亲属活体供肾者围手术期的处理

目的：探讨亲属活体供肾者的围手术期处理方法。方法：对５例活体供肾者的术前、术中、术后处理情况进行回顾性分析。结果：５例供肾者术后血常规和尿常规、肝肾功能、２４ｈ尿蛋白定量及血压检查均正常,平均住院１５ｄ。结论：亲属活体供肾者手术的安全系数较高,术后康复理想。     

经皮肾镜碎石术中肾通道处理的临床进展

经皮肾镜碎石术是当前肾结石处理的重要方法,术中肾通道的处理经历了一个发展过程,起初留置大口径的肾盂引流管为术中的常规步骤,随着操作技术及器械的发展和患者对术后恢复的高要求,渐向留置小口径引流管甚至无管化发展,并且止血凝胶、激光被应用于对肾通道的处理,获得了满意的临床效果。     

复杂左肾病变肾切除术-肠系膜根部法肾蒂血管处理体会

目的 介绍复杂左肾病变肾切除术中经肠系膜根部法早期处理左肾肾蒂血管的技巧. 方法 对51例巨大肾癌(伴或不伴肾静脉癌栓)、肾盂移行细胞癌及脓肾等复杂左肾病变,采用经腹肠系膜根部法早期处理肾蒂,行肾痛、肾盂癌根治术或其他肾切除术.对肠系膜根部、腹主动脉、肾静脉、肾上腺静脉及肠系膜下静脉的解剖关系及手术要点进行了介绍. 结果 手术均获得满意效果.从入腹腔到显露肾静脉的时间为3～5 min,处理肾蒂血管的时间为10～20 min.未发生严重并发症,无病例死亡. 结论 经肠系膜根部法处理肾蒂血管技术是可行的,并具有以下优点:利用肾蒂血管的解剖特点,分离显露肾蒂血管方便、快捷、出血少;不必过多游离、挤压病肾,防止肿瘤或炎症扩散,符合肿瘤根治早期结扎肾蒂血管的原则.本法适合于处理复杂左肾病变,尤其是伴有肾静脉癌栓或脓肾者.     

保留肾单位手术切缘阳性的影响因素、临床影响与处理进展

保留肾单位手术较肾根治性切除术减少了术后慢性肾病的及心血管疾病的危险性,并且会改善生存期,但保留肾单位手术可能会导致切缘阳性。本文就关于保留肾单位手术切缘阳性的影响因素、临床影响与处理进展做一综述。     

肾移植术中28例供肾异常血管的处理

报告在肾移植术中对２８例供肾异常血管的处理方法：多支动脉应尽力设法吻合，修复：双支静脉可结扎１支。遇有受体髂内动脉样硬化长段斑块形成严重阻塞血管腔不能进行有效血管吻合时，可采用肾动脉与髂外动脉端侧吻合术这一替代方法。处理时，供肾在冷缺血状态下进行多支肾血客的修复，可减少在体内操作时对供肾的损害。     

长期滞留双J管的临床处理并文献复习

目的:探讨长期滞留双J管的处理方法。方法:对11例长期滞留双J管患者分别采用或联合应用ESWL、输尿管镜(URS)、经皮肾镜(PCN)等方法进行处理。结果:11例患者均顺利拔除滞留的双J管。结论:术前完善影像学检查,明确双J管的位置及有无其他复杂情况,灵活应用ESWL、URS及PCN等多种内镜方法,多可顺利拔除滞留的双J管。     

肾移植手术中特殊供肾的处理

目的 总结特殊供肾的外科处理经验。方法 回顾性分析1996年1月-2001年6月间进行的868例尸体肾移植中326只特殊供肾的处理，并与542只普通供肾的移植效果进行比较。结果 326只特殊供肾均得到了利用，血管变异的供肾移植后1个月血肌酐水平，急性肾小管坏死（ATN）发生率及1年移植肾存活率与普通供肾均远见显著差异；其他特殊供肾均未发生与修整术有关的并发症。结论 畸形供肾或损伤供肾，通过合理手术整形，灵活运用等方法保肾，并不影响肾移植的效果。     

