单孔腹腔镜技术在外科的应用

微创外科是当今外科学的发展方向,腹腔镜手术因创伤小、痛苦轻、恢复快、瘢痕小、疗效肯定等优点被广泛应用于腹部外科的各类手术中。自单孔腹腔镜技术被引入到微创外科领域中以来,因其不仅具有传统腹腔镜手术的优点,而且具有良好的美容效果,该理念越来越多的受到人们的重视。本文回顾分析了近年来的相关文献,对单孔腹腔镜技术的发展和现状作一综述。     

经脐单孔腹腔镜阑尾切除术的现状与展望

随着微创外科技术的发展,腹壁无瘢痕手术成为新的趋势,腔内镜手术从传统的多孔途径向经自然腔道手术和单孔腹腔镜手术领域过渡。腹腔镜阑尾切除术是最常用的微创手术之一,经脐单孔腹腔镜阑尾切除术不仅将切口减为单孔,而且具有减少腹腔镜术后疼痛和切口并发症等手术创伤的潜在优势,以及腹壁无瘢痕的美容效果,因此近年来成为迅速发展的重点,有了较多的临床应用。     

经脐单孔腹腔镜技术在妇科手术中的应用现状

经脐单孔腹腔镜技术不但具有传统腹腔镜手术的优点,还有手术瘢痕隐蔽的优点,其术后恢复情况及美容效果较传统腹腔镜手术更具有优势。该技术自引进微创外科领域后即引起广泛的关注,近几年在妇科手术领域发展迅速。现就经脐单孔腹腔镜技术在妇科手术中的应用现状进行综述。     

经脐单孔腹腔镜胃手术的研究进展

经脐单孔腹腔镜手术技术是近年兴起的一种微创外科技术,其在胃外科中的应用尚处起步阶段。本综述回顾性分析传统腹腔镜胃切除的历史并总结近年来关于经脐单孔腹腔镜胃手术在早期胃癌、胃间质瘤、远端胃大部切除及袖状胃切除中的应用现状。同时,总结并分析单孔腹腔镜胃手术与传统腹腔镜胃手术的优缺点,为微创外科医生了解和掌握微创胃手术提供参考。     

常规器械经脐单孔腹腔镜脾切除术8例报道

微创外科是当今外科学的发展方向，腹腔镜手术因创伤小、痛苦轻、恢复快、瘢痕小、疗效肯定等优点被广泛应用于腹部外科的各类手术中。自单孔腹腔镜技术被应用到腹部微创外科领域以来，因其较传统腹腔镜手术更小的手术创伤和更好的美容效果，该技术已受到越来越多的重视。经脐入路内镜手术（trans umbilical endoscopic surgery，TUES）由朱江帆等于2007年提出，并于2008年通过动物实验验证了该技术在腹腔镜脾切除术中的可行性， Barbaros ， Targarona于2009年各报道了2例经脐入路的腹腔镜脾切除术。云南省第一人民医院医院在成功实施300余例经脐单孔腹腔镜胆囊切除术的基础上，于2011年4月至2013年8月成功实施8例经脐单孔腹腔镜脾切除术，现报告如下。     

单孔腹腔镜结直肠切除术与传统多孔腹腔镜结直肠切除术的比较

经脐单孔腹腔镜手术技术是近年来刚刚兴起的一种微创外科技术。其在结直肠外科中的应用尚处在起步阶段。本综述回顾性分析传统腹腔镜结直肠外科除的历史并总结近年来关于经脐单孔腹腔镜结直肠手术与传统腹腔镜结直肠手术对比的文献资料,探讨两种术式在总转换率、术中出血量、手术时间、切口长度、术后并发症及住院时间之间的差异,为微创外科医生了解和掌握单孔腹腔镜结直肠手术提供参考。     

经脐单孔腹腔镜胆囊切除术与传统腹腔镜胆囊切除术的对比研究

<正>由于传统的腹腔镜手术在腹壁所做的多个穿刺孔愈合后仍会留下多个手术瘢痕,为了使手术更加微创,近年来腹腔镜无瘢痕手术应运而生,其目的是将微创与美观完美结合,体现术后疼痛小、恢复快等优点。随着腹腔镜手术技术的不断熟练与完善及手术器械的不断改进与更新,经脐单孔腹腔镜技术应运而生并取得迅速发展[1-2]。2011年5月至2012年8月,我们对单孔腹腔镜与传统腹腔镜胆囊切除术进行了对比研究,以探讨经脐单孔腹腔镜胆囊切除术的优缺点。     

