理念革新:微创外科新视角

腹腔镜视觉平台的发展与革新,推动了整个外科从开腹手术到微创手术的理念革新与技术变革。从最初利用烛光反射镜装置窥视人体内部的内镜雏形,到高清、超高清腹腔镜视觉系统,从腹腔镜胆囊切除术,到腹腔镜下包括肿瘤根治手术在内的各类普通外科手术的普及与推广,外科手术因微创技术而发生巨大变革。进入新时代,3D、4K腹腔镜的应用,再次给微创外科带来新视角,从而推动手术朝着精准解剖和功能保护方向发展。未来,新型冠状病毒后疫情时代带来的理念革新,有可能使第5代移动通信技术加持下的虚拟现实技术和机器人手术,及在此基础上的远程医疗与远程教学成为微创外科发展的新视角。     

Evaluation of a laparoscopic grasper with force feedback

BACKGROUND: The clinical implementation of laparoscopic tools with haptic feedback is far from becoming a reality, partly because current tools with force feedback are not configured like conventional surgical instruments. Hence, our goal was to incorporate force sensing into existing laparoscopic tools for use in robot-assisted surgery. METHODS: We developed a laparoscopic grasper with force-feedback capability that would help surgeons to differentiate tissue stiffness based on the measured tissue deformation. RESULTS: Surgeons and nonsurgeons alike were able to qualitatively characterize different tissue samples with a high degree of accuracy. The observed force vs deformation characteristic for various tissue samples confirmed the ability of our apparatus to characterize tissues of varying stiffness. CONCLUSION: This innovative laparoscopic grasper with force-feedback capability enables accurate characterization of tissue deformation and is a promising tool for minimally invasive surgery.     

Gynecologic laparoscopy

Gynecologic laparoscopy is an evolving discipline. Major advances in technology have facilitated the transition from traditional "open" surgery to minimally invasive procedures. This article reviews the basic tenets of gynecologic laparoscopy: pelvic anatomy, general procedures, laparoscopic instruments, complications, and common gynecologic surgeries. Highlighted procedures include adnexal surgery, laparoscopic hysterectomy, and operations for female malignancies.     

经自然腔道取标本手术在结直肠外科手术中的应用进展

随着腔镜技术的进一步发展以及微创理念应用于结直肠外科疾病的诊治中,结直肠相关疾病的诊治发生了翻天覆地的变化。由传统的经腹手术到腹腔镜手术、经自然腔道手术,再到经自然腔道取标本手术(NOSES),结直肠疾病的外科诊治在微创领域取得了巨大成果。NOSES技术是目前结直肠外科在微创领域前沿的手术方式之一,它通过经直肠、阴道取标本来避免了腹壁的辅助取标本切口,从而将结直肠外科手术进一步微创化。NOSES技术集传统腹腔镜手术的优势与现代微创外科的理念于一体,它在确保手术效果的基础上集中体现了微创、加速康复外科、功能外科、"无疤"等理念的特点。本文主要就国内外各中心开展NOSES技术在结直肠外科诊治开展中的相关经验、心得和体会进行综述。     

Minimally Invasive Surgery in Gastrointestinal Cancer: Benefits,Challenges, and Solutions for Underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.     

全腹腔镜全胃切除腔内消化道重建术式研究进展

随着腹腔镜器械的改进及外科腔镜下技术的提高,腹部微创手术得到快速发展,腹腔镜胃癌手术也正逐渐走向成熟。对于胃上部癌、胃体癌、皮革胃患者来说,全腹腔镜全胃切除术(TLTG)作为一种微创术式被广泛应用于临床,更小的手术创伤使患者更快的康复,明显提高了患者围手术期生活质量,已成为治疗胃癌,特别是早期可切除胃癌的主要方式之一。TLTG的技术要点和难点是如何在全腹腔镜视野下完成消化道重建,全腔镜下食管空肠吻合是TLTG消化道重建的难点,因此探讨TLTG消化道重建方式成为临床工作者的研究重点。本文就TLTG消化道常见术式作一综述,以期更好地为临床术式选择提供参考。     

Minimally invasive surgical treatment of sigmoid diverticulitis

Introduction

Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications.

Methods

A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis.

Results

In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning.

Conclusion

Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.     

Adrenal masses in children: the role of minimally invasive surgery

The development of laparoscopic surgery has extended its uses to include adrenalectomy in children and in adults. Because conventional adrenalectomy requires a large incision, minimally invasive surgery offers a less aggressive solution in some selected cases. Twenty-nine adrenal masses in 26 children were treated using adrenalectomy between 1994 and 2004 (12 were treated laparoscopically, the remaining 17 with open surgery). Minimally invasive procedures were limited to the removal of small localized adrenal tumors and to biopsies. Although this approach must be limited to operations on lesions presumed to be benign, preoperative criteria for nonmalignancy are often difficult to define. Indications can be expanded to include to stage I neuroblastoma. There seems to be no age and weight limit. The technique applied varies in accordance with anatomy and the surgeon's experience: minimally invasive adrenalectomy, in our experience, was preferentially performed through a lateral retroperitoneal approach. Laparoscopic adrenalectomy can be used if the selection of cases is rigorous and the operations are performed by well-trained laparoscopic surgeons.     