肾移植中供受者血管变异的处理

在肾移植中,常会遇到供受者动脉病变及多支血管变异,如处理不当,常导致移植肾失败或肾功能不全.本院共施行肾移植350例,其中受者髂内动脉严重粥样斑块硬化、管腔接近闭塞者30例,供肾多支动脉变异36例,供肾动脉与髂内动脉管径悬殊较大8例,均作了合理的处理.术后移植肾血供良好,1年后随访,吻合血管通畅,肾功能正常,现将其处理经验介绍如下.1 处理方法1.1 髂内动脉严重粥样斑块硬化的处理髂内动脉管腔很小,接近闭塞.这种髂内动脉如与肾动脉吻合,开放血流后移植肾常供血不足,肾色虽鲜艳,但充盈张力差,术后常发生急性肾衰及无尿,导致肾移植失败.对此,我们有沉痛的失败教训.后来我们对25例粥样斑块硬化患者采取髂内动脉斑块切除,然后与肾动脉作端端吻合,开放血流后移植肾充盈张力良好.对5例斑块不能切除者,采取肾动脉与髂外动脉端侧吻合,同样取得良好效果.术后随访1年,肾功能正常,肾动脉无血管杂音,B超、彩色多普勒血流图、肾动脉造影(部分患者)未发现异常变化.     

肾移植中供肾血管变异的处理

目的提高血管变异的供肾的临床应用价值。方法根据具体情况，将血管变异的供肾进行合并、修整、重建等，使供肾安全、有效的移植给受者。结果78只供肾动脉变异(包括23只供肾静脉变异)经处理后，77只供肾良好。供肾移植后数分钟内有尿排出，2周内肾功能恢复正常，1年后随访无并发症。仅有1例因肾静脉回流障碍，被迫切除移植肾。结论供肾血管变异只要正确处理，移植后可获得良好效果。     

161例肾损伤的处理

目的探讨严重肾损伤的概念及治疗方案。方法对１９６５至１９９６年收治的１６１例严重肾损伤病例资料进行回顾分析。结果１６１例病人,伴有合并伤１１６例（７２．０％）。保守治疗７７例,发生并发症６例,治愈率９２．２％;手术治疗７３例,其中肾切除３２例,切肾率１９．９％;选择性肾动脉栓塞治疗１１例,治愈率１００．０％;死亡１５例,死亡率为９．３％。结论（１）强调手术治疗与非手术治疗的指征。（２）对有合并伤者,应全面、准确、及时的进行伤情评估。（３）对疑有内脏损伤者,应仔细探查,发现损伤应一并处理。     

Hand-assisted laparoscopic splenectomy for ruptured spleen

Although the laparoscopic technique is an accepted method for elective splenectomy, it is controversial in the setting of trauma. A few reports have described laparoscopic splenorrhaphy for trauma, but none have performed laparoscopic splenectomy for splenic rupture. When the spleen is injured, vascular control and poor visibility due to bleeding present obstacles to laparoscopy. The development of the hand-assist device has helped surgeons make the transition from laparotomy to laparoscopy because of the advantages it provides, such as tactile sensation and immediate vascular control. We utilized these benefits of the hand-assist device to convert a laparoscopic operation to a hand-assisted laparoscopic operation and were thus able to avoid a laparotomy. We report a case in which the hand-assist device was used as an alternative to conversion during a laparoscopic splenectomy for ruptured spleen.     

Laparoscopic vascular control techniques in donor nephrectomy: Effects on vessel length.

BACKGROUND: Various techniques for vascular control have been used during urologic laparoscopic procedures. The importance of optimizing the vessel length and securing reliable vascular control are critical for procedures like laparoscopic donor nephrectomy. We aimed to determine the length of vessel lost by using 4 common techniques of vascular control in a fresh human cadaveric vascular model. METHODS: The techniques include application of 2 non-absorbable polymer-ligating clips (10-mm Hem-o-Lok MLX Weck Closure Systems, Research Triangle Park, NC), Endo-GIA II stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT), Endopath ETS35 stapler (35 mm length, 2.5mm staples, Ethicon Endo-Surgery), and the Endo Ta-30 stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT). RESULTS: The Endo-TA-30 stapler and the polymer clips resulted in significantly less compromise of the vessel length, when compared with the other methods of vascular control. CONCLUSIONS: The Endo-TA-30 stapler and the polymer clips can be applied during laparoscopic procedures where optimizing vascular length is important.     

