完全腹腔镜下主-双股动脉旁路术治疗主、髂动脉硬化闭塞症

目的探讨完全腹腔镜下主一双股动脉旁路术治疗主、髂动脉硬化闭塞症的安全性和可行性。方法2008年11月～2012年11月,完全腹腔镜下主一双股动脉旁路术连续治疗7例主、髂动脉硬化闭塞症。7例均为男性,年龄52—70岁,平均60．6岁。Rutherford分级3级5例,4级I例,5级1例。主、髂病变TASC分级C级2例,D级5例。全麻,先用完全腹腔镜技术经左侧结肠后肾后入路游离肾下腹主动脉,再将“Y”形涤纶人工血管近端与之行端侧吻合,人工血管远端经腹膜后隧道引出至相应侧腹股沟,直视下分别与双侧股动脉吻合。结果5例顺利完成腹腔镜下主一双股动脉旁路术,2例中转开腹（肠系膜下动脉断端的钛夹脱落出血1例,结肠损伤1例）。手术时间420～840rain（中位数585min）,主动脉吻合时间40～150min（中位数65rain）,术中出血量400—1500ml（中位数800m1）。未中转的5例均在术后12—40h恢复进食,术后顺利康复出院。结肠损伤患者术后结肠漏二次开腹手术,结肠漏治愈,术后46天死于呼吸衰竭。一过性左肾积水1例,治愈。吻合口近端腹主动脉残留重度狭窄1例行支架治疗治愈。无症状的部分左肾梗死1例。6例随访2—51个月,平均11．2月,均健在,超声随访移植物均通畅,静息痛和间歇跛行症状均消失。结论完全腹腔镜下主一双股动脉旁路术治疗主、髂动脉硬化闭塞症是安全、可行的。在学习曲线中及时中转保证手术安全是必要的。     

Total Laparoscopic Aortic Aneurysm Surgery

This paper describes our technique and results with total laparoscopic aortic aneurysm repair. Material and Methods: A transperitoneal left retrorenal access was used in all cases. Special laparoscopic clamps often in combination with balloon catheters were used to occlude the aorta and the renal arteries. Exactly the same techniques like in open surgery were used. Either a tube graft or a bifurcated graft, anastomosed with the iliac arteries or the femoral arteries, was implanted to exclude the aneurysm.

Laparoscopic surgery is becoming a third way to perform aortic aneurysm repair. In contrast to EVAR it can offer to aneurysm patients the same definitive outcome which we obtain in open surgery.     

Potential Benefits of Laparoscopic Aorto-Bifemoral Bypass Surgery

Background : This series aims to prove the positive impact of laparoscopic approach in aortofemoral bypass grafting.

Methods : It concerns a retrospective non randomized study comparing 58 consecutive patients treated with laparoscopic procedure (n = 30) and with a standard open procedure (n = 28) in a single center. The different operating times, the complications and the follow-up of these two groups are compared

Results : The demographics and angiographic data of the two groups were comparable. Operating time was longer in the laparoscopic group. However, we noticed a significant shorter hospitalisation stay (p < 0.0001) after the laparoscopic procedure with a mean 5.1 days. There was no significant difference of morbidity.

Conclusion : We suggest that the trans-peritoneal approach is the best way in laparoscopic procedure in term of exposure and ergonomics. Laparoscopic aortofemoral bypass grafting is feasible, safe and effective. Shortening of operating time is observed as surgeon’as experience grows.     

Hand-assisted Laparoscopy Versus Conventional Median Laparotomy for Aortobifemoral Bypass for Severe Aorto-iliac Occlusive Disease: A Prospective Randomised Study

OBJECTIVES: To demonstrate that hand-assisted laparoscopy for aortofemoral bypass for severe aorto-iliac occlusive disease reduces morbidity with earlier recovery of bowel function and shorter in-hospital stay. DESIGN: Randomised controlled trial. MATERIALS AND METHODS: Thirty-six consecutive patients with severe aorto-iliac occlusive disease (TASK C/D) without history of major abdominal surgery necessitating an aortobifemoral bypass were randomised between a hand-assisted laparoscopic (HALS) approach and a conventional medial laparotomy. Operative data, early recovery data, quality of life and vascular outcome were analysed. RESULTS: No significant differences in operative data were found. Fluid and solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p = 0.016) (45.6 hrs vs. 105.6 hrs; p = 0.02) and in-hospital stay was shorter (7.5 vs. 8.9 days; p = 0.005) in the HALS group. Six weeks post-operatively social functioning measured by the SF-36 survey score was better in patients randomised to HALS (p=0.023). CONCLUSIONS: HALS is a less invasive approach for aortofemoral bypass.     

