前方经胸骨或侧前方经肩胛下入路手术治疗上胸椎结核

目的:探讨前方经胸骨或侧前方经肩胛下入路治疗上胸椎(T1～T4)结核的手术方法及疗效.方法:2000年6月～2008年12月收治上胸椎结核患者26例,其中16例采用经胸骨入路行一期病灶清除、前路减压、植骨融合及内固定术(A组),年龄37～72岁,平均48.6岁,术前神经功能按Frankel分级A级2例.B级1例.C级2例,D级6例,E级5例,术前胸椎后凸Cobb's角为15°～40°,平均22°±3.5°;10例采用侧前方经肩胛下入路行一期病灶清除、减压、植骨融合及内固定术(B组),年龄33～69岁,平均45.3岁,术前按Frankal分级A级1例,B级1例,C级1例,D级4例,E级3例.术前胸椎后凸Cobb's角为13°～39°～平均2l°±3.7°.结果:两组患者均能很好耐受手术.A组患者术中显露清楚,病灶清除彻底,手术时间为120～150min,术中出血量为300～600ml;1例患者术后出现声音嘶哑,考虑为喉返神经牵拉伤.术后2周恢复正常:术后胸椎后凸Cobb's角为10°～25°,平均17°±2.5°;随访6～72个月,末次随访时1例A级恢复到D级,1例B级恢复到C级,2例C级恢复到D级,4例D级恢复到E级,余无变化.B组患者不能完全显露对侧,病灶清除不易彻底,手术时间为150～220min,术中出血量为500～900ml,1例发生胸导管损伤,经对症治疗1周后痊愈;术后胸椎后凸Cobb's角90°～24°,平均为16°±2.3°,均有肩关节活动障碍;随访12～96个月,末次随访时4例仍有肩关节轻度障碍:1例A级恢复到C级,1例B级恢复到C级,1例C级恢复到D级,4例D级恢复到E级,其余患者神经功能无变化.两组均无结核复发,无内同定物断裂、松动等并发症.所有植骨均愈合,愈合时间为3～6个月,平均4.4个月.结论:与侧前方经肩胛下入路相比,经胸骨入路町以更清楚地显露上胸椎,创伤小,能达到一期病灶清除、前路减压及植骨内固定治疗上胸椎结核的目的.     

前路病灶清除植骨内固定治疗胸腰椎结核

目的探讨胸腰椎结核前路病灶清除植骨内固定手术治疗的效果。方法本组104例采用前路病灶清除植骨内固定治疗脊柱结核,病变位于胸椎30例、胸腰椎24例、腰椎50例,术前有后凸成角畸形38°±19°。手术前后配合正规化疗,根据X线片观察脊柱融合时间,手术前后后凸角度变化以及按照Frankel分级的神经功能变化。结果全部病例伤口均一期愈合,未出现严重并发症。随访时间10～48个月,植骨界面骨性融合时间平均5个月。后凸平均矫正度数为18°±5°,22例术前伴有神经损害症状者Frankel分级平均提高2级。结论脊柱前路一期病灶清除植骨内固定治疗胸腰椎结核具有能矫正后凸成角畸形、预防畸形复发、术后患者能早期离床活动等优点,治疗效果满意。     

一期前路手术内固定治疗脊柱结核

目的:总结一期前路病灶清除、椎体间植骨及前路内固定治疗脊柱结核的临床疗效,探讨一期重建脊柱稳定性的必要性和安全性。方法:自2000年5月至2003年1月共收治21例脊柱结核患者,采用一期前路病灶清除、椎体间植骨及前路内固定治疗,其中颈椎2例、胸椎6例、胸腰段5例、腰椎8例。平均受累椎体数为2.6个。结果:经平均17个月随访,所有患者均临床痊愈,无伤口感染或窦道形成,植骨均完全融合,融合时间平均为3.6个月。术前后凸畸形角度为41.1°±15.6°,术后为13.5°±8.3°,平均17个月随访时为15.9°±6.7°。后凸畸形矫正角度平均为27.6°±9.2°,后期矫正度丢失为2.4°±3.3°。结论:一期前路手术内固定治疗脊柱结核能有效清除病灶、矫正后凸畸形、早期重建脊柱的稳定性及促进椎体间植骨的融合,是一种安全有效的治疗方法。     