Techniques of vascular control in laparoscopic donor nephrectomy

OBJECTIVES: Laparoscopic donor nephrectomy has become the method of choice for removal of living donor kidneys. The ENDO GIA stapler is commonly used for division of the renal vessels, but it can lead to some loss of graft vascular length. Besides, stapler malfunction can occur. In this study, we report our experience using polymer locking clips for vascular control, compared with previous experience using the ENDO GIA stapler. MATERIALS AND METHODS: Eleven donors underwent laparoscopic donor nephrectomy from November 2005 to September 2007. Both renal artery and vein were divided after 2 or more polymer locking clips had been applied on the donor side. The operative times, warm ischemia times, graft function, and vascular complications were compared with the previous 33 donors using the ENDO GIA stapler for renal vein control. RESULTS: The operative and warm ischemia times were similar. With the polymer locking clip technique, we harvested nearly the entire renal vein length. There were no vascular complications or graft loss with the use of polymer locking clips. In our series, malfunction of the ENDO GIA stapler device occurred in 1 patient requiring the surgery to be converted to an open procedure. Both donor and recipient outcomes were similar no matter whether polymer locking clips or the ENDO GIA stapler was used for vascular control during the laparoscopic donor nephrectomy. CONCLUSION: In our series, there were no vascular complications and no device failure during vascular control using polymer locking clips. We believe that polymer locking clips are safe, yielding greater vessel length during laparoscopic donor nephrectomy.     

Routine vascular control using the Hem-o-lok clip in laparoscopic nephrectomy: animal study and clinical application

BACKGROUND AND PURPOSE: During laparoscopic nephrectomy (LPN), a stapling device is often used for vascular control, especially of the renal vein. Herein, we report our experience using a polymer clip (Hem-o-lok) for routine control of the vessels during LPN in the animal and clinical setting. PATIENTS AND METHODS: Fifty ablative and fifteen live-donor nephrectomies were performed in domestic pigs. Hem-o-lok clips (10 mm; Weck Closure System, Research Triangle Park, NC) were routinely used for vascular control. In addition, from January 2001 to July 2002, 46 patients underwent hand-assisted laparoscopic (HAL) (N=40) or laparoscopic (N=6) nephrectomy for renal disease or donor nephrectomy. Venous control was achieved solely by the Hem-o-lok clips where at least two clips were applied on the patient side. Arterial control was obtained by the Hem-o-lok clips either alone or in combination with the metal clips. The technical difficulty in obtaining vascular control, transfusion requirement, and clinical outcome were evaluated. RESULTS: In the animal study (total 65 nephrectomies), individual vascular control was obtained by the Hem-o-lok clip in all cases except two, where vascular injury during dissection necessitated endoscopic stapling of renal hilum or open conversion. The warm ischemic time for animal donor kidney harvest was uniformly <2 minutes. In the clinical study, arterial control was obtained mostly by a combination of Hem-o-lok and metal clips. Venous control using the Hem-o-lok was successful in all 46 cases without any slipping of clips or uncontrolled bleeding. The mean operating time was 148 minutes. No open conversion was required. The transfusion rate was 6.5% (N=3), with none of the transfusions being related to inadequacy of vascular control using the Hem-o-lok. Major complications included deep vein thrombosis and postoperative retroperitoneal hemorrhage (same patient) and acute respiratory distress syndrome (N = 1). The mean postoperative stay was 5.2 days (range 1-20 days). CONCLUSION: The Hem-o-lok is a reliable and economical device for vascular control in laparoscopic renal surgery.     

腹腔镜肝切除术中预防和控制出血的策略

近年来,腹腔镜微创技术发展迅速,腹腔镜肝切除术被逐渐运用于各种肝脏疾病的治疗,但由于创面出血难以控制的特点,腹腔镜下肝切除术仍具有一定难度。只有有效预防和控制术中出血,腹腔镜肝切除术才能顺利完成。目前预防和控制术中出血的方式主要有:肝血流阻断的方式、各种腹腔镜断肝器械的运用、腹腔镜超声技术、低中心静脉压技术、肝实质断面的处理等。笔者对以上几种方式做一个综述。     

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??Evaluation of different methods of hepatic vascular occlusion in laparoscopic hepatectomy ZHANG Wan-guang, CHAI Song-shan. Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College , Huazhong University of Science & Technology, Wuhan 430030, China
Corresponding author??ZHANG Wan-guang??E-mail??wgzhang@tjh.tjmu.edu.cn
Abstract Laparoscopic liver resection and bleeding control techniques are the central link in laparoscopic hepatectomy. At present, there are so many laparoscopic hepatic vascular occlusion, such as total inflow occlusion, regional hepatic vascular occlusion, hepatic vein occlusion and the inferior vena cava occlusion, etc. Surgeon should combine their own llaparoscopic technique level, the range and position of the liver resection, the degree of liver cirrhosis to select the appropriate liver blood flow blocking technology to reduce the incidence of intraoperative bleeding, improve the success rate of laparoscopic hepatectomy, and also promote the further development and promotion of laparoscopic hepatectomy.     

