腹腔镜二孔法与三孔法阑尾切除术的对比研究

目的探讨腹腔镜二孔法与三孔法阑尾切除术的临床应用指征。方法回顾性分析腹腔镜阑尾切除术(Laparoscopic Appendectomy，LA)的临床资料，比较二孔法与三孔法LA的手术时间、戳孔感染率。本组206例完成LA术，其中三孔法148例(9例由二孔法中转)、二孔法58例。结果平均手术时间二孔法显著短于三孔法(P=0．000)。急性单纯性阑尾炎和慢性阑尾炎LA术后戳孔均无感染，急性化脓性阑尾炎戳孔感染率二孔法与三孔法无显著性差异(P=1．000)，急性坏疽性阑尾炎戳孔感染率二孔法显著高于三孔法(P=0．039)。结论LA二孔法具有更加微创、美容的特点，可作为单纯性、化脓性及慢性阑尾炎的首选术式．但对于坏疽性阑尾炎则宜选择三孔法。     

改良悬吊固定法在腹腔镜阑尾切除术中的应用

目的探讨改良悬吊固定法在腹腔镜阑尾切除术中的临床应用价值。方法对我科在2008年1月．2008年8月诊断的急慢性阑尾炎的22例患者,采用改良悬吊固定法,行三孔法腹腔镜阑尾切除术进行回顾性分析。端相对固定,然后行阑尾切除术。结果手术均获成功,无中转开腹,平均手术时间30min,比常规腹腔镜阑尾炎（LA）缩短10—15min,平均住院3d。结论改良悬吊固定法LA较非固定LA具有简单易行,手术时间短,安全快捷。     

改良两孔法腹腔镜阑尾切除术106例报告

目的:探讨改良两孔法腹腔镜阑尾切除术的手术方法及优点。方法:回顾分析2012年3月至2013年5月为106例急、慢性阑尾炎患者行改良两孔法腹腔镜阑尾切除术的临床资料,评价分析手术操作过程、术后恢复及出院后回访情况。结果:106例手术均顺利完成,手术时间18~46 min,平均(25±6.5)min;手术操作简单,术后仅5例应用镇痛药,无腹腔残余感染、肠漏、肠梗阻等并发症发生,腹部仅2个切口,均一期愈合。住院2~5 d,平均(3±1.5)d。结论:改良两孔法腹腔镜阑尾切除术具有手术时间短、患者创伤小、疼痛轻、住院时间短等优点,切口较小,术后腹壁疤痕不明显,更具心理与美容效果。     

改良二孔法与三孔法腹腔镜胆囊切除术的对比研究

目的 比较改良二孔法与三孔法腹腔镜胆囊切除术的疗效.方法 回顾性分析200例LC患者的临床资料,其中100例行改良二孔法腹腔镜胆囊切除术(简称二孔法组),100例行三孔法腹腔镜胆囊切除术(简称三孔法组),对比分析两组手术时间、中转率、术后6h疼痛程度、术后住院时间以及并发症.结果 两组均无并发症发生,二孔法组与三孔法组手术时间分别为(45.3±11.2)min和(41.1±10.8)min(P＞0.05),中转开腹手术率分别为3%和2%(P＞0.05),术后6h疼痛程度分别为(1.9±0.5)分和(2.5±0.7)分(P＜0.05),住院时间分别为(2.6±1.3)d和(3.8±1.7)d(P＜0.05).结论 改良二孔法与三孔法腹腔镜胆囊切除术一样安全有效,且具有创伤更小、疼痛更轻、住院时间更短等优点.     

改良经脐单孔腹腔镜阑尾切除术的临床分析(附55例报告)

目的:探讨改良经脐单孔腹腔镜阑尾切除术(laparoscopic appendectomy,LA)治疗青少年及儿童急性阑尾炎的临床应用价值。方法:回顾分析2015年9月至2017年3月为55例急性阑尾炎患儿行改良经脐单孔LA的临床资料,术中使用常规腹腔镜器械操作。结果:55例患儿中50例成功完成手术,5例因化脓、粘连严重中转为三孔法LA,手术成功率90.9%。手术时间平均(45.55±6.33)min,术中出血量平均(5.25±1.10)ml,术后排气时间平均(12.20±4.24)h,平均住院(5.60±1.42)d,55例均治愈出院,无一例发生腹腔残余感染及切口感染。术后病理证实急性单纯性阑尾炎44例,化脓性阑尾炎11例。术后随访3～9个月,无粘连性肠梗阻、脐疝等并发症发生。结论:对于青少年及儿童急性阑尾炎,改良经脐单孔LA优势明显,值得临床推广应用。     