Robot-assisted Laparoscopic Aortobifemoral Bypass for Aortoiliac Occlusive Disease: Early Clinical Experience

BACKGROUND: Robotic technology may facilitate laparoscopic aortic reconstruction. We present our early clinical experience with laparoscopic aortobifemoral bypass, aided by two different robotic surgical systems. METHODS: Between February 2002 and April 2004, we performed eight robot-assisted laparoscopic aorto-bifemoral bypasses for aortoiliac occlusive disease. All patients were male; median age was 55 years (range: 36-64). Dissection was performed laparoscopically and the robotic system was used to construct the aortic anastomosis. RESULTS: A robot-assisted anastomosis was successfully performed in seven patients. Median operative time was 405 min (range: 260-589), with a median clamp-time of 111 min (range: 85-205). Median blood loss was 900 ml (range: 200-5800). Median anastomosis time was 74 min (range 40-110). In two patients conversion was necessary, one due to bleeding of an earlier clipped lumbar artery after completion of the anastomosis, the other because of difficulties with the laparoscopic exposure of the aorta. On post-operative day 3 one patient died unexpectedly as a result of a massive myocardial infarction. Median hospital stay was 7.5 days (range: 3-57). CONCLUSION: Our initial experience with robotic assisted laparoscopic surgery (RALS) shows it is a feasible technique for aortoiliac bypass surgery. However, laparoscopic aortoiliac surgery demands considerable experience and operative times need to be reduced before this technique can be widely implemented.     

Hand-Assisted Laparoscopic Surgery for a Mesenteric Teratoma

Mature cystic teratomas are benign neoplasms of germ cell tumors that occur most frequently in gonadal sites. The tumors usually contain 2 or 3 well-differentiated elements of endodermal, ectodermal, and mesodermal origin. Although relatively uncommon, teratomas can be composed of mature tissue originating from only 1 germ cell layer. This is known as a monodermal teratoma.Extragonadal teratomas, especially mesenteric teratomas, are extremely rare. Currently, only 21 cases of mesenteric teratoma have been described in the English literature. Mesenteric teratomas are rarely diagnosed preoperatively because pathological examination is necessary to make a definitive diagnosis.We herein report a rare case of mesenteric monodermal teratoma and review the literature. To the best of our knowledge, this is the first case of mesenteric teratoma treated with hand-assisted laparoscopic surgery.     

多科疾病同期腹腔镜手术治疗的临床体会

目的总结妇科疾病合并外科疾病经腹腔镜同期治疗的效果。方法对25例妇科疾病合并外科疾病患者选择腹腔镜同期联合手术,术中根据疾患情况决定手术顺序。结果25例均顺利完成腹腔镜手术,无并发症,效果满意。结论多科疾病行腹腔镜手术治疗不增加病人痛苦,可避免上下腹同时切开或需扩大手术切口,避免多次手术,住院时间短、费用低、美容效果好。     

Pituitary Apoplexy after Aortic Abdominal Aneurysm Surgery: a Case Report

Pituitary apoplexy (PA) occurring after surgery is a rare but life-threatening acute clinical situation following extensive haemorrhage or necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. One of the pathophysiological mechanism that has been postulated is the fall of arterial blood pressure inducing ischaemia followed by infarction of the pituitary gland. We report a case of pituitary apoplexy following aortic abdominal surgery. To our knowledge, this has not been previously reported. A 73-year old man complained of headache and diplopia. At clinical examination, he presented a right oculomotor nerve palsy. Magnetic resonance imaging (MRI) showed a haemorrhagic sellar mass. In our case, intraoperative hypotension could have been the precipitating factor. Diagnostic and therapeutic measures are discussed.     

