后腹腔镜输尿管上段切开取石术

目的　探讨经后腹腔镜输尿管上段切开取石不放支架管的可行性。　方法　 2 0 0 2年 11月～ 2 0 0 3年 3月经腹腔镜行输尿管上段切开取石术 9例 ,平均年龄 5 5岁 ,7例曾行体外震波碎石 (ESWL)治疗无效 ,经B超和IVP确诊为输尿管上段结石 ,结石直径 0 8cm～ 1 8cm。　结果　 8例获得成功 ,1例中转开放取石 ,手术时间 0 8h～ 10h ,平均 3 5h ,失血量平均 35ml(10ml～ 70ml) ,漏尿时间 2天～ 2 1天 ,平均 7天 ,全部病例随访 2月～ 7月 ,平均 4 6月 ,所有病例肾盂积水缩小 1cm～ 3cm。　结论　后腹腔镜下行输尿管上段切开取石 ,是一种安全有效的途径 ,取石后不放支架管同样可获得良好的治疗效果 ,但适宜结石 >1cm。     

后腹腔镜输尿管切开取石术

目的探讨后腹腔镜输尿管切开取石术的安全性和疗效。方法回顾性分析我院3年来经后腹腔镜下输尿管切开取石术25例患者临床资料。其中,男13例,女12例;年龄23～67岁,平均46．7-8．7岁。均为单侧结石,其中左侧7例,右侧18例。结石直径7～15mm。经超声、IVU、CTU、MRU等明确诊断。所有病例术中均留置双J管。结果25例手术全部成功。手术时间67—180min,平均87．7±20．5min,住院时间5-8d,平均6．3d。随访时间1个月-3年,平均1．1年,无并发症发生。结论后腹腔镜下输尿管切开取石术安全性高、效果好,是治疗输尿管结石的有效方法之一。     

后腹腔镜输尿管切开取石术

目的评价后腹腔镜输尿管切开取石术的安全性和有效性。方法从2006年9月至2007年12月,采用后腹腔镜输尿管切开取石术治疗58例输尿管上段和中段结石患者,其中39例曾行ESWL治疗失败。结果所有病例均成功取出结石,手术时间中位数120（50～220）min、术中失血量中位数45．5（20～80）ml、平均术后肠道恢复时间（35．0±5．8）h、平均术后住院时间（7．0±0．7）d,无严重术后并发症发生。术后随访时间中位数为9（3～18）个月,无输尿管狭窄发生。结论后腹腔镜输尿管切开取石术对输尿管上段和中段结石是一个安全且有效的治疗选择。     

后腹腔镜在输尿管切开取石术中的应用

目的探讨后腹腔镜输尿管切开取石术治疗嵌顿性输尿管结石的临床价值和技术要点。方法2006年12月至2009年9月,对66例嵌顿性输尿管中上段结石采用后腹腔镜输尿管切开取石术,术中取石后于镜下直接置入双J管,以4-0人工合成可吸收线（SAS）间段缝合输尿管切口。结果66例手术均获成功,无中转开放手术,结石清除率100％。术后创腔引流液量少,无一例发生尿漏。3-5d拔除引流管,1周出院,术后3周膀胱镜下拔除双J管。随访1-33个月,平均16.3个月,超声复查显示肾积水明显好转或消失,无结石复发。结论后腹腔镜输尿管切开取石术治疗嵌顿性输尿管结石具有创伤小,疗效好、术后恢复快等特点,明显优于开放手术及其他手术,值得推广应用。     

后腹腔镜输尿管切开取石

输尿管结石的传统治疗选择有体外震波碎石、经皮顺行取石和输尿管镜。然而对于那些坚硬、较大和梗阻的结石以及曾行微创手术取石失败的输尿管结石，需行开放手术取石。对于上述情况，后腹腔镜输尿管切开取石是一个理想的选择。作者为此报告31例改进的后腹腔镜输尿管切开取石的经验。     

