腹腔镜精索内静脉结扎术的临床应用

应用腹腔镜行精索内静脉高位结扎术１８例（３１侧）与传统手术相比，该手术具有方法简便，创伤小，效果可靠，住院时间短及术后恢复快等优点，尤其适用于常规手术后复发，有腹股沟手术史，双侧精索静脉曲张需同时处理及常规手术困难者。     

腹腔镜下精索静脉高位结扎术治疗精索静脉曲张28例临床分析

对28例精索静脉曲张患者行腹腔镜下精索内静脉高位结扎术。结果28例手术均获成功，平均手术时间32min，手术基本无出血，术后平均住院3d，随访3～9个月无复发。认为腹腔镜精索内静脉高位结扎术治疗精索静脉曲张创伤小、恢复快、治疗效果好，可同时处理双侧病变。     

腹腔镜精索静脉高位结扎术治疗单侧精索静脉曲张30例临床观察

目的探讨腹腔镜精索静脉曲张高位结扎术治疗单侧精索静脉曲张的临床效果及安全性。方法将同期收治的60例单侧精索静脉曲张患者随机分为观察组和对照组各30例,分别行腹腔镜精索静脉曲张高位结扎术及传统开放手术（精索静脉曲张后腹膜高位结扎术）。观察两组术中出血量、手术时间、并发症发生率、住院时间、视觉模拟疼痛（VAS）评分;术前和术后12、24及48 h分别测定血清C反应蛋白（CRP）、IL-6及内皮素（ET）水平。结果两组术中出血量、手术时间无显著差异,观察组住院时间明显短于对照组、VAS评分及并发症发生率显著低于对照组（P〈0.05、0.01）;两组血清CRP、IL-6及ET水平在术后12 h及24 h呈上升趋势、48 h呈下降趋势,观察组变化幅度均低于对照组（P〈0.05）。结论腹腔镜精索静脉高位结扎术治疗单侧精索静脉曲张临床效果优于传统开放手术。     

腹腔镜下精索静脉高位结扎术治疗精索静脉曲张80例临床分析

近年来,我院应用腹腔镜下精索静脉高位结扎术治疗精索静脉曲张80例,效果满意。现报告如下。     

腹腔镜下精索内静脉高位结扎术治疗精索静脉曲张23例

对23例原发性精索静脉曲张患者行腹腔镜精索内静脉高位结扎术。结果顺利完成手术，手术时间35-65min，平均42min，术后当日可下床活动，无并发症发生，平均住院时间3d-精索静脉曲张消失或明显改善，术后半年随访未见复发及睾丸萎缩。认为腹腔镜精索内静脉高位结扎术具有视野清、恢复快等优点，为当前治疗精索静脉曲张的最佳手术方法之一。     

保留精索动脉对腹腔镜精索静脉高位结扎术后患者生精功能的影响

将86例精索静脉曲张所致精液质量异常患者随机分成A、B两组。A组45例,行保留精索动脉的腹腔镜精索静脉高位结扎术;B组41例,行常规腹腔镜精索静脉高位结扎术。结果术后3、6、9、12个月A组患者的精液质量明显优于B组。认为对精索静脉曲张所致精液质量异常患者行腹腔镜精索静脉高位结扎术时应尽量保留精索动脉,以求最大限度地恢复睾丸功能,提高精液质量。     

腰硬联合麻醉在腹腔镜精索静脉曲张高位结扎术中的应用

比较腰硬联合麻醉和气管内全麻在腹腔镜精索静脉曲张高位结扎术中对患者循环、呼吸及血气变化的影响。观察结果表明，腰硬联合麻醉应用于腹腔镜精索静脉曲张高位结扎术，虽然患者的循环和血气指标不如气管内全麻者稳定，但术后能短期内解除高碳酸血症，而气腹时间短、恢复快、麻醉操作简单，费用亦低。     

