改良腹式子宫全切术67例临床分析

本院自２０００年９月至２００１年３月，根据以色列医生Stark创立的新式剖宫产术（Themisgavladachmethod）为基础，改良应用于６７例经腹子宫全切术，取得明显效果。现总结如下。资料与方法１．一般资料：本院自２０００年９月至２００１年３月对子宫小于５米大小良性病变（包括子宫肌瘤、功血、子宫腺肌瘤等）患者，采用改良腹式子宫全切术共６７例为实验组，同期传统腹式切口子宫全切６２例为对照组。两组病例年龄、手术适应征、子宫大小、盆腔粘连程度均无显著差异，具有可比性。２．改良腹式子宫全切术：切口选择耻骨联合上二横指，…     

腹式小横切口子宫筋内全切术的探讨

经腹子宫切除术是妇产科疾病的常用术式．传统的手术进路是下腹正中切口．至目前为止．仍然广泛应用于各基层医院。但由于此术式腹壁瘢痕形成较大．不但影响美观及腹壁缩复功能．而且切口中上端壁层腹膜与网膜及（或1肠管易造成粘连．有的甚至因粘连而发生肠梗阻。为了探讨一种经腹微创术式．笔借鉴腹腔镜下子宫手术创伤小及新式剖宫产术㈦腹壁切口位置低、愈合好的特点．自2002年10月至2005年10月．对手术治疗的440例患子宫良性疾患的手术方式进行了改进．与同期腹壁纵切口子宫切除手术400例相比较。通过术后随访．证实了该改良术式具有手术时间短、术中出血少、肛门排气早、切口愈合好、无肠粘连等优点。同时对因故再次手术的患进行检查．未发现盆腔有粘连征象．     

腹股沟疝修补术剥离疝囊法的改进

笔者从1974～1981年对43例腹股沟疝修补术剥离疝囊法进行改进,收到良好效果。手术方法沿精索方向纵行切开提睾肌,在显露部位,以两把止血钳提起疝囊,在两把血管钳间的疝囊壁与粘连组织之间,注入1%普鲁卡因少许,使局部隆起,疝囊壁与周围组织分离。用血管钳钝性分离后切开疝囊。将内容物回纳,用血管钳夹住疝囊切口边缘,探查后,以左手食指伸入疝囊孔,并将血管钳拉挺疝囊。在其周围再注入1%普鲁卡因于疝囊壁与粘连组织之间,边注边进针,直至疝囊颈部。沿疝囊切口缘环形     

传统包皮环切术和套环环切术在小儿包茎治疗中的比较分析

目的 比较分析传统包皮环切术和套环环切术在治疗小儿包茎中的利弊,为不同包茎患者选择环切术式提供参考.方法 对182例小儿包茎患者随机行包皮传统环切术或套环环切术,统计术前情况、手术时间和术后情况,对所有采集资料进行回顾性分析.结果 术前有粘连的小儿包茎患者术后愈合时间传统环切术[（9.14±2.71）d]较套环环切术[（13.01±3.12）d]更短（P＜0.05）,无粘连患者两种手术方式愈合时间差异无统计学意义（P＞0.05）;手术时间套环环切[（6±1.8）min]较传统环切[（15±2.5）min]明显缩短（P＜0.01）;术后伤口裂开渗血、粘连及水肿等并发症的发生率套环环切术较传统环切术更低（P＜0.05）;术后疼痛持续时间传统环切术较套环环切术更短（P＜0.05）.结论 两种手术方式均为小儿包茎患者的有效治疗方法,套环环切术因手术时间短、操作简单、术后并发症少和切口美观的优点可作为首选治疗方式,但术前有粘连的小儿包茎患者更推荐行传统环切术.     

Lilly氏法切除胆总管囊肿8例手术体会

治疗先天性胆总管囊肿，目前认为最合理的术式是囊肿切除、胆道重建。但对Ⅰ型囊肿（即胆总管囊状或梭状扩张）切除有一定难度。因囊肿后壁常与门静脉、肝动脉等重要血管粘连，剥离囊肿时容易损伤而致大出血，危及病人生命。自1988年以来，我们采用Lilly氏保留囊肿后壁外层的囊肿切除方法，共8例，均顺利完成手术。现介绍如下：1手术方法取右上腹直肌切口或旁正中切口。先切除胆囊，于囊肿前壁中部缝两针牵引线，在两线间横向切开前壁全层。吸尽囊液，将切口向两侧延伸。当接近囊肿后壁（约距门静脉1cm）时，改为分层解剖囊壁的方法，从切…     

