腹腔镜超声在腹腔镜肝脏外科中的应用进展

腹腔镜超声(LUS)可弥补腹腔镜手术的缺陷,有助于提高手术的精准性。利用LUS可对肝脏恶性肿瘤进行准确地临床分期,有助于降低术后复发率和避免不必要的剖腹探查术,LUS引导的射频消融为肝癌晚期患者提供了更有价值的治疗手段。带有彩色多普勒功能的探头可精准显示肝中静脉位置及走行,以此为标准的半肝切除术更加精准,提高了手术的安全性。随着3DLUS的出现及发展,术中3D超声"实时导航"给术者提供了更多的手术相关信息。本文就LUS在肝脏外科中的临床应用和最新进展进行综述。     

肠粘连松解术在腹腔镜精索静脉高位结扎术中应用的研究

目的:研究肠粘连松解术在腹腔镜精索静脉高住结扎术中的应用及临床意义.方法:对以下腹部坠胀不适症状为主要就诊原因的194例精索静脉曲张患者进行研究.194例患者均采用腹腔镜行精索静脉高位结扎术,术中腹腔镜直视下发现其中168例患者伴有下腹部肺粘连.采用随机对照性研究,将168例患者随机分为二组,A组75例,单纯行腹腔镜精索静脉高住结扎术.B组93例,行腹腔镜精索静脉高位结扎术+肠粘连松解术,所有患者术前均经B起证实为精索静脉曲张.术前记录患者精索静脉曲张程度,并记录患者下腹疼痛及坠胀不适情况、阴囊坠胀及阴囊潮湿等症状.术中腹腔镜直视下记录患者腹腔肠粘连情况.术后1个月、3个月、6个月分别随访一次,观察患者相应症状改善情况.结果:A、B两组共168例怠者均顺利完成手术.术后2～3天出院,无手术并发症发生.术后第1、3、6个月随访,A、B两组在阴囊坠胀不适,睾丸疼痛、阴囊潮湿等症状的消除缓解上均有明显改善,两组无明显差异;在下腹疼痛、坠胀不适等症状的缓解消除上,两组有明显差异,B组明显优于A组.结论:对于精索静脉曲张的患者,如合并下腹疼痛、坠胀不适等症状,应考虑同时存在肠粘连的可能.行腹腔镜精索静脉高位结扎术时,可同时行肠粘连松解术,对于下度疼痛、坠胀不适等症状的缓解和消除有明显效果.     

Advanced laparoscopic skills acquisition: the case of laparoscopic colorectal surgery

Acquisition of advanced technical skills requires commitment, time, patience, and discipline (eg, the 10-year rule). Dabbling is not a recipe for success. Despite the value of all other teaching methods, guided practice with feedback is essential to develop the high level of visuospatial perceptual ability (observation and performance with feedback) that is necessary for advanced MIS. The necessary ingredients to skill acquisition for advanced MIS procedures (laparoscopic colorectal surgery) for a practicing surgeon include introduction through short courses, access to skill stations, and access to preceptorship or mini-sabbatical. For residents in training, there is no better alternative than an MIS fellowship. In an ideal world where there are enough trainers, the residency environment should provide this training. Comprehensive strategies of knowledge transfer for practicing surgeons should be designed with the input of experts in knowledge transfer.     

腹腔镜模拟训练系统用于腹腔镜手术基本技能训练的研究

目的:总结腹腔镜模拟训练系统对不同操作组腹腔镜手术基本技能的提高情况。方法:本科实习生组、研究生无腹腔镜操作经验组、本院进修医师无腹腔镜操作经验组,分别使用腹腔镜模拟训练系统练习镜下夹取黄豆、缝合及器械打结技术,2周后进行统计学分析。结果:操作训练前,本科实习生夹取黄豆、缝合技术及器械打结技术明显不如本院研究生及进修医师(P<0.05),经过2周训练,较简单的技能操作如夹取黄豆和研究生及进修医师无统计学差异(P>0.05),较复杂的技能操作如缝合技术、绕线打结练习训练前、后和本院研究生及进修医师相比差异有统计学意义(P<0.05);但是3组人员训练后与训练前相比,腹腔镜的基本技能操作均显著提高(P<0.05)。结论:腹腔镜模拟训练系统能提高腹腔镜手术操作者的基本技能,值得推广。     