二孔法牵拉式腹腔镜阑尾切除术15例报告

目的探讨二孔法牵拉式腹腔镜阑尾切除术治疗急、慢性阑尾炎的可行性。方法回顾性分析我院2004年2月～2005年10月15例急、慢性阑尾炎患者行二孔法牵拉式腹腔镜阑尾切除术的临床资料。结果15例均顺利完成手术,手术时间平均23.5(15～90)min。15例平均随访5.1(3～13)个月,无腹壁切口感染、腹痛、肠粘连等并发症。结论二孔法牵拉式腹腔镜阑尾切除术治疗早期急性阑尾炎和慢性阑尾炎可取得满意效果。     

改良腹腔镜阑尾切除术290例应用分析

目的总结归纳改良腹腔镜阑尾切除术(laparoscopic appendectomy,LA)的操作技巧。方法采用小操作孔三孔法操作、阑尾系膜单极电凝法、体外打结、推结器推结结扎阑尾根部、自制标本袋取出阑尾等改良的LA技术操作,行改良LA 290例。结果 290例均成功完成手术,无一例中转开腹。手术时间30~60 min,平均45 min。290例术后随访3~24个月,平均6个月,无出血、残端瘘、肠梗阻等并发症。结论改良腹腔镜阑尾切除术操作简单,安全可靠,治疗费用更低。     

二孔法及改良二孔法腹腔镜胆囊切除术

目的探讨二孔法及改良二孔法腹腔镜胆囊切除术的临床应用。方法对选择性113例二孔法及改良二孔法腹腔镜胆囊切除术进行总结。结果113例患者采用该术式顺利完成手术,应用二孔法完成30例,改良二孔法完成83例,手术时间为(32.3±12.5)min;无中转三孔、四孔腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)及开腹胆囊切除术;平均住院时间为(4.7±1.2)d,无近期并发症,全部治愈出院。随访9～12月未见远期并发症,腹部切口愈合疤痕不明显且隐蔽。结论有选择性开展二孔法及改良二孔法腹腔镜胆囊切除术安全、可行;可最大程度满足患者对手术微创、疤痕小等要求。     

改良两孔悬吊法腹腔镜小儿阑尾切除术62例报告

目的:探讨改良两孔悬吊法腹腔镜阑尾切除术治疗小儿急性阑尾炎的可行性、优点及注意事项。方法:回顾分析2011年6月至2012年5月采用改良两孔悬吊法腹腔镜阑尾切除术治疗62例小儿急性阑尾炎患者的临床资料。结果:62例均顺利完成改良两孔悬吊法腹腔镜阑尾切除术,手术时间平均(48±13)min,术后12~23 h恢复通气。4例患儿术后2~3 d右上腹切口感染,经换药、微波理疗1周后愈合。术后均无粪瘘,腹、盆腔脓肿及粘连性肠梗阻等其他并发症发生,术后平均住院(4±1)d。随访1~2年,无粘连性肠梗阻等相关并发症发生。结论:改良两孔悬吊法腹腔镜阑尾切除术治疗小儿急性阑尾炎具有创伤小、康复快、住院时间短、并发症少、安全有效等优点,但应根据术中实际情况操作,切不可盲目追求微创。     

单孔悬吊法腹腔镜阑尾切除术的应用体会

目的：探讨单孔悬吊法腹腔镜阑尾切除术（laparoscopic appendectomy,LA）的可行性,并总结治疗体会。方法：为43例阑尾炎患者施行单孔悬吊法LA。经脐部单孔分别置入腹腔镜和操作钳,找到阑尾后,从右下腹置入细铜丝悬吊起阑尾根部,在腹腔内完成阑尾切除,经脐孔拖出阑尾。结果：手术时间25-97min,平均36min,1例中转开腹,1例经两孔法切除。术后1例发生脐孔感染,无其他并发症发生。所有患者均痊愈出院。平均住院4.5d。结论：单孔悬吊法LA操作简单、有效、可行,扩大了单孔LA的适应证,并且有很好的美容效果。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.