肝胆管结石的微创外科治疗进展

目的探讨肝胆管结石的微创外科治疗进展。方法对国内、外有关肝胆管结石的微创外科治疗方面的文献进行综述。结果腹腔镜肝切除术和腹腔镜下胆道探查取石可获得良好的效果，纤维胆道镜在肝胆管结石术中和术后的应用具有重要的意义。结论肝胆管结石应采取个体化的治疗方案，腹腔镜、纤维胆道镜等多路微创手术的联合应用可提高肝胆管结石的治愈率。     

肝胆管结石的微创治疗的进展

肝胆管结石在我国是常见病和难治性胆道疾病，发病率在结石性胆道疾病中达80％以上，具有病变广泛、病情复杂、并发症发生率高、术后残留结石或复发率高的特点。肝胆管结石的传统疗法主要采用开腹手术。随着内镜及腹腔镜技术的日臻成熟，微创外科改变着我国传统胆道外科的格局，微创治疗不仅仅用于胆囊结石和肝外胆管结石，而且还用于肝胆管结石的治疗。迄今为止，肝胆管结石的微创外科治疗主要包括腔镜外科、内镜外科等。     

肝胆管结石的再手术治疗

肝胆管结石病的再手术治疗特别在基层医院仍存在一定困难 ,现将我院 1990～ 1999年间经再次手术治疗肝胆管结石5 9例治疗体会报告如下。临床资料一般资料 :男 14例 ,女 45例 ,年龄 2 7～ 61岁 ,均为 1～ 3次手术后病人 ,其中行 2次手术者 11例 ,3次手术者 8例 ,第 1次手术为单纯胆囊切除者 3例 ,Ｔ形管引流 15例 ,胆总管十二指肠吻合术 2 2例 ,第 2次手术方式为Ｔ形管管引流术 5例 ,胆总管十二指肠吻合 4例 ,胆管空肠Ｒｏｕｘ Ｙ吻合 2例 ,第 3次手术方法为胆管十二指肠吻合 2例 ,胆管空肠Ｒｏｕｘ Ｙ吻合 6例。全组病人合并胆汁性肝硬化 7…     

肝胆管结石的再手术治疗

胆石病中肝内外胆管结石是胆道外科治疗中的难题 ,往往需再手术。我院 1994年 1月～ 2 0 0 1年1月收治再次手术的肝胆管结石患者 35例 ,现报告如下。临床资料一、一般资料　本组病例中 ,男 16例 ,女 19例 ;年龄 32～ 80岁。二、手术方式　胆总管切开取石加Ｔ管引流术5例 ,其中 1例因术后残余结石行胆道镜取石 ;胆肠吻合术 2 7例 ,其中胆肠Ｒｏｕｘ Ｙ型吻合术 2 3例 ,胆总管十二指肠吻合术 4例 ;肝脏部切除术 8例 ,其中左外叶切除 2例 ,左半肝切除 2例 ,肝方叶切除 4例。三、再手术原因　 (1)术后残余结石或结石复发 ;(2 )术后反复胆道感染 …     

肝胆管结石外科治疗的手术策略

肝胆管结石是我国的常见疾病 ,近 10～ 2 0年来 ,城市地区的发病率已有逐渐下降的趋势 ,但在广大农村地区仍是常见的疾病 ,由于其肝脏及胆道病理改变复杂 ,严重并发症多及再次手术率高等特点 ,外科医师仍应高度重视有关肝胆管结石的诊断和治疗问题。1　肝胆管结石的肝脏及胆管病理改变特点肝胆管结石造成的肝胆管梗阻及胆道感染是形成肝脏及肝胆管系统病理改变的基本因素 ,长期的肝胆管梗阻和反复发作的胆道感染可以损害所引流的肝脏发生纤维化和萎缩等。在病变不断发展的过程中 ,范围不断扩大 ,病变不断加重。根据肝胆管结石病程的发展及肝…     

肝胆管结石再手术107例体会

目的探讨肝胆管残余或复发结石的再手术方式及其临床效果。方法回顾性分析107例肝胆管结石病人再次手术的临床资料,其中行胆总管探查+T管引流术58例,左肝外叶切除+胆总管探查T管引流术32例,肝左外叶切除+胆总管探查+(肝)胆管空肠Roux-en-Y吻合术8例,左半肝切除+胆总管探查T管引流术2例,胆总管探查+胆总管空肠Roux-en-Y吻合术2例,肝右叶部分切除+胆总管探查T管引流术3例,胆管空肠Roux-en-Y吻合口重建术2例。结果本组无死亡病例,术后发生胆漏4例,胆道出血1例,腹腔出血1例,切口感染3例,肺部感染3例,除1例腹腔出血行开腹止血外,余均经非手术治愈。86例获随访,平均10月(6月~3年),优良率占89.5%,9例(10.5%)结石再次复发,仍需进一步手术。结论肝胆管结石病人视病灶部位决定术式,以胆总管探查经胆道镜取石为主,联合肝叶切除,适当进行(肝)胆管空肠Roux-en-Y吻合术效果良好。     

