机器人手术系统在胆囊切除术中的应用

上世纪80年代起,机器人手术系统逐渐出现于外科手术中,并在神经外科、心脏外科、妇产科、泌尿外科、普外科等领域得到广泛应用。其中,机器人腹腔镜胆囊切除术是最早报道的机器人腹腔镜手术,多项研究显示其应用安全可行,但仍有不足之处。本文就机器人手术系统在胆囊切除术中的应用作一综述。     

Laparoscopic Cholecystectomy: 111 Consecutive Cases

Laparoscopic cholecystectomy removes the gallbladder through three or four puncture wounds in the abdominal wall. The technique reduces the recuperative time to full activity, from as long as 4 wk to as little as 3 days, compared with conventional cholecystectomy. We herein present our initial experience with this procedure. In this series of 111 laparoscopic cholecystectomies, there were no mortalities and only one morbidity. Thirty-nine patients (35%) had a history of prior abdominal surgery. Fourteen underwent laparoscopic lysis of adhesions. Intraoperative cholangiograms were performed in 24 patients (21%), demonstrating choledocholithiasis in three. Two of the three patients underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP); in the other, laparoscopic common bile duct exploration was performed. In each case, the common bile duct (CBD) was completely cleared of stones. Incidental laparoscopic appendectomy was also performed in three patients. The average time for completion of laparoscopic cholecystectomy in cases of chronic cholecystitis was 40 min. If the gallbladder was acutely inflamed, the procedure took a mean of 126 min. This series had a higher percentage of patients (19%) with acute cholecystitis then previously reported; therefore, the 2% conversion rate in this series emphasizes the broad applicability of the technique. The average length of stay in the hospital was 1.4 days, and patients returned to work in about 7 days.     

Cholecystectomy: laparoscopic or conventional?]

Cholecystectomy remains the gold standard in the treatment of cholelithiasis. With the emerging of laparoscopic techniques a new modality in the surgical therapy is available. However efficacy, morbidity and pretended advantages have to be judged in comparison to the conventional technique. Indications for cholecystectomy are not altered by the new technique. Beside some few preoperative contraindications, the definite choice of the operative procedure is determined intraoperatively according to the anatomical facts and the experience of the surgeon. The frequency of the laparoscopic approach varies between 67 and 97%. A conversion to open cholecystectomy is necessary in 3.6-4.7%. The overall complication rate is 2.6-5.1%. Outstanding from those are the iatrogenic lesions of the bile-duct, especially in the initial learning period with 1-2%. The hospital stay is dramatically reduced to 1.2-3 days as well as the postoperative recovery period with 7-14 days. Thus resulting in a cost saving up to $1200 per patient. Because of the obvious advantages of less pain, early mobilisation, less scars and an enormous cost saving the laparoscopic cholecystectomy will be the gold standard in the future. Open cholecystectomy will be restricted to complicated cases. However, in order to prevent serious injuries of the bile-duct an appropriate training in laparoscopic surgery is necessary.     

Early Single-Site Experience With Transcatheter Tricuspid Valve Replacement

Objectives

This study presents a single-site experience of 5 patients with severe tricuspid regurgitation (TR) who underwent implantation of a novel transcatheter tricuspid valve replacement device.

Cystic Duct Fistula: A Complication of Cholecystectomy

Two patients with postcholecystectomy cystic duct fistulas are described. Although still a most uncommon diagnosis, newer imaging procedures have facilitated recognition of this problem. Cystic duct fistulas may contribute to the subhepatic collection found in many patients postcholecystectomy.     

Laparoscopic Cholecystectomy: Results of an Early Experience

Ninety consecutive patients over a 6-month period with acute (31 patients) or chronic (59 patients) cholecystitis underwent a laparoscopic cholecystectomy on an ambulatory (49 patients), one-night (33 patients), or two-night (5 patients) basis. Three patients required open procedures for 1) perforated duodenal ulcer at 48 h, postoperatively, 2) a cholecystoduodenal fistula, and 3) Mirizzis syndrome with erosion of the common duct. The procedure is safe, efficacious, and should be offered to patients with acute and chronic biliary disease.     

Delayed Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage Versus Emergency Laparoscopic Cholecystectomy for Acute Cholecystitis: A Meta-Analysis

Background: The purpose of this meta-analysis is to appraise the efficacy and safety of delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage (PTGBD) versus emergency laparoscopic cholecystectomy (ELC) for acute cholecystitis.Methods: The kinds of literature were searched by Web of Science, PubMed, OVID, Cochrane Library, and EMBASE between the year 2000 and 2019. RevMan 5.3 was used for meta-analysis.Results: Seventeen studies with 2135 participants were included in our study. Compared with the ELC group, delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage group (PTGBD group) had a significant better effect in intraoperative bleeding (P = .002), conversion rate to open surgery (P = .02), postoperative complications (P ＜ .00001), bile leakage (P = .01), bile duct injury (P = .02), and wound infection (P = .02). There was no significant difference between the two groups in operative time (P= 32), postoperative hospital stay (P = .30), and intraperitoneal hemorrhage (P = .39). PTGBD group had a significantly longer overall hospital stay than the ELC group (P ＜ .00001).Conclusion: Compared with the ELC group, the PTGBD group has several advantages, including bile duct injury, intraoperative bleeding, bile leakage, conversion rate to open surgery, postoperative complications, and wound infection. The only drawback in the PTGBD group is to lengthen the total hospital stay.     

Robotic laparoscopic fundoplication

Opinion statement Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more longterm outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.     

Robotic heart surgery

Advances in computer and robotic technology are transforming cardiac surgery, overcoming the limitations of conventional endoscopic tools. Using minimal access through 5 millimeter ports, computer-enhanced instruments provide superhuman dexterity through tremor filtration and motion scaling, and are capable of precise manipulation in confined body cavities. Using these technologies, endoscopic beating heart coronary bypass surgery as well as complex mitral valve repairs have been performed in the last few years. However, the current world experience with robotic heart surgery is mostly anecdotal, retrospective, and noncontrolled. Results of rigorous prospective randomized studies in the United States under Food and Drug Administration approved protocols, are awaited. The use of robotic telemanipulation technology for heart surgery is restricted in the United States to patients enrolled in clinical studies in a few elite centers. Further refinement in robotic and image-guided technology for cardiac surgery may further expand the use of computer enhanced instrumentation in the near future.