腹腔镜外科医师的规范化培训

自1987年法国里昂医生Phillips Mouret成功实施第一例腹腔镜胆囊切除手术以来，腹腔镜外科手术就以其创伤小、痛苦少、恢复快、疗效好且具有美容特点等优势被全世界外科医生认可。她就像一个刚刚出生而又具备旺盛生命力的婴儿，迅速茁壮长大，引起了现代外科学领域的一场深刻变革，正在形成具有鲜明特点的专门学科，被认为是外科发展史上又一里程碑。腹腔镜外科时代的到来也引发了人们的许多思考，     

腹腔镜外科医师现代化培训模式探讨

腹腔镜外科手术是一项技术依赖性很强的外科实用技能,在传统的外科培训过程中,教授与年轻医生之间的教学实践往往是建立在患者的实际手术当中,往往导致学习过程中出现过多的并发症^[1-3]。由于腹腔镜外科手术操作技术的特殊性,这种培训肯定不是理想的教学模式,也不符合现代伦理学道德要求。因此,如何有效地提高微创外科手术的操作技能和临床适应能力,降低复杂微创手术的危险性,是以下将要探讨的问题。     

腹腔镜外科医师规范化培训模式探讨

由于微创外科手术难度较传统术式大,学习并掌握技术有相当的难度。对于传统的学习环境,学员大多采用理论讲解,手术观摩及实验动物练习等培训方式,局限了培训的效果。如何有效地提高微创外科手术的操作技能和临床适应能力,降低复杂微创手术的危险性,是本文将要探讨的议题。1腹腔镜外科技术特点1.1视觉差异腹腔镜手术中改变平时的肉眼三维立体视野为彩色监视屏幕的二维平面图像;腔镜下手术视野的观察方向相对固定缩小;在多血的视野里,图像彩色分辨率和光亮度均有衰减;摄像系统的配置和镜头质量及清洁保养均对手术视野显露效果产生影响。1.2触…     

美国腹腔镜内镜外科医师协会与《美国腹腔镜内镜外科医师协会杂志》简介

The Society of Laparoendoscopic Surgeons（SLS）（美国腹腔镜内镜外科医师协会）是北美也许是全世界最大的微创或腹腔镜协会,正式会员超过6000人。包括腹腔镜和微创外科各专业,主要有3个：普通外科、妇科、泌尿外科的腹腔镜内镜。SLS的重点是多专业化,为医师更好决策和使患者得到更好的效果,从全面、     

胡三元教授主译的《腹腔镜外科学》出版发行

由美国著名的腹腔镜专家KARL．A．ZUCKER主编，我国著名腹腔镜外科专家胡三元教授主泽的《腹腔镜外科学》第二版已由山东科技出版社出版发行，本书南数十位国际著名腹腔镜专家共同编写而成，自1991年首次出版以来，迅速被美国、加拿大等多个围家的多个腹腔镜临床培训中心用作教材，是腹腔镜外科领域的权威著作。现向广大医务工作者推荐本书最新版第二版。     

腹腔镜手术的基础培训

目的探讨腹腔镜手术的培训方法和重要性. 方法总结591名腹腔镜手术的医生、护士培训的经验. 结果 59名学员均通过理论考核,能完成常规腹腔镜手术,70%(296/422)的医院能独立开展腹腔镜手术. 结论短期小型培训班的形式是理论联系实践的、有效的腹腔镜手术培训方式,对提高质量,促进腹腔镜手术技术的快速发展有积极作用.     

谈外科医师的腹腔镜技能培训

自Mouret于1987年行第一例腹腔镜胆囊切除术以来,腔镜外科经历了一两年的争论和彷徨,及此后一段轰轰烈烈的发展过程,现在已进入成熟的临床应用.目前就腹腔镜而言,暂且将手术指征放置一边,凡是开腹能作的手术,用腹腔镜都有可能完成.1988年德国外科医师协会已将内镜技术列入外科医师进修课程.美国在全国各大城市和医疗中心建立腹腔镜培训中心,并将之列为医学继续教育计划.近些年我国除在大城市,重点院校医院开展腔镜手术外,许多地区、县区医院也已开展腔镜手术.而我国尚未建立一套完整的腔镜外科医师培训制度和腔镜外科医师审查标准.所以,外科医师必须在作腔镜手术前参加严格的腔镜外科技能培训.     

