4K和3D腹腔镜结直肠癌根治术中主观感受调查研究

目的 探讨4K、3D腹腔镜在结直肠癌根治术中的主观感受优势。方法 选择2018年8月至2019年2月上海交通大学医学院附属瑞金医院胃肠外科参与腹腔镜结直肠癌根治术的医师（主刀医师、第一助手、扶镜手）进行问卷调查,所使用器械包括2D、3D以及4K腹腔镜。主观感受调查问卷内容包括：视力疲劳度、术中眩晕度、空间定向感、视野和视角操控协调度、手术视敏度、光亮度、平面分辨率、纵深感分辨率、颜色分辨率、术中操作感、最佳观赏距离、帧数及刷新频率、对比度。结果 共完成有效调查问卷124份,其中2D腹腔镜组38份,3D腹腔镜组43份,4K腹腔镜组43份。（1）所有手术医师主观感受评分：3组医师的空间定向感、视角操作协调度、视敏度、分辨率、纵深感、颜色分辨率、术中操作感、术者与屏幕距离、刷新频率的评分差异存在统计学意义（P＜0.05）。（2）主刀医师主观感受评分：3组在分辨率、纵深感、颜色分辨率、术中操作感的评分差异存在统计学意义（P＜0.05）,其中4K腹腔镜在分辨率、颜色分辨率最具优势,3D腹腔镜在纵深感、术中操作感最具优势。（3）第一助手主观感受评分：3组的视力疲劳度、视角操作协调度、分辨率、纵深感、术中操作感、刷新频率的评分差异存在统计学意义（P＜0.05）,其中4K腹腔镜的视角操作协调度、分辨率最具优势,而3D腹腔镜虽然视力疲劳度的评分最低,但在纵深感、术中操作感最具优势。（4）扶镜手主观感受评分：3组的视敏度、分辨率、纵深感、术中操作感、术者与屏幕距离、对比度的评分差异存在统计学意义（P＜0.05）,其中4K腹腔镜的视敏度、分辨率、对比度最具优势,3D腹腔镜的纵深感、术中操作感最具优势。结论 在结直肠癌根治术中,与传统腹腔镜相比,4K腹腔镜可提供更好的分辨率、视角操作协调度、视敏度、颜色分辨率,而3D腹腔镜系统可提供更好的纵深感及术中操作感。     

3D高清腹腔镜在减重代谢手术中的应用

目的探讨3D高清腹腔镜技术在减重代谢手术中的应用价值。方法纳入笔者所在医院科室2015年1月至2017年5月期间接受减重代谢手术患者64例,采用随机对照双盲研究方法分成3D腹腔镜组和2D腹腔镜组,手术方式包括腹腔镜下胃旁路术及腹腔镜下袖状胃切除术,分析比较不同手术方式下的总手术时间、缝合操作时间、消化道重建时间、术中出血量、术后住院时间及术后并发症指标。结果 3D腹腔镜组32例,其中袖状胃切除术19例,胃旁路术13例;2D腹腔镜组32例,其中袖状胃切除术21例,胃旁路术11例。64例减重代谢手术均在腹腔镜下完成,无中转开腹手术者,并且3D腹腔镜组中无中转更改为2D腹腔镜情况发生。(1)2D和3D腹腔镜下袖状胃切除术治疗结果比较:在3D腹腔镜下的缝合胃切缘时间明显短于2D腹腔镜(P0.05),术中出血量也少于2D腹腔镜(P0.05);2种方式下的总手术时间及术后住院时间比较差异无统计学意义(P0.05),均无胃漏等严重并发症发生。(2)2D和3D腹腔镜下胃旁路术治疗结果比较:在3D腹腔镜下的总手术时间、制作胃小囊时间、胃-空肠吻合和空肠-空肠吻合时间以及术中出血量均明显优于2D腹腔镜(P0.05);2种方式下的术后住院时间比较差异无统计学意义(P0.05)。结论从本研究中有限的数据初步得出,与2D腹腔镜比较,3D腹腔镜下清晰的三维立体视觉,使解剖层次更加清晰可辨,有助于减重代谢手术的精细操作,缩短手术时间,使医师和患者均能获益。     

