阶梯式培训模式在消化内科规培生教学中的应用研究

目的 评估阶梯式培训模式在消化内科规培生教学中的可行性.方法 对12名在解放军总医院海南医院2018年4月1日至2018年6月30日进行规培轮转的住院医师进行为期3个月的培训.带教医师将规培医师分为三个层次,初、中、高级.后根据比例随机分为两组,传统培训组及阶梯式培训组.教师及规培医师均应用李克特量表调查问卷检测培训前...     

腹腔镜模拟培训在微创外科研究生临床教学中的应用

目的探讨腹腔镜模拟培训在微创外科专业学位研究生临床教学中的应用效果。 方法采用腹腔镜模拟训练结合临床教学模式对我科24名微创外科专业学位研究生进行临床教学,教学结束时考核教学效果,调查教学满意度,比较考核前后的成绩。 结果培训后学生出科平均成绩、合格率、优秀率、主观对自己基本操作熟练程度评分、满意度评分等均高于培训前,且差异有统计学意义（P<0.001）。 结论微创外科研究生临床教学理论与腹腔镜模拟培训相结合,可有效提高微创外科研究生对腹腔镜基本操作及视觉能力,提高腹腔镜操作者的基本技能,取得良好的教学效果,但考核标准仍需要完善。     

阶梯式教学法在实习护士培训考核中的应用与效果评价

目的探析阶梯式教学法在实习护士培训考核中的应用与效果评价。方法选取2018年7月-2019年4月在我院实习的60名护士作为主要对象,采用数字随机表法分组,各30名。对照组采用传统方法进行考核培训,观察组采用阶梯式教学法进行考核培训,对两组实习护士的考核成绩、自我评价及实习护士满意度等进行对比。结果观察组实习护士的基础理论成绩、案例分析成绩和实践操作成绩明显高于对照组,有显著差异;观察组实习护士的专业知识掌握程度、操作技能熟悉程度、护患沟通能力、理论与实践结合能力均高于对照组,有显著差异;患者对观察组实习护士护理工作的满意度显著高于对照组,有显著差异。结论在实习护士护理培训考核中应用阶梯式教学法可提高实习护士的各项成绩,实习护生的自我评价更高,可激发实习护士的积极性和主动性,值得推广应用。     

临床教学路径在护理带教中的应用

目前,带教已经成为临床科室的重要工作内容之一,将统一的带教计划与一对一的传统带教方式相结合,可提高带教质量。2009年,我院对42名护生在普外科护理带教中应用临床教学路径取得了满意效果。现报告如下。     

加速康复外科模式在腹腔镜胃癌根治术中的应用

目的观察在加速康复外科(ERAS)模式指导下行腹腔镜胃癌根治术治疗胃癌的安全性和有效性。方法对2018-05～2018-10兰州大学第一医院肿瘤外科收治的51例行胃癌手术患者的临床资料进行回顾性对照研究,按治疗方式的不同分为两组。应用传统开腹+ERAS模式的27例为A组,应用腹腔镜手术+ERAS模式的24例为B组。比较两组术前白细胞(WBC)计数和D-二聚体水平、手术时间、术中出血量、淋巴结清扫数目、切口长度、首次经口进食时间、首次肛门排气时间、腹腔引流管放置天数、术后住院时间、住院费用、并发症及死亡发生情况、术后第1天、第3天WBC计数和D-二聚体水平等。结果 B组在术中出血量、皮肤切口长度、首次经口进食时间、首次肛门排气时间、腹腔引流管放置天数均优于A组,差异有统计学意义(P0.05),但手术时间延长(P0.05),住院费用增高(P0.05)。两组患者淋巴结清扫数目、术后住院天数、术后并发症发生率及术前1 d、术后第1天、术后第3天WBC计数及D-二聚体定量比较差异均无统计学意义(P0.05)。结论与传统开腹手术+ERAS模式相比,腹腔镜手术+ERAS模式具有加快术后肠道功能恢复、缩短腹腔引流管放置天数、减少术中出血量等优点。加速康复外科模式可安全、有效地在腹腔镜胃癌根治术中展开实施。     

