门静脉重建技术在肝切除术中的应用

门静脉重建技术是复杂肝脏外科手术的必备技术.结合精准肝切除技术可使复杂肝胆肿瘤治疗达到手术切缘无残留或肉眼无残留,从而有效提高患者存活时间及生存质量.该技术要求对肝脏入肝血管解剖及胆道解剖极其熟悉.同时,还需术前精确评估影像学资料,制定手术预案,充分利用团队力量,合理运用术中超声、冷冻复苏血管技术、血管成型技术,以达到最佳治疗效果.     

Navigation surgery for pancreatic disease using multislice computed tomography

In navigation surgery, preoperatively acquired image data are used so that surgical instruments can be guided inside the body while their location is displayed on a computer monitor. It is used in cranial nerve and spinal surgery. In the field of abdominal surgery, however, surgical manipulations in the target area cause major changes in the displayed images compared with those obtained preoperatively, and therefore, with the exception of certain organs, navigation surgery is difficult to apply. In general, this type of surgery aims to use intraoperative image information to improve surgical precision, carry out the preoperative plan accurately, and avoid dangerous areas. Three-dimensional images of the vascular architecture obtained with multislice computed tomography (MS-CT) make it possible to visualize arteries, the portal vein, bile duct, and even the pancreatic duct from any angle, which cannot be done with conventional angiography. Accurate positional relationships in the affected region can be determined preoperatively by manipulating multiplanar reconstruction images at a work station. MS-CT is extremely useful in navigation for safe performance of all types of pancreatectomy.     

Spiral saphenous vein graft for portal vein reconstruction in pancreatic cancer surgery

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.     

腹腔镜微创技术在门脉高压症外科治疗中瓶颈与术式变迁

门静脉高压症大多是由肝脏自身病变、肝内外胆管疾病、门静脉血管病变等引起的一类症候群。门静脉高压常常引起严重的临床症状体征,主要有脾大、脾功能亢进充血性脾大、大量腹水形成、门体侧枝循环的形成、门静脉高压性胃肠血管病(portalhypertensivegastrointestinalvasculopathy,PHGIV)、肝性脑病。其中上消化道出血是最严重的并发症。临床治疗方法多是以控制上消化道出血、提高患者的生存质量为目的。内科治疗方法中包括药物硬化、内镜套扎及介入栓塞治疗。外科治疗方法包括活体肝脏移植、分流术、断流术三种。由于我国活体供肝资源短缺,到目前为止肝脏移植开展的医院并不是很多且技术并不成熟。目前公认且可取的断流术是贲门周围离断术联合脾切除术,分流术是选择性远端脾肾分流术。传统开腹手术创伤较大、术后恢复时间较长、术后并发症多。随着腔镜外科的迅猛发展,微创外科如同核武器般占据着手术发展的主流,所以一个敞亮的切口已经不再是解决一个复杂手术的好武器。目前越来越多的门静脉高压患者接受腹腔镜微创技术的治疗,但是仍然缺少大样本的临床研究。因此,尚需要进行大样本、多中心的临床和循证医学研究,旨在为门静脉高压的外科治疗提供治疗策略,为临床应用和研究提供基础。     

Portal vein thrombosis: an emergency solution for blood flow in liver transplantation

Recipient portal vein thrombosis in liver transplantation is a contingency that increases surgical difficulty as well as patient morbidity and mortality. The aim of this paper is to demonstrate a surgical technique for reconstruction of portal blood flow in emergency situations of portal vein thrombosis with inadequate blood flow and a poor vascular bed for re-vascularization.     

Posterior exposure of the popliteal artery in reoperative vascular surgery

Reoperative vascular surgical procedures play an important role in the successful salvage of ischemic limbs. Such secondary procedures frequently involve difficult situations where the surgical incisions and the vascular anatomy have been compromised by infection of prior surgery. In such instances an alternative surgical approach may provide a significant advantage and aid in successful revascularization. Use of the posterior approach in reoperative vascular surgery is unusual. The application of this exposure may facilitate selected secondary surgical procedures. We review the use of the posterior approach to the popliteal vessels in three patients who required reoperative vascular reconstruction. These cases illustrate the judicious application of this technique and the resultant benefit of this unusual surgical approach.Presented at the Twelfth Annual Meeting of the Southern California Vascular Surgical Society, Coronado, Calif., September 17–19, 1993.     