外科学基础研究的现状与展望

（续上期）５．肿瘤　肿瘤是各专业外科最常见的疾病之一。因此，肿瘤的发病机制、诊断、治疗在外科学基础的教学和科研中倍受关注。（１）发病机制：从遗传学的角度上来认识，肿瘤是一种基因病，即基因突变（包括癌基因的激活和抑癌基因的失活）和基因表达调控失常。每种肿瘤不仅仅是一种基因突变的结果，而是多种基因突变积累的过程，是经过长期的、分阶段、多步骤而发生的。环境因素和机体的免疫监视功能在肿瘤的发生机制中起重要作用。（２）早期诊断和综合治疗：这是肿瘤防治的关键。综合治疗包括根治性外科手术、放疗、化疗和生物疗法…     

我国腹腔镜外科发展的现状、问题和对策

1991年4月，云南省曲靖第二人民医院苟祖武等在国内成功地独立施行首例腹腔镜胆囊切除术，标志着我国大陆腹腔镜外科发展进程的开端。15年来，由于腹腔镜外科将现代高科技成果融于传统的外科技术之中，以微小的创伤达到了良好的手术效果。因其“损伤小、痛苦少、恢复快、疗效确切、切口美观”等深受广大患者和外科医师的欢迎，从而得到了蓬勃发展。     

拓展腹腔镜外科手术种类的基础及其依据

腹腔镜外科手术是依靠光源、腹腔镜摄像机和监视器代替医师肉眼观察手术部位并通过腹壁穿刺口进行的腹腔手术 ,其目的是在达到开腹手术效果的基础上 ,减轻手术本身对病人特别是对腹壁组织的创伤 ,缩短术后的康复时间 ,并减少并发症的发生率。自 1987年法国人Ｍｏｕｒｅｔ进行首例腹腔镜胆囊切除术后 ,腹腔镜手术已迅速在全世界得到普及 ,并与高科技产品电视摄像系统、手术专用器械如切割器、吻合器、超声刀等结合开创了腹部手术的新型而理想的途径 ,是微创外科的典型代表。但目前国内绝大部分医院仍仅进行一些简单的手术 ,如何拓展腹腔镜手…     

Comparison of Gas-less laparoscopy-assisted surgery, hand-assisted laparoscopic surgery and pure laparoscopic surgery for radical nephrectomy

BACKGROUND: We report our experience with Gas-less laparoscopy-assisted surgery (Gas-less LAS), hand-assisted laparoscopic surgery (HALS) and pure laparoscopic surgery (LS) for renal carcinoma and compare the characteristics and usefulness of these methods. METHODS: Seventeen, 14 and 16 patients were subjected to Gas-less LAS, HALS and LS, respectively. The study started with Gas-less LAS and then gradually shifted to HALS and LS. We evaluated the operative and postoperative parameters for each group. The learning curve effect was evaluated based on data from the first 10 cases of each group, which were operated on by the same surgeon and operation team. RESULTS: The learning curve of operation times in the LS group demonstrated that the operation time for this procedure is acceptable even in early-stage cases. Differences in mean operative time between the three surgical groups, excluding the conversion cases, were not statistically significant; however, there was a significant difference in blood loss volume between the groups (P 相似文献   

机器人辅助后腹腔镜肾上腺醛固酮瘤切除术

目的探讨机器人辅助后腹腔镜下治疗肾上腺醛固酮瘤的临床应用及手术疗效。 方法回顾性分析首都医科大学附属北京安贞医院泌尿外科自2015年1月至2018年1月行机器人辅助后腹腔镜肾上腺醛固酮瘤切除术患者的临床资料及术后随访结果。 结果21例患者,其中男性7例、女性14例,左侧12例、右侧9例,均行保留肾上腺手术,手术均获得成功,手术时间(110.54±29.21)min,出血量(25.12±10.01) ml,住院时间5.15～1.21 d,术后无严重并发症发生。术后随访时间0.5～2年,比较患者术前与术后1年的血压、血钾、血醛固酮/肾素、降血压药物种类等指标,各项指标均得到明显缓解,差异具有统计学意义(P <0.05),21例患者中血压恢复正常6例(28.6%),15例(71.4%)术后仍持续高血压,其中13例(86.7%)患者减少降血压药物使用。 结论机器人辅助后腹腔镜肾上腺醛固酮瘤切除术安全有效,是肾上腺原发性醛固酮增多症外科手术治疗的较好选择。     

A modular laparoscopic training program for pediatric surgeons.