3D腹腔镜与2D腹腔镜宫颈癌根治术的比较研究

目的比较3D腹腔镜与传统2D腹腔镜宫颈癌根治术的手术结果和临床评价,以期为临床决策提供医学证据。方法 2013年8月~2014年10月,我院采用3D高清腹腔镜(3D组,18例)或2D高清腹腔镜(2D组,20例)对早期宫颈癌(Ⅰ~ⅡA期)行广泛性子宫切除+盆腔淋巴结清扫术,回顾性对比2组手术时间、术中失血量、住院费用。术后术者和助手完成对3D腹腔镜设备临床评价的问卷调查。结果所有手术均在腹腔镜下顺利完成,无中转开腹。术中出血量3D组明显低于2D组[(73.9±47.5)ml vs.(134.5±69.8)ml,t=-3.094,P=0.004]。2组手术时间、盆腔淋巴结切除数、手术并发症、术后排气时间、术后腹腔引流量、术后住院时间、住院总费用差异无显著性(P0.05)。术者评价3D腹腔镜可提供三维立体手术视野和精确的空间立体定位,使解剖层次清晰,利于精细解剖分离和体内缝合。结论 3D高清腹腔镜拥有传统2D腹腔镜系统所不具有的深度知觉和空间定位感,给术者提供更优越的高清立体视野及更确切的手术操作环境,减少术中出血量,不增加手术时间、手术并发症及额外的手术费用,是安全、有效、舒适的。     

3D腹腔镜平行重叠吻合法联合NOSE在右半结肠癌切除术中的应用研究

目的:探讨3D腹腔镜平行重叠吻合法联合NOSE在右半结肠癌切除术中的临床应用效果。方法:回顾性分析2017年1月至2019年10月68例右半结肠癌腹腔镜手术患者临床资料,其中3D腹腔镜平行重叠吻合法联合NOSE组(观察组)46例,2D腹腔镜改良三角吻合法组(对照组)22例。结果:两组吻合时间、排气时间、进食时间差异具有统计学意义,吻合口漏、吻合口出血发生率、术中出血量差异无统计学意义(P>0.05)。3D腹腔镜手术时术者团队协调度、吻合口操作难度、手眼协调度、画面体力感与2D腹腔镜手术时差异有统计学意义(P<0.05)。结论:3D腹腔镜平行重叠吻合法联合NOSE在右半结肠癌切除术中更具有优势。     

3D与2D腹腔镜系统在结直肠癌手术应用的随机对照研究

目的研究3D腹腔镜系统在结直肠癌根治术中手术操作技术、术后短期疗效、可行性、安全性及肿瘤根治性。方法采用前瞻性分析法,收入2013年11月至2015年6月在上海市微创外科临床医学中心进行腹腔镜结直肠癌根治术的74例病人,按照随机数字表法分为2D(高清)腹腔镜组及3D腹腔镜组。2D腹腔镜组共38例,其中男性20例、女性18例,中位年龄为60.5岁(46~83岁);3D腹腔镜组共36例,其中男性16例、女性20例,中位年龄为62岁(37~84岁)。38例2D腹腔镜组病人中,腔镜右半结肠癌根治术12例,腹腔镜左半结肠癌根治术4例,腹腔镜横结肠癌根治术1例,腹腔镜乙状结肠癌根治术2例,腹腔镜根治性直肠前切除术17例(其中3例行末端回肠造口术),腹腔镜腹会阴联合直肠癌根治术2例。36例3D腹腔镜病人中,腹腔镜右半结肠癌根治术15例,腹腔镜左半结肠癌根治术3例,腹腔镜横结肠癌根治术1例,腹腔镜乙状结肠癌根治术3例,腹腔镜根治性直肠前切除术10例(其中5例行末端回肠造口术),腹腔镜腹会阴联合直肠癌根治术4例。结果所有病例均成功接受手术,无术中严重并发症和手术死亡发生,无中转开腹手术。2D腹腔镜组平均手术时间为(153.3±54.9)min,平均术中出血为(117.9±102.5)ml,平均排气时间为(2.3±0.9)d,平均住院天数为(9.6±7.8)d。3D腹腔镜组平均手术时间为(152.9±48.3)min,与2D腹腔镜组比较P=0.973;平均术中出血为(100.3±66.3)ml,与2D腹腔镜组比较P=0.386;平均排气时间为(2.1±0.8)d,与2D腹腔镜组比较P=0.228;平均住院天数为(8.1±3.2)d,与2D腹腔镜组比较P=0.289。术后2D腹腔镜组有1例腹腔镜根治性直肠前切除术及1例腹腔镜右半结肠癌根治术出现吻合口漏;3D腹腔镜组有1例腹腔镜腹会阴联合直肠癌根治术出现会阴切口感染。以上病人予对症治疗后均好转,无行二次手术病人。结论 2D腹腔镜系统与3D腹腔镜系统在手术操作上相似,两者手术后临床短期疗效、肿瘤根治程度相当。进一步研究尚需病例的积累与远期疗效的观察。     