包囊内粘连性肠梗阻（病例报告及文献复习）

本文报告4例少见的包囊内粘连性肠梗阻,复习文献对命名、病因、诊治进行了讨论。 病例资料 例1:男,44岁。胃大切术后65天因粘连性肠梗阻再次来院手术。术中除见空肠与原切口粘连扭转成环形致梗阻外。再检查见距胃空肠吻合口约25cm处有一椭圆形囊性包块,约6×8cm,似膨大之肠管,触之软而滑,将囊壁切开发现为一类似浆膜样组织包裹一团肠管呈“Z”形,粘连易于分开,切除全部囊壁,术后恢复顺利。     

小切口漆关节粘连松解术后及连续被动活动治疗膝关节僵直

研究了治疗膝关节粘连僵直的最佳手段。方法：设计小切口膝关节粘连，僵直松解术后手术方式，手术方法，手术器械。该手术方式分为单侧小切口；内外两仙切口；及内外侧切口加关节后切口。切口可在髌骨上内上缘或髌骨外上缘及关节后侧分别做一长约２ｃｍ的切口，有髌股关节髌上囊及两侧股骨髁的粘连处进行分离。     

小儿腹股沟斜疝腹腔镜手术与开放手术的对比研究

目的探讨腹腔镜下疝囊高位结扎术与传统术式的手术效果。方法对我院在2008年1月～2009年12月收治120例小儿腹股沟斜疝分别采用微型腹腔镜及传统手术治疗进行回顾性分析。微型腹腔镜手术组采用微型腹腔镜下缝扎内环口的方法,传统术式组采用经腹股沟切口行疝囊高位结扎术。结果微型腹腔镜术手组较传统术式组在手术时间、术中出血、术后并发症发生率、术后住院时间等方面明显优于传统术式组,并且疗效确切。结论腹腔镜下疝囊高位结扎术与传统术式相比,具有手术创伤小、术后疼痛轻、恢复快、住院时间短、无切口瘢痕等优点,是治疗小儿腹股沟斜疝较理想的手术方式。     

改良的肾盂癌肾输尿管全切术

目的：探讨经尿道输尿管口环切在肾输尿管全切术中的临床应用价值。方法：经尿道输尿管口环切后，作腰部斜切口行肾输尿管全切治疗肾盂移行细胞癌10例，并与传统的双切口肾输尿管全切术进行比较。结果：10例术后无一例出现尿漏，感染，出血等并发症，平均手术耗时2．5h，术后平均住院8d，与双切口术式相比差异有极显著性意义（P＜0．01），术后随访3－20个月，膀胱镜和CT检查未发现肿瘤复发，结论：本改良术式创伤小，并发症少，操作简单，疗效确切，较传统的双切口肾输尿管全切术有明显优点，值得推广应用。     

袖套式包皮环切术联合Z改形治疗包皮过长

目的介绍袖套式包皮环切术联合Z改形关闭切口治疗包皮过长与包茎的方法和效果。方法 1%利多卡因阴茎根部浸润麻醉后,根据包皮过长的程度单纯去除相应包皮内、外板的皮肤层,保留完整的肉膜,如果局部存在环形筋膜缩窄环则给予适当松解,缝合时在切口两侧各作1个Z成形术关闭切口。结果利用该术式治疗包皮过长、包茎20例,术中出血少,术后组织水肿反应轻,并发症少,效果满意。结论袖套式包皮环切术联合切口Z改形关闭切口治疗包皮过长具有手术创伤轻、术后组织水肿轻微,切口愈合快,愈合后皮肤不与白膜粘连或出现切口瘢痕挛缩等优点。     

防止椎板切除术后硬脊膜外瘢痕粘连的实验研究

作者在４个平面间隔切除１１只山羊的椎板，分别用硅胶膜、自体游离脂肪片、带蒂肌肉瓣覆盖硬脊膜，一处平面作空白对照。术后４个月组织学检查，结果显示，硅胶膜后方有少许瘢痕组织增生，间质中有炎细胞灶状浸润，硅胶膜与硬膜囊无瘢痕形成，新形成的椎管后壁光滑，硬膜囊无受压；脂肪片被纤维组织取代，周围纤维组织增生轻微，形成菲薄之纤维膜，与硬脊膜容易分离；带蒂肌肉瓣周围形成较多瘢痕与硬脊膜粘连重，肌肉瓣已完全纤维化，空白组形成瘢痕最多，与硬脊膜粘连最重。术后硬膜囊矢状径以硅胶膜组最大，脂肪片组次之，带蒂肌肉瓣组再次之，空白组最小。作者认为，硅胶膜与脂肪片能明显防止椎板切除术后纤维瘢痕粘连对硬膜囊的压迫，在支架诱导作用方面，硅胶膜优于脂肪片，在生物相容性方面脂肪片优于硅胶膜。带蒂肌肉瓣优于对照组，但不及前两者。     

