3D腹腔镜在泌尿外科手术中的应用体会

目的 探讨3D腹腔镜在泌尿外科手术中的应用价值.方法 应用Storz 3D腹腔镜完成泌尿外科手术48例,参照经典的手术方式在三维立体手术视野下完成手术.统计手术时间、术中出血量、术后引流量、并发症、术后住院天数等.结果 本组除1例中转开放性手术外,其余均在3D腹腔镜下顺利完成手术.后者手术时间29 ～ 365 min,其中经腹后腔肾上腺肿瘤切除术、根治性肾切除术(5例)、单纯性肾切除术、包膜下肾切除术、肾和输尿管全程切除术、肾囊肿去顶减压术、肾部分切除术、肾盂输尿管成形术时间分别为29 ～ 150min、46 ～ 175min、60～105min、96～145min、135 ～ 150min、35～50min、125 min、105 ～ 120min;经腹腔肾上腺肿瘤切除术(1例)、根治性肾切除术(3例)、输尿管狭窄闭锁段切除吻合术、输尿管粘连松解术、输尿管切开取石术、双侧输尿管膀胱再植术、根治性膀胱切除+回肠膀胱术(双侧髂血管旁淋巴结清除+膀胱切除时间)、膀胱壁修补术时间分别为175min、148 ～ 164min、90～140min、45min、45～55min、185min、246～268min、30 ～ 48 min.肾蒂阻断时间、肾盂输尿管成形吻合时间、输尿管端端吻合时间、输尿管缝合时间、双侧输尿管膀胱吻合时间分别为22min、90 ～ 105min、40～ 44min、10～35min、82min.术中出血量10 ～ 450mL,术后引流量100～ 500mL,术后继发出血2例,术后住院5～21d,无一例因手术死亡.结论 3D腹腔镜适用于泌尿外科各种手术,特别是高难度手术更有优势,提供了真实的三维立体术野,有较好的应用价值.     

3D腹腔镜在泌尿外科手术中的应用(附6例报告)

目的:探讨3D腹腔镜成像系统在泌尿外科手术中的应用。方法:2014年5月~2014年6月应用德国蛇牌3D HD腹腔镜系统完成腹腔镜手术6例,包括肾囊肿去顶减压术3例,肾上腺肿瘤切除术2例,肾蒂淋巴管结扎术1例,统计手术时间、出血量、术后住院时间等数据。结果:6例手术均获成功,无中转开腹。手术时间20~70min,其中肾囊肿去顶减压术20~30min,肾上腺肿瘤切除术25~60min,肾蒂淋巴管结扎术70min;术中出血量20~30ml。术后住院时间4~8d,平均5.8d。结论:3D腹腔镜成像系统是传统腹腔镜技术的一大进步,降低了手术难度,缩短了手术时间。该系统具备传统腹腔镜与开放手术的共同优势,手术解剖更精确,手术操作相对更容易。     

3D腹腔镜在泌尿外科手术中的应用

【摘要】 腹腔镜手术在现今泌尿外科手术中被广泛应用,例如肾癌根治术、肾部分切除术以及前列腺癌根治术等。3D腹腔镜提供了更佳深度的感知与空间定向。本文就3D腹腔镜在泌尿外科手术中的应用作一综述。     

3D腹腔镜在泌尿外科手术中的应用进展

3D腹腔镜克服了传统腹腔镜无立体视野的缺点,术者可以准确掌握组织解剖层次,减少创伤,具有良好的应用前景和广阔的发展空间。本文就3D腹腔镜的技术基础、在泌尿外科手术中的应用及进展作一综述。     

单孔腹腔镜技术在泌尿外科手术中的初步应用和体会

目的:总结单孔腹腔镜技术在我院泌尿外科应用的初步经验。方法:回顾性分析2011年7月在我院泌尿外科行单孔腹腔镜手术的7例患者的临床资料。结果:采用单孔X-CONE建立操作通道,使用常规及弯曲腹腔镜器械完成7例单孔腹腔镜手术。其中包括肾上腺腺瘤2例,肾囊肿2例,精索静脉曲张2例,乳糜尿1例。3例手术经脐腹腔路径,4例经后腹腔。7例手术均获成功,手术时间27～135min,出血量5～40ml,术后住院时间2～6d。无明显术中和术后并发症。切口愈合良好,瘢痕小。结论:单孔腹腔镜手术对操作技能、解剖认识要求较高,该技术安全可行,具有创伤小,恢复快,切口美观的优点。进一步的临床实践和器械的改进将有助于该技术推广应用。     