微创技术在肝胆管结石诊治中应用进展

正肝胆管结石是一种常见的胆道系统疾病,在亚洲国家如中国、韩国及日本比较常见,其发病机制目前尚未完全清楚,可能与胆管解剖异常、胆管狭窄、胆道感染等有关。大多数肝胆管结石会引起病人反复发作胆管炎,若缺乏合理有效的治疗,最终可导致胆汁性肝硬化、门静脉高压症,甚至癌变~[1]。虽然肝胆管结石是一种良性疾病,但治疗较困难,一些复杂的肝胆管结石病人经历反复多次手术治疗仍难以治愈,如何提高肝胆管结石的手术效果是胆道外科     

肝胆管结石的基础与临床——肝胆管结石合并肝胆管癌

自Sands和MacCalum1952年首先报道2例胆管癌发病同时合并肝胆管结石以来，胆管结石合并胆管癌的现象越来越引起人们的重视。Chijiwa等报道肝内胆管结石合并肝内胆管癌的发生率约为7．3％，Kubo等报道为2％～10％。国内报告肝胆管结石发生肝胆管癌为0．36％～10．00％。这种发病率的差异与治疗对象、诊断方法、随诊     

手术治疗肝胆管结石合并狭窄的体会

目的 总结手术治疗肝胆管结石合并狭窄的经验。方法 对126例肝胆管结石合并胆管狭窄患者进行手术并随访,其中行T管引流33例,肝肠盆式Roux-Y吻合47例。胆肠Roux-Y吻合28例,胆囊人工乳头问置肝总管十二指肠吻合18例,同时附加肝左外叶切除75例,右肝部分切除27例。结果 术后发现残余结石23例(残石率18.％),胆瘘及肝脓肿各1例,上消化道出血3例,无死亡病例。随访102例,其中3年以上者87例,效果优良者占86.2％;结石复发2例,不同程度的胆管炎12例。结论 术前影像检查和合并症的处理是手术成功的保证,术式选择要视梗阻部位,胆管狭窄和扩张的程度而定,以肝叶或段切除和保留Oddi括约肌功能者疗效佳。     

手术治疗肝胆管结石475例

我院外科自1986年6月至1997年3月共手术治疗肝胆管结石患者475例，取得满意疗效，现报告如下。     

手术机器人在微创外科的应用进展

微创外科是二十世纪医学科学发展的伟大成就之一,以切口小、创伤轻、痛苦少、恢复快等优点迅速在外科各专业领域得以推广应用。手术机器人的出现,使微创外科的发展进入新的一页。目前手术机器人的临床应用已扩展到外科领域的各个分支,极大地拓展了传统的腹腔镜微创外科,将掀起微创外科的又一次新技术革命浪潮。     

微创外科时代的机遇、挑战和思考

创新是外科学持续发展的灵魂和动力.面对二十一世纪微创外科时代腹腔镜技术给我们带来的机遇和挑战,勇于创新的同时我们还应该多一些冷静的思考.一些传统外科的观念和方法可以进行重新评估和发展,但外科学的一些基本原则不应随意改变.外科学是实用性的科学,创新应该建筑在实用的基础之上,微创外科技术的发展依托的是现代科学技术的发展.     

Toward effective pediatric minimally invasive surgical simulation

Background/Purpose

Simulation is increasingly being recognized as an important tool in the training and evaluation of surgeons. Currently, there is no simulator that is specific to pediatric minimally invasive surgery (MIS). A fundamental technical difference between adult and pediatric MIS is the degree of motion scaling. Smaller instruments and areas of dissection under greater optical magnification require finer, more precise hand movements. We hypothesized that this can be used to detect differences in skills proficiency between pediatric and general surgeons.

Methods

We programmed a virtual reality simulation of intracorporeal suturing with modes that used motion scaling to mimic conditions of either adult or pediatric MIS. The participants consisted of pediatric and general surgeons who wore motion-sensing gloves. Metrics included time elapsed, penetration errors, tool movement smoothness, hand movement smoothness, and gesture level proficiency.

Results

For all measures, pediatric surgeons demonstrated superior proficiency on exercises conducted in pediatric conditions (P < .05). Performance in adult conditions was similar between the 2 groups.

Conclusion

Pediatric surgeons possess unique skills compared with general surgeons that relate to the technical challenges they routinely face, reinforcing the need for a surgical simulator specific to pediatric MIS. This validates our simulator and the manipulation of motion scaling as a useful training tool.     

微创手术平台与微创手术方式的未来走向

近30年来,随着能量平台、器械平台、显像平台三大手术平台的发展,微创外科有了突飞猛进的提升。以结直肠癌手术为例,手术方式的五要素都有着不同程度的发展：手术入路经历了"从大到小"的过程;切除范围从单纯肠段切除到根治术或扩大根治术,再到注重保留器官功能的手术;随着对正常淋巴引流方向和肿瘤淋巴转移特点的认知,淋巴结清扫愈趋规...     