3D腹腔镜在右半结肠癌根治术中的应用

目的探讨3D高清腹腔镜在右半结肠癌根治术中的临床应用价值。方法回顾性分析2014年5月~2015年12月腹腔镜右半结肠全系膜切除术资料,3D高清腹腔镜(3D组)24例,2D高清腹腔镜(2D组)26例,对比2组在手术时间、术中出血量、淋巴结清扫数量、住院费用方面的差异。结果 3D组手术时间为(126.7±4.5)min,2D组为(132.6±3.8)min,差异有统计学意义(t=5.171,P=0.000),但无临床意义,3D组术中失血量(62.5±12.2)ml,2D组(65.8±13.4)ml,无统计学差异(t=0.908,P=0.368);3D组淋巴结清扫数量(12.9±3.7)枚,2D组为(13.3±2.1)枚,差异无统计学意义(t=0.720,P=0.351);住院费用3D组(5.2±1.2)万元,2D组(5.0±1.3)万元,无统计学差异(t=0.564,P=0.575)。2组术后无吻合口漏、腹腔感染和肠梗阻等重大并发症,均痊愈出院。结论 3D高清腹腔镜能提供清晰的三维立体视觉,良好的深度感,可实现精确操作,同时淋巴结清扫效果相近。     

3D腹腔镜与传统2D腹腔镜在保留性神经根治性膀胱切除手术中的比较研究

目的:评价3D腹腔镜在保留性神经膀胱全切术中的应用以及与传统2D腹腔镜的差别与优势。方法:收集2012~2015年112例行保留性神经膀胱全切及开放下回肠代膀胱术后患者的资料,其中3D腹腔镜作为辅助方式的有34例,我们通过比较术中淋巴结清扫数量及时间,闭孔神经保留率,腹腔镜下膀胱摘除手术时间,腹腔镜手术出血量,患者围手术期并发症,术后勃起功能恢复情况以及术者术后疲劳评分情况来评价3D腹腔镜相对传统2D腹腔镜的优势。结果:与传统2D腹腔镜相比3D腹腔镜有更少的腹腔镜下膀胱摘除手术时间、患者术后勃起功能得到更好的保留以及术后术者眼睛疲劳指数更低。在单因素分析及多因素分析中术前IIEF-5评分、年龄60岁以及使用3D腹腔镜作为辅助技术与IIEF-5评分独立相关。结论:相对于传统2D腹腔镜而言,3D腹腔镜在保留性神经膀胱全切手术中能有效缩短腹腔镜下膀胱切除手术时间、降低术者手术疲劳的程度以及能更好的保留血管神经束,更有利于患者术后勃起功能的保留。     