后腹腔镜输尿管切开取石术26例

目的：探讨后腹腔镜输尿管切开取石术的技术要点及临床价值。方法：采用后腹腔镜技术行输尿管切开取石术26例，其中18例分别于术前行体外冲击波碎石术(ESWL)、输尿管镜取石术或两者结合而失败，8例术前未行其他治疗；结石直径12—25mm，平均18．5mm。结果：1例因结石移人肾脏改行开放性手术，余25例取石成功；手术时间40—240min，平均70min；术中出血量10—50ml，平均21．3ml；肠功能恢复时间l2—24h，术后4d拔除腹膜后引流管，无漏尿；术后住院时间5—6d；2l例获随访2—38个月，所有病例肾功能均得到改善，无结石复发及输尿管狭窄发生。结论：后腹腔镜输尿管切开取石术是安全有效的治疗输尿管结石的方法，可部分代替传统开放性手术，对于较大的输尿管上段结石可作为首选的治疗方法。     

腹腔镜下中上段输尿管切开取石术

目的：探讨腹腔镜下中上段输尿管切开取石术的疗效和临床意义。方法：2005年9月～2006年12月收治输尿管中上段结石18例,采用经腹腔途径腹腔镜下施行输尿管中上段切开取石术手术,取石后直接于镜下置入双J管,缝合输尿管切口及肾周筋膜。结果：18例手术均获成功,无一例中转开放手术,手术时间30～93min·平均44min,失血20～50ml,均未输血,术后次日可下床活动,1～2天均肛门排气,1～3天拔除腹腔引流管,5～7天拔导尿管,肉眼血尿3～5天,术后住院时间5～7天,3～4周后膀胱镜下拔除双J管,随访3～15个月,B超显示肾积水明显好转或消失。结论：腹腔镜下中上段输尿管切开取石术疗效好,创伤小、痛苦少、恢复快,更适田平茱目名蛤屠管【磐掊沿名翔持术的茸昆厍瞎     

单孔腹腔镜输尿管切开取石术的初步应用体会

目的 探讨经腹膜后途径,行单孔腹腔镜输尿管切开取石术的可行性及疗效.方法 2010年6月至2011年2月,收治8例单侧输尿管上段结石患者,采用自制多通道套管,经腹膜后途经,行单孔腹腔镜输尿管切开取石术.以同一术者完成的15例传统腹腔镜经腹膜后输尿管切开取石术作为对照组.对比两组的手术时间、出血量、手术并发症、平均住院时间、术后镇痛药应用时间及腹膜后引流管停留时间等指标.结果 所有单孔腹腔镜手术均获成功、无1例转为传统腹腔镜或开放术式.结石平均长径18 mm,平均手术时间131±16min,失血量30±5 ml,1例术后出现尿漏、于术后第3天停止;无其他手术并发症.两组手术时间、出血量、腹膜后引流管停留时间等无明显差异.单孔腹腔镜组在平均住院时间、术后镇痛药应用天数及美容效果等方面优于传统腹腔镜组.两组患者均获得治愈.结论 单孔腹腔镜输尿管切开取石术是可行、有效的,适用于治疗部份体积较大的输尿管结石病例,其远期效果有待增加病例数进一步评估.     

后腹腔镜输尿管上段切开取石术

目的探讨后腹腔镜输尿管上段切开取石术的临床价值.方法采用后腹腔镜技术行输尿管上段切开取石术22例,经后腹腔操作,分离出上段输尿管和结石,用尖刀切开输尿管取出结石,常规在输尿管内置入支架管并缝合输尿管切口.结果1例因结石进入肾内术中改开放手术,1例术后出现持续漏尿500～800 ml/d,3d后改开放手术放置双J管治愈出院.余20例手术均获成功,手术时间50～240 min,平均110 min.术中出血量30～100 ml,平均50 ml.肠功能恢复时间12～30 h,平均18 h.术后住院5～8 d,平均6.8 d.手术成功的20例随访1～12个月,平均5.8月,B超及IVU复查,15例肾盂积水消失,5例轻度肾盂积水,无结石残余及输尿管狭窄.结论后腹腔镜输尿管切开取石术是安全有效的治疗输尿管上段结石的方法,具有创伤小,恢复快等特点,对于较大的输尿管上段结石可作为首选的治疗方法.     

