无胸壁缺损的心外胸骨旁小切口的可行性研究

目的 研究以带蒂复合组织瓣修复胸骨旁小切口术后胸壁缺损的可行性。方法 观察尸体前胸壁深层结构的血供规律，测量胸骨外侧缘与胸廓内动脉之间的距离，并在此基础之上设计以胸阔内动脉为蒂的肋软骨肋间肌瓣。结果 前胸壁深层各结构均由胸廓内动脉及其分支供血，胸廓内动脉距胸骨外侧缘的距离为１cm左右。紧挨胸骨外侧缘切开肋软骨，可以避免胸廓内动脉的损伤，以该动脉为蒂，可以保证数种肋软骨肋间肌瓣有良好的血供。结论 用以胸廓内动脉为蒂的肋软骨肋间肌瓣修复心脏外科术后的胸壁缺损具有良好的可行性。     

左侧胸骨旁切口的评价

目的 系统评价左侧胸骨旁切口，为临床使用提供参考。方法 随机选取福尔马林保存成人尸体6具，模拟不同平面的上半部分胸骨劈开切口，从显露效果、美容效果和损伤程度三方面对该切口进行评价。结果 左侧胸骨旁切口的皮肤切口较为隐蔽，长度较短，美容效果较好；由于术野较小，损伤结构不多，损伤较小；合理选择切口水平，左心各结构可依次被显路。结论 左侧胸骨旁切口是一种较美观、损伤小的小切口，该切口对心脏左侧各结构，如肺动脉干、肺动脉瓣、右室流出道、左冠状动脉主干等依次显露，对心脏右侧各结构显露不佳。     

心脏外科胸骨旁小切口的解剖学研究

目的：研究心脏外科胸骨小切口的显露范围及手术适应证。方法：以１６具正常成人福尔马林浸泡尸体，建立不同平面的胸骨旁小切口模型。测量皮肤切口长度，经牵引后切口的内、外缘及上、下缘的最大长度。观察心脏外表及与心脏手术相关的部位的显露情况。观察经右房右侧壁切口及两房项切口对心脏内部结构的显露情况。结果：切除右侧第２、第３、第４、第２，３，第３，４和第２，３，４肋软骨的胸骨帝小功口的皮肤切口长度部位，但范围     

左侧胸骨旁切口的评价

目的系统评价左侧胸骨旁切口,为临床使用提供参考。方法随机选取福尔马林保存成人尸体6具,模拟不同平面的上半部分胸骨劈开切口,从显露效果、美容效果和损伤程度三方面对该切口进行评价。结果左侧胸骨旁切口的皮肤切口较为隐蔽,长度较短,美容效果较好;由于术野较小,损伤结构不多,损伤较小;合理选择切口水平,左心各结构可依次被显露。结论左侧胸骨旁切口是一种较美观、损伤小的小切口,该切口对心脏左侧各结构,如肺动脉干、肺动脉瓣、右室流出道、左冠状动脉主干等可依次显露,对心脏右侧各结构显露不佳。     

右腋下小切口与胸骨正中切口在心脏直视手术中的比较

心内直视手术,多采用胸骨正中切口,随着医学模式的转变,对手术中如何减少手术创伤和保持美观提出了更高的要求.因此,小切口入路越来越多地应用于治疗先天性心脏病.本研究对右腋下小切口与常规的胸骨正中切口在心脏直视手术中的应用情况进行比较,以评价两种切口的临床应用效果.     

