经股动、静脉插管建立体外循环行电视胸腔镜与心内直视手术138例

目的总结采用股动、静脉插管建立体外循环(CPB)技术应用于电视胸腔镜心脏手术和某些心内直视手术的临床经验。方法采用右股动脉插供血管,右股静脉和/或上腔静脉插引流管建立CPB,在电视胸腔镜下行房间隔缺损(A SD)修补术46例,室间隔缺损(V SD)修补术58例,电视胸腔镜辅助下加小切口行二尖瓣置换术29例,心脏不停跳下直视肺动脉瓣狭窄矫治术5例。结果所有患者无死亡,灌注流量1.6~2.4L/m in.m2,平均1.9L/m in.m2;灌注压50~80mmHg(1 kPa=7.5mmHg),平均56mmHg;CPB时间8~157m in,升主动脉阻断时间18~65m in。2例患者于术后出现右下肢局部麻木、疼痛,均于7d后消失,未发生其它与周围CPB有关的并发症。结论股动、静脉插管建立CPB技术可应用于电视胸腔镜心脏手术和某些有适应证的心脏手术患者,其风险小、安全、简便、省时,有临床应用价值。     

泌尿外科单孔行腹腔镜手术:早期经验总结

目的 介绍使用Uni-X单孔腹腔镜系统完成泌尿外科单孔腹腔镜手术的早期经验,这套系统包括一个单孔多通道的套管和一套特别设计的弯曲的腹腔镜器械.方法 我们对10名患者施行了泌尿外科单孔腹腔镜手术,包括4例冷冻治疗,1例肾楔形活检,1例根治性肾切除,4例经腹腔阴道骶骨固定术.经腹腔入路时,单孔多通道系统经脐置入:经腹膜后入路时,单孔多通道系统经第12肋末梢处置入.相关数据由前瞻性的数据注册登记审核委员会收录.结果 从2007年9月25日起,10名患者因腹部及盆腔疾病接受了单孔腹腔镜手术.所有手术均顺利完成,无中途转为标准腹腔镜术式.肾脏手术平均手术时间2.5小时(范围2～3.2小时),阴道骶骨固定术平均手术时间2.5小时(范围2～3小时).肾脏手术平均失血量100ml,阴道骶骨固定术平均失血量90 ml.肾脏手术平均住院时间2.8天(范围1～8天),阴道骶骨固定术住院时间2天.1例接受冷冻治疗的患者并发充血性心力衰竭,术后给予面罩吸氧,使其住院时间延长1周.此患者术前因贫血输3U浓缩红细胞,术后CT扫描发现一小的肾周血肿.结论 以单孔腹腔镜行肾脏冷冻治疗、肾楔形活检、根治性肾切除和阴道骶骨固定术安全可行.尚需行进一步实践和跟踪观察.     

Minimally Invasive Surgery for Gastric Cancer: The Future Standard of Care

Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.     

Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy (HIPEC) by Minimally Invasive Approach,an Initial Experience

Background

The cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard treatment in patients with carcinomatosis peritoneal from different origins. The use of a minimally invasive approach for this high complex procedure might be an alternative that provides them less morbidity and faster recovery with similar oncologic outcomes.

Methods

We describe the initial experience of CRS and HIPEC done via the laparoscopic route in patients with minimal peritoneal metastases in our Unit from March 2016 to January 2018.

Results

A total of eight patients were operated by this minimally invasive approach. The different diagnoses were low-grade pseudomyxoma peritonei (2), benign multicystic mesothelioma (2), primary epithelial ovarian carcinomatosis (2) and locally advanced colon carcinoma T4 (2). The median age was 54 (20–62) years, the median PCI was 3 (2–4), the median operative time was 287 min (240–360), complete cytoreduction CC0 was achieved in all the patients, and no major morbidity was observed. The median length of stay was 4.75 days (4–5). After a median follow-up of 9.5 months, no relapse has been observed.

Conclusion

The results suggest that this minimally invasive approach for CRS and HIPEC is feasible and safe in a highly selected group of patients with peritoneal surface malignancies.

     

Minimally Invasive Gastric Bypass in a Morbidly Obese Patient with Myasthenia Gravis

Associated or rare diseases, such as myasthenia gravis, introduce a challenge to the perioperative management of severely obese patients undergoing bariatric surgery. We report the surgical management and unique anesthetic approach to a 55-year-old morbidly obese woman with a complex past medical history that included myasthenia gravis, who underwent laparoscopic gastric bypass. Her myasthenia was controlled on pyridostigmine and her greatest concern was the potential need for postoperative mechanical ventilation. While the laparoscopic surgical approach was ideal to reduce pain and the adverse effects on ventilatory mechanics associated with open upper abdominal surgery, a combined inhalational and intravenous anesthetic without muscle relaxants resulted in satisfactory surgical conditions, and allowed for immediate postoperative extubation followed by an uneventful postoperative course. Continued perioperative anticholinesterase administration may have facilitated this successful outcome. We conclude that a diagnosis of myasthenia gravis does not mandate postoperative mechanical ventilation following laparoscopic gastric bypass.     