Ⅰ期前路与后路病灶清除内固定治疗胸腰段结核的疗效比较

目的:比较前路与后路手术治疗胸腰段脊柱结核的临床疗效。方法:对2005年1月至2014年12月手术治疗的97例胸腰段脊柱结核患者回顾性分析,其中男59例,女38例;年龄20~68岁,平均53.7岁;病程1~13个月,平均(6.9±2.3)个月;采用后路手术治疗54例(后路组),前路手术治疗43例(前路组)。观察两组患者的相关指标,包括手术时间、术中及术后出血量、术后住院时间及并发症、VAS评分、ODI评分、神经功能Frankel分级、骨融合时间及Cobb角矫正率。结果:后路组手术时间(174.4±9.9)min、术中出血量(885.0±95.7)ml、术后出血量(103.2±11.5)ml、术后住院时间(15.1±0.7)d;前路组手术时间(229.5±15.2)min、术中出血量(1 326.0±113.5)ml、术后出血量(153.2±16.7)ml、术后住院时间(19.0±0.8)d,两组间的差异均具有统计学意义。并发症发生率前路组为16.3%,后路组为9.3%,差异有统计学意义。后路组的Cobb角矫正率为(73.4±3.2)%,优于前路组的(62.3±2.5)%。两组间的植骨融合时间差异无统计学意义。术后VAS、ODI评分及神经功能分级均较术前明显改善,但两组比较差异无统计学意义。结论:Ⅰ期前路或后路手术均能有效治疗胸腰段脊柱结核,但是后路手术相对于前路手术,创伤更小,畸形矫正效果更好。     

三种不同植骨方式在胸、腰椎结核手术治疗中的观察

目的:对比观察块状植骨、颗粒植骨和钛网植骨三种不同植骨方式在后路胸腰椎结核手术中的临床应用效果.方法:选取我院93例胸、腰椎结核患者,分为三组,彻底结核病灶清除后,分别采用块状植骨(32例)、颗粒植骨(35例)、钛网植骨(26例)三种不同植骨方式,对三组术中植骨所需时间,术中出血量,术后后凸畸形角纠正状况,末次随访后凸畸形角丢失状况,植骨融合时间进行对比.结果:患者均得到12～36个月随访,植骨所需手术时间A组为23.4±4.3min,B组为5.2±2.4min,C组为25.6±3.6min,B组植骨所需时间明显短于A组、C组(P＜0.05),A组、C组比较差异无统计意义(P＞0.05);术中出血量A组为553±53ml,B组为352±48ml,C组为564±47ml,B组明显少于A组、C组(P＜0.05),A组、C组比较差异无统计意义(P＞0.05);术前Cobb角A组为36.5°±5.9°,B组为36.2°±4.7°,C组为36.8°±5.1°,三组差异无统计学意义(P＞0.05),术后Cobb角A、B、C三组分别为15.3°±3.6°、15.6°±3.1°及15.1°±2.9°,三组间差异无统计学意义(P＞0.05);末次随访时Cobb角A组为16.9°±3.6°,平均丢失1.6°,B组为17.5°±3.1°,平均丢失1.9°,C组为16.8°±2.9°,平均丢失1.7°,三组差异无统计学意义(P＞0.05);植骨融合时间A组为5.9±0.4个月,B组为4.1±0.3个月,C组为6.2±0.5个月,B组明显短于A组、C组(P＜0.05),A组、C组比较差异无统计意义(P＞0.05).结论:颗粒骨植骨较传统块状植骨和钛网植骨植入方便易行,植入时间短,出血量少,植骨融合时间短,是后路胸椎结核病灶清除术后理想的植骨方式.     

