腹腔镜高位肛门闭锁一期成形术4例报告

目的 探讨腹腔镜辅助下高位肛门闭锁一期肛门成形术的可行性。方法先天性高位肛门闭锁患儿4例，男3例，年龄1天～3天；女1例，年龄3个月，为先天性-穴肛畸形。术中首先腹腔镜监视下，游离直肠，分离结扎断离直肠尿道瘘管；然后通过穿刺盆底肌肉中心形成隧道，将直肠从中脱出，与会阴皮肤吻合。结果4例均在腹腔镜辅助下一期完成肛门成形术，腹腔镜手术操作时间40分钟～90分钟，平均718分钟。出血量(5—20)ml，平均8．3ml。无需要输血，未出现术中并发症。所有病人术后恢复顺利，于术后11天去除尿管和膀胱造瘘管，无尿道瘘憩室发生，无切口感染。术后随访3月至1年，I例手术后1月出现肛门狭窄，于术后3月行狭窄段切除术治愈。另外3例无并发症发生，目前4例排便控制功能良好。结论腹腔镜铺助肛门一期成形术是治疗高位肛门闭锁的有效方法，手术打击小，处理直肠泌尿系瘘方便，辨认盆底肌中心准确，可免除患儿分期手术。     

腹腔镜辅助中位肛门闭锁成形术11例报告

目的 探讨腹腔镜辅助中位肛门闭锁成形术的可行性。方法 腹腔镜监视下,游离松解直肠;断离修补直肠尿道（阴道）瘘管,其中6例经腹腔镜离断修补,4例经会阴切口离断修补;然后在电刺激仪的引导下经会阴肌肉中心1.0cm左右小切口向盆底肌肉中心分离形成隧道,最后将直肠从隧道中拖出,与会阴皮肤吻合,同时关闭结肠造瘘口。结果 11例患儿均在腹腔镜辅助下完成肛门成形术,腹腔镜手术操作时间平均32.8min（25～78min）,出血量平均5.3ml（2～10ml）,无需要输血者。术后11d去除尿管或膀胱造瘘管,无尿道瘘或憩室出现,无切口感染发生。11例术后随访3～66个月,平均45个月。根据肛门功能临床评分标准评分（6分法）,排便优8例（72.7%）,良3例（27.3%）。结论 腹腔镜辅助中位肛门闭锁成形术处理直肠泌尿系瘘方便,辨认盆底肌中心准确及避免切口污染等优点,是治疗中位肛门闭锁有效方法。     

腹腔镜在婴幼儿肛门闭锁手术中的应用

比较小儿科其他病种的腹腔镜临床应用,在先天性肛门直肠畸形中的应用相对开展较晚,并且其推广和普及程度也不同于其他术式,相对滞后,并存在一定争议。美国Georgeson等2000年首先报道了11例腹腔镜辅助下将直肠经会阴拖出治疗先天性肛门闭锁,其中7例为新生儿期先行结肠造瘘术后,二期在腹腔镜辅助下行肛门直肠拖出成形术;4例为新生儿一期拖出,     

一期后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形疗效分析

目的探讨一期后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形的疗效。方法回顾分析了2003年10月至2008年4月在我院采用后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形12例．总结术后疗效并随访其排便功能。结果病例随访显示,12例患者的肛门具有良好收缩力,无明显肛门失禁,排便功能良好,效果满意。排便情况经临床评分结果为优良。结论经后矢状入路肛门直肠成形术治疗中高位肛门直肠畸形,可以达到充分暴露术野．缩短治疗时间的目的,效果良好。     

腹腔镜技术在小儿肛门闭锁中的应用

目的探讨腹腔镜辅助下先天性高位、中位肛门闭锁患儿手术的可行性。方法 6例先天性高位、中位肛门闭锁患儿,均在腹腔镜监视下游离出直肠盲端及瘘管,切断瘘管,腹腔镜下修补尿瘘或阴道瘘。电刺激找到盆底肌肉中心点,做成一隧道,将直肠盲端从此隧道内拖出,与肛穴缘皮肤吻合。结果 6例均在腹腔镜辅助下完成直肠肛门成形术。腹腔镜手术操作时间35～74 min（平均46.5 min）,术中出血量〈15 ml,住院时间10～18 d（平均14.5 d）。无并发症发生。术后随访6～12个月,无肛门失禁、直肠后间隙感染等并发症,均能够正常排便。肛门功能评分优4例,良2例。结论腹腔镜辅助下直肠肛门成形术是一种安全、有效的方法,处理瘘管方便,辨认盆底肌中心准确,手术后可获得良好的排便功能,具有创伤小、恢复快、疗效优等特点。     