Origin of spinal subdural hematomas: a postmortem anatomical study

OBJECTIVE: Although the mechanism by which cranial subdural hematomas form is known, the formation of spinal subdural hematomas is less clearly defined. The aim of this study was to identify vessels that can be found in the dural sac and whose rupture might lead to the formation of spinal subdural hematomas. MATERIAL AND METHOD: The dura mater, subdural space, and the arachnoid mater were studied in samples of dural sac taken from the eleventh thoracic vertebra to the fifth lumbar vertebra. The samples were taken from 3 fresh cadavers. Some were fixed in glutaraldehyde, dehydrated, and metallized with gold for scanning electron microscopy. Others were fixed in glutaraldehyde, treated with osmium tetroxide, and embedded in an epoxy resin for observation under a transmission electron microscope. RESULTS: Small hematomas--some on the internal surface of the dura mater and others surrounding nerve roots--were found within a thin, translucent arachnoid mater. Vessels measuring up to 100 microm were found within the dura mater, between its inner and outer laminae. Venules and capillaries were observed in the subdural space and in the arachnoid mater. CONCLUSIONS: Vessels are present between the laminae of the dura mater, in the subdural space, the arachnoid mater, and in spinal nerve roots. The rupture of these vessels could account for the formation of spinal subdural hematomas.     

The morphology and clinical significance of the dorsal meningovertebra ligaments in the lumbosacral epidural space

STUDY DESIGN.: A dissection-based study of 30 embalmed cadavers. OBJECTIVE.: To determine the morphology and morphometry of the dorsal meningovertebral ligaments in the lumbosacral segments and to discuss their clinical significance. SUMMARY OF BACKGROUND DATA.: Postoperative cerebrospinal fluid leakage is associated with longer hospital stays and significant implications for the patient, the surgeons, and society as a whole. To protect the dural sac during lumbar surgery, knowledge of the surgical anatomy of the dorsal meningovertebral ligaments is crucial. METHODS.: A total of 30 adult embalmed cadavers (52-70 yr of age; mean age of 64 yr) were used. The vertebral canal was divided to expose the dural sac and the spinal nerve roots, and the spinal cord was removed. The morphology, quantity, and attachment of the dorsal meningovertebral ligaments in the lumbosacral region were observed, and the length, width, or diameter and thickness of the ligaments were measured with vernier calipers. RESULTS.: The dorsal meningovertebral ligaments in the lumbosacral region connect the dura to the ligamenta flava or the lamina. The number of the attachment points on the ligamenta flava was relatively larger than that on the lamina, and the occurrence rate of dorsal meningovertebral ligaments was 97% at L5-S1. The thickest ligaments were observed at the L5 and S1 vertebrae. The length of the ligaments varied from 5.16 to 40.24 mm, and the ligaments extended caudally from their origin on the dura to their attachment to the lamina or the ligamentum flavum. The morphology of the dorsal meningovertebral ligaments was divided into 5 types: strip type, cord type, "Y"-shaped type, grid type, and thin slice type. CONCLUSION.: The dorsal meningovertebral ligaments may contribute to dura laceration and epidural hemorrhage during flavectomy and laminectomy, and an appreciation of this relationship might help reduce the risk of such complications.     

A model of unilateral frontal focal cerebral venous occlusion in the rat.

OBJECTIVE: The aim of this experimental study was to create a new focal venous infarction model in rats. METHOD: 20-male Sprague-Dawley rats were used in this experiment. Unilateral frontal strip craniectomy was done in front of the coronal suture. Frontal veins were observed by using the operative microscope. In this study we used the bipolar coagulation method over the transparent dura mater for occlusion of the bridging veins for venous infarction. Specimens were evaluated by histopathological techniques. RESULTS: Unilateral frontal hemispheric swelling, midline shift, brain edema, subcortical petechial hemorrhage, hemorrhagic infarction and necrosis were the histopathological findings on microscopic examination. CONCLUSION: Our results revealed that the bipolar coagulation method over the transparent dura mater for occlusion of the unilateral frontal cortical veins for venous infarction might be a new experimental model in the evaluation of brain damage after disturbance to the venous circulation.     