日本4K时代腹腔镜胃癌手术标准

恶性肿瘤的标准化诊断与治疗对于患者预后十分重要。然而,庞大的国土面积和人口数量使中国在恶性肿瘤标准化诊断与治疗方面存在地域性差异。因此,中国和日本的外科学专家策划,由《中华消化外科杂志》编辑委员会主办“4K时代中日胃肠微创手术标准解读交流会”,其目的是为从事胃肠微创外科的中青年学者搭建中国和日本专家之间学术交流平台,推进中国胃肠微创外科手术规范化、精细化,引领中国胃肠微创外科技术发展。笔者于2018年开始,参加了5次“4K时代中日胃肠微创手术标准解读交流会”,于会议中讲解腹腔镜胃癌手术的操作技术,介绍日本内镜外科学会关于腹腔镜技术的认定制度。此举有利于推动腹腔镜胃癌手术技术的标准化进程,提高中青年医师的教学效果,从而促进胃癌诊断与治疗水平的整体发展。     

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??A rational evaluation of open surgery in the era of minimally invasive surgery GU Jin. Department of Gastrointestinal Oncology, Peking University Cancer Hospital; Pediatric Surgery, Shougang Hospital, Peking University,Beijing100042,China
Abstract Nowadays, laparoscopic resection of colorectal cancer is widely used. Robust evidence to conclude that laparoscopic surgery and open surgery have similar outcomes in colorectal cancer. Undeniably, we have entered an era of minimally invasive surgery, and our traditional open surgery is being replaced by minimally invasive surgery in recent decades owing to favorable short-term outcomes, such as less pain, reduced blood loss, and improved recovery time. Surgeons should be soberly aware that there is a serious tendency for young surgeons in the field of surgery to simply pursue technology. They no longer pay attention to traditional open surgery, but are keen on the latest minimally invasive technology to make and show a beautiful surgery.In this era of minimally invasive surgery, Surgeons must realize that open surgery still plays an important role in tumor treatment.     

Quantitative evaluation of three advanced laparoscopic viewing technologies: a stereo endoscope, an image projection display, and a TFT display

BACKGROUND: Compared to open surgery, minimally invasive surgery (MIS) relies heavily on advanced technology, such as endoscopic viewing systems and innovative instruments. The aim of the study was to objectively compare three technologically advanced laparoscopic viewing systems with the standard viewing system currently used in most Dutch hospitals. METHODS: We evaluated the following advanced laparoscopic viewing systems: a Thin Film Transistor (TFT) display, a stereo endoscope, and an image projection display. The standard viewing system was comprised of a monocular endoscope and a high-resolution monitor. Task completion time served as the measure of performance. Eight surgeons with laparoscopic experience participated in the experiment. RESULTS: The average task time was significantly greater (p <0.05) with the stereo viewing system than with the standard viewing system. The average task times with the TFT display and the image projection display did not differ significantly from the standard viewing system. CONCLUSION: Although the stereo viewing system promises improved depth perception and the TFT and image projection displays are supposed to improve hand-eye coordination, none of these systems provided better task performance than the standard viewing system in this pelvi-trainer experiment.     

腹腔镜远端胃癌D2根治术中胃周血管的解剖概要

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,腹腔镜远端胃癌D：根治术已逐步应用于治疗进展期胃癌。然而,该术式在技术层面的要求高,尤其是在进行D2淋巴结清扫时,对于准备开展该术式的外科医生而言．术中突发的出血状况往往是阻扰他们顺利进行手术的原因之一。因此,熟练掌握胃周血管的解剖对安全有效地实施腹腔镜远端胃癌D2根治术是必需的。     

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??Contrast study of short-term effect between the Da Vinci surgical robot and laparoscopic technology in patients after distal gastric cancer surgery ZHAO Kun??PAN Hua-feng??WANG Gang??et al. Department of General Surgery, Nanjing General Hospital of Nanjing Military Command, Nanjing 210002, China
Corresponding author:JIANG Zhi-wei,E-mail:surgery34@163.com
Abstract Objective To make a contrast between the Da Vinci surgical robot ( referred to as "robots") and laparoscopic technology in patients’ postoperative recovery after distal gastric cancer surgery. Methods Thirty robotic distal gastric cancer patients as robotic group and 30 laparoscopic gastric cancer patients as compared group both admitted from January 2012 to May 2012 in Nanjing General Hospital of Nanjing Military Command were analyzed. Perioperative situation was compared between the two groups. Results The robotic group was better than the laparoscopic group in intraoperative bleeding, the surgical incision length, postoperative incision pain and the first feeding time (P < 0.05). There was no statistical significance in lymph node dissection and postoperative complications. Conclusion Robot distal gastric cancer surgery is worthy of popularization and application for its less invasive surgery and quicker postoperative recover than laparoscopic surgery.     

