腹腔镜手术治疗卵巢良性肿瘤110例分析

目的:探讨腹腔镜手术治疗卵巢良性肿瘤的效果。方法:回顾性分析1996年4月至2008年8月我院应用腹腔镜手术治疗110例卵巢良性肿瘤患者的临床资料。结果:92例行腹腔镜下肿瘤切除术,18例行附件切除术。术后96例获随访6~60个月,1例术后1年复发,为同侧卵巢浆液性囊腺瘤;1例术后5年发生双侧卵巢乳突状浆液性囊腺癌;余术后均无复发及腹腔粘液瘤发生。结论:经过严格的术前筛查,腹腔镜手术治疗卵巢良性肿瘤安全、有效,值得推广应用。     

Laparoscopic microwave ablation and enucleation of small renal masses: preliminary experience

Advancements in imaging and laparoscopy have led to the expansion of minimally invasive techniques in the ablation of small renal masses (SRMs). We report the results of a study aimed at assessing the efficacy of thermoablative microwave (MW) effects on SRMs and the haemostatic as well as necrotic MW effects on the parenchyma surrounding the neoplasm.From November 2008 to October 2010, 10 patients with SRMs underwent laparoscopy-guided Tru-Cut biopsy, MW tumour ablation, and enucleation. Mean age was 66 yr (range: 46-84 yr). Mean renal tumour diameter was 2.75 cm (range: 1.3-4.2 cm). MW antennas were applied one to three times depending on tumour volume, location, and shape. After MW thermoablation, laparoscopic enucleation was performed to evaluate the histopathologic and haemostatic effects of MW.The mean MW antenna application time was 14.1 min (range: 4-30 min). Enucleation did not require renal pedicle clamping in any of the cases because no significant bleeding took place. Preablation pathology revealed clear cell renal carcinoma of Fuhrman grade I-II in all cases. Postablation pathology showed extensive coagulative necrosis without skipped tumour areas. No intra- or postoperative complications were reported.Histopathologic effects on SRMs provide consistent proof of principle for future studies.     

Minimally invasive adnexa-sparing surgery for benign ovarian and paratubal masses in children

BackgroundThe precision of minimally invasive surgery (MIS) to resect benign ovarian and paratubal masses while preserving adnexa in children is unclear. This study evaluated the integrity of laparoscopy to spare adnexa while resecting benign pathologies in children.MethodsThe institutional pathology database was queried to identify patients aged 18 years and younger having any ovarian or tubal lesion resected at a comprehensive children's hospital between 2006 and 2021. Adnexa-sparing surgery was defined as preserving both the ovary and tube from which the lesion was resected. Postoperative ultrasounds were reviewed to document ovarian follicles, blood flow, volumes, and lesion recurrence.ResultsAdnexal preservation was implemented in 168 of 328 pathological resections. MIS approach was used in 149 cases. Median age was 13.4 [11.0–15.3]. Among sparing surgeries, MIS associated with benign pathology, shorter operative time (median minutes: 78 MIS [59–111.5]; 130 open [92.8–149.8]; 174 MIS-to-open [132.8–199.5]; p = 0.010), and reduced hospital stay (median days: 1 MIS (Lindfors, 1971; Lovvorn III et al., 1998) [1-2]; 2 open [2–2.9], 2 MIS-to-open [1–3.3]; p = 0.001). Postoperative ovarian volume ipsilateral to the MIS procedure (median, 7.6 ml [4.3–12.1]) was relatively smaller than the contralateral ovary (median, 9.1 ml [5.5–15.0]). Blood flow was documented to the ovary in 70/94 (74.4%) of patients after MIS adnexal-sparing surgery. Distinct follicles were detected in 48/74 (64.8%) of post-menarchal patients after MIS adnexal-sparing surgery. Five ovarian cysts recurred.ConclusionsMIS preserves adnexa reliably, with postoperative ovarian follicles and blood flow detected in most patients, and maintains ∼80% of contralateral volume, while achieving definitive tumor resection.Level of evidenceIII     

早期胃癌的微创外科治疗

开腹手术一直是早期胃癌的有效治疗方式,但开腹手术创伤大,术后并发症多,如何降低早期胃癌手术的创伤、减少并发症一直是外科医师致力解决的问题.随着早期胃癌发现率的提高和微创外科技术的发展,越来越多的外科医师和患者倾向于使用微创技术治疗早期胃癌.早期胃癌微创治疗方式多样,从当前文献报道来看都取得了不错的进步,但也都存在不足....     

Current Status of Robotic Surgery

Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms “robotic surgery, telesurgery, and laparoscopy.” A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.     

Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy

Background The role of laparoscopic appendectomy for perforated appendicitis remains controversial. This study aimed to compare laparoscopic and open appendectomy outcomes for children with perforated appendicitis. Methods Over a 36-month period, 111 children with perforated appendicitis were analyzed in a retrospective review. These children were treated with either laparoscopic (n = 59) or open appendectomy. The primary outcome measures were operative time, length of hospital stay, time to adequate oral intake, wound infection, intraabdominal abscess formation, and bowel obstruction. Results The demographic data, presenting symptoms, preoperative laboratory values, and operative times (laparoscopic group, 61 ± 3 min; open group, 57 ± 3 were similar for the two groups (p = 0.3). The time to adequate oral intake was 104 ± 7 h for the laparoscopic group and 127 ± 12 h for the open group (p = 0.08). The hospitalization time was 189 ± 14 h for the laparoscopic group, as compared with 210 ± 15 h for the open group (p = 0.3). The wound infection rate was 6.8% for the laparoscopic group and 23% for the open group (p < 0.05). The wounds of another 29% of the patients were left open at the time of surgery. The postoperative intraabdominal abscess formation rate was 13.6% for the laparoscopic group and 15.4% for the open group. One patient in each group experienced bowel obstruction. Conclusions Laparoscopic appendectomy for the children with perforated appendicitis in this study was associated with a significant decrease in the rate of wound infection. Furthermore, on the average, the children who underwent laparoscopic appendectomy tolerated enteral feedings and were discharged from the hospital approximately 24 h earlier than those who had open appendectomy.     

Navicular stress fractures treated with minimally invasive fixation

Background:

Stress fractures of the naviculum bone are uncommon injuries occurring predominantly in athletes. These fractures are usually treated nonoperatively with a nonweight bearing cast for a minimum of 6 weeks followed by rehabilitation. Further, there is a paucity of literature on the long term clinical followup of these patients. These fractures do not heal predictably with conservative management, which does not inspire great compliance and their clinical outcome is variable. We report on the outcome of these fractures following early operative intervention by minimally invasive fixation and early weight bearing and rehabilitation. We propose that this is reliable and a successful treatment regimen and its role as the definitive management of this clinical problem should be explored.

Materials and Methods:

Nine athletes with ten stress fractures of the navicular treated at our institution between April 1991 and October 2000. The mean age of the patients was 22.8 years (range 18-50 years). All patients were treated by minimally invasive screw fixation and early weight bearing mobilization without a cast. The average followup was 7 years (range 2-11 years).

Results:

Seven of the nine patients returned to their pre-fracture level of sporting activity at an average of 5 months (range 3-9 months). One patient returned to full sporting activity following a delay of 2 years due to an associated tibial stress fracture and one patient had an unsatisfactory result. Long term review at an average of 7 years showed that six of these eight patients who returned to sports remained symptom free with two patients experiencing minimal intermittent discomfort after prolonged activity.

Conclusions:

We recommend percutaneous screw fixation as a reliable, low morbidity procedure allowing early return to full sporting activity without long term complications or recurrences.     

SUPRAPUBIC LAPAROSCOPIC CHOLECYSTECTOMY: TECHNIQUE AND PRELIMINARY RESULTS

Background

The minimally invasive abdominal surgery has evolved to reduce portals, culminating with a single incision and natural orifice operation. However, these methods are still expensive, difficult to implement and with questionable aesthetic results.

Aim

To present the standardization and preliminary results of a technique for performing laparoscopic suprapubic access by the principle which was called the Supra Pubic Endoscopic Surgery for cholecystectomy.

Method

The average body mass index of patients, the mean operative time, clinical data of the postoperative complications and quality of life were prospectively studied. The operation incisions consisted of: A) umbilical for instrumental dissection and clipping; B) in the right groin for handling and gallbladder gripping; C) suprapubic for the camera. With the patient in reverse Trendelenburg and left lateral decubitus, the operation flew by the camera trocar in C, proceeding with dissection and isolation of the biliary pedicle, identification of cystic duct and artery, with usual instrumentation. Transcystic intraoperative cholangiography was performed in all cases in which there were indications. The procedure was completed with clipping and sectioning of the cystic duct and artery, retrograde resection of the gallbladder and extracting it by the umbilical trocar incision under direct vision.

Results

Thirty patients undergone this surgical procedure between March and June 2012 and were evaluated. The mean age was 40.7 years and the indications were typical biliary colic in 18 cases (60 %), cholecystitis in five cases (16.6 %), biliary pancreatitis in one case (3.3%); polyp in three cases (10%) and obstructive jaundice at three cases (10%). The average body mass index was 27.8 (23.1-35.1) and surgical time ranged between 24 and 70 minutes.

Conclusion

The technique proved to be feasible and safe , with no significant complications, and satisfactory cosmetic results.     