Minimally Invasive Direct Coronary Artery Bypass Grafting: Two-Year Clinical Experience

Background. Interest in minimally invasive coronary artery bypass grafting has been increasing.

Methods. From April 1994 through December 1996, 199 patients (age, 36 to 93 years) underwent minimally invasive coronary artery bypass grafting through minithoracotomy, subxiphoid, and lateral thoracotomy incisions, with internal mammary artery, gastroepiploic artery, and composite grafts placed using local coronary artery occlusion.

Results. The conversion rate to sternotomy was 7% (14/199). Preoperative risk factors included unstable angina (n = 83), reoperative coronary artery bypass grafting (n = 54), low ejection fraction (n = 53), congestive heart failure (n = 44), renal insufficiency (n = 25), chronic obstructive pulmonary disease (n = 36), cerebrovascular accident (n = 22), and diffuse vascular disease (n = 47). Morbidity included wound infections (n = 5), reoperation for management of bleeding (n = 6) and acute graft occlusion (n = 2), perioperative stroke (n = 1), atrial fibrillation (n = 14), and perioperative myocardial infarction (n = 7). The operative mortality was 3.8% (7/185). The number of grafts placed in 185 patients was as follows: single, 156; double, 28; and triple, 1. Early (less than 36 hours) angiography and Doppler flow assessment of the coronary anastomoses in 85% of the patients showed that 92% were patent. Routine use of mechanical stabilization of the coronary artery since April 1996 was found to be associated with an increase in the patency rate of the left internal mammary artery–left anterior descending coronary artery anastomosis to 97%, versus 89% (p = 0.055) associated with conventional immobilization techniques. Of the 148 patients followed up beyond 1 month (range, 1 to 32 months; mean, 9.2 ± 7.4 months) postoperatively, 3 have died (3 to 7 months), and of the 145 survivors the cardiac-related event (percutaneous transluminal coronary angioplasty, reoperation, readmission for recurrent angina, and congestive heart failure)–free interval was 93%.

Conclusions. The minimally invasive coronary artery bypass grafting operation is safe and effective. Regional cardiac wall mechanical immobilization enhances the early graft patency and must be considered an essential part of this operation.     

Laparoscopic Gastric Bypass after Antireflux Surgery for the Treatment of Gastroesophageal Reflux in Morbidly Obese Patients: Initial Experience

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven effective against gastroesophageal reflux disease (GERD) in morbidly obese patients. We present our experience with revision of antireflux procedures to LRYGBP in obese patients with recurrent GERD, weight gain or a combination of both and discuss the indications and technical considerations involved. Methods: Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI of 37.5 kg/m² underwent revision of an antireflux procedure to LRYGBP by our group. Important steps of the revision include dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. Results: Mean operative time was 6 hr 12 min and length of stay was 4.8 days. There were 3 major complications postoperatively and no deaths. During follow-up, 5 patients developed anastomotic strictures and 2 patients were re-explored for gastric remnant herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months, mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were improved or resolved. GERD evaluation with the GERD-HRQL scale showed a significant reduction of GERD scores postoperatively (P =0.006). Conclusions: Although LRYGBP after antireflux surgery is a technically more difficult procedure with a higher morbidity, it is feasible and effective for the treatment of recurrent GERD and worsening obesity with the additional advantage of weight loss and improvement of co-morbidities.     

Hybrid Percutaneous Coronary Intervention and Minimally Invasive Reoperative Mitral Valve Surgery

Abstract   We report a complex case of peripheral vascular disease (PVD), coronary artery disease (CAD), and three prosthetic heart valves, who developed severe mitral regurgitation (MR) due to healed endocarditis. She was successfully managed with a hybrid approach utilizing percutaneous coronary intervention (PCI) followed by minimally invasive mitral valve surgery (MIMVS) through right minithoracotomy. This was the patient's fifth cardiac surgery and she was discharged home on the fourth postoperative day (POD) .     

Gasless Laparoscopy-Assisted Subtotal Gastrectomy for Early Gastric Cancer: A Novel Minimally Invasive Surgery

