Mirror glasses for minimally invasive surgery

Introduction The operator performing minimally invasive surgery is prevented from seeing the whole field with both eyes by the restricted small thoracotomy incision. To overcome this problem, we developed mirror glasses. Methods Use of these glasses was evaluated in terms of the time required for threading of sutures with endoscopic forceps. Three surgeon ligated thread a suture five times with and without use of the glasses in the box, and the mean time was calculated for each surgeon. Results The time required for ligation (mean ± SD) was 24.2 ± 2.9 s with mirror glasses and 27.0 ± 2.5 s without the glasses (p = 0.01). Conclusion The mirror glasses may be found useful for fine manipulation for minimally invasive surgery.     

机器人微创心脏手术的应用现状

微创是心脏外科的发展方向之一.随着自动机械和计算机技术的进步,机器人微创外科手术已成为现实.机器人微创心脏手术具有创伤小、操作精细等优点,是微创心脏外科的前沿技术之一.作为一种革新的手术方式,机器人辅助下微创心脏手术得到了极大的关注,本文就机器人心脏手术的临床应用及手术效果作一综述.     

质量赢未来:我国微创外科的发展路径

医疗质量始终是医疗技术得到发展的首要条件.要提高一项医疗技术乃至一个学科的水平和质量,首先需有正确的规范在质量控制上加以管理和约束以保障医疗质量;其次,需要有多中心协作、设计合理的临床研究以保障研究质量,为其进一步发展推广提供坚实可信的数据基础;再次,需要有完善的人才培养和培训体系以保障人才质量,为其发展提供源源不断的新生力量;最后,尚需有创新思维和理念,推动其在未来竞争中不断获得更高层次的发展.     

微创手术平台与微创手术方式的未来走向

近30年来,随着能量平台、器械平台、显像平台三大手术平台的发展,微创外科有了突飞猛进的提升。以结直肠癌手术为例,手术方式的五要素都有着不同程度的发展：手术入路经历了"从大到小"的过程;切除范围从单纯肠段切除到根治术或扩大根治术,再到注重保留器官功能的手术;随着对正常淋巴引流方向和肿瘤淋巴转移特点的认知,淋巴结清扫愈趋规...     

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。     

Long-term results of minimally invasive surgery for symptomatic epiphrenic diverticulum

Background

The real incidence of epiphrenic diverticulum is unknown, and only 15% to 20% of cases are symptomatic.

Methods

From January 1994 to May 2009, 20 patients were treated laparoscopically for this condition.

Results

The most common operation performed was transhiatal diverticulectomy with myotomy and partial fundoplication. No case was converted to open surgery. Esophageal leak occurred in 1 patient (5%). The postoperative courses were uneventful in the remaining 19 patients. After a median follow-up period of 52 months (range, 1–141 months), 1 patient had died of squamous cell carcinoma, 1 had mild solid-food dysphagia, 1 had chest pain, and 1 had heartburn. Manometry was performed postoperatively in 7 patients; all had normal lower esophageal sphincter pressure. In 5 patients who underwent 24-hour postoperative pH monitoring, pathologic reflux was absent.

Conclusions

In patients with symptomatic epiphrenic diverticulum, laparoscopic surgery is feasible, providing good access to the distal esophagus and inferior mediastinum. Long-term outcomes are satisfactory.     

微创时代食管外科的现状与思考

食管癌是全球常见的恶性肿瘤之一,外科治疗因可根治性切除肿瘤和显著改善患者的症状而成为食管癌治疗的首选方式.食管胸腔镜手术近年来发展迅速,因其具有微创、出血少、疼痛轻、术后并发症少及术后恢复快等独特优势,并且在淋巴结清扫范围、术后生存率等方面与开胸手术基本相同.因此,在有条件的医院,胸腔镜手术目前已成为治疗食管良性疾病和早期食管癌的首选术式.但由于胸腔镜食管癌切除术与传统手术比较在操作上有许多不同点与难点,国内微创食管外科的发展现状总体来讲还处于不平衡阶段,开展较好的单位已经成为一种常规的术式,但绝大多数医院仍未开展这项手术.通过对食管胸腹腔镜手术发展历程及现状的总结,提出对微创食管外科的一些思考.     

Two year outcomes of minimally invasive hallux valgus surgery

Background

We report our experience with the Minimally Invasive Chevron Akin (MICA) technique for correcting hallux valgus, and evaluate its effectiveness and associated complications.