循证医学在普通外科住院医师培训中的应用

目的探讨循证医学在普通外科住院医师培训中的认知程度与应用价值。方法对参加规范化培训的住院医师进行问卷调查,调查问卷内容主要集中在对循证医学的认知程度、运用循证医学的能力、在学习中遇到的障碍等方面。结果 55%的被调查者认为应在本科阶段开始接触循证医学,在住院医师培训中得到进一步提高;59%的被调查者能够以他们自身的能力,利用循证医学帮助他们做出临床决策。结论循证医学在普通外科住院医师培训中具有重要的作用,将其科学合理地融入到该培训的教学实践中,会提高教学质量。     

无气腹腹腔镜在老年人急性胆囊炎中的应用

CO2气腹是提供腹膜腔操作空间最常用的一种方法。然而，CO2注气法导致腹内压增高和腹膜CO2的吸收，可诱发一系列并发症，对部分有心肺功能障碍的老年患者，CO2气腹腹腔镜已列为禁忌。我们于2001年3月至2002年10月应用无气腹腹腔镜对30例急性胆囊炎老年患者进行腹腔镜手术治疗，以克服CO2气腹所导致的生理影响，取得满意的疗效。     

3D腹腔镜技术在微创外科中的现状与思考

随着微创技术的发展,3D腹腔镜作为腹腔镜技术的重要革新之一,能够为外科医生提供真实的视野和高清晰的图像。虽然目前的3D技术尚存在一些不足之处,但可以预计3D技术将促使微创外科进入"精准时代"。     

心电图带教方法在住院医师规范化培训中的运用与改进

心电图操作和诊断是住院医师规范化培训中重点考核的技能之一。针对该技能学科要求特殊和学习安排时间较短的情况,我科在住院医师心电图带教中充分利用带教老师和大量实践资源,注重心电图理论和操作技能的学习,以心电图诊断为重点,加强一对一带教,取得了良好的效果。     

单孔腹腔镜技术在子宫内膜癌治疗中的应用

子宫内膜癌是发生于子宫内膜的一组上皮性恶性肿瘤,占女性生殖系统恶性肿瘤的20%～30%,是最常见的妇科恶性肿瘤之一。近年来随着人均寿命的延长,肥胖、糖尿病、高血压等高危因素出现,全世界范围内子宫内膜癌发病率呈明显上升趋势,严重危害女性健康。大多数子宫内膜癌可以早期诊断,并通过手术进行治疗。传统腹腔镜手术经过多年的发展,已广泛应用于妇科各类手术,但体表瘢痕、腹壁血管损伤、切口疝及切口感染等问题仍然存在。随着人们对美观、微创的不断追求,单孔腹腔镜技术随之问世,其降低了相关并发症的风险,并具有术后疼痛轻、美容效果佳等突出的优势。目前单孔腹腔镜技术在妇科领域已经能够完成多种良恶性疾病的治疗,该文主要对单孔腹腔镜手术在子宫内膜癌治疗中的应用现状、优劣势、技术要点及发展前景进行简要阐述。     

经自然腔道内镜手术研究进展

经自然腔道内镜手术（NOTES）利用人体自然开口和管腔，通过内镜进人体腔进行内镜手术。在动物模型上经胃、结肠、阴道、甚至膀胱，食管等腔道进入腹腔、纵隔，已经成功施行腹腔探查、肝脏活检、胃肠吻合、阑尾切除、胆囊切除、输卵管结扎、子宫部分切除、肾切除、脾脏切除、胰腺尾部切除、纵隔探查等手术：最近有成功应用于临床的报道。虽设备及技术逐渐完善，但还有许多问题有待解决，如：入路途径和切口闭合等问题。随着技术和观念的进步，经自然腔道内镜手术有望再次革新傲创外科手术。     

Progress in laparoscopic anatomy research: A review of the Chinese literature

The development of laparoscopic surgery has generated the new field of study, laparoscopic anatomy. This article reviews the reported literature on laparoscopic anatomy and explores how it has evolved along with advances in abdominal surgery. In addition, the principal concerns in current laparoscopic anatomy research are discussed, including: (1) types of special adjacent anatomical structures; and (2) special surgical planes and anatomical landmarks. Understanding of systematic laparoscopic anatomy can pr...     