不同手术入路治疗成人胸腰椎结核疗效的Meta分析

[目的]系统评价前路或后路病灶清除植骨融合内固定术治疗胸腰椎脊柱结核的疗效.[方法]计算机检索PUBMED、MEDLINE、EMBASE、中国生物医学文献、中国期刊全文以及万方数据库.手工检索相关的中英文杂志.制定纳入与排除标准,利用RevMan 5.0.1软件进行数据分析.[结果]共有5篇研究纳入,共303例,其中前路组166例,后路组137例.前路组与后路组相比,手术后凸畸形矫正度后路大于前路(P＜0.01),末次随访矫正丢失度、Frankel评分、植骨融合率以及并发症发生率方面无统计学差异.[结论]前路或后路治疗成人胸腰椎脊柱结核都取得了良好的临床效果,本Meta分析的结果显示,后路病灶清除植骨融合内固定术可能有着更好的畸形矫正及维持能力,但具体入路的选择还应综合考虑.     

一期前路病灶清除植骨融合联合后路经Wiltse入路椎弓根螺钉内固定治疗L5/S1椎间隙感染

目的:探讨一期前路病灶清除植骨融合联合后路经Wiltse入路椎弓根螺钉内固定治疗L5/S1椎间隙感染的临床疗效及意义。方法:回顾性分析2011年3月~2015年1月我院收治并应用一期前路病灶清除植骨融合联合后路经Wiltse入路椎弓根螺钉内固定治疗的13例L5/S1椎间隙感染患者,其中男8例,女5例;年龄28~60岁(41.6±11.0岁);记录患者术中手术时间、出血量、术后并发症,记录术前、术后腰部疼痛视觉模拟评分(visual analogue scale,VAS)评估临床症状,术前术后腰骶角(lumbosacral angle,LSA)评估腰骶段前凸恢复情况。结果:所有手术均顺利完成,手术后1例出现逆行性射精,1例患者发生单侧下肢肌间静脉血栓,未出现严重并发症;前路手术时间为70~120min(90.0±27.5min),失血量为200~600ml(361.5±150.2ml);后路手术时间为50~70min(57.7±8.3min),失血量为50~200ml(106.9±56.9ml)。术后培养结果其中7例为金黄色葡萄球菌感染,3例为大肠杆菌,1例为铜绿假单胞菌,2例未见细菌生长,但病理检查结果提示感染性病变。病例均获随访,时间6~30个月(16.6±7.8个月)。末次随访时所有患者均达临床愈合,骨融合率100%,随访期内未见复发病例。VAS评分术前平均7.8±0.7分,术后6个月平均1.3±0.5分,与术前比较差异有统计学意义(P0.05);LSA术前4.4°±2.9°,末次随访时17.5°±2.8°,与术前比较有统计学意义(P0.05)。结论:一期前路病灶清除植骨融合联合后路经Wiltse入路椎弓根螺钉内固定治疗L5/S1椎间隙感染的手术创伤小、固定可靠、疗效确切,可以作为治疗L5/S1椎间隙感染的一种手术方法。     