糖尿病前期不育病人精索静脉高位结扎术后精子质量恢复的临床研究

目的研究糖尿病前期不育病人在接受腹腔镜下高位结扎术后精子质量恢复情况。方法该研究回顾了2010年1月—2013年6月,在该院接受腹腔镜下精索静脉高位结扎术的625例病人,对BMI≥25的病人常规采用了葡萄糖耐量实验。对葡萄糖耐量实验异常(IGT)和空腹血糖(IFG)异常的均给予抗胰岛细胞抗体、抗胰岛素自身抗体和酪氨酸脱羧抗体检查。给予病人常规精子质量分析和性激素六项检查。结果糖尿病前期的病人共120人,精子质量分析主要表现为死精症,精子成活率0~40%。给予生精病治疗2个月后,患有糖代谢异常的病人中有3例病人精子恢复正常,而未患有糖代谢的4例精子质量均恢复正常。二组病人情况通过χ2相比,P<0.05有显著差异。结论在目前糖尿病发病率不断增高的情况下,糖尿病前期在男性不育中所起到的作用,及其对精索静脉高位结扎后术后效果的影响,应该得到临床的高度重视。     

两孔法腹腔镜精索血管高位集束结扎治疗精索静脉曲张疗效观察

目的：观察两孔法腹腔镜精索血管高位集束结扎治疗精索静脉曲张的疗效。方法实施两孔法腹腔镜下精索血管高位集束结扎的精索静脉曲张患者238例,对手术区域附近可见的细小血管逐一电凝,术前B超诊断为左侧精索静脉曲张的患者,腹腔镜下发现其右侧精索静脉明显增粗,术中一并将右侧精索血管集束结扎。结果均在腹腔镜下顺利完成手术,在168例左侧精索静脉曲张患者中,38例术中发现右侧精索静脉不同程度曲张,术中做出相应处理。平均手术时间20 min,术后平均8 h患者可下床走动,平均住院2 d,均未出现睾丸鞘膜积液、阴囊气肿、睾丸萎缩等并发症。随访3～12个月,复发3例（1．26％）,均为左侧。结论两孔法腹腔镜精索血管高位集束结扎治疗精索静脉曲张安全、有效、创伤小、恢复快、并发症少、复发率低。     

超声刀在腹腔镜阑尾切除术中的临床应用

超声刀作为一种新型的手术器械,正逐渐应用于临床外科。我院自2000年6月以来,应用超晰迅声止血刀进行腹腔镜阑尾切除术46例,均获得了令人满意的临床效果。现报告如下。 1.临床资料:本组阑尾炎患者共46例,男26例,女20     

Three-Port laparoscopic partial hepatectomy using an ultrasonically activated device (USAD)

Background/Purpose

We provide an initial report of the indications and procedure for three-port laparoscopic partial hepatectomy.

Methods

Three-port laparoscopic partial hepatectomy was performed in nine patients (age, 49 to 73 years) at our department. Eight patients (seven men and one woman) had hepatocellular carcinoma (HCC); six of these patients had liver cirrhosis (LC) and two had chronic hepatitis (CH). The ninth patient, a woman had a single metastatic liver tumor from colon cancer. The tumors were located in regons S₂, S₃, S₄, S₅, S₆, and S₈. Preoperative liver function assessment revealed Child-Pugh classification A or B. All the tumors were located superficially, and their diameter averaged approximately 3?cm. Hepatectomy was performed laparoscopically, using an ultrasonically activated device (USAD) with or without microwave coagulation therapy (MCT).

Results

The operative time was 50 to 168?min, and the intraoperative blood loss ranged from 32 to 158?g. The postoperative hospital stay was 5 to 17 days. No recurrences, including local relapse, were observed.

Conclusions

Three-port laparoscopic partial hepatectomy is safe and feasible for patients with Child-Pugh liver function classification A or B if the tumor is located superficially and is less than 3?cm in diameter.     