Remote evaluation of laparoscopic performance using the global operative assessment of laparoscopic skills

Background

Although numerous assessment tools currently exist to evaluate laparoscopic surgical skills, no studies have demonstrated the reliability of such tools when used with telementoring technology. This study aimed to determine the reliability of the Global Operative Assessment of Laparoscopic Skills (GOALS) rating scale for assessing laparoscopic skills remotely and to identify how factors unique to remote assessment such as bandwidth and image quality influence its reliability.

Methods

Four trained observers evaluated 19 participants for their technical performance during a laparoscopic cholecystectomy using the GOALS assessment tool. One observer assessed the study participants directly in the operating room, whereas the three remaining observers were randomly assigned and blinded to a high- (1.5 Mbps), medium- (256 kbps), or low- (64.4 kbps) bandwidth restriction and observed remotely via Skype. The Maryland Visual Comfort Scale was used to evaluate the video quality of the respective connections.

Results

The intraclass correlation coefficient (ICC) calculated for the total GOALS score demonstrated a statistically significant correlation of high, medium, and low bandwidths respectively with ICC 0.693 (95 % confidence interval [CI], 0.226–0.883), 0.518 (95 % CI 0.089–0.783), and 0.499 (95 % CI 0.025–0.781). There was a statistically significant difference in the overall perceived visual quality between the high/low (Z = ?3.222; P = 0.001) and the medium/low (Z = ?3.567; P < 0.001) bandwidth comparison but no difference between the high/medium bandwidths (Z = ?0.610; P = 0.542).

Conclusion

The data suggest that the GOALS assessment tool retains its reliability for intraoperative assessment of laparoscopic skills when used remotely. This is a key requirement in telesimulation programs allowing for structured feedback between the mentor and the mentee. This study quantifies the effect that bandwidth has on the reliability of remote assessment, demonstrating that higher bandwidths improve the utility of these tools.     

A warm-up laparoscopic exercise improves the subsequent laparoscopic performance of Ob-Gyn residents: a low-cost laparoscopic trainer.

INTRODUCTION: Residents traditionally acquire surgical skills through on-the-job training. Minimally invasive laparoscopic techniques present additional demands to master complex surgical procedures in a remote 2-dimensional venue. We examined the effectiveness of a brief warm-up laparoscopic simulation toward improving operative proficiency. METHODS: Using a "Poor-Man's Laparoscopy Simulator," 12 Ob/Gyn residents and 12 medical students were allocated 10 minutes to transfer 30 tablets with a 5-mm grasper from point A to point B via laparoscopic visualization in a warm-up exercise. Participants repeated the exercise following a 5-minute pause. Mean scores, expressed in seconds/tablet, and overall improvement (percentage difference between warm-up and follow-up) were analyzed according to postgraduate standing (PGY14), dexterity skills, and pertinent vocational activities. RESULTS: Significant improvements were noted for both residents (+25%) and medical students (+29%), P<0.0001. Scores between the 2 groups, however, were not significant (P=0.677). Proficiency was not influenced by PGY standing. Interestingly, the best (8.73 sec/pill) and the worst (25 sec/pill) scores were attained by a medical student and a chief resident, respectively, suggesting the contribution of individual aptitude. CONCLUSION: A brief warm-up exercise before an actual laparoscopic surgical procedure significantly improves subsequent laparoscopic performance.     

