正中小切口全胸骨劈开术应用于多数心脏手术策略

目的：探讨正中小切口全胸骨劈开术应用于多数心脏手术策略和实施技巧。方法：作者总结了个人近两年进行的302例全胸骨劈开正中小切口心脏直视手术经验;同时选取不同手术方式的二尖瓣修复手术进行手术效果、手术时间、主动脉阻断时间、出血量和ICU停留时间的比较。结果：正中小切口这种微创手术方式,将胸骨全切开,但将常规的20cm切口长度缩小到6～8cm,胸骨只撑开6cm,可以进行多数心脏手术,取得良好效果。适应症广泛,具备微创手术的切口小,美观的优点,对胸廓影响小,又具备正中开胸的心脏显露清楚,手术迅速确切,心脏中心插管,手术安全性高,不增加手术时间、主动脉阻断时间、出血量和ICU停留时间,不需要单肺通气等诸多优势。结论：正中小切口这种微创手术方式,适应症广泛,操作比较方便,尤其易于推广。     

右前外侧小切口微创心脏手术的临床研究

目的探讨右前外侧小切口微创心脏手术的临床疗效。方法选取二尖瓣病变或房间隔缺损患者43例,将其分成小切口组21例和正中切口组22例。比较两组患者疼痛度、输血量、术后引流量、建立体外循环时间、阻断时间、ICU监护时间及转流时间。结果小切口组建立体外循环时间、转流时间及阻断时间均与正中切口组无显著差异,而切口长度、引流量、输血量、术后呼吸机通气时间、ICU监护时间、住院时间、曲马多使用次数均较正中切口组减少,差异具有显著性。小切口组出现右肺局限性肺不张2例。因主动脉根部插管部位出血延长切口止血1例,起搏导线失效1例,二次开胸止血1例。结论右胸前外侧小切口行微创心脏手术安全有效,美容效果好,但需注意防止并发症的发生。     

小切口心脏跳动下心内直视手术80例

目的探索显露好、适应面广、创伤小、美容效果好的心脏外科小切口手术方法。方法本组80例先天性心脏病及风湿性心脏病人,均采用小切口胸骨下段Y形劈开心脏跳动下心内直视手术。结果全组病人手术均顺利完成,痊愈出院。结论小切口胸骨下段Y形劈开,保留了传统胸骨正中切口显露好的优点,同时也避免了胸骨全部锯开后胸骨上窝的止血问题,有利于保持胸骨的完整性及坚固性。心脏跳动下手术,心肌持续供血,避免缺血再灌注损伤,是较好的心肌保护措施。     

小切口心脏瓣膜置换术

目的报告67例小切口心脏瓣膜置换手术临床经验。方法经胸骨上段小切口行主动脉瓣置换6例、二尖瓣及主动脉瓣置换9例。右胸前外侧小切口二尖瓣置换26例，二尖瓣加主动脉瓣置换1例，右腋下小切口二尖瓣置换25例。结果本组病例无死亡，与同期180例正中开胸瓣膜置换术相比，心脏阻断时间、体外循环时间延长，术后呼吸机辅助时间无显著差异，胸液引流量明显减少，住院时间明显缩短。结论小切口心脏瓣膜置换手术疗效好、安全、可靠。经胸骨上段小切口适合于主动脉瓣置换：右侧腋下、前外侧小切口适合于二尖瓣置换。     

