胆道外科:路在何方?

从内镜、腹腔镜、机器人外科出现以后,一些胆道外科同仁就发出了一个问题,传统胆道外科向何处去?自从1882年第1例胆囊切除术之后,胆道外科一直停留在Langenbuch时代,而今,胆囊切除术95%都被腹腔镜做了,胆管下端括约肌手术基本上都是内镜做了,还有一些其他手术和介入处理,那么胆道外科向何处去?这并不是不需要思考的问题.其实,由肝内胆管和肝外胆管组成的胆道系统,一共有10个分级,只有3个是在肝外,而7个都在肝内.同时,胆道并不是单纯的一个管道,它是一个器官,是一个系统.那么胆道外科应该立足在什么地方、怎么办自然就很清楚了.     

腹腔镜肝切除术适应证再探讨

1991年Reich等[1]成功实施了世界首例腹腔镜肝切除术,开辟了腹腔镜技术在肝脏外科临床应用的先河。历经20余年的临床实践,克服重重困难,腹腔镜肝切除术已成为一项较成熟的外科术式,应用范围逐步拓展,手术安全性大大提高。     

微创肝切除手术入路动态匹配决策模型及应用

<正>自1991年Reich等~([1])完成首例腹腔镜肝切除术,肝脏外科进入了微创手术的时代。尽管微创手术已成为当代外科发展的主要趋势,但由于肝脏双重血供、管道变异较多的解剖学特性及对术中显露、控血技术的高要求,早期微创肝切除的发展举步维艰。1991～2001年全球共报道腹腔镜肝切除术200例~([2]),同期我国仅报道完全腹腔镜肝切除术17例,其中大部分是有选择的边缘型肿瘤切除、肝左外叶     

机器人肝脏切除手术的临床现状与研究进展

随着外科手术器械和腹腔镜技术的不断发展,肝脏外科已经进入微创外科和精准外科时代。机器人辅助肝脏切除术已包含几乎所有传统开腹手术的适应证。目前临床研究显示,与开腹手术和传统腹腔镜手术相比,达芬奇手术机器人在肝脏切除术中的应用是安全、可行的。本文综合文献报道及临床实践,针对达芬奇机器人在肝脏切除术的临床现状和研究进展做一综述。     

机器人肝切除术与腹腔镜肝切除术治疗结直肠癌肝转移的对比研究

目的 探讨对比机器人与腹腔镜肝切除术治疗结直肠癌肝转移的安全性和有效性.方法 回顾性分析2019年4月至2020年6月南京大学医学院附属鼓楼医院肝胆外科实施的结直肠癌肝转移手术切除患者资料,其中达芬奇机器人肝切除术(机器人组)25例,腹腔镜肝切除术(腹腔镜组)28例,对比分析两组临床基本信息、手术时间、术中出血输血情况...     

全腹腔镜下超左半肝切除术

近年来,随着腹腔镜技术的进步和专用手术器材的发展,腹腔镜肝切除的范围已由肝缘、浅表病变的局部切除扩大到半肝乃至更大范围的肝切除.尤其是腹腔镜技术和肝外科技术的有机整合使全腹腔镜下超半肝切除术的实施成为可能.     

腹腔镜肝脏切除术

腹腔镜手术具有创伤轻,术后恢复快等优点。近年来,随着腹腔镜外科技术的不断成熟及腹腔镜器械的不断改进创新,手术的安全性得以不断提高,腹腔镜手术己向腹部外科的各个领域渗透。目前,一些腹腔镜手术如腹腔镜胆囊切除术、胃底折叠术已成为标准的手术方式,并开始探索腹腔镜下完全或部分实质器官的切除,腹腔镜肝切除术处在整个腹腔镜外科的最前沿。1991年,Reich等首先报道了腹腔镜肝脏切除术。此后,有关此类手术的报道不断增加。国内,周伟平教授于1994年完成了国内首例腹腔镜肝脏切除术。笔者于1998年率先采用刮吸解剖法断肝术行完全腹腔镜下…     

机器人辅助腹腔镜肝切除术难点及对策

近年来,机器人手术系统被越来越多地应用于肝脏外科手术中,其手术适应证亦逐步扩大。除传统腹腔镜肝切除术的一些创伤小和恢复快的优势外,机器人辅助腹腔镜由于具备内腕结构和精细操作能力,更加适用于一些复杂的肝切除手术。目前有关机器人辅助腹腔镜肝切除手术仍处于逐步完善阶段,一些具体操作细节如体位、trocar布局、术中肿瘤定位、血流阻断和肝实质离断等方面,均明显有别于传统腹腔镜肝切除技术。尽管机器人辅助腹腔镜肝切除术的近期效果与传统腹腔镜乃至开腹手术相当,但由于总体例数还有限,且观察时限尚短,其长期治疗效果还有待于进一步评估。     

腹腔镜肝切除治疗肝肿瘤的临床应用体会

外科微创化是21世纪外科的发展趋向,而腹腔镜外科则是微创外科的重要组成部分.近年来,腹腔镜肝部分切除术报道逐渐增多[1],但由于肝脏解剖结构的特殊性,腹腔镜肝部分切除术仍面临许多困难.我院2008年4月至2009年11月共行腹腔镜肝切除20例,现回顾报道如下.     