术中超声监测在经后路硬膜囊前方减压治疗胸腰椎骨折伴截瘫中的应用

目的　观察超声扫查法对判断硬膜囊前方致压因素及减压完全与否的实用价值。方法　１６ 例患者经后正中切口切除椎板后,于手术区域注入生理盐水,以频率为５．０ ＭＨｚ 的超声探头进行扫查。结合术前影像学检查（ＣＴ或ＭＲＩ）,判断硬膜囊前方致压因素的位置。然后在超声仪监测下取出游离于椎管内的组织碎块（ 骨或间盘）,并在Ｄｉｃｋ 器械的帮助下将受损伤脊柱的远、近端复位,对向后膨出的骨块,在超声监测下向前方嵌入复位。应用超声判断硬膜囊前方完全复位的指征为前侧蛛网膜下腔清晰可见,前侧硬膜囊回声平滑。结果　１６ 例术中均达到了硬膜囊前方减压的超声标准,术后Ｘ 线片及ＣＴ 复查未见有后移骨块,其中１３ 例患者神经功能获部分或完全恢复。结论　在超声监测下不仅可辨认出硬膜囊前方的致压因素,而且还为施术者提供了判断硬膜囊前方减压完全与否的可靠标准。     

The morphology and clinical significance of the dorsal meningovertebra ligaments in the cervical epidural space

Background contextThe dural sac is anchored within the vertebral canal by connective tissue called meningovertebral ligaments in the epidural space. During flavectomy and laminectomy, inadvertent disruption of the dorsal meningovertebral ligaments may lead to dura laceration and cerebrospinal fluid (CSF) leaks. All the described dorsal meningovertebral ligaments were located in the lumbar region. A rare study is available about dorsal meningovertebral ligaments of the cervical spinal dura to the adjacent vertebrae.PurposeTo identify and describe the dorsal meningovertebral ligaments at each cervical level and discuss their clinical significance.Study designA dissection-based study of 22 embalmed cadavers.MethodsThe anatomy was studied in 22 whole cervical cadavers (11 females, 11males), prepared with formaldehyde, whose ages at the time of death ranged from 55 to 78 years. The vertebral canal was divided to expose the dural sac and the spinal nerve roots. At all levels of the cervical vertebra, the morphology, quantity, origin, insertion, and spatial orientation of the dorsal meningovertebral ligaments were determined and the length, width or diameter, and thickness of the ligaments were measured with vernier calipers.ResultsThe dorsal meningovertebral ligaments in the cervical region anchored the posterior dural sac to the ligamentum flavum or laminae. The number of attachment points on the ligamentum flavum was relatively larger than that on the lamina, and the occurrence rate of dorsal meningovertebral ligaments was 100% at C1–C2 and C4––C5. The thickest ligaments were observed at the C1 and C2 vertebrae. The length of the ligaments varied from 1.50 to 35.22 mm, and the orientation of the ligaments mostly was craniocaudal. The morphology of the dorsal meningovertebral ligaments was divided into four types: strip type, cord type, grid type, and thin slice type.ConclusionsIn the cervical spine, the dorsal meningovertebral ligaments exist between the posterior dural sac and the ligamentum flavum or lamina. The dorsal meningovertebral ligaments may be of clinical importance to surgeons. Dissecting the dorsal meningovertebral ligaments before the cervical flavectomy and laminectomy may be an important step in reducing postoperative dura laceration and CSF leaks, which may result in significant benefits for patients and health-care organizations.     

Metastatic hepatocellular carcinoma presenting as epidural hematoma: case report

OBJECTIVE: Sacrifice of a bridging vein in the cranial base occasionally may cause significant postoperative morbidity. We report a simple method for preserving large bridging veins of the cranial base by reflecting the dura when a subtemporal or transsylvian approach is used. METHODS: In the subtemporal approach, when a larger bridging vein enters the dura attached to the bone of the temporal base before it empties into the dural sinus, the dura is dissected widely from the bone and is cut vertically toward the medial side of the temporal base in front of the entrance of the vein into the dura. The dura, which includes part of the entrance and interdural course of the vein, is reflected and retracted over the brain. In the transsylvian approach, when the bridging segment of the superficial sylvian vein becomes taut because of retraction of the temporal lobe, the dura is incised along the sphenoid ridge and is dissected and freed from the sphenoid bone. RESULTS AND CONCLUSION: This dura-reflecting technique facilitates brain retraction without exerting tension on the bridging vein of the cranial base and is expected to help avoid injury to bridging veins during neurosurgical procedures.     