腹腔镜模拟训练在腔镜外科中的应用

目的探讨腹腔镜模拟训练机对不同临床经验参与者的培训效果。方法在腹腔镜模拟机上培训9名无任何临床经验的志愿者(对照组)、9名6年级医学实习生(学生组)和9名有2～3年临床经验的住院医生(医生组),包括0°、30°腹腔镜的操作、眼-手协调、钛夹应用、抓-钳夹、剪切、电凝和物体转运,每天训练30min,共5d,比较培训前后各组的得分。结果培训前3组在0°、30°腹腔镜的操作,抓-钳夹,电凝,眼-手协调得分都有统计学差异(P<0.05);培训后各组在0°腹腔镜的操作、抓-钳夹、眼-手协调的得分有统计学差异(P<0.05)。所有参与者培训后在0°、30°腹腔镜操作、电凝得分和眼-手协调得分和时间均较培训前明显提高(P<0.05)。结论腹腔镜模拟训练机培训可以提高不同临床经验参与者的腹腔镜操作技巧,并且可以区分不同临床经验者。     

小儿腹腔镜技术短期强化培训模式的初探

目的探讨强化小儿腹腔镜训练技术的培训方法。方法 2001~2008年,来自全国63家儿童医院和综合医院小儿外科的352名外科医生在小儿微创外科中心接受腹腔镜技术强化培训,每期强化训练44学时,培训内容包括理论学习（4学时）、训练仪操作（28学时）、动物手术训练（8学时）和临床实践（4学时）,培训结合国内外专家讲课、实践操作指导、动物模拟手术、观摩手术录像和现场手术演示等方式,使学员熟悉和掌握小儿腹腔镜手术操作技能。本文通过回顾8年培训资料和经历,总结和探讨小儿腹腔镜手术的培训经验。结果全部学员均通过理论考核,实践操作和动物模拟手术成绩合格,学员返回原单位后陆续开展小儿腹腔镜手术,从常规手术到复杂手术,目前已有74.6%（47/63）的医院能独立开展小儿腹腔镜手术,微创手术进展顺利。结论腹腔镜短期强化培训班的形式是理论联系实际、行之有效并符合我国国情的培训方式,是迅速培养我国小儿腹腔镜医生的有效途径。     

Construct Validity of an Inanimate Training Model for Laparoscopic Appendectomy

Background and Objective:

The use of training models in laparoscopic surgery allows the surgical team to practice procedures in a safe environment. The aim of this study was to determine the capability of an inanimate laparoscopic appendectomy model to discriminate between different levels of surgical experience (construct validity).

Methods:

The performance of 3 groups with different levels of expertise in laparoscopic surgery—experts (Group A), intermediates (Group B), and novices (Group C)—was evaluated. The groups were instructed of the task to perform in the model using a video tutorial. Procedures were recorded in a digital format for later analysis using the Global Operative Assessment of Laparoscopic Skills (GOALS) score; procedure time was registered. The data were analyzed using the analysis of variance test.

Results:

Twelve subjects were evaluated, 4 in each group, using the GOALS score and time required to finish the task. Higher scores were observed in the expert group, followed by the intermediate and novice groups, with statistically significant difference. Regarding procedure time, a significant difference was also found between the groups, with the experts having the shorter time. The proposed model is able to discriminate among individuals with different levels of expertise, indicating that the abilities that the model evaluates are relevant in the surgeon''s performance.

Conclusions:

Construct validity for the inanimate full-task laparoscopic appendectomy training model was demonstrated. Therefore, it is a useful tool in the development and evaluation of the resident in training.     

后腹腔镜输尿管切开取石术治疗困难的输尿管中上段结石

目的探讨后腹腔镜输尿管切开取石术在治疗困难的输尿管结石中的临床效果。方法 2006年6月～2010年6月,对51例困难的输尿管中上段结石行后腹腔镜输尿管切开取石术。结石位于中段6例,上段45例,结石长径15～30mm。患侧均伴有不同程度的肾盂积水,轻度10例,中度35例,重度6例。术前26例有ESWL史7,例有输尿管镜碎石史。经后腹腔操作,分离出输尿管中上段,用尖刀或电钩切开输尿管并取出结石,通过trocar留置双J管并间断缝合输尿管切口。结果 51例手术均取得成功。手术时间55～200 min,平均90 min,出血量10～100 ml,平均30 ml。无感染、尿漏等并发症。术后住院3～9 d,平均6 d。术后复查KUB及B超无结石残留。随访6～12个月,B超示39例肾积水消失,12例中度积水,无输尿管狭窄和结石复发。结论后腹腔镜输尿管切开取石术治疗输尿管中上段结石效果确切,创伤小,并发症少,可作为ESWL和腔内碎石等治疗方法失败的难治性输尿管结石的首选方法。     