减重手术临床并发症的分析

目的:探讨减重手术的并发症及其处理方法。方法:回顾分析31例糖尿病及单纯性肥胖症患者行腹腔镜胃旁路术、胃束带、袖状胃切除、改良胃转流术(袖状胃手术基础上,再行远端空肠与十二指肠球部吻合)的临床资料,总结其并发症情况。结果:本组中,2型糖尿病21例,其中发生左侧胸腔积液1例,吻合口狭窄1例,吻合口溃疡3例,营养不良4例,腹腔内疝1例,粘连性肠梗阻1例,术后胃功能性排空障碍2例。单纯性肥胖症10例,发生减重效果不明显1例,胃小囊及食管扩张1例,注水泵皮下脂肪液化1例,取出胃束带1例。结论:初期开展腹腔镜减重手术难免出现一些并发症,术者应完善术前检查,术中仔细操作以减少不必要的损伤,术后积极采取措施治疗,有的并发症是可以避免的。     

3D高清腹腔镜在腹腔镜辅助根治性全胃切除术中的应用

目的探讨3D高清腹腔镜在腹腔镜辅助根治性全胃切除术中的应用价值。方法选取我科2014年4月~2015年5月收治的胃上部癌43例,依据住院号单双号分别采用3D高清腹腔镜(3D组,21例)和2D高清腹腔镜(2D组,22例)行根治性全胃切除术,比较2组食管-空肠吻合口单针缝合时间、脾门清扫时间、总手术时间、术中失血量、淋巴结清扫数、总住院费用等方面的差异。结果食管-空肠吻合口单针缝合时间3D组[(32.3±4.3)s]2D组[(49.5±5.5)s,t=-11.400,P=0.000);脾门清扫时间3D组[(28.6±5.0)min]2D组[(38.5±4.6)min,t=-6.811,P=0.000];总手术时间2组差异无显著性[3D组(198.7±14.9)min,2D组(205.5±18.5)min,t=-1.320,P=0.194];术中失血量3D组[(54.3±9.0)ml]2D组[(76.8±22.5)ml,t=-4.349,P=0.000];淋巴结清扫数2组差异无显著性[3D组(27.3±8.1)枚,2D组(24.6±8.3)枚,t=1.082,P=0.286];总住院费用2组差异无显著性[3D组(6.31±0.51)万元,2D组(6.20±0.50)万元,t=0.685,P=0.497)。结论 3D比2D高清腹腔镜能提供更清晰的三维立体视觉效果,良好的景深度,实现精确操作,缩短单针缝合时间和脾门清扫时间,并减少术中出血量,且未明显增加住院费用。     

3D与2D单孔充气式纵隔镜联合腹腔镜食管癌根治术的近期疗效对比研究

目的探讨3D单孔充气式纵隔镜联合腹腔镜食管癌根治术的安全性和有效性。方法回顾性分析2018年6月至2019年6月我科收治的28例实施单孔充气式纵隔镜联合腹腔镜食管癌根治术的食管鳞状细胞癌患者的临床资料,其中男25例、女3例,年龄51~76岁。根据手术方法不同,将患者分为两组,即3D纵隔镜组(3D组,10例)和2D纵隔镜组(2D组,18例)。比较两组近期疗效。结果3D组手术时间明显短于2D组(P=0.017)、清扫淋巴结数目多于2D组(P=0.005)、出血量少于2D组(P=0.015),差异均有统计学意义。两组在主刀医师眩晕感及视觉重影方面差异无统计学意义(P>0.05)。两组在颈部引流管置管时间、术后住院时间、肺部感染、心律失常、吻合口瘘、喉返神经损伤等方面差异无统计学意义(P>0.05)。结论3D充气式纵隔镜联合腹腔镜食管癌根治术优化了2D操作,实践中是安全、可行的,可以作为未来的一种术式去尝试。     