一期前路病灶清除钛网植骨内固定术治疗胸椎及胸腰段结核

目的:探讨一期前路病灶清除钛网植骨内固定术治疗胸椎及胸腰段脊柱结核的疗效。方法:2003年4月～2007年3月共收治胸椎及胸腰段脊柱结核患者31例,男17例,女14例;年龄21～72岁,其中65岁以上患者5例。胸椎(T4～T10)结核13例,胸腰段(T11～L2)结核18例,单节段6例,2节段21例,3节段4例,无跳跃病灶。所有患者均有相应病变部位疼痛不适,疼痛视觉模拟(VAS)评分平均7.4±0.5分;13例有神经功能损害,Frankel分级A级4例,B级3例,C级2例,D级4例;术前后凸Cobb角平均25.3°±8.2°,其中后凸Cobb角在30°以上者9例;病变椎体后壁破坏侵蚀至椎管者13例,椎体后壁结构完整者18例。均采用一期前路病灶清除、钛网植骨及前路内固定治疗,随访观察治疗效果。结果:手术时间平均3h,术中出血平均400ml,所有患者伤口均获一期愈合,术后胸腔积液1例,经穿刺抽液治愈;无肺部感染、呼吸衰竭等并发症发生。术后2周患者症状明显缓解并开始下床活动。13例有脊髓功能损害者,术后神经功能均有1级以上改善。随访24～72个月,平均41个月。患者疼痛均明显改善,末次随访时VAS评分平均2.0±1.2分,与术前比较有显著性差异(P0.05)。术后1周时后凸Cobb角平均6.5°±3.1°,矫正率为(74.3±15.1)%,至末次随访时矫正角度丢失1.5°±1.0°。所有患者内固定位置良好,无松动、断裂等并发症,结核均治愈,无复发,植骨均获融合,融合时间3～6个月,平均4.3个月。结论:一期前路病灶清除钛网植骨内固定治疗胸椎及胸腰段脊柱结核能有效地矫正脊柱畸形,解除脊髓压迫,重建脊柱稳定性,促进植骨融合,缩短卧床时间,提高脊柱结核的治愈率。     

不同手术入路治疗腰椎结核疗效分析

目的比较不同手术入路治疗腰椎结核手术效果。方法手术治疗158例腰椎结核患者,分别采用侧前路入路手术病灶清除植骨钢板内固定59例（A组）、后路病灶清除减压内固定49例（B组）、前路减压病灶清除后路内固定50例（C组）。观察手术时间、出血量、截瘫缓解情况、植骨融合情况、后凸畸形矫正情况。结果平均手术时间：A组（170.5±18.3）min,B组（130.3±26.8）min,C组（208.5±18.3）min;平均出血量：A组（520.4±53）ml,B组（535.8±62）ml,C组（750.6±91）ml。组间比较差异有统计学意义（P〈0.05）。随访9-24个月。3组均无严重并发症发生,A组1例出现结核脓肿复发,窦道形成,经前路脓肿清除后治愈,1例术中损伤髂总静脉,行修补术。末次随访时所有植骨均获骨性融合,无内固定松动及断裂出现。3组的ASIA分级、Cobb角变化程度比较差异无统计学意义（P〉0.05）。结论一期侧前路病灶清除植骨融合内固定术治疗胸腰椎结核,后路病灶清除植骨融合内固定术以及前后路联合术式均可获得较好的治疗效果,但手术入路的选择应根据病灶侵蚀的范围、节段、患者的耐受能力以及手术者的习惯来决定。     

单纯前路或后路病灶清除植骨融合内固定术治疗腰椎结核的疗效对比

目的 :对比分析一期单纯前路或后路病灶清除内固定植骨融合术治疗腰椎结核的疗效及其优势。方法:回顾性分析2002年1月~2012年1月我院收治的216例腰椎结核患者的资料,选择单纯前路或后路手术治疗且随访超过3年的单节段腰椎结核患者纳入研究。共纳入117例,其中前入路一期行病灶清除、植骨融合内固定术者为前路组(45例);后入路一期行病灶清除、植骨融合内固定术者为后路组(72例)。对比两组间的创伤指标(手术时间、出血量、住院时间、并发症)、影像学指标(植骨融合时间、后凸Cobb角、矫正率)及临床疗效指标[Oswestry功能障碍指数(ODI)、疼痛视觉模拟评分(VAS)及改善率],并进行统计学分析。结果:前路组的手术时间(207.9±30.9min)、术中出血量(409.5±107.9ml)、住院时间(11.5±1.2d)均低于后路组(287.5±30.7min、835.7±161.9ml、19.2±1.4d),差异有统计学意义(P0.05);并发症发生率前路组为15.56%(7/45),后路组为13.89%(10/72),两组间差异无统计学意义(P0.05)。骨性融合时间前路组为7.6±1.2个月、后路组为7.5±1.2个月,两组间比较差异无统计学意义(P0.05)。末次随访时,后凸Cobb角前路组为12.37°±1.58°,较术前(27.66°±6.83°)明显改善,改善率为(55.28±5.45)%;后路组为7.91°±1.34°,较术前(28.84°±8.32°)明显改善,改善率为(72.57±3.17)%,后路组在改善后凸畸形方面优于前路组(P0.05)。末次随访时,前路组和后路组ODI分别为(10.10±1.38)%和(7.90±1.84)%,改善率分别为(72.11±2.12)%和(78.55±1.57)%,两组间比较差异无统计学意义(P0.05);VAS评分分别为1.21±0.67分和2.31±0.83分,改善率分别为(85.98±5.45)%和(72.57±5.04)%,两组间差异有统计学意义(P0.05)。结论:两种手术方式治疗腰椎结核均可获得良好的临床疗效,前入路行病灶清除内固定植骨融合术,手术时间短、出血少、住院时间缩短,且不破坏正常的后路韧带复合体(PLC),术后腰背痛发生率低。     