微创食管癌切除术应注意的问题

食管癌居全球常见恶性肿瘤发病率的第8位,是一种严重威胁人类健康的消化系统肿瘤.开放食管切除和区域淋巴结清扫是治疗局限性食管癌的标准手术方式,但手术并发症发生率和病死率较高.与传统开放手术比较,微创食管癌切除术(MIE)具有出血量少,并发症发生率低,住院时间短等优势,而肿瘤切除、淋巴结清扫及术后病死率与开放手术相当.结合第三军医大学大坪医院野战外科研究所全军胸外科研究所的临床经验,展开讨论对MIE手术指征和禁忌证的把握,手术方式和径路的选择,手术体位的选择,术后并发症的预防,以及MIE的学习和掌握,以期有助于MIE的推广和普及.     

Mirror glasses for minimally invasive surgery

Introduction The operator performing minimally invasive surgery is prevented from seeing the whole field with both eyes by the restricted small thoracotomy incision. To overcome this problem, we developed mirror glasses. Methods Use of these glasses was evaluated in terms of the time required for threading of sutures with endoscopic forceps. Three surgeon ligated thread a suture five times with and without use of the glasses in the box, and the mean time was calculated for each surgeon. Results The time required for ligation (mean ± SD) was 24.2 ± 2.9 s with mirror glasses and 27.0 ± 2.5 s without the glasses (p = 0.01). Conclusion The mirror glasses may be found useful for fine manipulation for minimally invasive surgery.     

Designing safety into the minimally invasive surgical revolution

Surgical errors with minimally invasive surgery differ from those in open surgery. Perforations are typically the result of trocar introduction or electrosurgery. Infections include bioburdens, notably enteric viruses, on complex instruments. Retained foreign objects are primarily unretrieved device fragments and lost gallstones or other specimens. Fires and burns come from illuminated ends of fiber-optic cables and from electrosurgery. Pressure ischemia is more likely with longer endoscopic surgical procedures. Gas emboli can occur. Minimally invasive surgery is more dependent on complex equipment, with high likelihood of failures. Standardization, checklists, and problem reporting are solutions for minimizing failures. The necessity of electrosurgery makes education about best electrosurgical practices important. The recording of minimally invasive surgical procedures is an opportunity to debrief in a way that improves the reliability of future procedures. Safety depends on reliability, designing systems to withstand inevitable human errors. Safe systems are characterized by a commitment to safety, formal protocols for communications, teamwork, standardization around best practice, and reporting of problems for improvement of the system. Teamwork requires shared goals, mental models, and situational awareness in order to facilitate mutual monitoring and backup. An effective team has a flat hierarchy; team members are empowered to speak up if they are concerned about problems. Effective teams plan, rehearse, distribute the workload, and debrief. Surgeons doing minimally invasive surgery have a unique opportunity to incorporate the principles of safety into the development of their discipline.     

肝内胆管结石手术疗效进展分析

目的探讨肝内胆管结石手术治疗的疗效及进展。方法对我院2000年1月~2012年12月经手术治疗的157例肝内胆管结石患者(研究组)的临床资料进行回顾性分析,同时回顾性分析了1985年1月~1999年12月手术治疗的203例肝内胆管结石患者(对照组)的资料,并比较了两组的疗效。结果研究组残石率(18.5%)显著低于对照组(43.3%),P=0.000,疗效优良率(89.6%)显著高于对照组(71.6%),P=0.000,再手术率(5.7%)低于对照组(14.8%),P=0.026,而两组的手术并发症差异并无显著性意义,P=0.529。结论肝内胆管结石疗效的提高与发病情况的变化、新诊疗技术的应用及肝叶切除术应用比例提高有关。     

Long-term results of minimally invasive surgery for symptomatic epiphrenic diverticulum

Background

The real incidence of epiphrenic diverticulum is unknown, and only 15% to 20% of cases are symptomatic.

Methods

From January 1994 to May 2009, 20 patients were treated laparoscopically for this condition.

Results

The most common operation performed was transhiatal diverticulectomy with myotomy and partial fundoplication. No case was converted to open surgery. Esophageal leak occurred in 1 patient (5%). The postoperative courses were uneventful in the remaining 19 patients. After a median follow-up period of 52 months (range, 1–141 months), 1 patient had died of squamous cell carcinoma, 1 had mild solid-food dysphagia, 1 had chest pain, and 1 had heartburn. Manometry was performed postoperatively in 7 patients; all had normal lower esophageal sphincter pressure. In 5 patients who underwent 24-hour postoperative pH monitoring, pathologic reflux was absent.

Conclusions

In patients with symptomatic epiphrenic diverticulum, laparoscopic surgery is feasible, providing good access to the distal esophagus and inferior mediastinum. Long-term outcomes are satisfactory.