微创时代外科医生的成长与挑战

Since the Success of the first case of laparoscopic cholecystectomy in 1987,minimally invasive surgery has become the most active field in all the branches of surgery.The traditional concept of surgery needs to be changed as the rapid development of surgical procedures,medical materials and devices,and the requirement of biopsychosocial model of medieine also poses great challenges to today's surgeons.Traditionally trained surgeons may find it difficult to adapt to the new developments.While,on the other hand,young laparoscopists may be at a loss when facing the difficulties encountered during the laparoscopic operation.The surgeons of tomorrow should have profound base of the knowledge of surgery and skillful in laparoscopy at the same time.     

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。     

微创胃肠外科的发展趋势与规范实施

胃肠外科作为普通外科领域中最重要的组成部分．其经过百余年的发展已臻成熟。随着上世纪末期腹腔镜技术在普通外科的兴起与发展．以之为代表的微创技术为胃肠外科的创新与发展注入了新的活力．微创技术在胃肠手术中的应用成为了胃肠外科新的发展方向之一．并在这短短20年时间内得到了迅猛发展。     

微创技术在胆道外科应用的现状

Minimally invasive biliary surgery developed rapidly and laparoscopic cholecystectomy has become the"gold standard"for the treatment of benign gallbladder disease.Combined application of endoscopic and ultrasonic technology improved the diagnosis of biliary diseases.Endoscopic balloon dilation or sphincterotomy of duodenal papilla to remove connon bile duct stones and internal biliary stent placement under ERCP for obstructive jaundice caused by biliary tumors provided safe and satisfactory therapeutic effect.However,in the laparoscopic era,minimally invasive techniques should still be used in conjunction with traditional biliary surgery.Meanwhile,strict indication should be emphasized to avoid the occurrence of complications.     

微创胃肠外科现状的反思

自1987年Mouret进行世界首例LC以来,以腹腔镜为基本技术的微创外科得到了迅猛的发展,成为外科发展史的一个里程碑。20年来,胃肠外科微创手术完成了从良性疾病向恶性肿瘤的过渡;微创理念深入人心,推广、普及非常迅猛,我国的胃肠微创手术水平跻身国际前列;微创胃肠手术已从精准化进入了功能化时代。然而,在遇到巨大发展机遇的同时我们也面临巨大的挑战,未来如何发展很大程度上取决于我们今天对微创胃肠外科现状的反思以及对未来的评估。     

微创胃肠外科现状的反思

Laparoscopic surgery for gastrointestinal neoplasms has made remarkable progress in the past 20 years.Laparoscopic surgery for patients with colon cancer is increasingly adopted by surgeons based on th...     

胃肠外科的微创实践与探索

21世纪外科学的发展已进入微创时代,目的在于减少外科治疗中的手术切口、手术操作、手术探查、麻醉用药等环节给患者机体带来的副损伤。要减少或消除这些副损伤,外科手术须由传统走向微创,再由微创走向极微创,这是医学历史发展的必然。     

微创技术在胃肠外科中的应用现状和进展

近20年来,手术技术、化疗、放疗、分子靶向治疗等治疗手段在胃肠外科领域飞跃发展,其中微创外科的发展备受瞩目.随着内镜、腹腔镜及达芬奇机器人等微创外科技术的进步,微创理念逐渐深入外科治疗的各个领域,在某种程度上有替代传统开腹手术的趋势.微创治疗的优势不仅确保了传统外科治疗的效果,而且可将手术创伤最小化及术后生命质量最大化.目前胃肠外科常用的微创外科治疗方法包括：消化内镜下切除、腹腔镜手术、达芬奇机器人辅助手术、经自然腔道内镜技术等.     