Core value of laparoscopic colorectal surgery

Since laparoscopy was first used in cholecystectomy in 1987, it has developed quickly and has been used in most fields of traditional surgery. People have now accepted its advantages like small incision, quick recovery, light pain, beauty and short hospital stays. In early times, there are still controversies about the application of laparoscopy in malignant tumor treatments, especially about the problems of oncology efficacy, incision implantation and operation security. However, these concerns have been fully eliminated by evidences on the basis of evidence-basis medicine. In recent years, new minimally invasive technologies are appearing continually, but they still have challenges and may increase the difficulties of radical dissection and the risks of potential complications, so they are confined to benign or early malignant tumors. The core value of the laparoscopic technique is to ensure the high quality of tumor’s radical resection and less complications. On the basis of this, it is allowed to pursue more minimally invasive techniques. Since the development of laparoscopic colorectal surgery is rapid and unceasing, we have reasons to believe that laparoscopic surgery will become gold standard for colorectal surgery in the near future.     

Robotic surgery for rectal cancer: Current immediate clinical and oncological outcomes

Laparoscopic rectal surgery continues to be a challenging operation associated to a steep learning curve. Robotic surgical systems have dramatically changed minimally invasive surgery. Three-dimensional, magnified and stable view, articulated instruments, and reduction of physiologic tremors leading to superior dexterity and ergonomics. Therefore, robotic platforms could potentially address limitations of laparoscopic rectal surgery. It was aimed at reviewing current literature on short-term clinical and oncological (pathological) outcomes after robotic rectal cancer surgery in comparison with laparoscopic surgery. A systematic review was performed for the period 2002 to 2014. A total of 1776 patients with rectal cancer underwent minimally invasive robotic treatment in 32 studies. After robotic and laparoscopic approach to oncologic rectal surgery, respectively, mean operating time varied from 192-385 min, and from 158-297 min; mean estimated blood loss was between 33 and 283 mL, and between 127 and 300 mL; mean length of stay varied from 4-10 d; and from 6-15 d. Conversion after robotic rectal surgery varied from 0% to 9.4%, and from 0 to 22% after laparoscopy. There was no difference between robotic (0%-41.3%) and laparoscopic (5.5%-29.3%) surgery regarding morbidity and anastomotic complications (respectively, 0%-13.5%, and 0%-11.1%). Regarding immediate oncologic outcomes, respectively among robotic and laparoscopic cases, positive circumferential margins varied from 0% to 7.5%, and from 0% to 8.8%; the mean number of retrieved lymph nodes was between 10 and 20, and between 11 and 21; and the mean distal resection margin was from 0.8 to 4.7 cm, and from 1.9 to 4.5 cm. Robotic rectal cancer surgery is being undertaken by experienced surgeons. However, the quality of the assembled evidence does not support definite conclusions about most studies variables. Robotic rectal cancer surgery is associated to increased costs and operating time. It also seems to be associated to reduced conversion rates. Other short-term outcomes are comparable to conventional laparoscopy techniques, if not better. Ultimately, pathological data evaluation suggests that oncologic safety may be preserved after robotic total mesorectal excision. However, further studies are required to evaluate oncologic safety and functional results.     