Leveling the learning curve for laparoscopic bariatric surgery

Background The learning curve for laparoscopic bariatric surgery is associated with increased morbidity and mortality.Methods The study included the first 100 patients undergoing laparoscopic Roux-en-Y gastric bypass (LGB) by a designated surgical team. Surgeon A operated as primary surgeon, with surgeon B assisting (Stage 1). Surgeon B learned LGB in stages: exposure and jejunojejunostomy (stage 2), gastric pouch (stage 3), gastrojejunostomy (stage 4), and sequence all steps (stage 5).Results Surgeon A achieved confidence with LGB after 20 cases and surgeon B after 25 cases (stage 2), 18 cases (stage 3), 21 cases (stage 4), and 16 cases (stage 5). Complications (8%) included small bowel obstruction (three); pulmonary embolus (two), and leak, stomal stenosis, and gastrogastric fistula (one each). There was a decreasing trend for operative duration, length of stay, and complications across the five stages (p < 0.05).Conclusions By transferring skills in stages, a laparoscopic bariatric program can be established with minimal morbidity and mortality.     

Effect of Location and Speed of Diagnosis on Anastomotic Leak Outcomes in 3828 Gastric Bypass Cases

Introduction Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome. Methods Retrospective review of 3,828 gastric bypass procedures. Results Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037). Discussion Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak. This paper was presented at The Society for Surgery of the Alimentary Tract, 47th Annual Meeting at Digestive Disease Week 2006, May 20–24, 2006, Los Angeles, California.     

Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift

BackgroundDuring the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals.MethodsWe reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded.ResultsThere were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient.ConclusionEIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.     

Omental Wrap: A Simple Technique for Reinforcement of the Gastrojejunostomy during Roux-en-Y Gastric Bypass

Background Anastomotic leak is one of the most dreaded complications following Roux-en-Y gastric bypass (RYGBP). A simple technique for reinforcement of the gastrojejunal anastomosis using an omental wrap during laparoscopic RYGBP is described.We recommend this technique particularly in those patients at high risk for gastrojejunal leak. Methods A 20 ml vertically-oriented gastric pouch, based on the lesser curvature of the stomach, is created using linear cutter staplers (endo-GIA).The gastrojejunal anastomosis is reinforced with an omental wrap (omental flap). The jejunojejunostomy is created 100–150 cm from the gastrojejunostomy, depending on the BMI. Results 124 laparoscopic RYGBPs were performed by the same surgeon. The omental wrap was successfully performed in all patients but two. There were no mortalities, leakages, or stenoses noted during follow-up. Conclusion During RYGBP, reinforcement of the gastrojejunostomy with an omental wrap is a simple, feasible, and protective adjunctive maneuver that can minimize the risk of gastrojejunal leak.     

Laparoscopic repair of gastrointestinal leaks after laparoscopic gastric bypass

Gastrointestinal (GI) leak after gastric bypass is a cause of significant morbidity and a mortality that may exceed 50%. This study was performed to review our experience with laparoscopic repair of GI leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective chart review of all patients who underwent LRYGB over a 25-month period was performed. Patients who had any operation for a GI leak after LRYGB were included in this study. There were 300 patients who underwent LRYGB. No intraoperative conversions occurred. Eight (2.7%) patients underwent operative repair of a GI leak. Another patient had a gastrojejunostomy leak that was managed nonoperatively. The rate of GI leaks reduced from 5.3 per cent in the first 150 cases to 0.7 per cent in the last 150 cases (P < 0.05). One patient was converted to an open approach. Average operative time for the laparoscopic repairs was 133 minutes (range, 75-182 minutes). Sources of leak found at operation were gastrojejunostomy (3), enterotomy (3), jejunojejunostomy (2), gastric pouch (1), and cystic duct stump (1). Two patients had a GI leak from two sources. Average length of stay was 28 days (range, 4-78 days). Three patients whose stay was greater than a month were the result of sepsis and ventilator dependence. Further reoperations were required in two patients (laparoscopic) for abdominal washout and one patient (open) for enterotomy repair. One patient required computed tomography-guided drainage of an abscess. Mortality was 22 per cent (2) in patients who developed GI leaks. One patient died from sepsis-induced multiple organ failure and the other patient from a presumed pulmonary embolus. GI leaks cause significant morbidity and mortality. GI leak rates decrease with experience. Laparoscopic repair of GI leaks should be used judiciously. Conversions and further reoperations may be necessary.     