Videotunneler for minimal and direct access aortoiliac reconstructive surgery

Despite improvements in surgical practice and postoperative care, the large vertical midline or transverse transperitoneal approaches used in abdominal aortic surgery are still associated with a relatively high perioperative morbidity and mortality rate even in patients who are considered good risks for undergoing aortic surgery. This significant perioperative morbidity is partly caused by the major surgical trauma. To decrease the surgical stress on these patients we have developed a less-extensive procedure for this type of vascular reconstruction. Technique: The abdominal aorta is explored using a special retractor through a short upper median minilaparotomy utilizing modified conventional surgical hand instruments. For an aortobifemoral graft implantation, a retroperitoneal tunnel is necessary. During the creation of this tunnel special care should be exercised to avoid troublesome hemorrhage with iliac and other vein lacerations. To overcome these difficulties, we have developed a new tunneling device, which allows us to have visual control of the tunneling procedure. This prototype device contains a semiflexible tube with an inflatable balloon and a flexible videoendoscope. It is introduced along the external iliac artery into the retroperitoneal space and creates a tunnel through step-by-step inflation of the balloon. After this, the graft is implanted in the usual manner. To date, 19 abdominal vascular reconstructions have been performed with this method.     

Management of biliary duct confluence injuries produced by hepatic hydatidosis

From 1978 to 1999 a total of 850 patients underwent surgical treatment for hydatid disease of the liver at our surgical department. Biliary duct confluence injuries produced by hepatic hydatidosis (HH) were founded in six patients (0.7%). Surgical intervention was undertaken to relieve the obstructive jaundice and clinical manifestations of cholangitis and to treat the hydatid cyst. A partially open cystopericystectomy technique was used in three patients with a double bilioenteric Roux-en-Y reconstruction. The remaining three patients (two with prehepatic portal hypertension and one with triple hepatic duct confluence) were subjected to a cystojejunostomy. There were no hospital deaths. Two cases of anastomotic leakage following a high bilioenteric anastomosis occurred but did not require surgical treatment. During the follow-up (5–19 years) one patient suffered local recurrence of the hydatid disease 7 years after cystojejunostomy. The site of intrahepatic biliary and vascular involvement, the presence of biliary duct anomalies, and the presence of portal hypertension are decisive factors when choosing the “ideal” procedure for reconstruction. Conservative surgical approaches (partial cystectomy and cystojejunostomy) are the treatments of choice. Radical surgery is often a serious matter.     

Dynamic retention: a technique for closure of the complex abdomen in critically ill patients.

Management of the open abdomen in the setting of massive visceral swelling or extensive intra-abdominal abscess may pose an extremely difficult surgical scenario. We herein describe the technique and results of dynamic-retention sutures used in 13 patients with abdominal catastrophes after trauma, vascular reconstruction, tumor extirpation, and intra-abdominal infection. Three of these patients died during their acute care hospitalization. The remaining 10 patients were discharged to home with no resultant fistulas and 1 recurrent hernia (10%). Dynamic-retention sutures provide a useful technique for the closure of the complex surgical abdomen. We observed a low complication rate. In properly selected patients, this technique avoids the use of mesh or additional surgical procedures such as skin grafting or plastic surgical reconstruction of the abdominal wall.     

对我国疝与腹壁外科专业发展的思考

疝与腹壁外科是外科学一个较新的亚专科。在国际上,虽然我国该学科起步较晚,但经过20多年的发展已取得令人瞩目的成果,奠定了在该领域的重要地位,为今后我国疝与腹壁外科专业的发展打下坚实基础。同时,国内研究者也应该清醒地认识到自身不足。笔者深度剖析国内外相关研究,总结并展望未来我国疝与腹壁外科领域的发展应该更细致深入地从以下...     

Nitrous oxide in abdominal surgery

Inhalation anaesthesia has traditionally been the method of choice for abdominal surgery. While most surgical interventions in the lower abdomen can be performed under regional anaesthesia, a general anaesthetic technique is frequently chosen for upper abdominal procedures. This explains the almost routine use of nitrous oxide (N₂O) for abdominal surgery.In addition to well-known contra-indications such as ileus and abdominal wall defects in infants, there is substantial scientific evidence against the application of N₂O in abdominal surgery. N₂O has an important role in the development of post-operative nausea and vomiting (PONV).     