手术直播演示结合分级腹腔镜模拟器训练法在普外科腹腔镜培训中的研究

目的手术直播演示结合分级腹腔镜模拟器训练法在普外科腹腔镜培训中的应用效果。 方法首都医科大学附属北京中医医院参加住院医师规范化培训基地第1阶段普外科、泌尿外科及妇科专业住院医师和本院纳入第1阶段住院医师规范化培训的普外科、泌尿外科及妇科专业研究生组成,共120名。腹腔镜基本技能培训为期1个月,内容包括3部分：手术直播演示每周2台;理论授课每周2次,每次1 h;模拟训练4周,操作每天4 h,包括（初级模块——基本技能训练;中级模块——简单及高级缝合训练;进阶模块——腹腔镜必要技巧训练;高级模块——模拟手术培训）。随机分为3组,其中试验组采用手术演示＋理论授课＋腹腔镜模拟训练;对照组采用理论授课＋手术演示;空白组采用仅进行理论授课,不参与其他培训,安排下一期参加培训。 结果培训后腹腔镜理论考核成绩试验组为（82.00±6.72）分,对照组为（83.40±6.51）分,空白组（83.20±5.72）分,均较培训前提高,但差异均无统计学意义（P＞0.05）,且3组间培训前后理论成绩差异不显著,差异无统计学意义（P＞0.05）。腹腔镜操作技能考核成绩试验组培训后初级模块——基本技能训练、中级模块——简单及高级缝合训练、进阶模块——腹腔镜必要技巧训练、高级模块——模拟手术培训各项操作技能成绩分别为（86.00±5.98）、（86.00±5.98）、（85.00±5.13）和（82.50±6.38）分,较试验组培训前的（37.00±10.81）、（18.00±7.68）、（16.00±8.21）和（10.50±10.50）分显著提高,差异有统计学意义（P＜0.05）;明显高于对照组（46.00±9.95）、（44.00±9.40）、（39.00±7.18）和（35.00±7.18）分,差异均有统计学意义（P＜0.05）;明显高于空白组（36.00±8.21）、（18.50±6.71）、（16.50±9.44）和（11.00±9.68）分,差异均有统计学意义（P＜0.05）。 结论腹腔镜技能模拟训练能有效提高临床医学生的腹腔镜操作技能。     

Review of single incision laparoscopic surgery in colorectal surgery

As surgical techniques continue to move towards less invasive techniques,single incision laparoscopic surgery(SILS),a hybrid between traditional multiport laparoscopy and natural orifice transluminal endoscopic surgery,was introduced to further the enhanced outcomes of multiport laparoscopy. The safety and feasibility of SILS for both benign and malignant colorectal disease has been proven. SILS provides the potential for improved cosmesis,postoperative pain,recovery time,and quality of life at the drawback of higher technical skill required. In this article,we review the history,describe the available technology and techniques,and evaluate the benefits and limitations of SILS for colorectal surgery in the published literature.     

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.     

Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: Current status

AIM: To investigate the cooperative laparoscopic and endoscopic techniques used for the resection of upper gastrointestinal tumors.METHODS: A systematic research of the literature was performed in PubMed for English and French language articles about laparoscopic and endoscopic cooperative, combined, hybrid and rendezvous techniques. Only original studies using these techniques for the resection of early gastric cancer, benign tumors and gastrointestinal stromal tumors of the stomach and the duodenum were included. By excluding case series of less than 10 patients, 25 studies were identified. The study design, number of cases, tumor pathology size and location, the operative technique name, the endoscopy team and surgical team role, operative time, type of closure of visceral wall defect, blood loss, complications and length of hospital stay of these studies were evaluated. Additionally all cooperative techniques found were classified and are presented in a systematic approach.RESULTS: The studies identified were case series and retrospective cohort studies. A total of 706 patients were operated on with a cooperative technique. The tumors resected were only gastrointestinal stromal tumors (GIST) in 4 studies, GIST and various benign submucosal tumors in 22 studies, early gastric cancer (pT1a and pT1b) in 6 studies and early duodenal cancer in 1 study. There was important heterogeneity between the studies. The operative techniques identified were: laparoscopic assisted endoscopic resection, endoscopic assisted wedge resection, endoscopic assisted transgastric and intragastric surgery, laparoscopic endoscopic cooperative surgery (LECS), laparoscopic assisted endoscopic full thickness resection (LAEFR), clean non exposure technique and non-exposed endoscopic wall-inversion surgery (NEWS). Each technique is illustrated with the roles of the endoscopic and laparoscopic teams; the indications, characteristics and short term results are described.CONCLUSION: Along with the traditional cooperative techniques, new procedures like LECS, LAEFR and NEWS hold great promise for the future of minimally invasive oncologic procedures.     

Tips and tricks of laparoscopic distal pancreatectomy for ductal adenocarcinoma

Laparoscopic distal pancreatectomy for pancreatic cancer can be a challenging procedure that requires adherence to surgical principles respecting tissue planes and critical vascular structures to obtain the optimal surgical margins and peripancreatic node harvest, while minimizing damage to surrounding structures. This report provides a basic approach with some tips and tricks based on my experience with this procedure.