机器人辅助单孔腹腔镜技术在妇科领域的应用

在外科学的发展史中,妇科是最早全面普及内镜技术的学科之一。从传统的多孔腹腔镜,到单孔腹腔镜,再到经阴道自然腔道的"无孔"内镜手术;由2D、3D腹腔镜到机器人手术系统;腹腔镜技术在妇科领域迅猛发展。单孔腹腔镜手术(laparoendoscopic single site surgery,LESS)和Da Vinci机器人手术系统结合,产生的机器人辅助单孔腹腔镜技术(robotic-assisted LESS,R-LESS)已能够完成多种良恶性手术,是安全可行的,也是微创手术领域的重大突破。     

经脐单孔腹腔镜胆囊切除术的护理体会

经脐单孔腹腔镜胆囊切除术具有切口隐蔽无瘢痕、创伤小、恢复快等特点，它比传统的腹腔镜胆囊切除术更微创，在微创外科领域得到越来越多的应用。我院在熟练掌握传统“三孔法、四孔法腹腔镜胆囊切除术”的基础上，总结经验，于2011年10月--2012年10月完成经脐单孔腹腔镜胆囊切除术32例，获得了满意的临床效果。现将护理体会总结如下。     

舒芬太尼复合布托啡诺用于上腹部术后镇痛临床观察

目的 观察舒芬太尼-布托啡诺和舒芬太尼-咪达唑仑用于病人自控静脉镇痛(PCIA)的镇痛效果和不良反应.方法 120例择期行上腹部手术的患者(ASAⅠ-Ⅱ级),按随机数字表随机分为4组:①S组(舒芬太尼0.15mg);②B组(布托啡诺15mg);③ SM组(舒芬太尼0.1mg+咪唑安定10mg);④SB组(舒芬太尼0.1...     

Admission Control Policies for Surgery Patients

In China, day surgery has been promoted because its operation time and post-operative hospital stay are shorter than those of elective surgery. Day surgery can speed up the turnover of beds and operation rooms. Usually, the conditions of elective surgery patients are more complicated than those of day surgery patients. The development of the discipline, which means that the hospital has improved the skills of the doctors and the ability of doctors to cope with serious diseases and has increased the overall medical level of the hospital, requires surgeons to operate in some complicated elective surgeries. In the case of operating rooms and beds in short supply, there is a trade-off between the promotion of day surgery and the development of the discipline. Day surgery is relatively uncomplicated, but it requires more highly qualified surgeons. However, the development of the discipline requires surgeons to take on some complicated elective surgeris. Moreover, according to the notion of grading treatment, class-A tertiary hospitals are more suitable for patients with relatively complicated and serious conditions. In the emerging context of day surgery, highly qualified surgeons need to perform both day surgeries and elective surgeries. This paper studied how to control the admission of surgery patients. We take into account both day surgery promotion and discipline development in decision-making. A dynamic programming model was built for admission control, and a γ-adjust-threshold heuristic policy was proposed. We then compared the heuristic policy to three other policies through simulation. The results show that our heuristic policy outperforms the hospital’s target policy.     

胸腔镜肺癌根治术后胸腔引流管应用的研究进展

肺癌(lung cancer)是我国发病率和死亡率最高的恶性肿瘤之一.如今肺癌根治术进入腔镜时代,同时快速康复外科学的倡导及患者对微创手术的青睐,胸腔镜手术更加成为普胸重要的手术方式,其可缩短患者住院时间,减小患者肢体创伤及术后瘢痕,然而患者术后所留置的胸腔闭式引流管却成为快速康复外科学的又一大难题,因术后引流液的量,...     

Functional outcome after open and arthroscopic Bankart repair for traumatic shoulder instability

Purpose

Both open and arthroscopic Bankart repair are established procedures in the treatment of anterior shoulder instability. While the open procedure is still considered as the "golden standard" functional outcome is supposed to be better in the arthroscopic procedure. The aim of this retrospective study was to compare the functional outcome between open and arthroscopic Bankart repair.

Materials and methods

In 199 patients a Bankart procedure with suture anchors was performed, either arthroscopically in presence of an detached, but not elongated capsulolabral complex (40) or open (159). After a median time of 31 months (12 to 67 months) 174 patients were contacted and agreed to follow-up, 135 after open and 39 after arthroscopic Bankart procedure.

Results

Re-dislocations occurred in 8% after open and 15% after arthroscopic Bankart procedure. After open surgery 4 of the 11 re-dislocations occurred after a new adequate trauma and 1 of the 6 re-dislocations after arthroscopic surgery. Re-dislocations after arthroscopic procedure occured earlier than after open Bankart repair. An external rotation lag of 20° or more was observed more often (16%) after open than after arthroscopic surgery (3%). The Rowe score demonstrated "good" or "excellent" functional results in 87% after open and in 80% patients after arthroscopic treatment.