Ultrasonically activated scalpel versus monopolar electrocautery shovel in laparoscopic total mesorectal excision for rectal cancer

AIM： To investigate the feasibility and safety of monopolar electrocautery shovel （ES） in laparoscopic total mesorectal excision （TME） with anal sphincter preservation for rectal cancer in order to reduce the cost of the laparoscopic operation, and to compare ES with the ultrasonically activated scalpel （US）.
METHODS： Forty patients with rectal cancer, who underwent laparoscopic TME with anal sphincter preservation from June 2005 to June 2007, were randomly divided into ultrasonic scalpel group and monopolar ES group, prospectively. White blood cells （WBC） were measured before and after operation, operative time, blood loss, pelvic volume of drainage, time of anal exhaust, visual analogue scales （VAS） and surgery-related complications were recorded. RESULTS： All the operations were successful; no one was converted to open procedure. No significant differences were observed in terms of preoperative and postoperative d I and d 3 WBC counts （P = 0.493, P = 0.375, P = 0.559）, operation time （P = 0.235）, blood loss （P = 0.296）, anal exhaust time （P = 0.431）, pelvic drainage volume and VAS in postoperative d 1 （P = 0.431, P = 0.426） and d 3 （P = 0.844, P = 0.617） between ES group and US group. The occurrence of surgery-related complications such as anastomotic leakage and wound infection was the same in the two groups.
CONCLUSION： ES is a safe and feasible tool as same as US used in laparoscopic TME with anal sphincter preservation for rectal cancer on the basis of the skillful laparoscopic technique and the complete understanding of laparoscopic pelvic anatomy. Application of ES can not only reduce the operation costs but also benefit the popularization of laparoscopic operation for rectal cancer patients.     

Laparoscopic hepatectomy with the hook blade of ultrasonic coagulating shears and bipolar cautery with a saline irrigation system

Background

The number of patients who have undergone laparoscopic hepatectomy is small, and the operative procedure is not yet well established.

Methods

We performed laparoscopic hepatectomy in eight patients, using the hook blade of ultrasonic coagulating shears, and bipolar cautery with a saline irrigation system, with minilaparotomy. The operative time, blood loss, and postoperative hospital stay of patients with laparoscopic left lateral segmentectomy were compared with these parameters in ten patients who had had a left lateral segmentectomy with laparotomy.

Results

The laparoscopic hepatectomies included seven left lateral segmentectomies and one nonanatomical partial resection of the lateral segment. The mean duration of the operation in these eight patients was 181.1 ± 44.6?min. The mean amount of blood loss was 177.6 ± 129.1?ml. Postoperative complications consisted of two cases of bleeding. The mean postoperative hospital stay in all eight patients was 9.88 ± 4.36 days. The mean duration of operation (185.9 ± 46.0?min) and mean postoperative hospital stay (9.47 ± 4.61 days) in the seven patients with laparoscopic left lateral segmentectomies were significantly shorter than these parameters (255.7 ± 59.4?min and 24.6 ± 8.82 days) in the ten patients who had had left lateral segmentectomies with laparotomy. The mean amount of blood loss (160.0 ± 128.9?ml) in the laparoscopic series was less than that (318.5 ± 192.2 days) in the patients who had had laparotomy.

Conclusions

Laparoscopic hepatectomy with the ultrasonic coagulating shears and bipolar cautery with minilaparotomy was safe, and less invasive than the open procedure, for minor hepatectomy procedures such as left lateral segmentectomy.     