Laparoscopic Roux-en-Y gastric bypass with linear cutter technique: comparison of four-row versus six-row cartridge in creation of anastomosis.

BACKGROUND: Morbid obesity is refractory to medical treatment. The introduction of laparoscopic linear staplers in the early 1990s contributed to the development of the laparoscopic Roux-en-Y gastric bypass technique. Many series have compared different brands of circular and linear staplers. The purpose of this study was to evaluate the 4-row versus 6-row endoscopic staplers in laparoscopic Roux-en-Y gastric bypass for creation of the anastomosis. METHODS: Between July 2000 and April 2004, 1240 patients underwent laparoscopic Roux-en-Y gastric bypass. The 4-row linear stapler was used in the first 664 cases (group 1) and the 6-row stapler in the latter 576 patients (group 2) to create the anastomosis. The medical records of those patients who developed leaks, gastrogastric fistulas, strictures, or bleeding were reviewed. Strictures were diagnosed using radiologic or endoscopic techniques. RESULTS: Leaks were more frequent in group 2 than in group 1 (1.56% versus 1.05%, respectively, P = .46). Documented bleeding occurred in 15 and 13 patients in groups 1 and 2, respectively (2.26% for both). Strictures were diagnosed in 7.68% of patients in group 1 (51 gastrojejunostomy and 4 jejunojejunostomy), and in 4.3% of those in group 2 (25 gastrojejunostomy stenosis, P = .017). Gastrogastric fistulas were found in 5 patients (.75%) in group 1 and 6 (1.04%) in group 2. CONCLUSION: Using a 6-row instead of a 4-row linear cutter technique to create the anastomosis yielded similar results, but the stricture rate at the gastrojejunal anastomosis was significantly lower with the newer, 6-row staplers.     

单中心3D/2D后腹腔镜无功能肾切除术的临床体会

目的对比3D和2D后腹腔镜下无功能肾切除术的临床疗效,总结后腹腔镜无功能肾切除的手术经验。 方法回顾性分析了2015年2月至2018年2月期间我科收治的69例无功能肾患者的临床资料,A组29例使用3D腹腔镜系统,B组40例使用2D腹腔镜系统。对比两组手术时间、术中出血量、术后通气时间、拔除引流管时间、住院时间、中转开放以及手术并发症情况。 结果69例手术均由同一术者完成,61例（88.4%）在后腹腔镜下顺利完成手术,8例因粘连严重或大出血而中转开放手术。A组手术时间显著短于B组[（118±21）min vs （134±19）min,t=-3.3003,P=0.0008]。两组术中出血量、术后通气时间、拔除引流管时间、住院时间、手术并发症差异均无统计学意义（P>0.05）。 结论后腹腔镜无功能肾切除术是一种安全、有效的肾切除术式。相对2D腹腔镜系统,3D腹腔镜系统有助于提高操作的效率和精准性,熟练后可有效缩短手术时间,值得临床推广应用。     

自动肝脏悬吊装置在腹腔镜下胃旁路手术中的应用

目的：探讨自动肝脏悬吊装置在腹腔镜下胃旁路手术中的应用。方法将75例接受腹腔镜下胃旁路手术的患者随机分为自动肝脏悬吊装置组与分叶拉钩组,比较建立小胃囊、小胃囊空肠吻合两大主要步骤所需时间。结果自动肝脏悬吊装置组建立小胃囊及小胃囊空肠吻合的时间分别是33.80±13.34 min 和22.44±5.26 min,显著短于分叶拉钩组,其时间分别为61.74±18.09 min和32.40±4.07 min（P 〈0.0001）。结论在腹腔镜下胃旁路手术中使用自动肝脏悬吊装置可以更好的显露手术视野,有效的缩短手术时间,有进一步推广应用的价值。     