腹腔镜超声在腹腔镜肝切除术中的应用

目的:探讨腹腔镜超声在腹腔镜肝切除术中的应用价值。方法:用腹腔镜行肝切除术24例,其中肝血管瘤17例,原发性肝癌7例。术中常规应用腹腔镜超声检查了解肿瘤与周围组织的解剖关系,确定肿瘤分期和手术解剖入路。结果:13例行全腹腔镜肝切除术,9例行手助腹腔镜肝切除术。术中超声检查后中转开腹2例。手术平均出血量230ml,术后无并发症发生。结论:腹腔镜超声在腹腔镜肝切除术中能够确定肿瘤位置、临床分期并指导手术入路,提高了肝切除术的安全性,减少了手术并发症。     

一组腹腔镜胆囊大部切除术病例的术后随访观察

目的随访观察一组腹腔镜胆囊大部切除术病例的术后疗效。方法回顾性分析2004年4月-2013年12月97例我院行腹腔镜胆囊大部切除术的患者资料。术后随访时间最长8年余,最短为6个月。随访期内行腹部彩超、CT、MRI等检查。结果术后右上腹疼痛者9例,3例因胆囊结石残留二次行胆囊残株切除术,无胆总管狭窄等严重远期并发症出现。结论腹腔镜胆囊大部切除术对某些病例是安全有效的治疗方法,对于结石残留的胆囊残株炎病例仍需二次手术切除残留的胆囊。     

机器人辅助腹腔镜与腹腔镜前列腺癌根治术的疗效比较

目的:分析比较机器人辅助腹腔镜与腹腔镜前列腺癌根治术治疗前列腺癌的效果,并探讨机器人辅助腹腔镜前列腺癌根治术的临床应用价值。方法:将2011年05月~2014年02月收治的38例前列腺癌患者作为机器人辅助腹腔镜手术组,以同期行腹腔镜前列腺癌根治术的32例患者为腹腔镜手术组。观察比较手术时间、术中出血量、术中输血率、术后引流管留置时间、术后住院时间、切缘阳性率、生化复发以及随访尿控及性功能情况。结果:两组均成功完成手术,机器人辅助腹腔镜手术组在术中出血量、术中输血率、术后引流管留置时间、术后住院时间、尿控及性功能保留方面均优于腹腔镜手术组,差异具有显著性(P0.05)。结论:机器人辅助腹腔镜前列腺癌根治术手术并发症少,术后尿控及性功能保留良好,是治疗前列腺癌安全、有效的微创术式。     

腹腔镜超声检查和超声刀在胃肠外科诊治中的应用

目的:探讨腹腔镜超声检查技术（LUS）和腹腔镜超声刀在腹腔镜胃肠外科手术中的应用价值。方法:对50例胃肠道肿瘤等病变采用腹腔镜超声进行前瞻性肿瘤分期诊断,结合腹腔镜超声刀开展腹腔镜胃肠手术治疗。结果:经腹腔镜和腹腔镜超声分期诊断,47例肿瘤患者均明确诊断,淋巴结穿刺活检与病理结果符合率为87.5％（7/8）;其中2例转开腹手术,6例避免了剖腹探查术,39例肿瘤患者成功地完成了腹腔镜手术。本组50例患者中42例在腹腔镜下成功完成姑息性或根治性胃肠切除术。平均手术时间190min,术中出血量平均120ml（20～250ml）,系膜淋巴结清除数平均6.5个（5～12个）,术后肠蠕动恢复时间平均36h,平均住院8.5d,无手术后并发症。术后随访3～36个月,未发现复发与转移及腹壁穿刺孔或切口转移。结论:腹腔镜胃肠手术中常规使用腹腔镜超声检查可准确为病变定位,完善肿瘤分期诊断,提高肿瘤可切除性的判断率,避免了不必要的剖腹探查;术中常规使用超声刀提高了手术安全性,扩大了腹腔镜手术范围。腹腔镜胃肠道病变切除术安全可行,近期效果良好,远期效果有待观察。腹腔镜胃肠手术将成为胃肠良恶性疾病的常规手术。     