胸骨正中小切口置换主动脉瓣

自1996年11月～1999年7月,笔者应用胸骨正中小切口剖胸法施行主动脉瓣置换术26例,临床效果满意,报告如下。1　临床资料1.1　一般资料　本组26例中,男性10例,女性16例,年龄31.4±10.3岁(18～53岁)。病种:风湿性心脏病、主动脉瓣狭窄4例,主动脉瓣关闭不全9例,主动脉瓣狭窄伴关闭不全7例,主动脉瓣关闭不全伴轻度二尖瓣关闭不全2例,亚急性细菌性心内膜炎4例。本组病例术前均根据临床表现、心电图、心脏X线平片及超声心动图等检查而确诊。与同期常规正中开胸施行主动脉瓣置换术者相比,两组年龄、心功能及心胸比率无显著差异。1.2　手术方法　病…     

胸骨正中小切口行心内直视手术37例

随着心脏外科技术的成熟,手术安全性的提高,90年代后期有报道开始采用小切口行心脏瓣膜手术[1].我院1999年12月至2004年10月,选择性应用胸骨下段小切口于心脏不停跳下完成心内直视手术37例,取得了良好的效果,现总结如下.     

经左胸胸骨旁途径动脉导管未闭微创封堵手术及术后管理

目的：总结经左胸胸骨旁途径微创封堵动脉导管手术及术后管理经验。方法回顾性分析21例接受食管超声心动图引导经左胸胸骨旁途径动脉导管未闭封堵手术患者的临床资料。结果21例成功完成封堵手术,全组无术中中转开胸及输血,术后无封堵器脱落、溶血、心律失常、二次开胸等并发症。全组随访1～10个月无并发症,出院后返院复查心脏彩超均未见残余分流及封堵器移位。结论经左胸胸骨旁途径微创封堵动脉导管未闭安全、创伤小、恢复快,值得推广;优质的术后管理配合保证手术成功及促进术后康复。     

微创Wheat手术4例报道

 目的  介绍我院采用经胸骨上段“J”型切口行微创Wheat手术的临床经验。 方法  2011年11月,我院采用胸骨上段“J”型切口为4例主动脉瓣病变合并有升主动脉瘤样扩张患者行微创Wheat手术,其中男性3例,女性1例,年龄43~62岁,平均55.3岁。结果  无院内死亡,低心排血量综合征、脑血管意外、肾功能不全、伤口愈合不良等并发症。术后1年随访升主动脉人工血管和主动脉瓣瓣膜功能良好,心功能恢复至I~Ⅱ级。结论  经胸骨上段“J”型切口行微创Wheat手术可安全有效地应用于主动脉瓣病变合并升主动脉瘤样扩张的患者,值得临床选择性应用。     

右胸前外侧小切口行微创室间隔缺损修补术

目的　总结右胸前外侧小切口行室间隔缺损修补术的治疗结果及手术经验。方法　右胸前外侧小切口行室间隔缺损修补手术 61例 ,男 3 8例 ,女 2 3例 ,年龄 2 .5～ 2 7岁 ,平均 ( 7.1± 4.8)岁 ,体质量 11～ 71kg ,平均 ( 2 2 .0± 11.6)kg。肺动脉压中度增高 10例。手术在浅低温深度血液稀释体外循环下施行 ,皮肤切口沿右侧第 5肋间长 5～ 8cm ,经第 3或第 4肋间入胸 ,距右膈神经前 2 .0cm纵向切开心包 ,主动脉及上、下腔静脉插管常规建立体外循环。心脏停跳下切开右心房 ,经三尖瓣显露和修补室间隔缺损。结果　 61例患者均痊愈出院 ,皮肤切口长 ( 6.9± 0 .9)cm。体外循环时间 ( 5 7.4±2 1.8)min ,主动脉阻断时间 ( 3 6.2± 14 .8)min ,术后气管插管呼吸机辅助时间 ( 8.5± 5 .8)h ,ICU时间 ( 3 3 .6± 16.9)h ,术后住院 ( 8.2± 1.9)d。术后胸腔引流量 ( 2 0 6.1± 15 0 .7)ml。 5 2例 ( 85 % )未输库血。术后随访 3个月至 4年 ,心功能较术前改善 ,残余分流 2例。结论　采用右胸前外侧小切口技术修补室间隔缺损 ,微创美观 ,安全可靠 ,手术操作简单 ,库血用量小 ,疗效满意。可经三尖瓣修补的室间隔缺损均可采用右胸前外侧小切口术式。     