急腹症行腹腔镜手术失败后再手术原因分析

目的分析急腹症患者行腹腔镜手术失败的原因,探讨腹腔镜急腹症手术中应注意的事项。方法回顾性分析2006年5月至2011年3月间广东省惠州市中心人民医院收治的17例急腹症行腹腔镜手术后失败再手术患者的临床资料。结果17例再手术患者中男11例．女6例,年龄16～68岁：上消化道穿孔修补术后8例,阑尾切除术后8例,消化道出血行小肠部分切除术后1例。再手术原因：腹腔脓肿13例,其中4例合并内瘘;回盲部牙签异物残留1例;回盲部淋巴瘤并梗阻1例：右侧闭孔疝1例：小肠血管畸形出血1例。12例患者经保守治疗无效后行再次腹腔镜探查手术,其中5例顺利完成腹腔镜手术,7例中转开腹手术;另有5例行急诊开腹探查手术。所有患者均救治成功,术后7～21d痊愈出院。结论腹腔镜技术应用于外科急腹症时,须严格掌握腔镜探查指征和遵循手术操作规范．对于病情特殊、诊断及手术有难度者应及时中转开腹。     

Surgical techniques for vascular reconstruction of the portal vein and hepatic artery in living-donor liver transplantation]

To decide how to reconstruct the portal vein and hepatic artery for liver transplantation, anatomical variation, diameter, length, and injury to vessels during surgery, and the quality of recipient vessels should be considered. Hence, it is of key importance for donor and recipient surgeries to prepare adequate vessels for reconstruction. For reconstruction of the portal vein, anastomosis with as large a diameter as possible is required to obtain good portal flow. In cases with sclerosing stenosis and old thrombus, technical innovations such as branch-patch, a conduit using a vein graft, and venoplasty using a venous patch are necessary. For reconstruction of the hepatic artery, selecting a satisfactory recipient artery, overcoming size mismatch, and gentle handling of a recipient artery with pathological changes are important. Arteries smaller than 3 mm are anastomosed with a surgical microscope using the united suture technique. The fishmouth technique or funnelization technique can be used for anastomoses with a significant size mismatch, and an autoarterial graft is used when arteries do not reach each other.     

腹主动脉瘤开腹手术与腔内修复术的对照研究

目的对比分析腹主动脉瘤病人开放手术与腔内修复术的治疗效果。方法收集新疆维吾尔自治区人民医院血管外科2012年7月至2017年6月收治的腹主动脉瘤病人,对比开放手术与腔内治疗病人的一般情况、住院情况、术后及随访期间并发症情况。结果 176例接受手术的腹主动脉瘤病人均获成功,其中腔内修复术(endovascular aneurysm repair,EVAR)156例,开放手术(open surgery,OS)20例,平均年龄(68.8±9.9)岁,平均随访时间(25.9±16.2)个月。OS组住院期间输注红细胞量、输注血浆量、术后重症监护室治疗时间、住院时间明显多于EVAR组(P0.05)。EVAR术后髂支闭塞、支架感染等问题值得重视。结论尽管腔内治疗效果优于开放手术的循证资料十分有限,EVAR仍然是一个令血管外科医生及病人容易接受的手术方式。     

Robot-assisted laparoscopic aortobifemoral bypass: initial experience developing a new program

Despite improved technology for endovascular treatment of aorto iliac occlusive disease, aortobifemoral bypass (ABF) continues to offer superior long-term patency. In an effort to reduce the morbidity of surgical ABF, multiple minimally invasive techniques have been reported. The da Vinci robot may facilitate the construction of a minimally invasive aortic anastomosis using standard vascular suture techniques. Our initial experience in the development of a minimally invasive surgical aortic reconstruction program is reported. After extensive time in the laboratory developing our surgical technique in human cadavers and a pig model, our team initiated a robotic vascular surgery program in 2007. A retrospective review of our initial six robot-assisted laparoscopic ABF cases was conducted. The aorta was exposed laparoscopically using the Stadler technique and the aortic anastomosis performed with the da Vinci robot. These results are compared with currently published reports of robotic ABF and alternative methods of minimally invasive aortic reconstruction. From January 2007 to August 2007, six robot-assisted laparoscopic ABFs were performed. Two patients had prior abdominal surgical procedures. Four patients had prior endovascular or surgical aorto iliac reconstruction. Operative time varied from 5 h 26 min to 8 h 12 min. Total clamp time, for the aortic anastomosis, ranged from 70 to 100 min with a mean of 75 min. Estimated blood loss ranged from 300 to 2,000 ml with a mean of 850 ml. Conversion with a short upper midline incision was required in one patient (16%) with an associated abdominal aortic aneurysm. Post operative length of stay ranged from five to ten days with a median of seven days. There was no operative mortality. Results from robotically assisted laparoscopic ABF are equivalent to those from other minimally invasive options while enabling a much shorter learning curve. Using the technique described, minimally invasive ABF was accomplished in a safe and reliable manner despite prior vascular treatment.     