Laparoscopic Surgery for Kidney Orthotopic Transplant in the Pig Model

Background and Objectives:

Laparoscopic surgery has rapidly expanded in surgical practice with well-accepted benefits of minimal incision, less analgesia, better cosmetics, and quick recovery. The surgical technique for kidney transplantation has remained unchanged since the first successful kidney transplant in the 1950s. Over the past decade, there were only a few case reports of kidney transplantation by laparoscopic or robotic surgery. Therefore, the aim of this study is to develop a laparoscopic technique for kidney transplantation at the region of the native kidney.

Methods:

After initial development of the laparoscopic technique for kidney transplant in cadaveric pigs, 5 live pigs (Sus scrofa, weighing 45–50 kg) underwent laparoscopic kidney transplant under general anesthesia. First, laparoscopic donor nephrectomy was performed, and then the kidney was perfused and preserved with cold Ross solution. The orthotopic auto-transplant was subsequently performed using the laparoscopic technique. The blood flow of the kidney graft was assessed using Doppler ultrasonography, and urine output was monitored.

Results:

The laparoscopic kidney transplant was successful in 4 live pigs. Immediate urine output was observed in 3 pigs. The blood flow in the kidney was adequate, as determined using Doppler ultrasonography.

Conclusion:

It has been shown that laparoscopic kidney orthotopic transplant is feasible and safe in the pig model. Immediate kidney graft function can be achieved. A further study will be considered to identify the potential surgical morbidity and mortality after recovery in a pig model before translating the technique to clinical human kidney transplantation.     

Application of Competency-Based Education in Laparoscopic Training

Background and Objectives:

To induce competency-based education/developing a curriculum in the training of postgraduate students in laparoscopic surgery.

Methods:

This study selected postgraduate students before the implementation of competency-based education (n = 16) or after the implementation of competency-based education (n = 17). On the basis of the 5 competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and professionalism, the research team created a developing a curriculum chart and specific improvement measures that were implemented in the competency-based education group.

Results:

On the basis of the developing a curriculum chart, the assessment of the 5 comprehensive competencies using the 360° assessment method indicated that the competency-based education group''s competencies were significantly improved compared with those of the traditional group (P < .05). The improvement in the comprehensive assessment was also significant compared with the traditional group (P < .05).

Conclusion:

The implementation of competency-based education/developing a curriculum teaching helps to improve the comprehensive competencies of postgraduate students and enables them to become qualified clinicians equipped to meet society''s needs.     

Development of a Training Model for Laparoscopic Common Bile Duct Exploration

Background:

Training and experience of the surgical team are fundamental for the safety and success of complex surgical procedures, such as laparoscopic common bile duct exploration.

Methods:

We describe an inert, simple, very low-cost, and readily available training model. Created using a “black box” and basic medical and surgical material, it allows training in the fundamental steps necessary for laparoscopic biliary tract surgery, namely, (1) intraoperative cholangiography, (2) transcystic exploration, and (3) laparoscopic choledochotomy, and t-tube insertion.

Results:

The proposed model has allowed for the development of the skills necessary for partaking in said procedures, contributing to its development and diminishing surgery time as the trainee advances down the learning curve. Further studies are directed towards objectively determining the impact of the model on skill acquisition.

Conclusion:

The described model is simple and readily available allowing for accurate reproduction of the main steps and maneuvers that take place during laparoscopic common bile duct exploration, with the purpose of reducing failure and complications.     