腹腔镜辅助下微创手术对胃癌患者胃动素和胃泌素影响的临床研究

目的研究腹腔镜辅助下微创手术对胃癌患者胃动素和胃泌素的影响。方法将2011-01-2012-12间我院及中山市人民医院收治的胃癌患者纳入研究,采用随机数表法分为给予腹腔镜下胃癌根治术的观察组和给予开腹手术的对照组,观察手术相关指标,检测进入手术室时(T0)、手术中(T1)、手术结束时(T2)、手术后1 d(T3)时的的胃动素、胃泌素含量。结果 (1)两组患者的手术时间、切缘-病灶距离的差异无统计学意义,观察组患者的术中出血量、术后肛门排气时间、进食流质时间、卧床总时间均短于对照组;(2)T2、T3时间点,观察组患者的胃动素和胃泌素含量均高于对照组。结论腹腔镜辅助下微创手术有助于改善胃动素、胃泌素的含量,促进胃肠功能的恢复,具有积极的临床价值。     

FAP伴直肠腺瘤癌变患者行腹腔镜大肠次全切除复合NOSES手术

目的探讨腹腔镜大肠次全切除术中组合应用两种不同取标本方式行经自然腔道取标本手术(natural orifice specimen extraction surgery, NOSES)的可行性。 方法2019年2月,四川省肿瘤医院收治了1例家族腺瘤性息肉病(familial adenomatous polyposis, FAP)合并直肠息肉癌变的患者,腹腔镜大肠次全切除术中先使用切除拖出的方式经直肠取出结肠标本,然后以经肛外翻拖出的方式切除直肠标本,顺利完成NOSES。 结果手术时间约360 min,术中出血量50 ml,术后12 d顺利出院,无手术相关并发症发生。 结论腹腔镜大肠次全切除复合NOSES安全可行,对有适应证的FAP患者有较好的临床应用前景,可以更好地展现NOSES技术的微创优势。     

Early experience with laparoscopic excision of choledochal cyst in 41 children

Objective

This study aims to review our center's early experience in managing children with choledochal cysts using laparoscopic excision.

Methods

A retrospective study was carried out from the time of our first case of laparoscopic excision (2010). A total of 41 patients with choledochal cysts underwent laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy. Patient demographics, operative data, and post-operative outcomes were recorded and analyzed.

Results

Forty patients underwent the operation successfully, and the mean time of operation was 210 min (range 140 min to 380 min). One case was converted to an open operation due to dense adhesions. All patients recovered uneventfully and were discharged between seven and ten days post-operatively. Four patients suffered minor bile leaks after their operations, but they required only percutaneous drainage. The mean time for follow-up was six months (range 1 month to 1 year). No significant complication was noted during that time.

Conclusions

We successfully introduced laparoscopic excision of choledochal cyst in our center and have found this to be a safe and effective method. Long-term follow up is awaited.     

腹腔镜胃癌外科的发展现状与思考

腹腔镜手术以其显著的微创优势。已成为外科医生治疗早期胃癌的首选方式之一。随着腹腔镜手术经验的不断积累．目前腹腔镜胃切除术的指征已逐渐从早期胃癌扩大到进展期胃癌。但是．由于缺乏长期疗效的循证医学证据支持．腹腔镜手术在进展期胃癌中的运用尚存争议。腹腔镜胃癌手术在技术层面的要求非常高．尤其在进行D2淋巴结清扫时。因此,在开展腹腔镜胃癌手术前．规范腹腔镜操作技术和流程的培训是必须的。     

微创肿瘤手术临床研究结果的启示与思考:如何提高微创外科手术的质量控制

以腹腔镜微创技术为代表的肿瘤微创外科发展已近30年。尽管手术技术及操作流程不断进步,但近来的临床研究结果显示:微创手术在部分恶性肿瘤中的肿瘤学疗效仍有争议。无论真相如何,手术的质量控制至关重要。严格把握手术指征,为肿瘤患者提供最合适的治疗方式有助于手术质量控制与风险降低。通过构建系统化培训体系,规范微创手术操作可保证肿瘤微创手术的质量。针对新兴微创手术技术,以严谨、审慎的态度加以开展,对于手术质量控制尤为重要。在微创外科高度发展的今天,除继续"保持速度",还应更好地"保证质量"才能使微创手术给更多的肿瘤患者带来获益。     

The Safety and Efficacy of Approaches to Liver Resection: A Meta-Analysis

Background:The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.Database:Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3–200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78–2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42–0.57).Conclusion:Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.     