肛门直肠畸形的合并畸形

肛门直肠畸形（anorectal malformation,ARM）是全世界小儿外科医师关注的一个话题。同样。足够的注意力也关注到了与ARM合并的其他系统的多发性先天性畸形。合并畸形的发生率约为50％～60％,ARM的位置越高,合并的畸形越多。许多合并畸形只是偶然发现,而有些畸形如心血管缺陷则可危及生命。     

基层医院治疗先天性肛门直肠畸形的体会

目的 探讨在基层医院开展治疗先天性肛门直肠畸形的方法。方法 1995年以来共收治36例患儿,对14例进行手术治疗,其中一期肛门成形术12例,二期手术2例。结果 一期腹会阴联合肛门成形术死亡2例,4例肛门狭窄,1例直肠尿道瘘复发;二期手术者全部治愈,无并发症。结论 在基层医院治疗先天性肛门直肠畸形,应争取手术治疗挽救患儿生命,一期手术损伤大、风险高、并发症多,应争取二期手术。     

经肛门拖出切除法在腹腔镜高中位直肠前切除术中的应用

腹腔镜微创手术在结直肠领域不断得到普及,并继续向创伤最小化发展。佛山市第一人民医院于2011年3月至2013年3月对部分行腹腔镜高或中位直肠前切除术的乙状结肠和直肠癌患者,采用经肛门拖出法切除肿瘤,共完成8例,取得较满意疗效,现报道如下。     

Hem-o-lok在后腹腔镜肾切除术中的应用

目的 探讨后腹腔镜下肾切除术中带锁塑料夹（Hem-o-lok）的应用效果. 方法 2003年11月～2006年11月行后腹腔镜下肾切除术178例.取腰部3个穿刺点入路,肾动脉和静脉分别用Hem-o-lok夹闭后切断,输尿管在近髂血管处切断.对于活体取肾,立即取出肾脏用4 ℃肾脏保存液灌注肾脏. 结果 178例手术均成功,无中转开放手术,无Hem-o-lok滑脱.手术时间平均100 min（60～200 min）,术中出血量平均95 ml（20～200 ml）.并发症2例：肾静脉损伤1例,胰尾损伤1例.术后住院平均5 d（4～8 d）.病理报告：65例肾透明细胞癌,肾囊腺癌3例,平滑肌肉瘤1例,肾淋巴瘤1例,肾嗜酸细胞瘤2例,肾错构瘤2例;输尿管移行细胞癌12例,输尿管鳞癌2例;肾盂移行细胞癌31例,肾盂黄色肉芽肿1例;肾结核4例,副肾1例,肾结石4例,肾积水4例,肾脓肿1例.136例随访1～36个月,平均25个月,64例随访＜1年,53例随访1～2年,19例随访2～3年,未发现肾窝及切口转移,未发现远处转移. 结论 后腹腔镜下肾切除术中使用Hem-o-lok处理肾脏血管安全可靠,疗效良好,对于活体取肾保证供肾血管长度有优势.     

Hem-o-lok结扎锁在腹腔镜阑尾切除术中的应用

目的总结腹腔镜阑尾切除应用Hem-o-lok结扎锁处理阑尾根部的经验。方法 2009年5月～2011年6月对284例急性阑尾炎和40例慢性阑尾炎急性发作行腹腔镜阑尾切除术,超声刀切断系膜至阑尾根部,16 mm Hem-o-lok结扎锁(Weck Closure Systems)处理阑尾根部。根部近心端1～2枚Hem-o-lok结扎锁夹闭,远心端以超声刀切断。结果 324例均顺利完成手术,未发生严重并发症。阑尾根部处理顺利,所有病例均用结扎锁完成,无结扎锁滑脱现象。手术时间20～70 min,平均35 min。术中出血2～20 ml,平均10 ml。术后住院3～5 d,平均4 d。300例随访5～14个月,平均7个月,无切口感染、再发右下腹痛等发生。结论腹腔镜阑尾切除术中应用Hem-o-lok结扎锁处理阑尾根部,安全可靠,经济实用,操作方便,值得临床推广应用。     