3D腹腔镜技术在泌尿外科应用的初步探讨

目的 探讨3D腹腔镜技术在泌尿外科手术领域的应用价值.方法 我院泌尿中心自2013年8月至2013年9月应用Viking 3D HD腹腔镜系统成功完成10例腹腔镜手术,包括肾囊肿去顶减压术3例;根治性肾切除术2例;根治性全膀胱切除术1例;肾上腺肿瘤切除术3例（患侧肾上腺全切2例、患侧肾上腺部分切除术1例）;肾盂输尿管成型术1例.结果 10例患者手术均在高清3D腹腔镜下顺利完成,无中转开放或术中更换为二维腹腔镜系统情况发生.手术时间30～210 min,平均72 min.术中、术后均无输血.10例患者术后均恢复良好,顺利出院.结论 3D腹腔镜提供了优良三维立体高清成像视野,可以实现精确操作,使得泌尿外科复杂、难度大的手术得以简化,从而缩短手术时间,提高手术的安全性.其在泌尿外科手术领域会有广阔的应用前景.     

我国泌尿外科腹腔镜微创手术步入3D时代

<正>腹腔镜手术的应用是泌尿外科微创手术的一个里程碑,自从1991年Clayman教授[1]首次报道腹腔镜单纯性肾切除术以来,腹腔镜手术以其创伤小、恢复快等特点得到了广大泌尿外科医师的认可、学习和使用,并成为现代泌尿外科手术的主要方式。但传统腹腔镜系统获得的是二维平面图像,即单眼视觉图像,与自然直视下双眼视觉比较,图像缺乏深度感觉,使刚开始学习腹腔镜手术的医师感到     

腹腔镜泌尿外科手术

腹腔镜泌尿外科手术北京医科大学泌尿外科研究所北京医科大学第一医院泌尿外科（１０００３４）吴刚那彦群８０年代以来，由于人工气腹装置、高清晰度人体腔内摄影系统和腹腔镜专用器械的开发和应用，腹腔镜技术已由最初用于诊断发展到可以治疗腹腔、盆腔和腹膜后腔器官疾...     

3D与2D腹腔镜系统在结直肠癌手术应用的随机对照研究

目的研究3D腹腔镜系统在结直肠癌根治术中手术操作技术、术后短期疗效、可行性、安全性及肿瘤根治性。方法采用前瞻性分析法,收入2013年11月至2015年6月在上海市微创外科临床医学中心进行腹腔镜结直肠癌根治术的74例病人,按照随机数字表法分为2D(高清)腹腔镜组及3D腹腔镜组。2D腹腔镜组共38例,其中男性20例、女性18例,中位年龄为60.5岁(46~83岁);3D腹腔镜组共36例,其中男性16例、女性20例,中位年龄为62岁(37~84岁)。38例2D腹腔镜组病人中,腔镜右半结肠癌根治术12例,腹腔镜左半结肠癌根治术4例,腹腔镜横结肠癌根治术1例,腹腔镜乙状结肠癌根治术2例,腹腔镜根治性直肠前切除术17例(其中3例行末端回肠造口术),腹腔镜腹会阴联合直肠癌根治术2例。36例3D腹腔镜病人中,腹腔镜右半结肠癌根治术15例,腹腔镜左半结肠癌根治术3例,腹腔镜横结肠癌根治术1例,腹腔镜乙状结肠癌根治术3例,腹腔镜根治性直肠前切除术10例(其中5例行末端回肠造口术),腹腔镜腹会阴联合直肠癌根治术4例。结果所有病例均成功接受手术,无术中严重并发症和手术死亡发生,无中转开腹手术。2D腹腔镜组平均手术时间为(153.3±54.9)min,平均术中出血为(117.9±102.5)ml,平均排气时间为(2.3±0.9)d,平均住院天数为(9.6±7.8)d。3D腹腔镜组平均手术时间为(152.9±48.3)min,与2D腹腔镜组比较P=0.973;平均术中出血为(100.3±66.3)ml,与2D腹腔镜组比较P=0.386;平均排气时间为(2.1±0.8)d,与2D腹腔镜组比较P=0.228;平均住院天数为(8.1±3.2)d,与2D腹腔镜组比较P=0.289。术后2D腹腔镜组有1例腹腔镜根治性直肠前切除术及1例腹腔镜右半结肠癌根治术出现吻合口漏;3D腹腔镜组有1例腹腔镜腹会阴联合直肠癌根治术出现会阴切口感染。以上病人予对症治疗后均好转,无行二次手术病人。结论 2D腹腔镜系统与3D腹腔镜系统在手术操作上相似,两者手术后临床短期疗效、肿瘤根治程度相当。进一步研究尚需病例的积累与远期疗效的观察。     