经胸骨下段小切口施行心脏瓣膜置换术

目的 :介绍经胸骨下段小切口施行心脏瓣膜置换手术的经验体会。方法 :本组 33例 ,男性 6例 ,女性 2 7例。年龄 17～73岁 ,平均 37.9± 11.9岁。切口自第 3胸肋关节水平至剑突 ,长度 8～ 13cm ,平均 10 .5cm ,自下而上纵行劈开胸骨至第 2肋间处向右侧横断。手术于常规体外循环下进行 ,包括二尖瓣置换 2 2例 ,主动脉瓣及二尖瓣双瓣置换 11例。 13例合并三尖瓣中度以上返流同时行DeVega环缩术 ,其中 2例以自体心包扩大三尖瓣前叶。 3例同时行左房血栓清除术。结果 :无手术死亡。平均主动脉阻断时间、体外循环时间、手术时间和关胸时间分别为 6 2 .4± 4 1.1min、99.4± 5 4 .5min、2 2 7.0± 6 7.4min和2 5 .8± 10 .3min。平均住院时间 10 .9± 2 .6d。术后 2 4h胸液量 30～ 10 5 0ml,平均 317.3± 2 5 2 .4ml,有 2 0例 (占 6 0 .6 % )未输血。结论 :经胸骨下段小切口可安全施行心脏瓣膜置换手术 ,创伤小 ,恢复快 ,美观     

胸骨上段正中小切口在心脏外科手术中的应用

目的:总结20例胸骨上段正中小切口心脏手术的经验.方法:2009年3月至2010年1月,我院共进行20例胸骨上段小切口行主动脉瓣置换手术,其中男12例,女8例,年龄16～69岁,平均42.5岁.皮肤切口长约6～8 cm.术中基本使用常规的手术器械,有15例为了术中体外循环引流满意而使用负压吸引.结果:小切口AVR组和常规切AVR组均无院内死亡,无再次手术,小切口组术后2例出现浅层伤口愈合不良.两组在体外循环时间、术后气管插管时间、术后胸腔引流量、术后ICU时间、术后住院时间无明显差异,但总手术时间要延长30～50 min(P＜0.05),小切口组皮肤切口长度有明显差异.结论:胸骨上段正中小切口行主动脉瓣置换术皮肤切口小,安全可靠,创伤减小,操作简单易行,有良好的手术效果.     

全机器人心脏手术新技术的应用与效果

目的了解机器人手术的方法和特点，提高对新技术开展的认识和手术的配合质量。方法对50例患者行全机器人不开胸心脏手术，与同期常规开胸心脏手术50例患者进行比较，对比两组手术出血量、术后引流量、切口大小及术后气管插管时间和ICU治疗时间。结果50例患者均成功接受了全机器人不开胸手术，与常规手术患者相比，手术切口小、气管插管和ICU治疗时间短、术中出血量、术后引流量明显减少，手术效果满意。结论机器人的出现将微创技术应用到了复杂的心脏外科手术中，减少了患者的痛苦，缩短了患者的住院时间，也使手术护士配合方式和管理理念发生了转变。     

微创胸部切口对主动脉瓣显露效果的观察

目的：观察不同微创胸部切口对主动脉瓣的显露效果。方法：在12具成人尸体上模拟不同部位的上半部分胸骨劈开切口、下半部分胸骨劈开切口、右侧胸骨旁切口、左侧胸骨旁切口、右前外侧小切口、左前外侧小切口以及正中小切口。对在各种切口中主动脉瓣的显露效果进行观察。结果：上半部分胸骨劈开切口中,下缘至第2肋间才可显露主动脉瓣。下半部分胸骨劈开切口中,上缘到第3肋间水平才可显露主动脉瓣。右侧胸骨旁切口或者第3肋间的右前外侧小切口对主动脉瓣显露较满意。正中小切口中,第2、3肋间水平的切口显露效果较理想。左侧胸骨旁切口和左前外侧小切口可显露主动脉瓣,但不适于手术。结论：右侧胸部微创切口可用于主动脉瓣的手术,但需要较好的牵引。左侧胸壁切口不适于主动脉瓣手术。正中部位微创切口是比较理想的主动脉瓣手术切口。     

小切口心脏手术的体外循环管理

随着心脏手术安全性的大幅提高，减少手术创伤和术后切口的美观已日益受到外科医师和患者的重视。传统的体外循环心内直视手术经胸骨正中切口进行，虽然显露好，但创伤大、出血多，切口长且位于胸部正中，严重影响患者美观。我院自2005年3月～2006年10月间共施行4种不同径路的小切口微创心脏手术48例效果良好。现报告如下：     