微创外科时代胆道外科的前程与归宿

Bile duct has great attraction to surgeons due to its special anatomical location,unique biological features and origin of complicate diseases. Minimally invasive surgery,represented by laparoscopic ch...     

Inconsistent reporting of minimally invasive surgery errors

Introduction

Minimally invasive surgery (MIS) is a complex task requiring dexterity and high level cognitive function. Unlike surgical ‘never events’, potentially important (and frequent) manual or cognitive slips (‘technical errors’) are underresearched. Little is known about the occurrence of routine errors in MIS, their relationship to patient outcome, and whether they are reported accurately and/or consistently.

Methods

An electronic survey was sent to all members of the Association of Surgeons of Great Britain and Ireland, gathering demographic information, experience and reporting of MIS errors, and a rating of factors affecting error prevalence.

Results

Of 249 responses, 203 completed more than 80% of the questions regarding the surgery they had performed in the preceding 12 months. Of these, 47% reported a significant error in their own performance and 75% were aware of a colleague experiencing error. Technical skill, knowledge, situational awareness and decision making were all identified as particularly important for avoiding errors in MIS. Reporting of errors was variable: 15% did not necessarily report an intraoperative error to a patient while 50% did not consistently report at an institutional level. Critically, 12% of surgeons were unaware of the procedure for reporting a technical error and 59% felt guidance is needed. Overall, 40% believed a confidential reporting system would increase their likelihood of reporting an error.

Conclusion

These data indicate inconsistent reporting of operative errors, and highlight the need to better understand how and why technical errors occur in MIS. A confidential ‘no blame’ reporting system might help improve patient outcomes and avoid a closed culture that can undermine public confidence.     

手术机器人在微创外科的应用进展

微创外科是二十世纪医学科学发展的伟大成就之一,以切口小、创伤轻、痛苦少、恢复快等优点迅速在外科各专业领域得以推广应用。手术机器人的出现,使微创外科的发展进入新的一页。目前手术机器人的临床应用已扩展到外科领域的各个分支,极大地拓展了传统的腹腔镜微创外科,将掀起微创外科的又一次新技术革命浪潮。     

483例微创手术在胸外科的临床应用

目的探讨微创手术在胸外科疾病诊治应用价值。方法回顾性分析我科在1996年6月至2006年6月采用电视胸腔镜手术（VATS）及电视胸腔镜辅助下或手辅助下小切口手术共治疗483例胸外科病人的临床资料。结果全组无发生院内死亡的病例,平均手术时间为55min,术中平均出血量为75ml,仅有4例中转开胸手术。术后发生并发症有21例,其中包括肺膨胀不全15例,胸腔包裹性积液6例和手汗症的胸交感神经切除术后躯体代偿性多汗5例。术后无伤口感染,病人全部治愈出院。术后随访1～10年,良性病变,气胸和手汗症均未见复发。结论胸部微创后术除了有助于术中明确诊断外,而且具有创伤小、痛苦轻、恢复快、术后并发症少及符合美容等优点。它可代替大部分开胸外科手术,但对复杂性手术或需要淋巴的清扫的恶性肿瘤手术仍有一定的局限性。     

Outcome of minimally invasive surgery in the management of tuberculous spondylitis

Introduction:

With the advancement of instrumentation and minimally access techniques in the field of spine surgery, good surgical decompression and instrumentation can be done for tuberculous spondylitis with known advantage of MIS (minimally invasive surgery). The aim of this study was to assess the outcome of the minimally invasive techniques in the surgical treatment of patients with tuberculous spondylodiscitis.

Materials and Methods:

23 patients (Group A) with a mean age 38.2 years with single-level spondylodiscitis between T4-T11 treated with video-assisted thoracoscopic surgery (VATS) involving anterior debridement and fusion and 15 patients (Group B) with a mean age of 32.5 years who underwent minimally invasive posterior pedicle screw instrumentation and mini open posterolateral debridement and fusion were included in study. The study was conducted from Mar 2003 to Dec 2009 duration. The indication of surgery was progressive neurological deficit and/or instability. The patients were evaluated for blood loss, duration of surgery, VAS scores, improvement in kyphosis, and fusion status. Improvement in neurology was documented and functional outcome was judged by oswestry disability index (ODI).