Laparoscopic vascular anastomoses: does robotic (Zeus–Aesop) assistance help to overcome the learning curve?

Background Considerable training is necessary to master laparoscopic suturing and knot-tying. Robotic systems are assumed to facilitate these skills and shorten the learning curve. The effect of laparoscopic experience and robotic assistance on the learning curve of vascular anastomoses was studied. Methods A laparoscopically experienced surgeon and a laparoscopically inexperienced surgeon made alternating laparoscopic vascular anastomoses and robot-assisted laparoscopic vascular anastomoses using a Zeus–Aesop surgical robotic system with various prosthetic conduits and suture materials in a laparoscopic training box. Results Neither laparoscopic method influenced the quality score or leakage rate, but with laparoscopic experience, significantly fewer failures were made. Suturing and knot-tying were faster with laparoscopic experience both with and without the robotic system, and fewer stitch actions and knot actions were performed. The learning curves of both surgeons were not improved by the robotic system. Conclusions Experience is the most important factor in the performance of laparoscopic vascular anastomoses. The robotic system was not helpful in shortening the learning curve.     

Totally laparoscopic abdominal aortic aneurysm repair

On the basis of our previous animal and clinical experience with laparoscopic intra-abdominal vascular reconstructions, and due to the prevalence of abdominal aortic aneurysms (AAA), we have recently broadened our scope to tackle more difficult aortic surgery laparoscopically. We present a case report of our first clinical experience with laparoscopic AAA repair using specialized laparoscopic vascular instrumentation. The patient was an 84-year-old hypertensive male with a 7-cm asymptomatic infrarenal abdominal aortic aneurysm that was discovered incidentally. He presented with postcoronary artery bypass grafting and had moderate chronic obstructive pulmonary disease (COPD). A spiral computed tomograph (CT) angiogram revealed an adequate infrarenal neck and aneurysmal involvement of the proximal iliac arteries. An eight-port transabdominal technique was used with the patient in the supine position. Proximal and distal control was achieved without difficulty. The aneurysm was excluded using endoscopic stapling devices, and an aortobiiliac reconstruction was performed with a 16 × 9-mm bifurcated dacron graft. Estimated blood loss was 1000 ml, and the operative time was approximately 7 hours. The patient was ambulating without assistance on postoperative day 3. Total hospitalization was 7 days (delayed secondarily to postoperative ileus). Minimal quantities of narcotics were required for analgesia. At 6-months follow-up, the patient has palpable peripheral pulses and no complications related to surgery. This case report shows that a completely laparoscopic approach to the abdominal aortic aneurysm is possible using instrumentation specifically designed for laparoscopic vascular surgery. The exact role that laparoscopic techniques will hold in vascular surgery remains to be determined because these procedures are time consuming and technically difficult. Received: 2 December 1997/Accepted: 4 March 1998     

Updates and Critical Insights on Glissonian Approach in Liver Surgery

Recent advances in surgical techniques have broadened the indications of surgical management of liver malignancies. Intraoperative bleeding is one of the known predictors of postoperative outcomes following liver surgery, signifying the importance of vascular control during liver resection. Furthermore, preservation of future liver remnant plays a critical role in prevention of post-hepatectomy liver failure as one of the main causes of postoperative morbidity and mortality. Glissonian approach liver resection offers an effective method for vascular inflow control while protecting future liver remnant from ischemia-reperfusion injury. Several studies have demonstrated the feasibility of Glisson’s pedicle resection technique in modern liver surgery with an acceptable safety profile. Moreover, with increasing popularity of minimally invasive surgery, laparoscopic liver resection via Glissonian approach has been shown to be superior to standard laparoscopic hepatectomy. Herein, we systematically review the role of Glissonian approach hepatectomy in current practice of liver surgery, highlighting its advantages and disadvantaged over other methods of vascular control.