Conclusion

In this retrospective investigation the open Bankart procedure demonstrated good functional results. The arthroscopic treatment without capsular shift resulted in a better range of motion, but showed a tendency towards more frequently and earlier recurrence of instability. Sensitive patient selection for arthroscopic Bankart repair is recommended especially in patients with more than five dislocations.

     

Manual Small Incision Cataract Surgery: Experience at a Military Hospital

Background

Small incision cataract surgery came into practice with the advent of phacoemulsification. However, manual small incision cataract surgery (SICS) is a useful alternative for those who do not have access to phacoemulsification machine.

Method

A total of 69 cases of cataract were undertaken for manual incision cataract surgery and intra ocular lens (IOL) implantation using 6mm straight incision. The surgical technique and postoperative results are compared with the results of phacoemulsification and IOL implantation.

Result

Average postoperative astigmatism was ± 0.75 dioptres. Postoperative uncorrected visual acuity (UCVA) of 6/18 or better was observed in 51(71.9%) cases after first week of the surgery.

Conclusion

The study concludes that both phacoemulsification and small incision cataract surgery with intraocular lens (IOL) implantation are effective methods. However SICS with IOL implantation is a useful alternative in the absence of phacoemulsification machine.Key Words: Manual Small Incision Cataract Surgery (SICS), Extra Capsular Cataract Extraction (ECCE), Phacoemulsification, Intraocular lens implantation     

Natural history,clinical pattern,and surgical considerations of pneumatosis intestinalis

Objective

Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods

The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results

Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions

The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.     

Sedation in hypoalbuminemic geriatric patients under spinal anesthesia in hip surgery: Midazolam or Propofol?

Objectives:

To compare midazolam and propofol sedation in hypoalbuminemic geriatric patients under spinal anesthesia in hip surgery with bispectral index monitoring.

Methods:

This prospective and randomized study was completed in the Department of Anesthesiology, Okmeydani Training and Research Hospital, Istanbul, Turkey between February 2013 and December 2014. Sixty patients undergoing elective hip surgery under spinal anesthesia in the geriatric age group with albumin levels below 3 g/dl were randomly divided into Group I and Group II. After administration of spinal block, Group I were given 0.05 mg/kg bolus midazolam, and then 0.02-0.1 mg/kg/hr dose infusion was begun. In Group II, 1 mg/kg bolus propofol was given within 10 minutes, and then 1-3 mg/kg/hr infusion was begun. The systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, heart rate, peripheral oxygen saturation values, respiratory rate, and Wilson’s 5-stage sedation score were recorded at 15-minute intervals. At the end of the operation, the recovery time and surgeon satisfaction were recorded.

Results:

The recovery times for patients in Group I were found to be longer than in Group II (p<0.05). The respiration rate in patients in Group I at the start of surgery, 15th minute of surgery, and after surgery were lower than in Group II (p<0.05).

Conclusion:

We conclude that propofol is more reliable in terms of hemodynamic stability than midazolam, as it causes less respiratory depression and faster recovery in the propofol group.Spinal anesthesia is used at very high rates in elderly patients, and is a well-tolerated anesthetic method. Even in geriatric patients with left ventricle failure and in spite of a clear reduction in systemic vascular resistance linked to spinal anesthesia, it is proven that stroke volume and cardiac output do not decrease much.1 Sedation is a very important component of patient management during regional anesthesia. As the patient is conscious during operation under regional anesthesia, the surgical environment may negatively affect the patient. These effects may be more obvious during orthopedic interventions due to the noise of tools used, long duration of tourniquet use, position given, and manipulation of patient extremities during the surgery. To remove the possibility of such effects, the most appropriate method is to administer sedation to the patient.2 It is very important that sedation administration be appropriate for the patient’s characteristics, as well as reliable, and effective. As a result, the appropriate dose of the correct sedative agent should be administered. In elderly patients especially, there is an increased sedative response to centrally effective agents.3,4 Midazolam and propofol are agents frequently used for sedation. Midazolam binds to plasma proteins, especially albumin at a rate of 98%. The free fraction increases in hypoalbuminemic patients.5,6 Propofol is significantly lipophilic and like medications, such as midazolam, 98% is carried bound to plasma proteins. As a result of pharmacokinetic changes due to advanced age, the same dose provides higher plasma concentrations, and this increase reduces the dose requirements. As maximal plasma concentrations are higher in the elderly, a situation occurs where the possibility of cardiorespiratory effects like hypotension, apnea, airway obstruction and/or oxygen desaturation is higher in these patients. Higher plasma levels reduce the distribution volume linked to age, and shows reduced clearance between compartments. As a result, lower doses of propofol are recommended for use in elderly patients at the start, and for maintenance, of sedation/anesthesia.7 In the elderly, hypoalbuminemia may occur linked to acute phase reaction, inflammation and trauma, in addition to malnutrition. Hypoalbuminemia is a frequent finding in geriatric hip surgery patients. Although there are many studies comparing propofol and midazolam sedation administered with spinal anesthesia,8-10 there is no study comparing the efficacy and reliability of midazolam and propofol for hypoalbuminemic geriatric patients. This study primarily aimed to prospectively and randomly compare the effects of midazolam and propofol on hemodynamic parameters and side effects in hypoalbuminemic geriatric patients undergoing hip surgery under spinal anesthesia. The secondary end points of this study were to compare the sedation levels of patients, postoperative recovery duration, and patient and surgeon satisfaction.     