Results:

The mean blood loss in Group A (VATS category) was 780 ml (330-1180 ml) and the operative time averaged was 228 min (102-330 min). The average preoperative kyphosis in Group A was 38° which was corrected to 30°. Twenty-two patients who underwent VATS had good fusion (Grade I and Grade II) with failure of fusion in one. Complications occurred in seven patients who underwent VATS. The mean blood loss was 625 ml (350-800 ml) with an average duration of surgery of 255 min (180-345 min) in the percutaneous posterior instrumentation group (Group B). The average preoperative segmental (kyphosis) Cobb''s angle of three patients with thoracic TB in Group B was 41.25° (28-48°), improved to 14.5°(11°- 21°) in the immediate postoperative period (71.8% correction). The average preoperative segmental kyphosis in another 12 patients in Group B with lumbar tuberculosis of 20.25° improved to –12.08° of lordosis with 32.33° average correction of deformity. Good fusion (Grade I and Grade II) was achieved in 14 patients and Grade III fusion in 1 patient in Group B. One patient suffered with pseudoarthrosis/doubtful fusion with screw loosening in the percutaneous group.

Conclusion:

Good fusion rate with encouraging functional results can be obtained in caries spine with minimally invasive techniques with all the major advantages of a minimally invasive procedures including reduction in approach-related morbidity.     

Development of pediatric minimally invasive surgery in mainland China

Pediatric laparoscopic surgery has developed rapidly in the past 20?years in mainland China with the help of international collaborative training programs. High-volume laparoscopic workload has enabled Chinese pediatric surgeons to innovate and gain experience within a short span of time. We feel that outcomes are comparable or even in some cases superior to that of open surgery. In this article, based on the Storz Lecture to the 65th BAPS Congress in Liverpool, we share our experience of this rapid development of pediatric laparoscopy.

微创食管癌切除术应注意的问题

食管癌居全球常见恶性肿瘤发病率的第8位,是一种严重威胁人类健康的消化系统肿瘤.开放食管切除和区域淋巴结清扫是治疗局限性食管癌的标准手术方式,但手术并发症发生率和病死率较高.与传统开放手术比较,微创食管癌切除术(MIE)具有出血量少,并发症发生率低,住院时间短等优势,而肿瘤切除、淋巴结清扫及术后病死率与开放手术相当.结合第三军医大学大坪医院野战外科研究所全军胸外科研究所的临床经验,展开讨论对MIE手术指征和禁忌证的把握,手术方式和径路的选择,手术体位的选择,术后并发症的预防,以及MIE的学习和掌握,以期有助于MIE的推广和普及.     

微创肿瘤手术临床研究结果的启示与思考:如何提高微创外科手术的质量控制

以腹腔镜微创技术为代表的肿瘤微创外科发展已近30年。尽管手术技术及操作流程不断进步,但近来的临床研究结果显示:微创手术在部分恶性肿瘤中的肿瘤学疗效仍有争议。无论真相如何,手术的质量控制至关重要。严格把握手术指征,为肿瘤患者提供最合适的治疗方式有助于手术质量控制与风险降低。通过构建系统化培训体系,规范微创手术操作可保证肿瘤微创手术的质量。针对新兴微创手术技术,以严谨、审慎的态度加以开展,对于手术质量控制尤为重要。在微创外科高度发展的今天,除继续"保持速度",还应更好地"保证质量"才能使微创手术给更多的肿瘤患者带来获益。     

400例机器人微创心脏手术入路

目的 分析机器人微创心脏手术手术入路及技术特点,总结选择手术入路的依据和不同手术入路的适用术式.方法 2007年1月至2011年3月,解放军总医院心血管外科使用"达芬奇S"全机器人手术系统,完成微创心脏手术400例.术中根据病种、手术计划及患者体形,于单侧胸壁开直径1cm的小孔 3～4个,并同机器人手臂系统连接.术者于控制台前遥拎器械完成手术.机械臂的位置、角度依据手术类型和术中要求作相应调整.超声引导下于右侧股动静脉及右侧颈内静脉插管建立体外循环.结果 右侧胸壁入路221例,用于房、室间隔缺损修补、二尖瓣手术、心房黏液瘤切除等体外循环下心内直视手术;左侧胸壁打孔178例,用于单侧或双侧内乳动脉游离、心脏不停跳下冠状动脉旁路移植术、心包疾病和纵隔肿瘤切除手术.1例患者因胸膜重度粘连改为正中开胸,其余患者均成功接受机器人微创心脏手术.术中无严重的机械臂碰撞、机械功能障碍而影响手术进程或导致术式转化.术后疼痛程度减轻,切口美观.结论 机器人微创心脏手术可安全的应用于常见心脏疾病的外科治疗,采用右侧或左侧胸壁打孔,手术入路应根据手术要求和患者的体形选择并作精确调整.