3D腹腔镜技术在泌尿外科的初步应用

随着腹腔镜技术的广泛应用,现代外科已进入微创时代,而自腹腔镜技术被引入泌尿外科以来,更使泌尿外科的微创手术有了突飞猛进的发展,目前,腹腔镜手术已几乎涵盖了泌尿外科的所有领域。     

泌尿外科腹腔镜手术常见并发症的处理

随着泌尿外科腹腔镜手术量的增加、腹腔镜手术难度的加大,其手术并发症的发生率及严重程度也随之上升。腹腔镜手术并发症可发生于麻醉、套管置入/移除、术中及关腹等各个手术步骤。因此,熟练的手术技巧、丰富的手术经验以及仔细的术中操作对腹腔镜手术的顺利完成都必不可少。此外,加强对腹腔镜手术并发症的认识、预防及处理对泌尿外科腹腔镜手术的发展意义重大。     

Comparison of clinical outcome of single-incision laparoscopic surgery using a simplified access system with conventional laparoscopic surgery for malignant colorectal disease

Aim Instrument crowding is encountered in single‐incision laparoscopic surgery (SILS). Our aim was to compare the results of SILS with those of conventional laparoscopic surgery (CLS) for malignant colorectal disease. Methods The records of 27 patients who received SILS for the treatment of malignant disease using a home‐made multiple‐port system were compared with those of 68 patients who received CLS performed in a standard manner using four to five trocar sites. Results There were no significant differences in age, gender, disease stage, tumour location or tumour size between the SILS and CLS groups. The most common surgery was high anterior resection in both groups (SILS, 63.0%vs CLS, 58.8%). There were no significant differences between the groups in types of surgery performed, length of bowel resected, resection margin, blood loss, duration of surgery or postoperative complications. Postoperative pain scores were significantly higher in the SILS group than in the CLS group (3.07 ± 1.14 vs 2.41 ± 0.63, respectively, P < 0.001). Conclusions SILS is as effective as CLS, and is not associated with increased duration of surgery, blood loss or complications.     

The use of three-dimensional computed tomography for assessing patients before laparoscopic adrenal-sparing surgery

OBJECTIVE: To evaluate the efficacy of three-dimensional computed tomography (3D-CT) in delineating the relationship of the adrenal mass to adjacent normal structures in preparation for laparoscopic partial adrenalectomy. PATIENTS AND METHODS: Multislice CT (1 mm slices, 0.5 s rotation time) was used to evaluate 12 patients before adrenal-sparing surgery for aldosterone-producing adenoma or phaeochromocytoma. The CT data were reconstructed using two rendering techniques; (i) volume rendering with the modified VOLREN software (Johns Hopkins Hospital, Baltimore, MD, USA) which allowed interactive 3D examination of the whole data volume within a few minutes; (ii) surface representations only of the interesting structures (kidney, adrenal tumour, vessels) represented in different colours and depicted together in a 3D scene using the software package 3DVIEWNIX. RESULTS: In all, 14 adrenal masses in 12 patients were evaluated with 3D-CT; the number and location of lesions was accurate in all cases with both rendering techniques. The coloured surface-rendered images showed a consistently better delineation of the adrenal tumour from the normal tissue than did the volume-rendering technique. From this information all laparoscopic partial adrenalectomies could be completed as planned. CONCLUSIONS: Interactive visualization of volume-rendered CT images was helpful for the planning and successful performance of the procedure, but coloured surface-rendered CT provided more convenient, immediate and accurate intraoperative information.     

Port site metastases in urological laparoscopic surgery

PURPOSE: Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it. MATERIALS AND METHODS: We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases. RESULTS: Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal). CONCLUSIONS: Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.     