个体化微创小切口CPB心内直视手术的临床研究

目的通过对南昌大学第二附属医院188例小切口体外循环心内直视手术的疗效观察,探讨微创个体化小切口在体外循环心内直视手术的临床研究。方法南昌大学第二附属医院2014-01—2015-07个体化小切口进行体外循环心内直视手术188例(A组)。根据体质量抽取同期南昌大学第二附属医院收治的传统正中开胸心脏病手术患者187例作为对照组。比较两组术中术后指标、治疗效果和住院费用等。结果A组在体外循环时间、主动脉阻断时间、呼吸机辅助呼吸时间等指标与B组比较差异无统计学意义(P0.05);A组术后胸腔引流血量(83.29±15.33)m L、术后输血量(98.92±19.85)m L、术后住院时间(5.85±1.47)d、住院费用(3.52±1.68)万元均明显少于B组(P0.05)。结论微创个体化小切口心脏直视手术是一种安全、有效、美观的手术方式,实用性强。     

Laparoscopic approaches for splenic artery aneurysms

Abstract

Background: Therapeutic options for splenic artery aneurysm include endovascular management, laparoscopic surgery, and open surgery, although their indications and applications as standard therapy remain controversial. Methods: Between August 2009 and March 2011, three patients with splenic artery aneurysm were treated at our institution. All patients underwent laparoscopic surgery. Results: There was no conversion to open surgery. The mean operative time was 204.7 min (range: 147–265 min) and the mean intraoperative blood loss was 30 mL (range: 0–90 mL). There was no mortality or morbidity. Conclusions: The laparoscopic approaches for splenic artery aneurysm were safe procedures.     

经皮椎间孔镜技术在腰椎手术失败综合征中的应用

目的探讨采用经皮椎间孔镜技术进行翻修手术治疗腰椎手术失败综合征的临床疗效。方法回顾性分析2012年1月-2017年6月该科室28例采用经皮椎间孔镜技术进行翻修手术治疗腰椎手术失败综合征的患者的临床资料。分析患者翻修手术前后腿痛视觉模拟评分(VAS),采用MacNab标准评估再次手术后的临床疗效。结果 28例患者均顺利完成椎间孔镜手术,手术时间55~95 min,平均(62.2±5.5) min;术前腿痛VAS评分为(8.1±0.3)分,术后腿痛VAS评分为(2.6±0.2)分,术前术后比较,差异有统计学意义(P 0.05)。按MacNab功能评定标准:优11例、良14例、可1例、差2例,整体满意度为89.3%。结论对于有手术适应证的腰椎手术失败综合征患者,可选择经皮椎间孔镜技术行翻修手术。     

Remimazolam benzenesulfonate anesthesia effectiveness in cardiac surgery patients under general anesthesia

BACKGROUNDSedation with propofol injections is associated with a risk of addiction, but remimazolam benzenesulfonate is a comparable anesthetic with a short elimination half-life and independence from cell P450 enzyme metabolism. Compared to remimazolam, remimazolam benzenesulfonate has a faster effect, is more quickly metabolized, produces inactive metabolites and has weak drug interactions. Thus, remimazolam benzenesulfonate has good effectiveness and safety for diagnostic and operational sedation. AIMTo investigate the clinical value of remimazolam benzenesulfonate in cardiac surgery patients under general anesthesia.METHODSA total of 80 patients who underwent surgery in the Department of Cardiothoracic Surgery from August 2020 to April 2021 were included in the study. Using a random number table, patients were divided into two anesthesia induction groups of 40 patients each: remimazolam (0.3 mg/kg remimazolam benzenesulfonate) and propofol (1.5 mg/kg propofol). Hemodynamic parameters, inflammatory stress response indices, respiratory function indices, perioperative indices and adverse reactions in the two groups were monitored over time for comparison.RESULTSAt pre-anesthesia induction, the remimazolam and propofol groups did not differ regarding heart rate, mean arterial pressure, cardiac index or volume per wave index. After endotracheal intubation and when the sternum was cut off, mean arterial pressure and volume per wave index were significantly higher in the remimazolam group than in the propofol group (P < 0.05). After endotracheal intubation, the oxygenation index and the respiratory index did not differ between the groups. After endotracheal intubation and when the sternum was cut off, the oxygenation index values were significantly higher in the remimazolam group than in the propofol group (P < 0.05). Serum interleukin-6 and tumor necrosis factor-α levels 12 h after surgery were significantly higher than before surgery in both groups (P < 0.05). The observation indices were re-examined 2 h after surgery, and the epinephrine, cortisol and blood glucose levels were significantly higher in the remimazolam group than in the propofol group (P < 0.05). The recovery and extubation times were significantly lower in the remimazolam group than in the propofol group (P < 0.05); there were significantly fewer adverse reactions in the remimazolam group (10.00%) than in the propofol group (30.00%; P < 0.05). CONCLUSIONCompared with propofol, remimazolam benzenesulfonate benefited cardiac surgery patients under general anesthesia by reducing hemodynamic fluctuations. Remimazolam benzenesulfonate influenced the surgical stress response and respiratory function, thereby reducing anesthesia-related adverse reactions.     