颈椎前路减压术中硬膜外造影术

目的在颈前路减压手术的同时行硬膜外造影术,以避免减压节段内残留压迫性组织并探讨此术式的临床效果。方法在直视下完成颈椎前路间隙或椎体次全切除减压术后,切开或切除后纵韧带,使用18#软套管注射针头,将5￣10mlOmnipaque300造影剂注入减压节段的上下方,采用“C”型臂X线机透视,观察造影剂在硬膜囊前方的分布情况,以此判断脊髓是否获得完全减压。共64例颈椎病患者进行了术中硬膜外造影术,男39例,女25例;年龄32～64岁,平均49岁。术后39例获得随访,随访9～16个月,平均13个月,其中18例在术后1￣12周内复查MRI。采用JOA评分比较手术前后神经功能。结果完成椎管减压后,首次造影显示造影剂连续者49例(77%),其中11例术后复查MRI,显示再无脊髓压迫。首次造影显示造影剂不连续者15例(23%),经进一步减压,造影剂开始出现连续;其中7例术后复查MRI,显示再无脊髓受压。39例获得随访的病例,术后神经功能恢复率52%,终末随访时,神经功能恢复率上升至61%,无一例神经症状加重者。终末随访时JOA评分与术前、术后相比,差异有统计学意义。结论在颈椎前路减压手术中,硬膜外造影术能够有效判断椎管内减压情况,操作方法简单,安全可靠。     

Laminar hook instrumentation in the cervical spine. An experimental study on the relation of hooks to the spinal cord

Several anterior and posterior methods are today available for stabilization of the cervical spine. Factors such as level and degree of instability, method of decompression, bone quality, length of fixation and safety factors influence the choice of method for a particular patient. The use of laminar hooks in the cervical spine has been restricted by fear of cord compression with the potential of tetraplegia. The aim of the present study was to assess the safety and determine the anatomical relation between hooks inserted in the cervical spinal canal and the dura and spinal cord. Thirteen cadavers from seven women and six men with no evidence of cervical spine disorder were included. The mean age was 81.3 years (range 65-101 years). The cervical spine was instrumented with cervical Compact Cotrel Dubousset hooks and rods. The effect of the hook on the dura was studied by myelography in nine cadavers. The deformation of the dural sac was quantified by measurement of the maximal width of the indentation of the contrast column at each level. A CT myelography scan was obtained in three cadavers. The ratio between the distance of maximal hook intrusion into the spinal canal and the canal diameter in the direction of the hook was calculated. The relation between inserted hooks and the spinal cord and dura was documented in a fresh cadaver studied with CT myelography. A hemilaminectomy was performed at all levels in three cadavers with direct visual inspection and photography of the hook sites before and after excision of the dura. A dural deformation of 2 mm or less, as observed by myelography, was found at four out of 77 (5%) hook sites. The deformation was caused by a supralaminar hook at C3, C6 and C7 and by an infralaminar hook at C6. The mean hook intrusion in the spinal canal, as observed on CT, was 27% (range 8-43) of the canal diameter. On visual inspection, 14 out of 18 hooks were in contact with the dura. After removal of the dura, two out of the 18 hooks in the same cadaver were in contact with the spinal cord. However, no deformation of the cord was observed. To our knowledge this is the first study systematically documenting the relation between hooks and the spinal cord in cadavers. In 95% of the hooks no deformation of the dural sac was observed and there was no evidence of spinal cord deformation. From an anatomical point of view, laminar hook instrumentation can be considered a safe procedure. The study shows, however, that hooks inserted in the cervical spine have a close anatomical relationship with the neuraxis, and at stenotic levels the use of other techniques is therefore recommended.     

腹部带蒂皮瓣设计改进及临床应用

目的　探讨传统腹部带蒂皮瓣切取后 ,皮瓣供区创面的闭合方法。　方法　按设计切取下腹带蒂皮瓣(供移位皮瓣 )后 ,以皮瓣蒂左右为起点分别以弧线向两侧延长切口至髂前上棘 ,通过分离形成可向移位皮瓣供区创面移动的对侧和同侧腹壁皮瓣 (供覆盖腹壁创面皮瓣 ) ,通过此皮瓣向相对应方向推移 ,闭合供移位皮瓣创面。 1998年 9月～2 0 0 3年 9月临床应用 12例 ,男 5例 ,女 7例。急诊手术 4例 ,择期手术 8例。病程 2 8～ 6 2 d。皮肤缺损为 7cm× 11cm～12 cm× 13cm。　结果　经皮瓣设计改进 12例 ,均一期闭合移位皮瓣供区创面 ,12例皮瓣全部成活。 1例覆盖腹壁创面皮瓣 (皮瓣对侧 )尖端坏死 ,范围 1.5 cm× 2 .0 cm,经换药后痊愈 ,其余供覆盖创面皮瓣均 期愈合。　结论　应用改进设计的腹部带蒂皮瓣 ,可免除较大皮瓣创面的植皮手术 ,为临床治疗提供了一种方法。