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??Consensus and controversy on clinical application of minimally invasive concepts and techniques in pancreatic surgery LI Fei, CAO Feng. Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053??China
Corresponding author: LI Fei, E-mail:feili36@ccmu.edu.cn
Abstract Nowadays, the concept of minimally invasive surgery has been widely accepted. In recent years, with the implementation of enhanced recovery after surgery, minimally invasive pancreatic surgery has progressed rapidly. In the treatment of late complications of acute pancreatitis, minimally invasive technique, represented by endoscopic and laparoscopic technique, have achieved great success and are consistently recommended by many guidelines. Laparoscopic pancreatoduodenectomy (LPD) and laparoscopic distal pancreatectomy (LDP) have developed rapidly and the safety has been confirmed. Retrospective studies suggested the similarity in oncologic, short-term and long-term results between LPD or LDP and open surgery in treatment of pancreatic cancer. Although complicated, the development and application of minimally invasive concepts and technology are the general trend.     

三维可视化联合3D腹腔镜右半肝切除术的关键技术和优势

腹腔镜肝切除术特别是解剖性肝切除术正在逐渐成为国内外肝脏微创外科发展的潮流和方向。腹腔镜右半肝切除术因镜下右半肝出入血流控制和断肝过程的复杂性,造成该术式发展缓慢。随着医疗器械的发展,其中3D腹腔镜、三维可视化技术的出现,为外科医师们带来了全新的手术视野。3D腹腔镜具有良好的景深感、空间定位和高清视野,术中有助于辨认肝门、肝脏深部各种管道结构。而三维重建、仿真手术、3D打印等三维可视化技术为外科医生提供全新的医学图像,可实现术前精确规划,术中实时指导。三维可视化联合3D腹腔镜在右半肝切除中的应用实现了在术前疾病诊断数字化,和在术中人体器官解剖结构可视化,外科手术微创化。     

Rapid communication: minimally invasive urologic surgery curricula

PURPOSE: Surgical education programs are being challenged to provide comprehensive training in the ever-expanding technologies and techniques. We present dedicated training curricula for several aspects of minimally invasive urologic surgery in an effort to provide a uniform training experience for all residents. MATERIALS AND METHODS: Five components of the curricula were developed, namely, cognitive objectives, skills objectives, competency of procedures, cognitive evaluation, and proficiency or skills evaluation. RESULTS: The five components of the curriculum were defined specifically for cystoscopy and transurethral surgery, ureterorenoscopy and intrarenal surgery, renal access surgery, and laparoscopic urology. CONCLUSION: This standardized curriculum overview for minimally invasive urologic surgery is an initial attempt to define one aspect of a urology training program. We hope these curricula will serve as a basis for further discussion and development of a comprehensive urology training program.     

从TaTME发展看直肠癌微创外科治疗进步

随着科学技术的进步和对疾病本身认识的深入，直肠癌的外科治疗从局部切除到全直肠系膜切除（TME），从开放手术到腹腔镜手术，再从腹腔镜手术到机器人手术，目前已经进入微创时代。在此时代背景下，经肛门全直肠系膜切除（TaTME） 应运而生。正如TME的提出者Heald所言：“TaTME是近30年直肠癌外科治疗技术的集大成者”，其发展的每一个阶段都有很强的代表性，已成为直肠癌微创外科治疗技术进步发展的一个缩影。     

腹腔镜右半结肠癌根治术

微创手术在腹腔镜平台发展已有30年之久,在消化道手术领域腹腔镜技术已进入成熟阶段。微创外科的近期发展在于对手术入路及解剖等进一步加以规范与推广,以及3D、4K等针对显像技术硬件设备的创新与开发。腹腔镜下尾侧－中间联合入路右半结肠癌根治术自回盲部背侧为起始点先行完成右半结肠系膜的后间隙游离,并结合传统中间入路进一步清扫系膜根部淋巴结。尾侧－中间联合入路可从不同角度完成右半结肠的系膜解剖,可帮助主刀医师完成右结肠后间隙的拓展,可成为手术医师首选的手术入路之一。     

Laparoscopic adrenalectomy and adrenal-preserving surgery

PURPOSE OF REVIEW: The aim of this paper is to define the current role of laparoscopy in the management of surgical adrenal diseases evaluating the surgical aspects, the indications and contraindications of laparoscopic adrenalectomy, focusing also on the most innovative tendencies in the laparoscopic adrenal-preserving surgery. RECENT FINDINGS: Recent publications have described some interesting new indications that need to be confirmed by long-term follow up. The present review mainly focuses on defining the state of the art of current adrenal laparoscopic surgery. SUMMARY: Laparoscopic adrenalectomy is becoming the 'platinum standard' for the treatment of the adrenal surgical diseases and it should be considered the treatment of choice for benign adrenal diseases. In cases of malignancy and conservative surgery, adrenalectomy appears to be very promising, although a longer follow up and further studies are still needed to accurately assess the role played by these procedures. Finally, who should do laparoscopic adrenalectomy? Every patient who requires the ablation of the adrenal should receive laparoscopic opportunity. And the surgeons? Only those with advanced laparoscopic skills and a good knowledge of adrenal anatomy and pathophysiology will obtain the same excellent results currently reported in the literature.     

Robotic renal surgery

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.