两种取石术在日间手术模式下治疗1至2 cm肾结石的疗效分析

目的 比较日间手术模式下行局部麻醉超微经皮肾镜取石术（SMP）和全身麻醉逆行输尿管软镜碎石取石术（RIRS）的疗效及可行性。方法 回顾性分析2021年6月－2022年6月该院泌尿外科100例行日间手术的肾结石患者的临床资料,结石直径1至2 cm,按术式分为局部麻醉SMP组（SMP组）和全身麻醉RIRS组（RIRS组）,各50例。比较两组患者手术时间、术后结石清除率和并发症发生率等指标。结果 所有患者均成功行日间手术,无严重并发症发生,SMP组结石清除率高于RIRS组（96.0%和82.0%,P = 0.025）,手术时间短于RIRS组［（34.86±8.10）和（45.66±9.62）min,P = 0.000］,RIRS组血红蛋白和红细胞比容下降较少（P < 0.05）。两组患者视觉模拟评分（VAS）、并发症发生率、住院时间、感染指标、血清肌酐变化和Clavien-Dindo分级系统比较,差异均无统计学意义（P > 0.05）。结论 经严格筛选合适的患者,在日间手术模式下开展局部麻醉SMP和全身麻醉RIRS均安全可行,彼此各有优势,SMP能有效提高近期结石清除率,RIRS能有效减少术中出血量,可根据实际情况合理选择。     

Up-to-date surgery for ulcerative colitis in the era of biologics

ABSTRACT

Introduction: In recent decades, biologics have resulted in significantly improved medical management of ulcerative colitis (UC). Rates of surgery for UC are declining. However, there is still a controversial question of the relation of biologics to postoperative adverse outcomes and the most appropriate timing for operative intervention.

Areas covered: In this review, we explore the updated treatment algorithm of acute severe colitis, describe postoperative outcomes in patients exposed to biologics preoperatively, and discuss the primary indications for staging surgery in chronic refractory cases, largely with prolonged medical therapy.

Expert opinion: Delaying pouch construction to when patients are in better health is suggested as a safer strategy over the long term. The surgical management of UC patients in the biologic era needs to be individualized, and a case-based multidisciplinary decision is critical for improved outcomes and a reduction of morbidity and mortality.     