OBJECTIVES: A structured endoscopic training program for pediatric surgeons has not yet been established. This study was conducted to develop a modular training program (MTP) for pediatric surgeons and to evaluate its effectiveness for surgeons with and without previous experience in laparoscopic surgery. METHODS: Nine pediatric surgeons participated in the study. They were divided into 2 groups: group A (n=4), surgeons who had experienced more than 10 cases of laparoscopic surgery prior to MTP; group B (n=5), those who had experienced fewer than 10 cases. They participated in a standardized MTP workshop, which consisted of 2 "see-through" and 3 "laparoscopic" tasks. Each participant's psychomotor skills were evaluated objectively before and after MTP with a computer-generated virtual simulator and were evaluated for precision, efficiency, and speed. RESULTS: In participants, speed was significantly enhanced after MTP. In group A, no differences were observed after MTP, whereas significant improvements were noted in efficiency and speed after MTP in group B. Before MTP, efficiency was significantly higher in group A than in group B; however, no difference remained between the 2 groups after MTP. CONCLUSIONS: MTP is effective for nonlaparoscopic pediatric surgeons to become familiar with basic endoscopic skills.     

‘Trainee’ evaluation of the English National Training Programme for laparoscopic colorectal surgery

Aim The aim of this study was to review trainees’ opinions of the training they had received through the National Training Programme (NTP). Method An online questionnaire was distributed to NTP trainees who had completed five or more training episodes within the programme. Demographic data were collected. Opinion was given using a five‐point Likert scale (1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, 5 = strongly agree). Percentages, mean values and SD were presented. ANOVA and Mann–Whitney U‐tests were used to examine the impact of different factors on ratings and the difference between ratings, respectively. Results Fifty‐four registered trainees fulfilled the inclusion criteria, and 37 (69% response rate) completed the questionnaire. Teaching sessions were organized using an inreach (11%), in‐house (11%), outreach (27%) or combination (51%) system of training. Trainees felt that their trainers seldom cancelled sessions (93%), that it was easy to organize (92%) and consent (100%) the patient, and that their hospital was supportive of training (97%). Trainees stated that overall their trainers were excellent at training (Likert scale = 4.71 ± 0.46) and that they received regular feedback (87%). The only variable to have a significant impact on the level of NTP approval was whether the trainee was able to choose his or her trainer (supportive of NTP, chose trainer P = 0.050; critical of NTP, chose trainer P = 0.020). Conclusion The large majority of trainees was highly satisfied with the training received in this innovative programme, irrespective of region or training structure used, thus demonstrating acceptability of the programme in its current form.     

结直肠癌腹腔镜手术与开腹手术的分析比较

结直肠癌是危害人类健康的主要恶性肿瘤之一,手术仍然是目前主要的治疗手段.腹腔镜结直肠癌手术已开展了十余年,不断发展,在结直肠外科领域逐渐巩固了地位.本文就结直肠癌的腹腔镜手术与开腹手术在安全性、对机体病理生理的影响、疗效等方面进行比较,探讨腹腔镜在结直肠癌治疗中的应用价值.     