Retrograde Intussusception 5 years after Roux-en-Y gastric bypass for morbid obesity

Introduction

Small bowel obstruction secondary to intussusception is a rare but important consequence of Roux-en-Y gastric bypass (RYGB).

Case report

A 37-year old female presented to the emergency department with abdominal pain. She had undergone RYGB 5-years previously for obesity. CT revealed a retrograde jejuno-jejunal intussusception. The intussusceptum was the common jejunal channel and the intussuscepiens was the jejunojejunostomy resulting in obstruction of both the alimentary and biliary limbs. The patient underwent laparotomy, small bowel resection and refashioning of the jejunojejunal anastamosis.

Conclusion

We report this case as it highlights both how a delay in diagnosis can occur and the importance of including this complication early in the differential diagnoses of any patient presenting with acute or chronic abdominal pain with a history of bariatric surgery. Retrograde intussusception is more common than previously thought and the incidence may increase as bariatric surgery is performed more frequently worldwide.     

5-Fluoro-Uracil and Low Molecular Weight Heparin in the Management of Proliferative Vitreo-retinopathy

Background

Proliferative vitreo-retinopathy (PVR) is the most common cause of failed repair of a primary rhegmatogenous retinal detachment (RRD). The success rates for the surgery of complicated RRD has doubled with improved vitreous techniques from 35–40% to approximately 65–75% at six months. However, despite these advances, recurrent vitreo-retinal traction leads to re-detachment in more than one-fourths of the initially successful cases. The use of adjunctive treatments to prevent cellular proliferation holds promise for the prevention of PVR or recurrences after surgery. One focus has been on the use of intra-vitreal antimetabolites to prevent the occurrence of PVR.

Methods

Thirty patients of complicated retinal detachment associated with PVR, C1 or more were managed by vitreo-retinal (VR) surgery with the addition of 250 μg / ml of 5-fluorouracil (5FU) and 1 IU / ml of low molecular weight heparin (LMWH) to the vitreous infusion. The patients were examined for any evidence of PVR till 180 days as also for any systemic or other ophthalmic complication.

Result

Out of the 30 cases in the study group, 25 (83.34%) cases had retinal settlement at the end of six weeks, which is similar to the outcomes of conventional VR surgery. There was no case of any serious complication.

Conclusion

The addition of LMWH and 5FU did not enhance the outcome of VR surgery.Key Words: Proliferative vitreo-retinopathy, Rhegmatogenons retinal detachment, 5-fluorouracil, Low molecular weight heparin     

Association between perioperative blood transfusion and early postoperative cognitive dysfunction in aged patients following total hip replacement surgery

Introduction. Accumulating evidence suggests that enhanced inflammatory responses contribute to the pathogenesis of postoperative cognitive dysfunction (POCD). Blood transfusion can trigger an enhancement of acute inflammatory responses. Therefore, we hypothesized that perioperative blood transfusion is associated with a higher risk of POCD in aged patients following total hip replacement surgery.

Material and methods. Patients older than 65 years undergoing elective total hip replacement surgery were enrolled from October 2011 to December 2012. Neurocognitive tests were evaluated at baseline and at 7 d after surgery by a Mini-Mental State Test. Multivariate logistic regression analysis was used to determine risk factors associated with POCD.

Results. Fifty-six patients (27.3%) developed POCD 7 d postoperatively. Patients who developed POCD were older, had a lower education level and preoperative hemoglobin concentration, had more blood loss, and had a lower body weight (p < 0.05). Patients with POCD were more likely to receive red blood cells (RBCs) transfusion (51.8% versus 31.5%; p < 0.05). A multivariable logistic regression model identified older age, lower education level, and perioperative blood transfusion of more than 3 units as independent risk factors for POCD 7 d postoperatively.

Conclusion. Our data suggested that perioperative blood transfusion of more than 3 units of RBCs is an independent risk factor for POCD in aged patients following total hip replacement surgery.