腹腔镜与内镜联合技术在胃肠外科中的应用现状及进展

随着腹腔镜和内镜手术技巧的提高及器械的发展,在胃肠外科疾病的诊治上已得到越来越广泛运用。但在实际临床问题上,两种技术均存在一定局限性,有时单一内镜或腹腔镜技术难以解决一些临床棘手问题。对于局限于黏膜层、肌层,且向腔内生长胃肠道肿瘤,由于腹腔镜只能通过视觉或器械的间接触觉来感受胃肠道的膨胀、狭窄、浆膜的侵犯破坏,存在术中定位和判断的盲区^[1]。而内镜则对切除深度存在局限,一般不超过黏膜肌层,而且切除肿瘤存在穿孔等风险。     

适应时代需求:开创腹腔镜胃肠外科培训新局面

腹腔镜胃肠外科技术飞速发展的同时也给培训工作带来新机遇和新挑战:腹腔镜技术的快速迭代需要不断更新培训内容;培训内容载体的不断升级需要培训模式与时俱进;针对院校教育、毕业后教育及继续教育的衔接需要优化完善整个培训体系。因此,为适应时代需求,笔者团队在腹腔镜技术培训内容更新、培训范式创新、培训体系完善等方面力求打开新局面,为我国腹腔镜胃肠外科培训工作贡献力量。     

解剖学微创向功能学微创的转变

With the development of minimally invasive management,laparoscopic operation has become more and more prevalent.As a surgical procedure,a serial of events,such as psychological damage,fasting,bleeding,...     

微创时代肝癌的微波消融治疗

Microwave ablation(MA)has been one of the most quickly developed minimally invasive techniques for trearing hepatocellular carcinoma(HCC)in the last decade.Under accurate imaging guidance,MA shares the common advantages of thermal ablation such as flexible treatment approaches,good tolerability and the ability to consistently create reproducible and predictable necrotic areas.It also exhibits several particular advantages compared with other thermal ablation methods,including higher thermal efficiency,higher capability of coagulating blood vessels,faster ablation time,and an improved convention profile.Over the years,MA equipments,especially the antenna,have been refined for safety and to increase the coagulation zone.With the development of internally-cooled antenna and using the frequency of 915 MHz nficrowave,the technique is becoming safer and the coagulation zone increased significantly.Initially,MA was limited to the treatment of small HCC,but with the improvement of antenna and treatment strategV,large HCC(＞5 cm)can also be ablated effectively.For the"curative"treatment of HCC.the following eriteria need to be met:single HCC with the lesion of 6 am or smaller;three or fewer HCC lesions with a maximum diameter of 4 cm,and absence of portal vein thrombosis or extrahepatic metastases.A five-year cumulative survival rate has exceeded 50%,which is comparable with resection.Moreover,the local immune function is enhanced after MA.A change in immunocyte infiltration takes place in number,configuration and location after patients with HCC are treated with MA.Further research for MA may be focused on the improvement of the maneuverability of the equipment,increase of the accuracy of antenna puncture and consummate the clinical therapeutic standardization.     

微创外科时代的胆道外科——胆囊切除术尚非平安无事

自从首例在腹腔镜下施行胆囊切除术之后,胆道外科技术经历了革命性的改变。当前,已经有越来越多的传统外科手术方法被腹腔镜外科所取代。然而,腹腔镜胆囊切除术并非平安无事。当前,由于影像学技术的发展,例如对肝内、外胆道的虚拟现实、三维重建等,可以有助于对复杂胆道外科问题如肝内胆管结石和其他肝内病变的手术前评估和手术设计。约占原发性肝癌5%～10%的肝内胆管癌由于其与肝细胞癌有不同的病理-生物学特点,故在治疗措施选择上应得到特殊的关注,一般应该施行广泛的肝切除手术而不是局部切除或消融。关于肝门部胆管癌的治疗,扩大的肝切除术可以改进早期的、无淋巴结转移病变治疗结果。当前,在微创外科时代,许多传统的外科手术将在微创外科理念下重新受到检验。     

微创时代肝癌的射频消融治疗

Recently radiofrequency ablaion(RFA)has been widely used for treating liver cancer,as it has the advantages of easy manipulation,safe,effective and causes only minor injury to the liver.RFA is suitable for patients with single and small hepatocellular carcinoma,in Child A or Child B classification,and without extrahepatie metastasis.Severe extrahepatic metastasis,such as tumor thrombus in the main portal vein,the main branch of portal vein and the hepatic vein are the contraindications of RFA.RFA is approached either via laparoscopy,celiotomy,or by ultrasound.The choice of procedure should be based on the tumor size and location,as well as the condition of blood supply.For tumor with the diameter≤3.0 cm,the efficacy of RFA is similar to that of hepatectomy.The common postoperative complications include intestinal perforation,abdominal hemorrhage,infection and needle tract seeding.Selecting the correct procedure according to the condition of the patient.correct manipulation,formalized therapeutic strategies and prepost training of surgeons are aspects that should not be overseen in the application of RFA.     