Single-incision laparoscopic surgery for colorectal cancer

AIM: To determine the effect of single-incision laparoscopic colectomy(SILC) for colorectal cancer on short-term clinical and oncological outcomes by comparison with multiport conventional laparoscopic colectomy(CLC).METHODS: A systematic review was performed using MEDLINE for the time period of 2008 to December 2014 to retrieve all relevant literature. The search terms were "laparoscopy", "single incision", "single port", "single site", "SILS", "LESS" and "colorectal cancer". Publications were included if they were randomized controlled trials, case-matched controlled studies, or comparative studies, in which patients underwent single-incision(SILS or LESS) laparoscopic colorectal surgery. Studies were excluded if they were non-comparative, or not including surgery involving the colon or rectum. A total of 15 studies with 589 patients who underwent SILC for colorectal cancer were selected.RESULTS: No significant differences between the groups were noted in terms of mortality or morbidity. The benefit of the SILC approach included reduction in conversion rate to laparotomy, but there were no significant differences in other short-term clinical outcomes between the groups. Satisfactory oncological surgical quality was also demonstrated for SILC for the treatment of colorectal cancer with a similar average lymph node harvest and proximal and distal resection margin length as multiport CLC.CONCLUSION: SILC can be performed safely with similar short-term clinical and oncological outcomes as multiport CLC.     

Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective resections with anastomosis

Aim The aim of this retrospective cohort study was to compare outcomes in patients who underwent elective laparoscopic colorectal resection with anastomosis performed by a single surgeon or his training fellow. Method A prospective electronic database of all laparoscopic procedures between January 2005 and September 2008 was used. Two groups were compared; those patients operated upon by the Consultant trainer (C) and those by seven supervised Fellows (F). Fellows were either post CCT or in their last year of training. Three hundred consecutive patients undergoing laparoscopic colorectal resection with anastomosis were examined, 150 in each group. Groups were matched for indication, age, American Society of Anesthesiology (ASA) grade, cancer T stage and resection performed. Preoperative work‐up, operative surgery and anaesthesia were identical between groups. Results No significant difference was demonstrated in age, mean 67 (26–91) or ASA grade. Indications for surgery were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn’s disease (C) 8, (F) 7. Fellow’s mean operative time was significantly longer at 123 min (95%CI 117–134) compared to the consultant trainer −105 min. (95%CI 98–111): P < 0.01). No significant differences in the complication or conversion rates were demonstrated. Length of stay and the 30‐day readmission rates were similar. Conclusion In this retrospective cohort study we have demonstrate that when matched patients are compared, supervised trainee operating time is significantly longer than that of the consultant trainer but without any significant increase in length of stay, complication or readmission rates. Training to a level of competency takes time but not at the expense of patient care.     

腹腔镜肾盂成形术的多模培训模式

目的：介绍一项腹腔镜肾盂成形术（Laparoscopic Pyeloplasty,LP）的多模培训模式,并评价其安全性、可行性和有效性。方法：该多模培训模式包括模拟器、动物模型和手术室培训三部分,5位具有不同开放肾盂成形术和腹腔镜经验的学员参加了这项培训,我们对5个学员参加培训过程中的相关数据和学员独立完成手术的5组LP患者的围手术期数据进行了评价。结果：5位学员均成功地完成了整个培训,并成功地独立完成了5例LP。所有患者手术均未转开放手术,均未输血,无患者死亡。模拟器培训和动物模型培圳所需的时间,学员1（3周,7天）比学员5（4周,8天）少,学员4（2周,6天）比学员2（3周,8天）和学员5（4周,8天）少。在手术室培训中,各学员训练每个手术步骤所需的手术例数相当。5位学员独立完成手术的5组患者手术时间、估计失血量、术后住院时间和围手术期并发症的差异均无统计学意义（P〉0．05）。结论：该项多模培训模式是安全、可行和有效的,并适合于没有开放肾盂成形术和腹腔镜经验的学员进行LP培训。     

Grasping and dissecting instrument for hand-assisted laparoscopic surgery

Background: The operative potential of hand-assisted laparoscopic surgery (HALS) could be enhanced by the introduction of a new generation of assisting instruments. These tools will have to meet specific requirements of shape, function, and safety of use. Methods: Problems related to the working environment of HALS and deriving projectual restrictions of HALS instruments were analyzed in order to develop and manufacture a working prototype with grasping and dissecting properties to assist during HALS procedures. The resulting instrument was mechanically and clinically tested in 22 HALS procedures. Results: The additional benefit of the new device was particularly appreciated during dissection and isolation of vascular pedicles (nephrectomies and splenectomies). It was shown to be safe and effective in providing the additional assistance it was designed for. Conclusion: The described grasping and dissecting instrument for HALS is of great value in assisting the surgeon during fine dissection, as required in selected procedures. New generation of HALS instruments should comply with the functional and safety issues analyzed in this report.