Abstract：

Objective Subject To summary the port placement and system set-up for robotic minimally invasive heart surgery using da Vinci S system in China. Methods 400 patients accepted selective robotic minimally invasive heart surgery from January 2007 to January 2011. We conducted a retrospective review of port placement and system set-up for all the surgeries. During the surgery 3-4 ports were made in the lateral thoracic wall and the position of ports were modulated according to the types of diseases, the procedure and patients' habitus. The surgeon completed the procedure before the surgeon console.The arms of da Vinci S system was adjusted according to surgery procedure. Results The right lateral ports were suitable for the intracardiac operation with extracorporeal circulation. And the left lateral ports can be used in the inner thoracic artery harvesting and coronary bypass graft on beating heart. Except for 1 case changed to sternotomy because of sever pleural adhesions,no arms collision and mechanical malfunction during the surgery that leaded to surgical conversion. Conclusion Robotic minimally invasive heart surgery can be safely applied to partial cardiac surgeries. The port position and system set-up should be adjusted according to the habitus of patients and surgical requirement.     

Lung herniation: a rare complication in minimally invasive cardiothoracic surgery

Objective: Lung herniation, defined as a protrusion of the lung parenchyma with pleural membranes through a defect of the thoracic wall, is a rare entity. As minimally invasive cardiac procedures evolve, different complications may be evident such as lung herniation. A retrospective review of all patients submitted to minimally invasive cardiac or transplant surgery through anterior mini-thoracotomy at our department revealed 16 patients with lung herniation and this experience is analyzed. Materials and methods: From 1996 through 2007, 12 male (75%) and 4 female ranging in age between 23 and 77 years submitted prior either to minimally invasive cardiac or transplant surgery were admitted at our department for a lung hernia. The location was right in eight cases, left in six, and in two cases the herniation was bilateral. The majority of our patients were symptomatic. Twelve of them (75%) complained of pain. The bulge was present regardless of straining. Diagnosis was confirmed by chest X-ray and tomographic scan in all of them. The surgical procedure included identification of the hernial sac and reconstruction of the defect. A variety of materials were used for chest wall reconstruction such as Vicryl and Goretex mesh. Results: There was no perioperative mortality or morbidity. Patients were discharged within 5–7 days postoperatively and in a follow up of 3 months to 8 years no recurrence was observed. Conclusions: (1) Since the thoracic cage has inherent weakness anteriorly near the sternum, attention is needed when the anterior approach is used. (2) Hernias with persistent pain and entrapped lung usually need reconstruction with a patch in order to avoid late complications such as recurrent pulmonary infections and hemoptysis due to strangulation.     

Economic impact of minimally invasive lumbar surgery

Cost effectiveness has been demonstrated for traditional lumbar discectomy, lumbar laminectomy as well as for instrumented and noninstrumented arthrodesis. While emerging evidence suggests that minimally invasive spine surgery reduces morbidity, duration of hospitalization, and accelerates return to activites of daily living, data regarding cost effectiveness of these novel techniques is limited. The current study analyzes all available data on minimally invasive techniques for lumbar discectomy, decompression, short-segment fusion and deformity surgery. In general, minimally invasive spine procedures appear to hold promise in quicker patient recovery times and earlier return to work. Thus, minimally invasive lumbar spine surgery appears to have the potential to be a cost-effective intervention. Moreover, novel less invasive procedures are less destabilizing and may therefore be utilized in certain indications that traditionally required arthrodesis procedures. However, there is a lack of studies analyzing the economic impact of minimally invasive spine surgery. Future studies are necessary to confirm the durability and further define indications for minimally invasive lumbar spine procedures.     

Minimally invasive pancreatic surgery

Robotic surgery remains in its infancy, and little experience has been reported, as surgeons carefully explore the application of this type of technology to diseases of the pancreas. While challenging and controversial, Dr. Zollinger would most likely support the ongoing research in the techniques of pancreatic surgery that can lead only to an improvement in the outcomes of our patients.