Shakespeare's view of the laparoscopic pneumoperitoneum

Background:

The laparoscopic pneumoperitoneum is created and maintained in a physiologically homeostatic potential space that is 37-degrees Centigrade (^oC) and covered by a wet film of peritoneal fluid. The currently used gas is carbon dioxide that is instilled at 21^oC and extremely dry. Altering this privileged space is a violation of surgical safety, principles, and reason. Maintaining normal healthy conditions in their original state by humidifying and warming the gas eliminates the rub of dry gas and takes arms against a sea of troubles.

Database:

Literature search using PubMed and Cochrane databases identifying articles focusing on laparoscopy, pneumoperitoneum, hypothermia, evaporation, desiccation, peritoneum, and morphology.

Conclusions:

Shakespeare''s premonitions regarding the chilling effects and intentionally induced unhappy events perpetrated on the peritoneal cavity is not nor cannot come to good. The absence of water in the gas going into a wetted cavity causes perilous circumstances, resulting in evaporative hypothermia, tissue desiccation, and damage that precede adhesion formation. Providing the most protective canopy for the intraabdominal cavity with humidity and warmth prevents calamitous clinical outcomes and mirrors nature''s intent. The virtue is in doing no harm.     

机器人辅助腹腔镜与腹腔镜保留肾单位手术治疗肾门唇部肿瘤的临床对比分析

目的:探讨机器人辅助腹腔镜与传统腹腔镜对肾门唇部肿瘤行保留肾单位手术的临床疗效对比及手术经验。方法:回顾性分析2016年1月～2018年8月我院行保留肾单位微创手术治疗的68例肾门唇部肿瘤患者的临床资料,其中前唇肿瘤45例,后唇肿瘤23例。肿瘤直径1.5～8.0cm,平均4.2cm。行机器人手术38例(机器人组),腹腔镜手术30例(腹腔镜组)。结果:68例手术均顺利进行,平均手术时间93min(60～180min,不包含机器人装机时间),平均肾动脉阻断时间21.6(7～44)min,平均术中出血量156(20～600)ml,平均术后引流管拔除时间4(3～6)d,平均术后住院5.3(4～9)d,未出现明显术后并发症。中位随访13.5(3～32)个月,无复发、转移、死亡病例。与腹腔镜相比,机器人手术可明显减少手术时间(P<0.001)和术中出血量(P=0.011);机器人组与腹腔镜组肾动脉阻断时间分别为(19.0±6.5)min和(25.0±7.4)min(P=0.001),住院费用分别为(5.2±0.4)万元和(3.7±0.4)万元(P<0.001)。结论:肾门肿瘤采用微创保留肾单位手术进行治疗是安全可行的。与传统腹腔镜相比,机器人手术的住院费用增加,但对于治疗肾门肿瘤优势明显,可以显著缩短热缺血时间,减少术中出血量,使患者得到最大程度的获益。     

全腔镜下吻合技术在腹腔镜胃癌根治术中的应用

目的 探讨全腔镜下吻合技术在腹腔镜胃癌根治术中的安全性及可行性.方法 回顾分析2012年7月-2013年7月吉林大学第二医院胃肠外科实施腹腔镜胃癌根治术全腔镜下吻合（36例,全腔镜吻合组）与小切口辅助吻合（47例, 小切口辅助组）患者的临床资料,并对两组临床资料进行对比分析.结果 83例患者均成功实施手术,无一例中转开腹.小切口辅助组切口长度为（7.1±0.9） cm,全腔镜吻合组为（2.6±0.4） cm.小切口辅助组吻合时间为（70.9±9.0） min,全腔镜吻合组为（29.1±4.9） min.术后小切口辅助组中度疼痛者6例,余41例为重度疼痛;全腔镜吻合组中度疼痛者29例,余7例为重度疼痛.小切口辅助组术后发生吻合口瘘1例,全腔镜吻合组未出现吻合口瘘及吻合口出血等并发症.结论 全腔镜下吻合技术在腹腔镜胃癌根治术中安全、可行,与小切口辅助吻合相比具有手术时间短和疼痛感减轻等优势.     