Clinical experience with routine activated coagulation time monitoring during elective PTCA

Background: Intracoronary thrombosis is an im portant factor in the pathogenesis of acute complications during percutaneous coronary interventions. The activated coagulation time (ACT) is a simple, reproducible bedside test that has become standard as the means of monitoring the anticoagulant effect of heparin during these procedures. To determine if ACT-adjusted heparin dosing reduces the procedure-related complications of elective PTCA, 1200 patients who underwent nonemergent percutaneous transluminal coronary angioplasty (PTCA) between January 1, 1988 and February 26, 1992 were studied.Methods/Results: Two groups were identified based on the use of empirical heparin dosage (group 1, before July 1, 1990) vs. ACT-guided heparin administration strategies (group 2, after July 1, 1990). Group 2 patients were older, had worse left ventricular function, and were more likely to have experienced a prior myocardial infarction than patients in group 1. Patients in group 1 were more likely to have chronic stable angina and a positive exercise test, while group 2 patients were more likely to be undergoing PTCA for post-myocardial infarction (MI) angina. Angiographie characteristics were also consistent with a higher risk profile in group 2 than in group 1 (92.7% vs. 83.4%, p < 0.001). Postprocedural complications, including abrupt closure and late closure, were lower in group 2 patients. The incidence of abrupt vessel closure was decreased by approximately 50% (6.9% vs. 3.5%, p < 0.025), and delayed vessel closure was significantly reduced by over 60% (3.2% vs. 1.0%, p < 0.05). There were no differences in femoral artery complications between the two specified groups.Conclusions: ACTguided heparin therapy during percutaneous coronary interventions decreases acute and delayed vessel closure, even in the presence of clinical and angiographic characteristics that would predict a higher incidence of these events.Presented in part at the 41st Annual Scientific Sessions of the American College of Cardiology, Dallas, TX, April 15, 1992.     

腹腔镜直肠全系膜切除术治疗中、低位直肠癌的临床研究

目的探讨腹腔镜直肠全系膜切除术(TME)治疗中、低位直肠癌的临床疗效。方法选择中、低位直肠癌患者96例,随机分为观察组与对照组各48例,观察组在腹腔镜下行TEM术,对照组则行开腹TME术,对比两组患者临床疗效。结果观察组术后肛门排气时间、住院时间及手术切口长度、术中出血量、术后VAS疼痛评分、围术期并发症发生率、术后性功能及泌尿功能障碍发生率等方面均显著优于对照组(P0.05),而手术时间、保肛率、肿瘤转移及复发率差异均无统计学意义(P0.05)。结论腹腔镜直肠全系膜切除术治疗中、低位直肠癌疗效确切且安全可靠,可在达到传统开腹手术疗效基础上降低并发症发生率。     

Reversal of low-molecular-weight heparin-induced bleeding in patients with pre-existing hypercoagulable states with human recombinant activated factor VII concentrate

Low-molecular-weight heparins are widely employed in prophylactic and therapeutic antithrombotic regimens for venous thromboembolic events. Excessive anticoagulation with low-molecular-weight heparins rarely can precipitate catastrophic bleeding complications. Currently, there is no specific or reliable antidote that can reverse the anticoagulant effects of low-molecular-weight heparins efficiently and safely. This report describes three individuals with underlying hypercoagulable states, who developed clinically significant bleeding complications while receiving therapeutic anticoagulation with enoxaparin. All of the hemorrhagic events subsequently were safely and effectively reversed with a single intravenous bolus infusion of recombinant activated factor VIIa (RFVIIa) concentrate. Hemoglobins, prothrombin times, and clinical overt bleeding were monitored before and after the administration of RFVIIa. In all three cases, bleeding was controlled without an increase in thrombotic events. Our findings demonstrate that RFVIIa can rapidly and safely reverse the hemorrhagic adverse effects associated with excessive levels of low-molecular-weight heparin in patients with pre-existing hypercoagulable conditions and/or acute venous thromboembolism.     