Giant Abdominal Aortic Aneurysms: Clinical and Technical Considerations

The rupture risk of abdominal aortic aneurysms (AAA) depends primarily on their diameter and increases substantially in large aneurysms. Only a few cases of giant AAAs, with a maximum diameter > 13 cm have been reported in the English literature. This case series report describes 3 cases of giant AAAs presented with rupture. All cases were managed with open surgical repair, since anatomic factors prevented us from choosing an endovascular approach. The huge size of the aneurysm, the short length of the neck and the dislodgement of abdominal organs, that may be densely adhered to its surface with fistula formation, make surgery of this entity very challenging. Open repair of giant AAAs is often the only available treatment, though not always with good results.     

Surgery for Acute Presentation of Thoracoabdominal Aortic Disease

1. Download high-res image (159KB)
2. Download full-size image

     

Limb Ischemia and Reperfusion During Abdominal Aortic Aneurysm Surgery

Purpose Abdominal aortic aneurysm (AAA) surgery involves ischemia and reperfusion of the lower extremities, but assessing the pathophysiological changes is difficult. We evaluated the extent and time course of ischemia–reperfusion injury of the lower extremities during AAA surgery.Methods To monitor oxygen metabolism, two near-infrared spectroscopy (NIRS) probes were positioned on each calf muscle of nine patients undergoing AAA surgery. Lactate and pH were also measured in both iliac veins.Results Near-infrared spectroscopy signals responded sensitively to aortic cross-clamping and declamping. Lactate increased gradually and exponentially during aortic cross-clamping, and reconstruction of the first iliac artery resulted in a further but transient increase in ipsilateral venous lactate. The time course of the pH level after declamping was almost a mirror image of that of lactate. Reconstruction of the first iliac artery did not affect the contralateral NIRS signals, lactate, or pH.Conclusions Near-infrared spectroscopy may be useful for monitoring limb ischemia during AAA surgery. The transient increase in lactate and the transient decrease in pH after first declamping may contribute to the mechanism of declamping shock. The fact that first declamping did not affect measurements on the other side shows that contralateral ischemia progresses steadily after reconstruction of the first iliac artery. Therefore, reconstruction of the second iliac artery should be done as soon as possible.     

腹主动脉瘤腔内修复与开腹切除术的麻醉管理比较

目的比较腹主动脉瘤腔内修复与开腹切除术的麻醉管理特点。方法 2010年2月~2011年1月,70例ASAⅡ~Ⅳ级,肾下型腹主动脉瘤行腔内修复术52例（腔内修复组）,开腹切除术18例（开腹切除组）。开腹切除组采用气管内插管全身麻醉。腔内修复组采用的麻醉方法包括气管内插管全身麻酔、全凭静脉麻醉（喉罩通气）和监护麻醉。气管内插管全身麻醉采用快速顺序静脉诱导,气管插管后机械控制呼吸,静吸复合方式维持麻醉;全凭静脉麻醉（喉罩通气）采用丙泊酚靶控静脉输注,经喉罩行机械通气控制呼吸;监护麻醉保留自主呼吸,适当镇静镇痛。结果开腹切除组在气管内插管全身麻醉下完成手术,术中均需要使用血管活性药物控制血压。腔内修复组有57.7%（30/52）的患者采用气管内插管全身麻醉、34.6%（18/52）的患者采用全凭静脉麻醉（喉罩通气）和7.7%（4/52）的患者在监护麻醉下完成手术。与开腹切除组相比,腔内治疗组术中血压较平稳,麻醉时间[（90±27）min vs.（210±44）min,t=13.668,P=0.000]、手术时间[（45±22）min vs.（187±36）min,t=-19.811,P=0.000]、术中输注晶体液[（750±178）ml vs.（1896±367）ml,t=17.486,P=0.000]、胶体液[（349±147）ml vs.（1257±266）ml,t=18.034,P=0.000]、异体血[（50±34）ml vs.（898±154）ml,t=-37.615,P=0.000]、术后返ICU患者比例（15.4%vs.66.7%,χ2=17.231,P=0.000）及术后住院时间[（8.5±2.1）d vs.（15.2±4.3）d,t=8.700,P=0.000]均明显降低。结论腹主动脉瘤腔内修复术的麻醉手术时间、液体出入量及血管活性药物应用水平远低于腹主动脉瘤开腹切除术,且监护麻醉、全凭静脉麻醉适用于该术式。     

Management of an Abdominal Aortic Aneurysm in a Patient with End-Stage Liver Disease

Concomitant abdominal aortic aneurysms and cirrhosis that need surgical attention are rare. Currently there are no guidelines with regards to the appropriate timing of the repair of these aneurysms and transplantation. In addition it also raises the issue of which procedure takes precedence. With the advent of endovascular repairs, this issue was resolved with relative ease, by doing the orthotopic liver transplantation (OLT) first and subsequent endovascular stenting on post-operative day 7 during the same hospitalization. This is the first case report of stenting an abdominal aortic aneurysm (AAA) in a liver transplant recipient. The rationale for the OLT and then AAA repair are discussed and formal guidelines are offered.     