腹腔镜肝切除术在肝血管平滑肌脂肪瘤中的应用

目的探讨完全腹腔镜肝切除术治疗肝血管平滑肌脂肪瘤(hepatic angiomyolipoma,HAML)的应用价值。方法回顾性分析2010年1月～2017年12月完全腹腔镜肝切除术治疗HAML 14例的临床资料,其中1例使用达芬奇机器人手术系统行右肝后叶切除术。结果手术时间80～280 min[传统腹腔镜(114. 6±51. 0) min,机器人手术280 min];术中出血量30～800 ml[传统腹腔镜(73. 1±27. 8) ml,机器人手术800 ml],并发症发生率14. 3%(2例肺炎),术后住院(7. 0±2. 0) d。全组随访8～98个月,中位数30个月,均未见复发。结论腹腔镜肝切除术(包括机器人手术)治疗HAML安全可行且具有微创优势,可有效用于肿瘤局部切除及规则性肝叶切除术。     

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??Minimally invasive surgery: changes in the changing world HUANG Zhi-qiang. Research Institute of Hepatobiliary Surgery PLA , General Hospital of PLA, Beijing100853??China
Abstract Since the first laparoscopic cholecystectomy undertaken at 1991 in China mainland, the progress of minimally invasive surgery in every field of surgical practice, both technically and conceptually, was rapid and widespread. Laparoscopic liver resection is no more a dream, but a reality. 2804 cases of hepatectomies under laparoscope have been collected from English literatures. Laparoscopic resection may be the modality of treatment for benign tumors of the pancreas, and minimally invasive surgery may serve as the method of injury control in cases of severe acute necrotizing pancreatitis and other severe surgical illness. Now, natural orifice transluminal endoscopic surgery (NOTES) and robotic surgery are gaining more and more great interest. The combination of imaging technology-endoscopy-laparoscopy-robotics-NOTES may make a great impact on present day surgery. Surgery to-day may be more and more digitalized.     

腹腔镜手术治疗胰腺肿瘤的现状

Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use.In the past,minimally invasive techniques in pancreatic surgery were only used for diagnostic laparoscopy,staging of pancreatic cancer and palliative procedures for unresectable pancreatic cancer.A growing number of case series and multi-institutional reports on safety and efficacy of minimally invasive pancreatic resection have been published.Current knowledge on minimally invasive pancreatic resection is based mainly on short-term outcomes from a small number of centers with cohorts too small to make strong arguments for or against its use.In carefully selected patients,minimally invasive pancreatic resection is safe and feasible.However,the procedure should only be attempted by surgeons who are experienced in open pancreatic surgery and in laparoscopic surgery.The role and oncologic safety of minimally invasive approach for pancreatic resection for pancreatic cancer remain unknown.     

Laparoscopic and minimally invasive resection of malignant colorectal disease

Minimally invasive surgery for colorectal cancer is a burgeoning field of general surgery. Randomized controlled trials have assessed short-term patient-oriented and long-term oncologic outcomes for laparoscopic resection. These trials have demonstrated that the laparoscopic approach is equivalent to open surgery with a shorter hospital stay. Laparoscopic resection also may result in improved short-term patient-oriented outcomes and equivalent oncologic resections versus the open approach. Transanal excision of select rectal cancer using endoscopic microsurgery is promising and robotic-assisted laparoscopic surgery is an emerging modality. The efficacy of minimally invasive treatment for rectal cancer compared with conventional approaches will be clarified further in randomized controlled trials.     

Laparoscopic Liver Resection Using the Lateral Approach from Intercostal Ports in Segments VI,VII, and VIII

Journal of Gastrointestinal Surgery - Laparoscopic liver resection (LLR) has been developed as a minimally invasive surgery. However, challenges such as difficulty securing visibility and limited...     