Background Due to the highly invasive nature of traditional surgery and the limitation of gas-filling laparoscopic surgery in gastric cancers, we developed a new method of gasless laparoscope-assisted subtotal gastrectomy (GLASG). This study investigated the technique and clinical results of this procedure and compared it with traditional radical subtotal gastrectomy (TRSG) for early gastric cancers. Methodology From December 2004 to January 2006, 41 patients diagnosed with early gastric cancer were included in the study. All cases underwent subtotal gastrectomy with standard radical lymph node dissection. Twenty patients underwent GLASG, whereas the other 21 patients underwent TRSG. In the GLASG group, we performed our newly developed method using three working ports created at the bilateral subcostal and umbilicus, which provided a 3-dimensional sensation by direct vision through a minilaparotomy and laparoscopic view simultaneously. B-II gastrojejunostomy reconstruction was performed by intracorporeal anastomosis using an endostapler. The TRSG group underwent the standard open method used for gastric cancer. Preoperative characteristics and postoperative recovery between the two groups were compared. Results The operative time was comparable between the two groups, but the bleeding was significantly less severe in the GLASG group. Postoperative pain was significantly less in the GLASG group, as well as body temperature from postoperative day 2 to 7. The number of days to first flatus, first oral intake, and discharge were all significantly less in the GLASG group. No major complications were noted in either group. Conclusions GLASG may be a feasible and safe procedure for early gastric cancer. Gasless laparoscopic gastrectomy has the advantages of less pain, better cosmetic outcome, and earlier recovery. The newly developed gasless environment may hybridize the advantages of open method and pure laparoscopic method. This paper was invited to be presented at International Society of Digestive Surgery, Roma, Dec. 1st, 2006.     

经皮微创与开放手术治疗胫骨远端骨折的疗效分析

目的探讨应用解剖型锁定钢板经皮微创与常规开放性手术治疗胫骨远端骨折的临床效果。方法回顾我院2007年1月至2012年12月期间对两组胫骨远端骨折患者实施手术,29例(观察组)应用解剖型锁定钢板经皮微创治疗,27例(对照组)应用常规开放性手术,比较两组患者的手术时间、术中出血量、住院日、踝关节功能保留及Johner-wruhs评分。结果两组患者均获得随访,时间8~24个月,平均随访16个月。所有患者切口均一期愈合,无内固定物松动,无骨不连、骨延迟愈合的发生。观察组:按Johner-wruhs评分,优20例,良6例,可3例,优良率为89.66%。手术时间(85±10)min、术中出血量(110±20)mL、平均住院日(10±2)d,平均临床愈合时间15周,踝关节背伸(20±3)°,踝关节跖屈(38±3)°。对照组:按Johner-wruhs评分,优10例,良10例,可5例,差2例,优良率为74.07%。手术时间(116±10)min、术中出血量(200±30)mL、平均住院日(12±2)d,平均临床愈合时间18周踝关节背伸(10±2)°,踝关节跖屈(26±3)°。两组间各指标进行比较,差异有统计学意义(P0.05)。结论锁定钢板经皮微创治疗胫骨远端骨折创伤小,骨折愈合率高,伤口并发症少,是一种较理想的手术方法。     

Minimally Invasive Direct Coronary Artery Bypass Surgery with Right Gastroepiploic Artery for Redo Patients

Coronary artery bypass grafting (CABG) has been widely performed for coronary artery disease. Therefore, cases requiring reoperative CABG are increasing. We performed a minimally invasive direct coronary artery bypass (MIDCAB) procedure on four patients, as reoperative CABG surgery for the right coronary artery (RCA), employing the right gastroepiploic artery (RGEA). The target sites were the distal RCA in two patients and the posterior descending (PD) branch in the other two. Complete revascularization was accomplished in all patients without sternotomy, cardiopulmonary bypass (CPB), or blood transfusion. The mean operative time was 3.0 h (range: 2.4–3.7 h). Postoperative coronary angiography showed all grafts to be patent. All patients were discharged without postoperative complications and remained free from cardiac events during a mean follow-up period of 1.5 years (range: 0.5–3.0 years). MIDCAB for the RCA, employing the RGEA via a subxiphoid incision showed, excellent revascularization in redo CABG cases. This technique is a safe and effective method for redo cases.     

Robotic Single-Port Cholecystectomy Using a New Platform: Initial Clinical Experience

Background  

The technique of single-port laparoscopy was developed over the past years in an attempt to reduce the invasiveness of surgery. A reduction of incisions and their overall size might result in enhanced postoperative cosmesis and potentially reduce pain when compared to conventional techniques. While manual single-port laparoscopy is technically challenging, a newly approved robotic platform used with the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) might overcome some of the difficulties of this technique.     

Minimally Invasive Cardiac Surgery in the Adult: Surgical Instruments, Equipment, and Techniques

To clarify the special instruments and equipment used for minimally invasive cardiac surgery (MICS), we examined the initial experiences with MICS operations with ministernotomy or minithoracotomy at our institution. Fifty adult patients with congenital, valvular, and/or ischemic heart diseases underwent MICS operations, and all surgical procedures were completed without conversion to full sternotomy. The length of the skin incision was about 10 cm or less in all patients. Postoperative recovery was favorable, and the majority of the patients were discharged from the hospital around the end of the second postoperative week. In this series of patients, an oscillating bone saw, lifting type retractor, 2 blade spreader, cannula with a balloon, and right-angled aortic clamp among other items, were very useful for successfully performing various operations with MICS approaches and techniques. The associated results suggest that MICS with ministernotomy or minithoracotomy was feasible using special instruments and equipment and could be encouraged for adult patients with various cardiovascular diseases.     

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

Background:

Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center.

Methods:

We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes.

Results:

There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients.

Conclusions:

The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients.