新生儿微创外科的进展

随着微创操作器械的不断精细,手术技术和麻醉水平的不断提高,近十年来微创外科-胸腹腔镜手术在新生儿外科的应用逐渐增多,主要有以下疾病. 1.先天性肥厚性幽门狭窄:自1912年Ramstedt开展幽门环肌切开术后至今,此方法 一直是治疗先天性肥厚性幽门狭窄的基本术式.1991年Alain等首先应用腹腔镜行幽门肌切开术,很快被一些儿外科医师接受和应用,但也有反对者,反对者认为脐上弧形切口小,愈合后瘢痕隐蔽几乎看不到,对腹腔镜手术的价值有异议.Kim等报告了290例病例,分为腹腔镜手术组、右上腹横切口组和脐切口组,手术时间腹腔镜组明显少于其他两组;腹腔镜组和脐周组切口瘢痕微小美观,但脐周切口组手术时间长、费用高和伤口并发症多.     

Recent advances in the management of rectal cancer: No surgery,minimal surgery or minimally invasive surgery

Over the last decade,with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer,there has been a significant increase in the literature regarding treatment options available to patients affected by this disease.That treatment related decisions should be made at a high volume multidisciplinary tumor board,after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision(TME)are accepted standard of care.More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders,which may be appropriate in 20%of patients.Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only,with transanal minimal invasive surgery(TAMIS)because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon,emerging as the leading option.Recent trials have raised concerns about the oncologic outcomes of the standardtop-downTME hence transanal TME(Ta TMEbottom-up)approach has gained popularity as an alternative.The challenges are many,with a dearth of evidence of the oncologic superiority in the long-term for any given option.However,this review highlights recent advances in the role of chemoradiation only for complete pathologic responders,TAMIS for highly selected early rectal cancer patients and Ta TME as options to improve cure rates whilst maintaining quality of life in these patients,while we await the results of further definitive trials being currently conducted.     

机器人微创心脏手术的应用现状

微创是心脏外科的发展方向之一.随着自动机械和计算机技术的进步,机器人微创外科手术已成为现实.机器人微创心脏手术具有创伤小、操作精细等优点,是微创心脏外科的前沿技术之一.作为一种革新的手术方式,机器人辅助下微创心脏手术得到了极大的关注,本文就机器人心脏手术的临床应用及手术效果作一综述.     

微创时代的神经外科

20世纪50年代经典神经外科趋于成熟。20世纪后半叶显微神经外科技术迅速发展和普及。20世纪90年代神经外科进入微创时代。     

胰腺外科微创手术临床研究进展及发展趋势

近年来,随着微创器械、设备的发展和手术技术的进步,胰腺微创外科进入了快速发展阶段,推动了大量临床研究的开展。研究表明：相比于传统开放手术,微创胰腺手术在减少手术创伤、缩短住院时间、加速病人术后康复方面具有一定优势,但在手术适应证选择、肿瘤根治性及术后并发症等方面仍有争议,亟需开展高质量临床研究。然而,目前的临床研究多为回顾性,前瞻性随机对照研究数量仍较少,且样本数量有限,难以充分回答上述争议,给胰腺微创外科的快速发展带来了一定阻碍。因此,扩大前瞻性研究样本量,探究胰腺癌病人的生存获益,关注术者的学习曲线,客观评估微创手术对并发症的影响并采取相应的预防措施将是未来胰腺微创手术研究的方向。     

Recent progress in minimally invasive conduit harvesting

Wound-related morbidity frequently encountered after open-incision harvesting of vessel conduits for coronary artery bypass grafting (CABG) is invariably recognized as an obstacle impeding the patient's path towards complete postoperative recovery. The endoscopic approach provides surgical access to the intended conduit vessel while affording an appreciably lower incidence of traumatic injury to the surrounding tissues. For this reason, the minimally invasive endoscopic dissection of vessel conduits is steadily gaining acceptance as a preferable alternative to the standard open-incision technique. Endoscopic systems, originally developed for general surgical procedures in the early 1990s, and readily adapted to saphenous vein harvesting by mid-decade, are now also being applied to minimally invasive radial artery harvesting. The growth of this surgical modality has paralleled the rapid development of remote access minimally invasive endoscopic devices and technologies and therefore remains an evolving body of knowledge. As experience and refinements in instrumentation progress, the endoscopic approach will undoubtedly become the procedure of choice for harvesting vessel conduits. This article provides a practical primer, based on the benefit of our serial experience with endoscopic vein and radial artery dissections, for those considering the minimally invasive endoscopic approach in harvesting vessels for CABG.     

甲状腺微创外科进展

随着国内外腔镜技术及微创理念的不断推广,腔镜甲状腺手术出现了各种不同的手术方式和快速发展,笔者就常见的腔镜甲状腺手术径路、建腔方式及新技术、新理念作一综述。     

Imaging systems in minimally invasive surgery

The imaging system is the eye of the laparoscopic surgeon. The success or failure of a minimally invasive procedure depends on the quality and working order of the imaging system used. The components that work together to produce an image on the monitor is called the imaging chain. The image displayed will be good as the chain's weakest component. Understanding how the pieces of this process work together will allow the surgeon to troubleshoot basic system problems, leading to improved image displays and safer operating environments. Continuous refinement of laparoscopes, lighting systems, cameras, monitors, and displays lead to an ever-improving operating environment.     

Anaesthesia and minimally invasive surgery

Minimally invasive surgery is commonly performed because of various advantages such as reduced postoperative pain, faster recovery, and reduced postoperative pulmonary complications. However, anaesthesia for laparoscopy can be difficult and potentially hazardous in long, complex surgical procedures and in sick patients. Establishment of CO₂ pneumoperitoneum produces adverse pathophysiological changes due to increased intra-abdominal pressure and hypercapnia, and these are further altered by postural changes. Laparoscopy is also associated with potential complications such as extraperitoneal gas insufflation and pneumothorax. It is important for the anaesthetist to understand the advantages and potential risks. General anaesthesia with endotracheal intubation is the most common anaesthetic technique, but supraglottic airway devices can sometimes be used. Neuroaxial anaesthesia has been used in some laparoscopic procedures as the sole anaesthetic technique. This article will focus on the pathophysiological changes caused by CO₂ pneumoperitoneum, the anaesthetic management for patients undergoing laparoscopy, and potential complications.     

Anesthesia for minimally invasive surgery

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Anesthesia in ambulatory minimally invasive surgery

The increasing popularity of minimally invasive surgery has grown concurrently with the demand for ambulatory surgery. Standard outpatient procedures such as tubal ligation are now being joined by ambulatory laparoscopic cholecystectomy. In order for ambulatory minimally invasive surgery to succeed, patient selection must be appropriate, careful attention paid to the physiologic changes of pneumoperitoneum, and pain and nausea treated pre-emptively.     

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasivesurgery(MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.     

Intraoperative enteroscopy in minimally invasive surgery

PURPOSE: The purpose of this study was to assess the efficacy and safety of intraoperative enteroscopy (IOE) in patients undergoing minimally invasive surgery. METHODS: Twelve patients underwent minimally invasive surgery and IOE at Miyazaki University Hospital. Patients included 11 men and 1 woman. After extraction of the intestine via minilaparotomy, enterotomy was performed, and a sterilized enteroscope was inserted. RESULTS: Length of the skin incision was 5.7+/-0.2 cm (mean+/-standard error). Length of the small intestine observed enteroscopically was 334+/-19 cm. Distance from the ligament of Treitz to the orally observed jejunum was 11.8+/-3.6 cm. In 5 of 9 patients with Crohn disease, additional lesions were found by IOE that were not found by preoperative examination. One additional tumor was found in 1 patient with ileal tumor. Postoperative complications occurred in 2 patients. CONCLUSION: IOE is efficacious in patients undergoing minimally invasive surgery.     

Training for minimally invasive surgery

Summary Controversy exists regarding the training of surgeons for the performance of minimally invasive surgical procedures. The use of live animals is essential, especially in teaching dissection techniques. Seventeen percent of animals experienced excessive operative hemorrhage, which contributed to premature mortality during training exercises, demonstrating the need for live animals in this component of the training. A number of abdominal procedures can be performed with minimally invasive techniques without suturing by utilizing a rapidly expanding array of devices. However, other procedures cannot be successfully accomplished without suturing skills. Laparoscopic suturing skills are particularly demanding; thus specific training and practice prior to hands-on exercises in animal models is recommended. Emphasis on acquisition of advanced laparoscopic surgical skills is a necessity.Presented at the Third World Congress of Endoscopic Surgery, June 20, 1992, Bordeaux, France