胸壁缺损34例重建体会

目的:探讨胸壁缺损后不同外科技术重建的效果。方法:对34例不同病因的胸壁缺损患者采用不同方法胸壁重建。骨性胸廓重建采用自体组织(肋骨条、腓骨、髂骨、阔筋膜、肌瓣)或人工材料(肋骨接骨板、复合肋骨接骨板、Dacron片、聚四氟乙烯(PTFE)网片+钛合金条、金属丝支架+大网膜瓣、Dacron+骨水泥三明治式复合体)。软组织修复主要用局部转移皮瓣、肌皮瓣或大网膜瓣。结果:全组胸廓外观满意、呼吸功能恢复好,无手术死亡。1例因感染摘除自体骨植入物。结论:肋骨接骨板对中小面积骨性胸廓缺损的重建效果好,使用简单;Dacron片+骨水泥三明治式复合体适于大面积骨性胸廓缺损重建;背阔肌瓣和大网膜瓣修复软组织效果较好,后者对因感染引起的胸壁缺损效果更佳。     

微创伤非体外循环房间隔缺损封堵术5例

目的介绍一种闭合房间隔缺损的微创伤非体外循环手术方法。方法对2002年1~12月在我院治疗的5例继发房间隔缺损患者经右前胸小切口直接闭合房间隔缺损。结果5例手术均1次成功,无残余分流,无封堵器脱落,平均住院时间7 d。结论该方法创伤小,操作简单,安全性高,具有推广应用价值。     

单腋窝和胸前径路达芬奇机器人猪甲状腺切除的对照研究

目的：达芬奇机器人（ da Vinci Si ）外科手术系统下单腋窝切口和胸前径路行猪甲状腺切除术,观察其安全性并积累手术操作经验。方法 da Vinci Si外科手术系统包括医生操控系统、床旁机械臂系统和成像系统。手术器械凭借腋窝/胸壁的切口连接到机器人的机械臂。术者坐于操控台前将手指分别放入操作手柄的指套内联合双脚控制手术器械和双目内窥镜,它可将外科医生的动作转换传递到手术器械的尖端。内置模拟手腕系统（ EndoWrist ）技术可使机械手进行上下左右旋转等7个自由的连续动作,超过了人手在开放手术时的灵活性。本组选用2头小型猪做da Vinci Si外科手术系统不同径路的甲状腺切除动物模型。采用气管插管全身麻醉。结果在da Vinci Si外科手术系统下完成2例不同径路的猪甲状腺切除和胸腺切除术。无中转开放或腔镜手术。手术时间分别为61 min和50 min。结论有开放性甲状腺外科手术经验的专科医师经短期da Vinci Si外科手术系统培训即可实施甲状腺腺叶切除术。在da Vinci Si外科手术系统辅助下行甲状腺切除术的学习曲线短。     

Subtemporal transpetrosal apex approach: study on its use in large and giant petroclival meningiomas

Background  The subtemporal transtentoral approach has been reported for nearly two decades; however it was not well used due to some limitations in dealing with large and giant petroclival meningiomas. The clinical outcome and merit of the modified subtemporal transpetrosal apex approach in large and giant petroclival meningiomas, as well as the choices, the improvements and the therapy strategies of the microsurgical approach in such patients were evaluated in this study.

Methods  Totally 25 cases of large and giant petroclival meningiomas undergone the modified subtemporal transpetrosal apex approach between April 2004 and January 2010 were enrolled in this study. The choice and improvement of the approach, the basis of anatomy and related research, the effect of accessory equipment, the exposure of tumor and the changes of neurofunction pre- and post-operation were all reviewed retrospectively. The operation outcomes and complications in this approach were also compared with those in the transpetrous presigmoid approach done in 14 cases in the same period.