Minimal-access aortic surgery: the potentials of hand-assisted laparoscopy

In analogy with the good results of laparoscopic abdominal procedures minimal-access aortic surgery looks very promising. However, in spite of the many technical improvements that have already been made, totally laparoscopic and even laparoscopically assisted aortic surgery remains technically demanding. This explains the rather slow introduction of minimal-access aortic surgery in the vascular society. In anticipation of increasing surgical experience and better instrumentation that will make the technique feasible for each vascular surgeon, hand-assisted laparoscopy (HALS) can be a valuable intermediate approach. HALS offers an easy to perform and still clearly less invasive approach for all aorto-iliac reconstructions.     

Operative Interdisziplinarität—Abdomen (ohne Becken)

Cooperation between different surgical disciplines arises from the employment of nonoperative procedures as a supplement to operative treatment (sequential multidisciplinary operations) and synchronized multidisciplinary or simultaneous operations. The objective is to ensure optimized treatment results. Complementary preoperative measures are the endoscopic removal of bile duct stones, interventional portal vein embolization, percutaneous abscess drainage, and so-called stenting in case of mechanical bowel obstruction. Intraoperative cooperation is advised in case of abdominal surgical diseases, especially with vascular surgery. Visceral surgeons should have a good command of vascular surgical techniques when performing corresponding operations. The aim of operative cooperation between different disciplines is to safeguard optimal treatment results. From this follows a right to and, for physicians, the duty of interdisciplinary cooperation. A prerequisite is the knowledge of the potentialities of the different disciplines as well as mutual respect for their limits. Intensive communication is an important aspect during the whole process of diagnostics, therapy, and postoperative care.     

'Shared spinal cord' scenario: paraplegia following abdominal aortic surgery under combined general and epidural anaesthesia.

Serious neurological complications of abdominal aortic vascular surgery are rare but devastating for all involved. When epidural blockade is part of the anaesthetic technique such complications may be attributed to needles, catheters or drugs. We present a patient who developed paraplegia following an elective abdominal aortic aneurysm repair. Continuous epidural blockade was part of the anaesthetic technique and postoperative analgesia. In this case the spinal cord damage was explained by ischaemia caused by the aortic surgery. This event has made us aware of a rare complication associated with abdominal aortic surgery and highlighted safety aspects of epidural anaesthesia in such patients.     

Abdominal surgery after lung transplantation

Among 450 patients who underwent lung transplantation (LuT) between April 1994 and April 2009 at a single academic hospital, 75 received surgical consultation, and 52 underwent 65 abdominal operations. Operations included colectomy (17), cholecystectomy (14), exploratory laparotomy (10), ulcer repair (five), hernia repair (four), Nissen fundoplication (four), pancreatic debridement (four), ostomy takedown (two), drainage of intra-abdominal abscess (two), and major vascular procedure, gastrostomy, splenectomy, fascial closure, laparoscopic common bile duct exploration, and small bowel resection (one each). Fourteen patients (27%) died within 30 days of surgery. On univariate analysis, age, race, comorbidities, history of previous abdominal surgery, transplant type, and timing of surgery after transplant were similar between the patients who survived and died. On multivariate analysis, emergent surgery, multiple medical comorbidities, and male gender were predictive of 30-day mortality (P < or = 0.05). Ulcer repair, major vascular procedures, pancreatic surgery, splenectomy, and exploratory laparotomy were associated with > or =50 per cent 30-day mortality. This is the largest series reporting outcomes of abdominal operations after LuT. Elective operations in LuT patients are safe, whereas emergent operations carry an extremely high short-term mortality rate. Aggressive prophylaxis for ulcer disease and early elective intervention for potential surgical problems, such as gallstones and uncomplicated diverticulitis, should be considered.