Systematic Review of Minimally Invasive Pancreatic Resection

Background  Pancreatic resection is associated with a significant morbidity. Efforts to reduce hospital stay and enhance recovery have seen the introduction of minimally invasive surgical techniques. This article reviews the current published literature on the safety and efficacy of minimally invasive surgery of the pancreas. Methods  An electronic search of the PubMed and Embase databases was performed from 1996 to May 2008 to identify all relevant publications; studies meeting predefined inclusion criteria were retrieved and analyzed using a standardized protocol. Data on the safety and efficacy of minimally invasive surgery of the pancreas were recorded and analyzed. Results  Of 565 abstracts reviewed, 39 studies were identified as eligible for inclusion. There were 37 case series and two case control studies. Compared with open pancreatic surgery, minimally invasive pancreatic resection is similar in terms of morbidity and mortality. Blood loss and length of stay are decreased. Conclusions  Laparoscopic distal pancreatic resection and enucleation of insulinoma appear to be safe procedures with reduced hospital stay, though morbidity remains significant. The evidence for laparoscopic pancreaticoduodenectomy is in its infancy, but the authors feel it is unlikely that many centers will achieve sufficient case load to make the introduction of minimally invasive resection feasible.     

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??Issues to be concerned for the implementation of perfect cholecystectomy in the era of minimally invasive surgery LI Hang-yu??LIU Jin-gang. Department of General Surgery??the Fourth Affiliated Hospital of China Medical University??Shenyang 110032??China
Corresponding author??LIU Jin-gang??E-mail??liujg51347@hotmail.com
Abstract Recently??laparoscopic cholecystectomy has become the preferred choice for the treatment of benign gallbladder diseases. Laparoscopic cholecystectomy has become a kind of routine operation??but there are still many imperfect performances in the aspects of preoperative preparation??intraoperative and postoperative disposal. Therefore??with the purpose of improving patient’s survival benefit??the implementation of perfect cholecystectomy under the guidance of precision medicine??individualized treatment and enhanced recovery after surgery is needed in the era of minimally invasive surgery??so as to encourage patients operated with minimally invasive gallbladder resection recovery in a safe and effective way.     

中国微创胃肠外科发展的思考

腹腔镜技术在结直肠肿瘤与早期胃癌中的应用已经获得广泛的认同与开展。在我国,微创胃肠外科经历了上世纪90年代良性病变及功能修复性手术的第一阶段和本世纪初10年的恶性肿瘤手术的关键技术突破、技术规范、推广普及的第二阶段．目前已在全国几乎所有的大中型医院都得到开展：下一个10年或更长的时间内将如何发展,是摆在我们面前的关键问题。把握正确的方向．开拓视野,踏踏实实努力工作．提升我国胃肠外科的诊疗水平,是我们共同的责任与目标。     

Laparoscopic central pancreatectomy

BACKGROUND: The role of mini-invasive surgery in pancreatic surgery is still being debated. Indications and results are still controversial. Only a few centers in the world report on laparoscopic pancreatic resections. With the aim of improving the use of minimally invasive surgery, we have devised a novel laparoscopic procedure for surgical treatment of neuroendocrine tumor of the neck of the pancreas. METHODS: A central laparoscopic pancreatic resection was successfully performed. The pancreatic resection was performed using the harmonic scalpel. The duct was isolated and transected. The proximal duct stump was closed by an endoscopic stitch. The pancreaticojejunostomy was intracorporeally performed using a Roux-en-Y loop. RESULTS: Histologic findings showed a well differentiated neuroendocrine tumor. Operating time was 330 minutes and blood loss 300 mL. The postoperative course was uneventful. CONCLUSIONS: Laparoscopic central pancreatectomy is a feasible and safe procedure. The minimally invasive approach ensures an adequate treatment despite requiring the expertise of highly skilled laparoscopic surgeons.     

腹腔镜结肠直肠肿瘤切除术的临床作用

目的：探讨腹腔镜手术在结肠直肠肿瘤切除术中的应用和临床效果。方法：利用腹腔镜技术对109例结肠直肠肿瘤病人进行手术，并对手术操作、术后情况以及并发症等进行分析。结果：109例病人中转开腹手术11例，占10．1％。98例采用腹腔镜方法完成手术切除，其中结肠直肠腺瘤3例，结肠直肠癌95例。95例结肠直肠癌行姑息性切除5例，根治性切除90例；术式为Miles手术31例，右半结肠切除27例，乙状结肠切除18例，前切除16例，降结肠切除2例，横结肠切除1例。本组病人术中无其他脏器损伤、大出血、气体栓塞等发生，术后无因出现并发症而行再手术治疗者，无一例死亡。在进行根治性切除并达到术后半年以上的病人中，目前有局部复发1例，肝和肺转移各1例，术后复发转移率为5．7％。目前尚未发现有腹壁切口和穿刺孔转移。结论：腹腔镜结肠直肠肿瘤切除手术创伤小，安全、可行，具有广阔的推广应用前景。