Results  All 25 cases underwent the modified subtemporal transpetrosal apex approach under electrophysiologic monitoring of cranial nerves and brain stem function. Trochlear nerve was partly wrapped in 14 cases, totally wrapped but can be explored in the initial segment of the cerebellum tentorium in 8 cases, totally wrapped and could not be seen until tumor was partly removed in 3 cases. The cerebellum tentorium was cut along the temporal bone from the anterior part of the apex to the mastoid part of superior petrous sinus in 6 cases, from the posterior part of the apex to the mastoid part of superior petrous sinus in 19 cases. Gross tumor resection was accomplished in 17 (68%) patients, subtotal resection in 7 (28%) patients, and partial resection in 1 (4%) patient. The most common postoperative complication was new neurological deficits or aggravations of preexisting deficit (64%). Follow-up ranged from 3 to 69 months. Compared with the transpetrous presigmoid approach done in 14 cases in the same period, the modified subtemporal transpetrosal apex approach showed obvious advantages such as simplicity in manipulating, microinvasiveness, less time-consuming, less complication, higher rate of tumor resection though the rates of gross tumor resection might be of no significant difference.

Conclusions  Modified subtemporal transpetrosal apex approach has obvious advantages compared with the transpetrous presigmoid approach. Some complications need to be solved by practice and modification of the approach as well as the accumulation of the experiences.

     

乳腺癌改良根治术不输血治疗98例

[背景 ]探讨乳腺癌不输血手术治疗的可行性 .[病例报告 ]1999年 3月至 2 0 0 1年 3月 ,对 98例乳腺癌患者施行乳腺根治性切除术 ,98例均为改良根治术 .98例乳腺癌患者平均每例失血约 12 5mL ,无 1例接受输血和使用血制品 ,7例使用了代血浆 ( 70 6代血浆 ) .术后平均住院天数为 17d ,与围手术期输血患者相比 ,在创口愈合、术后并发症、体质恢复等方面无明显差异 .[讨论 ]对乳腺癌患者施行不输血乳房根治性切除术是可行的 .     

人工材料复合体重建骨性胸壁缺损23例报告

目的 探讨巨大胸壁缺损后用人工材料复合体重建骨性胸廓的可行性及效果.方法 该院在2002年3月～ 2010年3月间收治的23例不同病因所致的巨大胸壁缺损患者,对其骨性缺损部分采用多层聚四氟乙烯网片+骨水泥的“三明治”式复合体进行骨性胸壁重建手术.结果 全组无手术死亡及严重并发症.随访时间最长达60个月,远期胸廓外形满意,呼吸功能良好.结论 聚四氟乙烯网片+骨水泥人工材料复合体修复大块骨性胸廓缺损效果良好,值得临床推广应用.     

Minimally invasive treatment of the KobyGard system for plantar fasciitis: a retrospective study

Background  Calcodynia is a persistent condition that podiatric surgeons frequently see among their patients, and plantar fasciitis is the main reason for pain. When systematic conservative treatments fail to alleviate these conditions, it requires surgical intervention, mainly plantar fascia release surgery, which used to be an open heel release surgery. This study aimed to investigate whether minimally invasive treatment of the KobyGard system is more safe and effective for plantar fasciitis.

Methods  From May 2009 to May 2012, a total of nine patients, three males and six females with plantar fasciitis, were treated in the Peking University People’s Hospital with minimally invasive instruments, the KobyGard system, for the release of plantar fascia. Three patients, experiencing bilateral calcaneodynia, underwent bilateral surgery. One patient had bilateral calcaneodynia with enthesiopathy of Achilles tendon, and underwent Achilles tendon surgery. Preoperative and postoperative Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, Roles and Maudsley scores and SF-36 questionnaires were evaluated.

Results  The nine patients were successfully followed up. The average postoperative follow-up time was 13.2 months and it varied from 2.0 months to 21.0 months. Pre- and postoperative average scores of VAS was 9.3 and 1.9 (P <0.001), respectively. Pre- and postoperative average scores of AOFAS hind foot was 36.0 and 82.0 (P <0.001), respectively. There was also a statistically significant amelioration in SF-36 scores and the Roles and Maudlesy scores. Eight patients were satisfied with the surgery outcome.

Conclusion  Minimally invasive surgery treatment of the KobyGard system for plantar fasciitis has the advantages of shorter operation time, ease of operation, and similar satisfaction rates with open surgery, but with smaller surgical incision.