1%), lipoblastoma (0.5%), and eosinophilic granuloma (1%). Out of the 196 patients, 176 underwent lateral thoracotomy and 20 patients with a chest wall deformity underwent midsternal incision. Complications were seen in 35 patients (18%): atelectasia and secretory retention (54%), wound infection (17%), hemorrhage (3%), chylothorax (3%), intrathoracic space (3%), and postoperative extended air leakage (20%). The mean hospital stay was 15 days and we did not encounter any mortality. The physiology and anatomy of the respiratory system and especially the respiratory control mechanism in pediatric patients vary from those of the adults, resulting in a more morbid course after thoracic surgery in children. Despite severe postoperative pain, posterolateral thoracotomy is the preferred approach in adults because of an advanced intrathoracic exposure and easy manipulation. On the other hand, lower pain threshold and the different types of diseases seen in children make lateral thoracotomy a more appropriate choice for thoracotomy, which, at the same time, spares the serratus anterior muscle decreasing its negative impact on postoperative respiratory function.     

Comparison of Posterolateral Thoracotomy and Video-Assisted Thoracoscopic Clipping for the Treatment of Patent Ductus Arteriosus in Neonates and Infants

This study was designed to compare the long-term clinical outcomes and costs between video-assisted thoracic surgery (VATS) and posterolateral thoracotomy (PT) in neonates and infants. This study enrolled 302 patients with isolated patent ductus arteriosus (PDA) from January 2002 to 2007 and followed them up until April 2010. A total of 134 patients underwent total VATS (VATS group), and 168 underwent PDA closure through PT (PT group). The two groups were compared according to clinical outcomes and costs. The demographics and preoperative clinical characteristics of the patients were similar in the two groups. No cardiac deaths occurred, and the closure rate was 100% successful in both groups. The operating, recovery, and pleural fluid drainage times were significantly shorter in the VATS group than in the PT group. Statistically significant differences in length of incision, postoperative temperature, and acute procedure-related complications were observed between the two groups. The cost was $1,150.3 ± $221.2 for the VATS group and $2415.8 ± $345.2 for the PT group (P < 0.05). No cardiac deaths or newly occurring arrhythmias were detected in either group during the follow-up period. Statistically significant differences in the rate of residual shunt and scoliosis were observed between the two groups. The left ventricular end-diastolic diameter and the pulmonary artery diameter could be restored to normal in the VATS group but not in the PT group. The study confirmed that VATS offers a minimally traumatic, safe, and effective technique for PDA interruption in neonates and infants.     

Video-assisted thoracoscopic surgery in the paediatric population

Objective: Video-assisted thoracoscopic surgery (VATS) is now widely practised in adults but there are few publications on its application in the paediatric population.
Methodology: Retrospective review of the authors' experience with VATS in children under 16 years old during an 18 month period in a university teaching hospital.
Results: From September 1993 to March 1994, VATS was attempted in 14 patients. Five were unsuccessful because of pleural symphysis or inability to collapse the upper lung. Ten cases of VATS were successfully performed in the remaining nine patients (eight males, one female; age range from 22 days to 15 years old). These included two drainages and limited decortications for loculated pleural effusion, one guided drainage of pericardial effusion, one thymectomy for thymic hyperplasia, three wedge resections for metastatic pulmonary osteosarcoma and three bleb excisions and pleurodesis for primary spontaneous pneumothoraces. There were no intra-operative complications. There was one death from dysrhythmia following an uneventful wedge resection. The mean duration of chest tube drainage was 1.4 days and postoperative hospital stay 2.6 days excluding two patients who stayed for further medical treatment.
Conclusion: VATS is a useful approach in selected cases but further development of this approach awaits refinement of anaesthetic technique and endoscopic instrumentation.     

神经内镜在小儿颅内囊液性病变治疗中的应用

目的 探讨神经内镜技术在小儿颅内囊液性疾病中的治疗应用,以及结合开颅术及分流术协同完成小儿颅内复杂畸形手术治疗的效果.方法 2004年2月至2009年2月,105例患儿接受内镜手术,年龄3个月至12岁.包括阻塞性脑积水53例,其中51例成功完成内镜下三脑室底造口术.脑内囊肿52例中有28例颞叶囊肿行镜下囊壁部分剥离术和脑池开放术,5例透明隔囊肿和5例侧脑室囊肿分别行囊肿-脑室造口术、3例鞍上及三脑室囊肿行囊肿剥离+三脑室底造口,幕下囊肿6例:其中内镜剥离1例,5例巨大囊肿合并脑积水者采取内镜结合分流或开颅显微镜下剥离术.幕上中线部位囊肿5例,囊肿部分剥离+开窗4例,1例多房打通结合囊肿腹腔分流术.结果 51例脑积水中,47例术后临床症状改善.52例颅内囊肿,术后随访2个月至3年,总体缩小率占98%,颞叶囊肿缩小率100%,11例术后有硬膜下积液,7例随访好转,4例术后4个月至1年出现慢性硬膜下血肿,行外引流术后治愈,1例合并中枢感染者放弃治疗.结论 内镜手术在小儿颅内囊液性疾病的治疗中效果良好,可优先选择.