肌间隙入路和传统入路在腰椎融合术中的对比研究

目的:比较经肌间隙入路和传统入路对腰椎融合手术患者的影响。方法:对2016年5月至2017年5月因腰椎间盘突出或MeyerdingⅡ度以内腰椎滑脱行2个节段以内腰椎融合手术治疗的70例患者进行回顾性分析。70例患者根据手术入路分为两组,肌间隙入路组35例,男18例,女17例,年龄(52±11)岁;传统入路组35例,男19例,女16例,年龄(51±14)岁。70例患者中包括腰椎间盘突出症38例,腰椎滑脱32例。记录两组患者的手术时间、术中出血量,术后引流量、腰腿痛VAS评分、外周血CK浓度以及MRI上多裂肌横截面积。结果:肌间隙入路组手术时间、术中出血量和术后引流量均少于传统入路组(P0.05)。术后7 d和3个月两组患者的VAS腰痛评分差异有统计学意义(P0.05);两组患者VAS腿痛评分,术后7 d差异无统计学意义(P0.05),术后3个月差异有统计学意义(P0.05)。术后1 d和3 d外周血CK浓度:肌间隙入路组分别为(400±103) U/L和(176±58) U/L,传统入路组分别为(598±57) U/L和(222±50) U/L,两组间差异有统计学意义(P0.05)。两组患者MRI上多裂肌横截面积:术前肌间隙入路组为(424±66) mm~2,传统入路组为(428±82)mm~2,组间差异无统计学意义(P=0.8);术后3个月肌间隙入路组为(347±73) mm~2,传统入路组为(239±78) mm~2,组间差异有统计学意义(P0.05)。结论:行腰椎融合手术,肌间隙入路与传统后正中入路相比,确实拥有手术时间短、对椎旁肌损伤小、术后腰腿痛缓解明显等优势,但在确定手术方案时,术者也应充分认识到Wiltse间隙在不同层面的解剖学差异可能对手术操作产生的影响。     

Surgical approaches for open reduction and internal fixation of intra-articular distal humerus fractures in adults: A systematic review and meta-analysis

BackgroundA number of surgical approaches have been described for open reduction and internal fixation (ORIF) of intra-articular distal humerus (IDH) fractures in adults. However, there is no consensus as to which approach is better in terms of functional outcomes and complications. The purpose of this study was to determine whether the functional outcomes and types and rates of complications are influenced by the choice of surgical approach for ORIF of IDH fractures (AO/OTA types 13 B & C).MethodsA systematic review of literature was performed using the PubMed, EMBASE and Cochrane Database of Systematic Reviews databases. Studies, both prospective and retrospective and comparative or non-comparative, dealing with surgical approaches for ORIF of IDH fractures in adult patients were included. Conference abstracts, studies looking primarily at the results of internal fixation rather than the surgical approach, those including extra-articular distal humeral fractures, pediatric distal humeral fractures (<18 years of age), delayed unions, non unions, malunions, cadaveric studies, pathological fractures and studies with <10 patients were excluded. Studies that looked at surgical modalities other than internal fixation (for e.g. total elbow arthroplasty) for intra-articular distal humerus fractures or those that did not report a validated functional outcome scoring system were also excluded.Results11 studies were included in the qualitative analysis, of which 5 were comparative studies and 6 were non-comparative. Quantitative analysis was performed on two sets of two studies, each set comparing the Bryan and Morrey or the triceps-split approach to the olecranon osteotomy approach, and revealed no significant differences in the Mayo Elbow Performance Score, range of motion and rates of complications. The overall methodological quality of the studies included in the review was low.ConclusionsHigh-quality evidence on surgical approaches for ORIF of IDH fractures in adults is lacking. Evidence from low-quality studies indicates that there is no difference in the functional outcomes or complication rates when comparing the Bryan and Morrey or triceps-split to the olecranon osteotomy approach. Future research in the form of high-quality randomized controlled trials is needed to determine which approach is superior in terms of functional outcomes and complications.     