Robotic urological surgery in patients with prior abdominal operations is not associated with increased complications

BACKGROUND: The da Vinci Surgical Robotic System is being increasingly used to perform complex urological operations by minimally invasive techniques. Prior abdominal surgery associated with intra-abdominal adhesions may complicate robotic surgery. METHODS: We used a cohort of consecutive 49 patients undergoing a variety of robotic urological procedures at our institution to study the impact of prior abdominal operations on early perioperative complications. RESULTS: A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%; Group B) had undergone prior abdominal surgery. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P=0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6-8% of complications occurring in each of the two groups (P=1.0). Comparative subset analysis of 28 patients in Group B, 15 (54%) and 13 (46%) with or without intra-abdominal adhesions did not reveal a significant difference in perioperative complication rates either. However, operative time was longer in patients with intra-abdominal adhesions compared to patients without, median of 590 (281-922) and 434 (153-723) min respectively, although not statistically significant (P=0.059). CONCLUSION: Our study demonstrates that robotic urological surgery can be performed in patients with prior abdominal surgery without increased perioperative complications.     

Mentorship in urological laparoscopic surgery: lessons learned

OBJECTIVE

To review the results of our experience with a mentorship programme in laparoscopic nephrectomy, set up in 1999 by the British Association of Urological Surgeons Section of Endourology.

METHODS

Mentors were contacted in 2007 to submit data on the number of visits and the outcome, which included whether a urologist was able to establish an independent laparoscopic practice and sustain it.

RESULTS

Four urologists acting as mentors reported a total of 164 procedures carried out in the training of 39 urologists during 148 visits. There were no conversions to open surgery and only one major complication. Overall, 29 of 39 mentored consultants were able to establish an independent laparoscopic practice and 23 continue to do so. The number of visits was associated with initial success, although this was not statistically significant. Working in a large department was associated with being able to sustain a laparoscopic practice. More experienced consultants were less likely to have initial success, but were more likely to sustain a successful practice.

CONCLUSIONS

Mentorship for laparoscopic nephrectomy has been carried out safely thus far. Sustaining a laparoscopic practice requires a critical volume of cases. Future efforts should be focused on trainees rather than consultants.     

腹腔镜联合手术198例分析

目的探讨腹腔镜联合手术在腹部外科的优越性和临床应用价值。方法回顾分析我院1994年8月至2005年5月198例23类腹腔镜联合手术的临床资料。结果198例腹腔镜联合手术中,4例中转,1例术后胆漏,1例胆总管残余结石术后行内镜下Oddi括约肌切开取石(EST),其余192例均获成功并且顺利恢复。结论只要严格掌握手术指征,腹腔镜联合手术能够安全、有效、经济地处理腹部多种疾病,值得临床推广普及。     

Serum laboratory values following uncomplicated laparoscopic urological surgery

PURPOSE: Presentation of complications following laparoscopic surgery can be different from corresponding open surgical complications. While leukopenia has been identified as a common finding in patients with unrecognized bowel injury following laparoscopy, to our knowledge no study has determined if leukopenia or other serum abnormalities are unique to patients with laparoscopic complications. We present an analysis of postoperative laboratory values from patients after uncomplicated urological laparoscopic surgery. MATERIALS AND METHODS: A retrospective review of 50 adult patients who had previously undergone uncomplicated laparoscopic urological procedures was performed. Exclusion criteria were preexisting hematological, immune, liver or pancreatic disorders. Common serum laboratory values were measured on postoperative day 1. RESULTS: All values for bilirubin were within normal limits. Of patients undergoing a right side renal procedure, 10 of 16 (63%) had a postoperative increase in liver function tests. Amylase or lipase was increased in a total of 12 (24%) patients. Patients undergoing laparoscopic prostatectomy accounted for the majority of this group with 9 of 21 (43%) patients having increased amylase or lipase. Finally, there were no patients with immediate postoperative leukopenia. CONCLUSIONS: Following uncomplicated laparoscopic procedures, bilirubin levels are rarely affected, amylase and lipase may be acutely increased following laparoscopic prostatectomy, and white blood count is commonly increased. While 16 (36%) patients had postoperative leukocytosis, leukopenia was not detected after uncomplicated laparoscopic urological surgery and should alert the surgeon to the possibility of an undiagnosed complication.