腹腔镜肝切除术在肝癌合并肝硬化患者的应用

目的：探讨腹腔镜下肝切除（LH）与开腹肝切除（OH）在治疗肝癌合并肝硬化患者近期疗效之间的差别。方法选取2010年9月至2012年6月武汉大学人民医院住院的肝癌合并肝硬化患者78例,分为2组,其中LH组32例,OH组46例,分析比较2组术中、术后恢复以及术后复发之间的差别。计量资料采用成组t检验和配对t检验,计数资料采用χ2检验。结果2组比较,术中失血量,LH组显著低于OH组（t＝0．057,P＝0．040）;手术时间,LH组高于OH组（t＝3．101,P＝0．003）;术后并发症方面,电解质紊乱、胆漏、腹水,LH组显著低于OH组（t＝3．001,3．241,4．255,P均＜0．05）;术后第1天肝功能水平（AST、ALT）,LH组显著低于OH组（t＝3．427、3．201,P＝0．001、0．002）;术后开始经口摄食的时间,LH组显著短于OH组（t＝3．012,P＝0．001）;住院时间LH组显著低于OH组（t＝2．157,P＝0．003）;肿瘤复发方面,LH组显著少于OH组（t＝2．751,P＝0．006）。结论对于肝癌合并肝硬化患者,LH较OH,无论在手术切口、术中失血量、术后腹水发生率、术后并发症、住院时间以及术后肿瘤的复发的发生方面都具有显著优势。     

The use of drotrecogin alfa (activated) in solid organ transplant patients: a case series

Background. Drotrecogin alfa (activated) (DAA), a recombinant human activated protein C, is indicated for the reduction of mortality in patients with severe sepsis who have a high risk of death. In the initial trial, DAA demonstrated a significant reduction in mortality at 28 days for patients treated with DAA in comparison with standard supportive treatment (placebo). However, solid organ transplant recipients were excluded from the study. Transplant recipients are at an increased risk for sepsis and there is minimal literature describing the safety and efficacy of DAA in the transplant population.
Methods. Thirteen solid organ transplant recipients who received DAA between November 2001 and January 2004 were included in this case series. Patients were prospectively identified and data collection occurred concurrently and by retrospective chart review. All patients met the DAA use criteria based on the institutional standard protocol.
Results. We report the outcomes of the 13 adult transplant patients who received a total of 14 courses of DAA for severe sepsis. At the time of DAA initiation, all patients required mechanical ventilation, 86% necessitated vasopressor support, and had a median of 3 dysfunctional organs. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score at initiation was 30. Overall, hemodynamic stability and APACHE II score improved at the end of DAA infusion. Causes of early discontinuation were bleeding (57%), scheduled procedure (14%), increased international normalized ratio (14%), and death (14%). In-hospital, 28-day, and 1-year mortality was 69%, 62%, and 83%, respectively.
Conclusion. DAA appears to be safe with appropriate monitoring. However, transplant recipients had a higher incidence of bleeding events leading to early discontinuation of DAA. Efficacy is difficult to assess without an appropriate control group for comparison.     

限制性结肠脾曲游离技术在腹腔镜直肠癌低位前切除术中的临床应用

目的评价限制性脾曲游离（LSFM）技术在腹腔镜直肠癌低位前切除术中的应用效果和安全性。 方法回顾性总结分析2018年6月至2019年3月间广东省中医院收治的75例直肠癌患者临床病理资料,按照脾曲游离方法分为LSFM组（35例）和完全性脾曲游离（CSFM）组（40例）。 结果两组患者均能完成腹腔镜下的直肠-结肠的无张力吻合,未发生术中毗邻脏器的医源性损伤,手术标本质量分级（Nagtegaal分级）均为3级。两组患者的手术时间无显著性差异（176.8±55.7 vs 205.5±72.4 min,P>0.05）,但LSFM组的脾曲游离时间明显短于CSFM组（4.5±3.1 vs 25.4±9.3 min,P<0.01）。术中出血量、预防性造口比例、淋巴结清扫数目、术后首次肛门排气时间、术后住院时间、盆腔引流管引流量、引流管留置时间和术后并发症发生率两组间差异均无统计学意义（P>0.05）。两组均无术后30 d内再住院、再手术和死亡病例。 结论在腹腔镜直肠癌低位前切除术中行LSFM是安全可行的,与CSFM相比可以明显缩短手术时间,降低手术难度,并能取得同样满意的游离效果。