The transsphincteric and transsacral approaches for the surgical excision of rectal and presacral lesions

In the decade from 1981 to 1990, 30 patients underwent a posterior transsacral approach at the Aichi Medical University Hospital for their benign or malignant rectal lesions. The operation was classified into two procedures, consisting of the transsphincteric approach and transsacral approach, in order to cope with the condition of the anal sphincter muscles; whether they were divided or not. Eleven rectal tumors were successfully excised through the opened-up rectum by using the transsphincteric approach, and excellent results were obtained without any postoperative complications. Using the transsacral approach, 2 presacral dermoid cysts and 11 rectal lesions were easily removed under direct vision. Their prognoses were excellent. The transsacral approach was also applied for the resection of recurrent rectal cancers after a radical abdominoperineal resection in 6 patients suffering from intolerable local symptoms. All the patients were free from these uncomfortable local symptoms after the surgery. The posterior transsacral operation is thus considered to be of value not only for resecting benign rectal and presacral lesions, but also for resecting malignant rectal tumors in frail subjects who are unfit for radical operation and/or recurrent rectal cancer.     

A Comparison of Risk of Dislocation and Cause-Specific Revision Between Direct Anterior and Posterior Approach Following Elective Cementless Total Hip Arthroplasty

BackgroundUse of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased over the last decade. We sought to investigate whether (1) a difference exists in dislocation risk for DAA compared with posterior THA, (2) a difference exists in risk for specific revision reasons, and (3) the likelihood of adverse 90-day postoperative events differs.MethodsWe conducted a cohort study using data from Kaiser Permanente’s Total Joint Replacement Registry. Patients aged ≥18 years who underwent primary cementless THA for osteoarthritis with a highly cross-linked polyethylene liner were included (2009-2017). Multivariable Cox proportional hazards regression was used to evaluate dislocation and cause-specific revision risks, and multivariable logistic regression was used to evaluate 90-day emergency department visits, 90-day unplanned readmissions, and 90-day complications (including deep infection, deep vein thrombosis, and pulmonary embolism).ResultsOf 38,399 primary THA, 6428 (16.7%) were DAA. All-cause revision at 2-years follow-up was 1.78% (95% confidence interval [CI] = 1.46-2.17) for DAA and 2.28% (95% CI = 2.11-2.45) for posterior. After adjusting for covariates, DAA had a lower risk of dislocation (hazard ratio [HR] = 0.39, 95% CI = 0.29-0.53), revision for instability (HR = 0.33, 95% CI = 0.18-0.58), revision for periprosthetic fracture (HR = 0.57, 95% CI = 0.34-0.96), and readmission (odds ratio = 0.82, 95% CI = 0.67-0.99) compared with posterior approach but a higher risk of revision for aseptic loosening (HR = 2.26, 95% CI = 1.35-3.79).ConclusionWhile the DAA associated with lower risks of dislocation and revision for instability and periprosthetic fracture, it is associated with a higher revision risk for aseptic loosening. Surgeons should discuss these risks with their patients.     