微创手术治疗桡骨远端Barton骨折

目的 探讨采用闭合复位内固定术和有限切开复位可吸收螺钉内固定治疗桡骨远端Barton骨折的可行性。方法 1990年5月-2004年5月，对25例桡骨远端Barton骨折的患者，采用微创手术治疗。其中16例在X线机透视下，采用手法复位克氏针内固定术（闭合复位内固定组）；9例采用有限切开复位可吸收螺钉内固定术（有限切开内固定组）。结果 术后23例获得6个月～1．5年随访，2例失访。闭合复位内固定组术后4～6周骨折达到骨性愈合，有限切开内固定组6．8周达到骨性愈合，其中1例出现骨性关节炎。按Deoliveiva腕关节功能评定标准：闭合复位内固定组优11例，良3例，可1例，优良率达93％。有限切开内固定组优4例，良3例，差1例，优良率达87％。结论 微创手术治疗桡骨远端Barton骨折，操作简单，创伤小，功能恢复满意。     

Role of minimally invasive techniques in gastrointestinal surgery: Current status and future perspectives

In recent years, the incidence of gastrointestinal cancer has remained high. Currently, surgical resection is still the most effective method for treating gastrointestinal cancer. Traditionally, radical surgery depends on open surgery. However, traditional open surgery inflicts great trauma and is associated with a slow recovery. Minimally invasive surgery, which aims to reduce postoperative complications and accelerate postoperative recovery, has been rapidly developed in the last two decades; it is increasingly used in the field of gastrointestinal surgery and widely used in early-stage gastrointestinal cancer. Nevertheless, many operations for gastrointestinal cancer treatment are still performed by open surgery. One reason for this may be the challenges of minimally invasive technology, especially when operating in narrow spaces, such as within the pelvis or near the upper edge of the pancreas. Moreover, some of the current literature has questioned oncologic outcomes after minimally invasive surgery for gastrointestinal cancer. Overall, the current evidence suggests that minimally invasive techniques are safe and feasible in gastrointestinal cancer surgery, but most of the studies published in this field are retrospective studies and case-matched studies. Large-scale randomized prospective studies are needed to further support the application of minimally invasive surgery. In this review, we summarize several common minimally invasive methods used to treat gastrointestinal cancer and discuss the advances in the minimally invasive treatment of gastrointestinal cancer in detail.     

关节镜辅助下有限切口治疗髌骨骨折的疗效评估

目的：评价在关节镜辅助下有限切口治疗髌骨骨折的效果。方法对2005年5月至2010年9月收治的81例髌骨骨折患者进行回顾性分析,分为两组：43例髌骨骨折患者在关节镜辅助下通过有限切口进行骨折诊断和治疗,38例患者行常规髌骨骨折手术治疗。两组患者年龄、性别、骨折性质等基本情况比较,差异无统计学意义（P＞0.05）。对比分析两组患者的切口长度、手术时间、术后肿胀程度、愈合时间和关节功能恢复情况。结果与常规组相比,关节镜组手术切口小,手术时间相对短,术后组织肿胀轻,平均住院日和平均愈合时间明显缩短,胥少汀膝关节功能为优的比例明显增高,Lysholm评分的改善程度明显增高[（89.43±12.43）分/（82.12±13.12）分],错误位置觉显著降低[（2.06±0.56）分/（2.75±0.73）分]。以上改善与常规组相比,差异均有统计学意义（均P＜0.05）。结论在目前微创技术发展时期,应用关节镜辅助切开复位内固定手术治疗髌骨骨折,对于减轻术中并发症及提高患者术后恢复效果明显。