Significance of Thoracoscopy-Assisted Surgery with a Minithoracotomy and Hand-Assisted Laparoscopic Surgery for Esophageal Cancer: The Experience of a Single Surgeon

Background

This retrospective study evaluated the surgical learning curve and outcomes of thoracolaparoscopic esophagectomy.

Patients and Methods

The study group comprised a series of 92 patients with preoperatively diagnosed resectable thoracic esophageal cancer. Additionally, the surgical outcomes in 79 esophageal cancer patients receiving open esophagectomies were compared. All patients underwent thoracolaparoscopic esophagectomy in the lateral decubitus position. The short- and long-term outcomes were evaluated, and the surgical learning curve was assessed.

Results

The total operation time was 477.8?±?102.2 min, the thoracoscopic time was 157.9?±?61.3 min, the total blood loss was 554.4?±?280.5 ml, and the number of retrieved lymph nodes was 34.3?±?14.3. Postoperative morbidity was observed in 23 patients. After the surgeon??s first 40 cases, the surgical technique and short-term outcomes were stable. The 5-year disease-specific survival was 66.6% and the 5-year overall survival was 64.6% in patients receiving R0 thoracolaparoscopic esophagectomy. Comparison of 5-year disease-specific survival rate according to tumor?Cnode?Cmetastasis stage between patients receiving R0 thoracolaparoscopic esophagectomy and conventional open esophagectomy showed that there were no significant differences in survival in any stage between the two groups. Loco-regional recurrence was observed in 6 patients, distant recurrence in seven, and combined recurrence in nine after R0 thoracolaparoscopic esophagectomy. There was no significant difference in the pattern of recurrence between the two groups.

Conclusions

Thoracolaparoscopic esophagectomy for esophageal cancer was technically feasible and oncologically satisfactory, according to the surgical learning curve.     

Repair of False Para-anastomotic Aortic Aneurysms Using an Endovascular Stent Graft Technique in a Patient with Severe Pulmonary Disease: Report of a Case

Conventional surgery for para-anastomotic aortic aneurysms is technically challenging, and is associated with high morbidity and mortality. This report describes the case of a patient with severe pulmonary diseases in whom false para-anastomotic aortic aneurysms were successfully repaired using an endovascular stent graft technique. Received: November 30, 2000 / Accepted: May 15, 2001     

胸,腹主动脉瘤腔内隔绝术的临床应用

目的:总结腔内隔绝术治疗胸、腹主动脉瘤的初步临床经验,探讨其指征、方法、操作要点及临床应用前景.方法:本组15例患者在DSA监视下经股总动脉小切口将人造血管内支撑复合体(移植物)导人腹主动脉瘤,从腔内将瘤体与血流隔绝.15例中置入直管型移植物4例,分叉型移植物11例.结果:13例患者于手术当日进食,次日下床活动;1例出现急性酸中毒;1例因髂动脉扭曲导致移植物将髂动脉阻塞,而加作股.股交叉转流术,恢复较慢.4例出现内漏,其中1例3月后自行愈合;1例术后第4天动脉瘤破裂,经传统开腹手术治愈;另2例随访中.2周及3月后分别复查彩超、螺旋CT.结果显示全部病例移植物中血流通畅,无移位.结论:腔内隔绝术简捷、方便,避免了常规开腹手术所见腹部及重要脏器并发症,创伤小、恢复快,适用于所有尤其是高龄高危肾下腹主动脉瘤及胸降主动脉瘤患者.全程内支架-人造血管复合体应用于EVGE效果良好.熟练的导管操作技巧及精确的术前评估有利于提高操作成功率及减少术后并发症.并发内漏的问题有待于继续观察探讨.