Microsurgical anatomy and related techniques to an anterolateral transthoracic approach to thoracic disc herniations

The microsurgical anatomy and related techniques of a modified anterolateral transthoracic approach to the thoracic disc space is presented. This procedure was performed on at least three thoracic levels of 12 cadavers within a few hours after death. Such an approach allows a safe decompression of the spinal cord and roots under full visual control. There is minimal risk to radiculome-dullary vessels, minimal osteoligamental resection, and no compromise of stability of the spinal column. Therefore, this procedure does not require surgical stabilization of the spinal column, postoperative bracing, or prolonged bed rest. The difference between this approach and anterolateral transthoracic, posterolateral, and transpedicular approaches is discussed.     

Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study

Background Endoscopic adrenalectomy is currently performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique in a prospectively designed analysis of a large series of patients operated on by a single team over a 10-year period.Methods From February 1994 to March 2004, 267 endoscopic adrenalectomies (retroperitoneal in 132 patients and transperitoneal in 135 patients) were performed in 245 consecutive patients. There were 102 right lateral and 121 left lateral procedures (22 patients had a bilateral procedure). The most prevalent indication was incidentaloma (35.9%), followed by pheochromocytoma and Conn’s adenoma.Results The endoscopic procedure was performed in 238 of 245 patients (97.1%). The conversion rate was 1.5% for the transperitoneal approach and 3.8% for the retroperitoneal approach. No statistically significant influence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be significantly longer for the retroperitoneal adrenalectomy. In addition, a variance analysis identified tumor size (>5 cm) as a significant factor influencing the operative time, whereas body mass index and localization (right/left lateral) did not prove significant.Conclusion Independent of the underlying pathology, endoscopic adrenalectomy using either the trans- or retroperitoneal approach can be performed in 96-98% of all patients. Differences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy.     

后外侧及内侧联合入路手术治疗三踝骨折

2008年3月～2011年1月,我科根据踝关节的解剖学特点,采用后外侧及内侧联合入路治疗三踝骨折12例,疗效满意,报道如下。1材料与方法1.1病例资料本组12例,男7例,女5例,年龄24～68(44±1.4)岁。骨折根据Lange-Hansen分型:旋后外旋型4例,     

超声引导下肋间通路经皮肾镜取石术的疗效和安全性

目的探讨超声引导下肋间通路经皮肾镜取石术的疗效及安全性。方法2006年5月～2008年6月由一个手术小组完成110例超声引导下经皮肾镜取石术,62例采用肋间通路（第12肋上）经皮肾镜取石术（肋间通路组）,48例采用肋下通路（肋缘下）经皮肾镜取石术（肋下通路组）。术前肋间通路组和肋下通路组分别有45例和36例行CT结石三维重建。结果肋间通路组结石取净率为72.6%（45/62）,肋下通路组结石取净率为60.4%（29/48）,2组结石取净率无统计学差异（χ2=1.818,P=0.178）。肋间通路组手术时间（78.6±5.1）min显著短于肋下通路组（102.4±7.1）min（t=-20.454,P=0.000）。肋间通路组及肋下通路组各有1例需要输血,肋间通路组有1例发生气胸,经保守治疗痊愈。结论肋间通路经皮肾镜取石术安全、有效。     

右房及肺动脉径路矫治法乐四联症

采用右房及肺动脉径路施行法乐四联症根治术２０例，无手术死亡，１例术后６２天死于金葡菌败血症。室间隔缺损全部经三尖瓣口修复。单纯经右房疏通漏斗部狭窄６例，同时经肺动脉切开解除肺动脉瓣环以上狭窄１４例，其中１０例跨瓣环补片加宽右室流出道，４例为瓣上肺动脉干补片加宽。术终右室／左室收缩压比值平均０．４６±１０．１７，右室－肺动脉收缩压力阶差平均１．７±０．３１ｋＰａ。与同期２０例采用传统右室切开行根治术者比较，二组数值均无显著差异（Ｐ＞０．０５）。文中讨论了该手术的适应证选择，重点介绍了室缺修复和流出道疏通的经验。