Total laparoscopic gastric mobilization for esophagectomy

Background and aims  The operative mortality and morbidity associated with esophageal surgery has been decreasing with advances in surgical techniques and equipment, however, postoperative complication remains a major cause of a potentially fatal outcome. We herein describe a new technique for esophagectomy by total laparoscopic gastric mobilization technique as a minimally invasive surgery. Patients and methods  Between April 2003 and August 2007, 36 patients who were suffering from esophageal cancer were surgically resected at Kochi Medical School. Operation-related parameters, mortality, postoperative complication, intubation time, and length of surgical intensive care unit in patients with total laparoscopic gastric mobilization for esophagectomy (the TLGM group, n = 16) were evaluated, compared to patients with ordinary thoraco-abdominal esophagectomy (the OPEN group, n = 20). Results  There was no mortality in the TLGM group and one hospital death in the OPEN group. Operation time of the OPEN group (506 ± 64 min) was significant shorter than that of the TLGM group (558 ± 67 min). The estimated intraoperative blood loss volume in patients of the TLGM group (496 ± 259 mL) was much smaller than those of the OPEN group (1,067 ± 566 mL). The intubation time and the intensive care unit stay in the TLGM group were much shorter than that in the OPEN group. Conclusions  Esophagectomy with regional lymphadenectomy combined with total laparoscopic gastric mobilization is a safe and beneficial opportunity for patients who underwent surgical procedure for esophageal cancer.     

Laparoscopic patch repair of diaphragmatic hernias with Surgisis

Background

Laparoscopic repair of congenital diaphragmatic hernias has been sparsely reported. Moreover, each report has primarily been a single operative case. In most of the reports, prosthetic mesh has not been used, and when used, it has been nonabsorbable in nature. Most of these case reports have documented only a few months of clinical follow-up.

Methods

After institutional review board approval (No. 01-12-115X), the clinical course and outcome of 3 patients undergoing laparoscopic repair of foramen of Morgagni and Bochdalek hernias using 4-ply Surgisis soft tissue graft (Cook Inc, Bloomington, Ind) were reviewed to determine if this approach is appropriate.

Results

In 2001, 2 patients, ages 9 months and 14 years, underwent laparoscopic foramen of Morgagni repair and one 5-day-old underwent laparoscopic foramen of Bochdalek repair using Surgisis soft tissue graft as a patch to close the diaphragmatic defects because there was too much tension with primary repair. In each case, the prosthesis was secured to the rim of the defect using interrupted silk sutures tied intracorporally. The mean operative time for repair of the Morgagni defects was 230 minutes with a postoperative discharge of 1 and 2 days. For the foramen of Bochdalek repair, the operative time was 204 minutes, and the patient was discharged at 3 weeks. No complications have occurred during or after any of the procedures, but the oldest patient underwent diagnostic laparoscopy 3 months postoperatively for a radiographic finding of suspected recurrence. At laparoscopy, the patch was intact, and no diaphragmatic hernia was noted.

Conclusions

Laparoscopic repair of congenital diaphragmatic defects using prosthetic material is possible although the operative time required is around 3.5 hours. Because of the brief postoperative course, the laparoscopic approach appears justified in the nonneonatal patients. Whether this approach is appropriate for repair of neonatal Bochdalek hernias remains unclear.     

隐蔽小切口内镜辅助下腮腺良性肿瘤切除术

目的　探索借助内镜经小切口在窄小人造腔室内实施腮腺手术的可行性和相关技术。方法　省略经典切口的颌下及大部分颌后段 ,保留其耳前部分和耳垂根下一弧形小段。前者后移至耳屏缘 ,后者不超过耳垂遮盖。切口长 3 5～ 5 5cm(平均 4 5cm)。采用分离 提吊 扩撑法先建起腺体上、后两个腔室 ,然后通过内镜视野 ,按面神经顺行解剖法和新建高频超声刀组织凝 切直断法操作。结果　良性肿瘤患者 2 6例肿瘤均被完整切除。除 1例出现暂时性口角歪斜外 ,余患者无面瘫 ;结论　借助内镜和改进技术 ,可经小切口在窄小人造腔室内安全实施腮腺手术。由于切口大幅压缩且被置于视觉盲区 ,不仅创伤明显减少 ,患者的术后外观也能得到显著改善     

Minimally invasive abdominal surgery: lux et veritas past, present, and future

BACKGROUND: Laparoscopic surgery has developed out of multiple technology innovations and the desire to see beyond the confines of the human body. As the instrumentation became more advanced, the application of this technique followed. By revisiting the historical developments that now define laparoscopic surgery, we can possibly foresee its future. DATA SOURCES: A Medline search was performed of all the English-language literature. Further references were obtained through cross-referencing the bibliography cited in each work and using books from the authors' collection. CONCLUSION: Minimally invasive surgery is becoming important in almost every facet of abdominal surgery. Optical improvements, miniaturization, and robotic technology continue to define the frontier of minimally invasive surgery. Endoluminal resection surgery, image-guided surgical navigation, and remotely controlled robotics are not far from becoming reality. These and advances yet to be described will change laparoscopic surgery just as the electric light bulb did over 100 years ago.