A Successful Model for Laparoscopic Training in Mongolia

The benefits of laparoscopic surgery have not been available to the majority of Mongolians. Mongolian surgical leaders requested assistance in expanding laparoscopy. A capacity-building approach for teaching laparoscopic cholecystectomy throughout Mongolia is reviewed. A laparoscopic cholecystectomy training program was developed. The program included a didactic course and an intensive 2-week practical operating experience. Courses were taught in Ulaanbataar and at 3 of the 4 regional diagnostic referral and treatment centers from 2006 to 2010. During this training period, a total of 303 teaching laparoscopic cholecystectomies were performed. There was one common bile duct injury and one duodenal injury. The conversion rate was 2.0%. This program has been successful in creating a self-sustaining practice of training. The traditional surgical approach to gallbladder disease in Mongolia has been challenged and has, in turn, been a stimulus for improvement in the medical community.     

微创经皮肾穿刺取石术和后腹腔镜下输尿管切开取石术治疗嵌顿性输尿管上段结石的疗效比较

目的比较微创经皮肾穿刺取石术（minimally invasive percutaneous nephrolithotomy,MPCNL）和后腹腔镜输尿管切开取石术（retroperitoneal laparoscopic ureterolithotomy,RLUL）治疗嵌顿性输尿管上段结石的疗效。方法对72例单侧嵌顿性输尿管上段结石采用MPCNL（45例）或RLUL（27例）治疗,对比2组手术时间、结石清除率和术后高热（〉38．5℃）率。结果72例手术全部成功,手术时间MPCNL组短于RLUL组[（43±9）min与（69±17）min,t=-11．564,P=0．000]。术后第2天结石清除率2组均为100％。术后高热率MPCNL组13．3％（6／45）,与RLUL组11．1％（3／27）比较差异无显著性（Χ^2=0．000,P=1．000）。术后随访1～24个月,平均8个月,2组均未发现有输尿管狭窄和结石复发。结论MPCNL和RLUL治疗输尿管上段嵌顿性结石均是安全、有效的,两者均可以选用。     

不同年龄医生应用腹腔镜模拟训练器的效果分析

目的 探讨不同年龄段医生参与腹腔镜模拟训练器的培训效果.方法 按年龄分3组,每组10人,低龄组(年龄≤25岁)、中龄组(年龄＞25 ～≤35岁)和大龄组(年龄＞35 ～≤45岁).训练内容为腹腔镜下夹取黄豆、剪切图形和缝合打结训练,分别在训练前、训练3次、训练6次记录1 min内的拾豆数,剪切一个几何图形所需的时间及10 min内的缝合打结数,各计数3次,取平均值.结果 训练前3组夹取黄豆数分别为(9.2±1.7)、(10.2±1.2)、(9.0±1.4)个/min,无统计学差异(F=1.97,P=0.159),训练3次后低龄组1 min夹豆数(17.2±2.1)个/min明显多于中龄组(14.2±1.9)个/min(q=5.342,P ＜0.05)和大龄组(11.3±1.2)个/min(q=10.507,P＜0.05),中龄组明显多于大龄组(q=5.164,P＜0.05);训练6次后3组比较无统计学差异(F=2.27,P=0.123).训练前3组剪裁几何图形所需时间分别为(11.2±1.6)、(10.2±1.2)、(10.2±1.2)min,无统计学差异(F=1.84,P=0.178),训练3次后低龄组剪裁几何图形所需时间(5.2±1.1)min明显少于中龄组(8.2±1.3)min(q =8.105,P＜0.05)和大龄组(11.2-1.1)min(q =16.210,P＜0.05),中龄组明显少于大龄组(q=8.105,P＜0.05),训练6次后3组比较有统计学差异(F=62.80,P=0.000)).训练前3组缝合打结数分别为(1.9±0.3)、(2.2±1.2)、(2.5±1.4)个/10 min,无统计学差异(F=0.77,P=0.471),训练3次后低龄组10 min缝合打结数(8.9±1.2)个/10 min明显多于中龄组(5.1±1.6)个/10 min(q =8.924,P＜0.05)和高龄组(4.3±1.2)个/10 min(q=10.802,P＜0.05),训练6次后3组比较有统计学差异(F=35.76,P=0.000).3组在训练前后1 min夹豆数、剪裁几何图形所需时间、10 min缝合打结数均有统计学差异(P＜0.05).结论 腹腔镜模拟训练可以提高不同年龄参与者的腹腔镜操作技巧,年纪越轻培训的优势越明显.