Techniques of laparoscopic gastric bypass: on-line survey of American Society for Bariatric Surgery practicing surgeons

BACKGROUND: Various techniques have been used for laparoscopic gastric bypass. This study was performed to survey American Society for Bariatric Surgery practicing surgeons on how they perform laparoscopic gastric bypass. METHODS: An Internet-based survey was sent to all practicing surgeons in the American Society for Bariatric Surgery database by way of e-mail. The survey was divided into sections, including experience, pouch, limbs, gastrojejunostomy (GJ), jejunojejunostomy, and band. The survey results were collected from the Internet site after 4 months. RESULTS: A total of 215 surgeons responded; 98% stated they performed laparoscopic gastric bypass. The surgeons had performed an average of 423 cases in their career and 95 cases during the past 12 months. The average pouch size was 25 cm(3) and approximately one half of the surgeons (49%) measured the pouch size by the distance for the gastroesophageal junction. Almost all surgeons (99.5%) performed Roux-en-Y and not loop GJ. The average biliopancreatic limb length was 48 cm, and the average Roux limb was 114 cm. About one half of the surgeons (46%) measured the limb length with an open grasper, and few (7%) used a suture or umbilical tape. The antecolic and antegastric approaches were the more common. The percentage of those using the circular stapler, linear stapler, and hand sewing was 43%, 41%, and 21% for the GJ technique. Most surgeons (93%) routinely tested the GJ intraoperatively. The percentage of those using staple anastomosis and hand-sewn common enterotomy, double stapling, triple stapling, and hand sewing was 53%, 36%, 13%, and 1% for the jejunojejunostomy technique. Most surgeons (94%) closed at least one mesenteric defect. Also, most surgeons (95%) did not place a band around the pouch. CONCLUSION: Technical variations exist in how laparoscopic gastric bypass procedures are performed by American Society for Bariatric Surgery practicing surgeons. Additional research is needed to explore the links between the technical variations and outcomes.     

Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity

OBJECTIVE: To determine the safety and efficacy of laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity. SUMMARY BACKGROUND DATA: Laparoscopic Roux-en-Y gastric bypass is a new and technically challenging surgical procedure that requires careful study. METHODS: The authors attempted total laparoscopic Roux-en-Y gastric bypass in 281 consecutive patients. Procedures included 175 proximal bypasses, 12 long-limb bypasses, and 9 revisional procedures from previous bariatric operations. The gastrojejunostomy and jejunojejunostomy were primarily constructed using linear stapling techniques. RESULTS: Eight patients required conversion to an open procedure (2.8%). The mean age of the patients was 41.6 years (range 15-71) and 87% were female. The mean preoperative body mass index was 48.1 kg/m2. The operative time decreased significantly from 234 +/- 77 minutes in the first quartile to 162 +/- 42 minutes in the most recent quartile. Postoperative length of stay averaged 4 days (range 2-91), with 75% of patients discharged within 3 days. The median hospital stay was 2 days. No patient died after surgery. Complications included three (1.5%) major wound infections (each followed a reoperation for a complication or open conversion), incisional hernia in 5 patients (1.8%), and anastomotic leak with peritonitis in 14 patients (5.1%). Three gastrojejunal leaks were managed without surgery, four by laparoscopic repair/drainage, and three by open repair/drainage. Only three patients had anastomotic leaks in the most recent 164 procedures (1.8%) since the routine use of a two-layer anastomotic technique. Data at 1 year after surgery were available in 69 of 96 (72%) patients (excludes revisions). Weight loss at one year was 70 +/- 5% of excess weight. Most comorbid conditions resolved by 1 year after surgery; notably, 88% of patients with diabetes no longer required medications. CONCLUSIONS: Laparoscopic gastric bypass demonstrates excellent weight loss and resolution of comorbidities with a low complication rate. The learning curve is evident: operative time and leaks decreased with experience and improved techniques. The primary advantage is an extremely low risk of wound complications, including infection and hernia.