采用阴囊V形切口的Borsellino术治疗隐匿性阴茎疗效分析

目的 探讨通过改良Borsellino术治疗隐匿性阴茎的疗效。方法 选择2017年1月至2021年10月在海军军医大学第一附属医院泌尿外科诊治的74例隐匿性阴茎患儿，合并蹼状阴茎患儿21例。对所有患儿均采用阴囊V形切口的改良Borsellino术，并在术后1、3、6个月进行随访。分析患者手术时间、术后阴茎延长长度、术后并发症及手术满意度等。结果 患儿年龄(11.1±3.0)岁，平均体质量指数(BMI)为(23.0±4.5)kg/m²。手术时间为(82.9±16.7)min。术后阴茎延长长度为(2.97±0.21)cm，其中合并蹼状阴茎组延长长度为(3.05±0.18)cm，大于不合并组[(2.93±0.21)cm,P<0.05]。术后发生包皮水肿(3例，4.0%)、包皮切口瘢痕(4例，5.4%)、切口感染(2例，2.7%)与血肿(1例，1.4%)。患儿家属非常满意40例(54.1%)、满意27例(36.5%)、一般5例(6.8%)，不满意2例(2.7%)。结论 该改良Borsellino术对隐匿性阴茎有较满意的手术效果，尤其适用于合并蹼状阴茎的隐匿性阴茎患儿...     

甲状腺功能亢进患者行乳晕入路腔镜下甲状腺手术的技巧探讨

目的 探讨乳晕入路腔镜下甲状腺手术治疗甲状腺功能亢进的操作技巧。方法 回顾性分析该院34例甲状腺功能亢进患者的病例资料,对手术情况及术中出血和腺体切除的方式进行分析。结果 该组病例无中转手术,手术时间（128.9±28.6）min,术中出血量（75.3±28.4）mL,术后2例出现甲状旁腺激素（PTH）降低,术中腺体血管出血200 mL以上者6例（17.6%）,腺体分块切除27例（79.4%）。结论 腔镜手术治疗甲状腺功能亢进难度较大,术中要控制出血,医师需掌握操作技巧,通过一定数量病例学习曲线的练习,才可保障手术的成功。     

Laparoscopic single-port Burch colposuspension with an extraperitoneal approach and standard instruments for stress urinary incontinence: Early results from a series of 15 patients

Abstract

Objective:We aimed to investigate the use of single-port laparoscopy in a series of patients undergoing Burch colposuspension with an extraperitoneal approach as an alternative treatment for scarless surgery in stress urinary incontinence. Material and methods: From September 2010 to May 2011 we performed single-port extraperitoneal laparoscopic Burch colposuspension for stress incontinence in 15 patients. Fifteen women who were diagnosed with urodynamic stress incontinence were included in the study. Demographic and clinical data, intraoperative findings, and postoperative course were recorded. Results:The mean age was 45,80 ± 9,91 years (range: 38–70 years). The mean body mass index was 25,67 ± 4.06 kg/m2 (range: 22.23–35.38 kg/m²). The mean operation time and mean blood loss were 40.80 ± 5.94 minutes (range: 30–50 minutes) and 30.67 ± 11.00 cc (range: 10–50 cc), respectively. The single-port laparoscopic operations were technically completed successfully without placement of additional trocars and there were no complications. The cure and improvement rates following laparoscopic Burch colposuspension via single port were 73.3 % and 20 % respectively. Conclusion: Single-port laparoscopic Burch can be an alternative treatment for scarless surgery in stress incontinence. Single-incision laparoscopic Burch colposuspension can offer suitable, effective and safe treatment in women with stress incontinence.     

腹腔镜下女性附件扭转保留卵巢的安全性及临床决策研究

目的 研究腹腔镜下女性附件扭转保留卵巢的安全性及临床决策问题。方法 选取于该院妇科住院并行腹腔镜下保留卵巢手术的附件扭转患者38例,观察患者的发病时间、卵巢囊肿扭转周数、术中保留卵巢的指标、术中平均出血量、手术时间和术后生殖激素水平等。结果 38例患者中顺向扭转17例（44.74%）,逆向扭转21例（55.26%）。平均扭转（1.28±0.44）周,手术时间（73.46±25.33）min,所有患者均顺利完成手术。术后平均血红蛋白下降（14.71±10.51）g/L,6例术后口服阿司匹林缓释片1个月,其余32例未作特殊处理。所有患者术后均无明显不适和并发症。术后复查超声均提示患侧卵巢恢复正常大小。结论 腹腔镜下附件扭转保留卵巢术,在卵巢质地不糟脆、剥离面有活动性出血的情况下,可行保留卵巢术,能避免切除患侧卵巢,并保留卵巢功能,可作为常规手术开展。