用Hem-o-Lok结扎夹行腹腔镜胆囊切除

目的探讨使用Hem-o-Lok结扎夹行腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的方法及优势.方法用Hem-o-Lok结扎夹对288例胆囊结石及胆囊息肉样病变施行LC,均采用三孔法. 结果手术均获成功,无中转开腹,264例(92%)用中大号(ML)结扎夹,剑突下切口几乎无痛感,术后平均住院时间2.7 d(1～3 d).另24例因手术困难改用大号(L)结扎夹,均成功.无出血、胆漏、胆管损伤等并发症. 结论使用中大号(ML)Hem-o-Lok结扎夹行LC,可使剑突下切口仅5 mm,使用常规的腹腔镜手术设备即可.     

Anorectal malformation with tubular hindgut duplication

The association of hindgut duplication and anorectal malformation is rare. Published classifications of this association are confusing in respect of terminology. We report a case of blind-ending, Y-shaped tubular duplication of the distal hindgut, associated with an anorectal malformation (rectourethral fistula) affecting the colon proper. Surgical options at time of presentation and of reconstructive surgery are discussed. A review and suggested modification of the classifications is presented.     

腹腔镜前列腺癌根治术后自动结扎夹移位的原因分析及防治对策

目的分析腹腔镜前列腺癌根治术（LRP）术后自动结扎夹（Hem-o-lok）移位导致膀胱结石的原因,探讨预防LRP术后膀胱结石发生及其治疗的方法。 方法回顾性分析2014年1月至2019年12月中山大学附属第三医院收治的12例LRP术后发生Hem-o-lok移位致膀胱结石病例资料,包括手术方案、术中情况、Hem-o-lok放置部位及数量、吻合口张力、膀胱碎石术中所见等,分析Hem-o-lok移位致膀胱结石的可能因素。 结果12例患者病理分期T1a-T2cN0M0,均行经腹腔/腹膜外LRP,术中在吻合口附近使用Hem-o-lok 1～2枚,在前列腺侧韧带附近使用Hem-o-lok 4～8枚,术后6～15个月出现膀胱结石1～2颗,结石核心为Hem-o-lok,其中2例合并吻合口狭窄,1例合并吻合口Hem-o-lok嵌顿。采用经尿道狭窄环冷刀切开及瘢痕电切术处理膀胱颈狭窄,气压弹道碎石及取出Hem-o-lok,术后痊愈出院。 结论在LRP术中,合理使用Hem-o-lok以及熟练的吻合技术,是预防术后吻合口狭窄及减少其移位形成膀胱结石的关键。     

Postoperative Fecoflowmetric Analysis in Patients with Anorectal Malformation

Because conventional methods of evaluating anorectal function do not necessarily provide good correlations between investigative results and symptoms in patients who have undergone surgery for an anorectal malformation (ARM), we recently introduced feco-flowmetry (FFM) to simulate natural anorectal evacuation. The purpose of this study was to embody significant parameters to elucidate the dynamics of anorectal activity on FFM. The parameters of FFM were compared with those of manometry and Kelly's clinical score (KCS) in 24 patients who underwent surgery for an ARM. There were three fecoflow patterns, namely, block (B) type, segmental (S) type, and flat (F) type. The B-type or S-type patterns were seen in patients classified as "clinically good." There were close relationships between the fecoflow pattern and both the operative procedure and the KCS (P = 0.01 and 0.001, respectively). Maximum fecal stream flow rate (Fmax) precisely reflected the tolerance rate of intended normal saline solution in the colorectum (TR), the evacuative rate (ER), and KCS. Fmax > 45 ml/s or TR > 70% or ER > 50% was statistically regarded as the borderline of fecal continence. Thus, the fecoflow pattern might reflect the motor activity of the pelvic floor muscle. FFM provided quantiative and qualitative evaluations concerning anorectal motor activity in patients who had undergone surgery for an ARM.     