改良两孔法与三孔法腹腔镜胆囊切除术的临床疗效比较

目的:对比改良两孔法与三孔法腹腔镜胆囊切除术的临床疗效。方法:选择98例接受腹腔镜胆囊切除术的患者作为研究对象,随机分为观察组与对照组,每组49例,观察组行改良两孔法腹腔镜胆囊切除术,对照组行三孔法腹腔镜胆囊切除术,比较两组手术情况、术后切口疼痛程度、腹壁外观满意程度及生活质量。结果:两组手术时间、术中出血量、中转四孔法手术例数及术后肛门排气时间、卧床时间差异无统计学意义(P0.05);观察组患者术后VAS评分低于对照组,术后腹壁美容满意程度优于对照组,生活质量评分高于对照组,差异有统计学意义(P0.05)。结论:改良两孔法腹腔镜胆囊切除术可取得与三孔法手术相当的效果,且可减轻术后疼痛程度,提高术后腹壁美容满意程度与生活质量。     

腹腔镜胆囊切除术并发症治疗的体会

目的:探讨腹腔镜胆囊切除术(LC)并发症发生的原因和防治方法。方法:总结LC7例并发症的临床资料。结果: 7例中发生MOF1例,胆漏2例,胆囊动脉出血3例,十二指肠损伤1例,均治愈。结论:严格掌握手术适应证,按照解剖结构,规范操作步骤,可减少并发症。     

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass

Background The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20–100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity. Methods The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series’ end. Results are presented as mean ± standard deviation and standard statistical analysis was applied. Results Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 ± 29, 132 ± 40, 127 ± 29, and 114 ± 30 min by quartile. Mean length of stay was 2.9 ± 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach. Conclusions A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success. Presented at the Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, 26–29 April 2006     

Evolution of the laparoscopic gastric bypass

Obesity is recognized as a health problem of epidemic proportions. Surgical intervention for the treatment of obesity is a well-studied and effective method. Various procedures have been utilized over the past decades. Roux-en-Y gastric bypass has emerged over the last 20 years and is currently the most commonly offered surgical treatment. Within the last decade, advances in laparoscopic technology and surgical experience have allowed the application of laparoscopic techniques to the surgical treatment of obesity. Many centers and individuals have developed excellent techniques through experience over time as well as improvements in instrumentation. Hand-assisted laparoscopy was reported as a technique, but has mostly fallen out of favor. Currently, laparoscopic application of adjustable gastric band and laparoscopic Roux-en-Y gastric bypass are widely used throughout the United States. Data have been generated to demonstrate the improvement in surgical outcomes associated with minimally invasive surgical techniques for the surgical treatment of obesity. Further advances will allow continued improvement in patient outcomes utilizing a variety of minimally invasive surgical approaches to the treatment of this difficult disease.     

双镜联合保胆取石术与腹腔镜胆囊切除术治疗胆囊结石的效果比较

对比腹腔镜联合胆道镜(双镜联合)保胆取石术与腹腔镜胆囊切除术治疗胆囊结石的效果。对我科2014年1月—2016年10月行双镜联合保胆取石的62例胆囊结石患者(观察组)和行腹腔镜胆囊切除术(LC)的62例胆囊结石患者(对照组)的临床资料进行比较。两组患者均顺利完成手术。观察组术后彩超复查未见结石残留,术后随访12个月、36个月,结石复发率分别为1.6%、3.2%;但术后腹胀、腹泻、反流性胃炎发生率明显较低,患者生活质量优于对照组。术前掌握好适应证,双镜联合保胆取石术治疗胆囊结石安全可靠。