Anorectal malformations with good prognosis: Variables affecting the functional outcome

Backgroud/Purpose

The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis.

Methods

Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery.

Results

6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p = 0.0029 and p = 0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5 ± 7.2 mmHg vs 32 ± 7.9 mmHg, p = 0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22 ± 10.24 mmHg vs 32.57 ± 6.68 mmHg, p = 0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p = 0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p = 0.014).

Conclusions

Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.     

Anorectal malformation and Down's syndrome in monozygotic twins

Anorectal malformation (ARM) can be divided in high, intermediate, and low forms according to the level of termination of the rectum in relation to the pubococcygeal and ischiatic lines. Patients with Down's syndrome have a high incidence of gastrointestinal anomalies, such as tracheoesophageal fistula, duodenal obstruction, annular pancreas, Hirschsprung's disease, and ARM. In these children, ARM is generally low with or without a fistula. The mode of inheritance of ARM and its genetic relation with Down's syndrome is not known, even if the association (ARM-Down's syndrome) seems not to be coincidental. We describe here a very rare case of monozygotic twins born with the association of ARM and Down's syndrome.     

Efficacy of Laparoscopic Management of Posterior Urethral Diverticulum in Anorectal Malformations

BackgroundA posterior urethral diverticulum (PUD) is a serious postoperative complication after anorectal malformation correction. Complete resection is technical demanding because of limited retrourethral working space deep in the pelvis.ObjectiveWe pioneered the single-incision laparoscopic approach for PUD excision and evaluated the efficacy.Design, setting, and participantsTwenty-six PUD patients undergoing redo surgeries between June 2011 and June 2021 were reviewed.Surgical procedureA series of transabdominal retraction sutures were placed through the PUD to facilitate dissection. The contents were evacuated to create a working space. Distal PUD dissection was carried along the submucosal layer to prevent injury of the urethra/pelvic nerve complex. The rectal mucosa was peeled off from the junction site for complete PUD excision. The muscular cuff of the distal rectum was then oversewn.MeasurementsOperative time, postoperative recovery, and complications were assessed.Results and limitationsThe mean age of redo surgery was 2.46 yr. The average operative duration was 2.35 h. The mean postoperative hospital stay, resumption of full diet, and bowel movement were 10.23, 2.15, and 1.54 d, respectively. The median follow-up period was 46 mo (12–132 mo). No remnant of PUD, recurrent fistula, or urinary leak was detected. None of the patients had difficulty in urination, urinary dribbling, urinary tract infection, constipation, or soiling. All patients retained morning erection, and two postpubertal patients had ejaculations.ConclusionsOur single-incision laparoscopic redo surgery provides an effective approach for PUD excision. It minimizes complications. It also preserves urinary and bowel continence and sexual function.Patient summaryComplete resection of a posterior urethral diverticulum (PUD) in anorectal malformation is technically demanding because of limited retrourethral working space in the deep pelvis. The outcomes of single-incision laparoscopic PUD excision were satisfactory.     

腹腔镜低位直肠癌经肛拖出切除吻合术的临床应用

目的 探讨腹腔镜低位直肠癌经肛拖出切除吻合术的临床应用价值.方法 2009年6月～ 2011年9月,对45例低位直肠癌行腹腔镜经肛拖出切除吻合术,均行腹腔镜下全直肠系膜切除,并行预防性回肠造瘘.结果 45例均完成手术,无中转开腹,切割圈均完整,无输尿管损伤.手术时间185 ～ 260 min,平均215 min,术中出血量50 ～250 ml,平均110ml.切除淋巴结15 ～ 20枚,平均16.5枚,术后病理9例有阳性淋巴结.术后回肠造瘘排气时间3～5d,平均3.5d,留置导尿3～4d.术后无切口感染、肠粘连、切口裂开,术后住院时间12～ 17 d,平均15 d.随访15～28个月,平均23个月,未发现局部复发及远处转移.回肠造瘘回纳后,肛门控便、控气功能良好.结论 腹腔镜低位直肠癌经肛拖出切除吻合术安全可行,为瘤体较小、组织学分型好的早、中期的低位直肠癌提供一种较好的术式选择.