Technical aspects and access devices for preperitoneal and retroperitoneal endoscopic surgery

The main advantages of preperitoneal and retroperitoneal endoscopic surgery over conventional laparoscopy or open surgery are the decreased risk of injury to organs and reduced postoperative adhesion formation. Exact knowledge of anatomy, as well as correct positioning of the patient, is essential for its success. While a blunt dissection technique, using either the fingers or an endoscope under pneumodissection, is preferred for preperitoneal surgery, the introduction of a balloon dissection device directly into the retroperitoneal cavity simplifies this procedure for retroperitoneoscopy. Different general surgical procedures are described for preperitoneal (hernia) and retroperitoneal (adrenalectomy, neurectomy/ sympathectomy) surgery. Urological/gynaecological procedures (kidney, tumor biopsy, lymphadenectomy) are excluded from this review. In recent years, the number of possible preperitoneal and retroperitoneal surgical procedures has increased, mainly as a result of the development of commercially-available balloon trocars and balloon-tipped trocars, which create and maintain a working space.     

Access-related complications - an analysis of 6023 consecutive laparoscopic hernia repairs

In order to investigate incidence rates and types of access-related complications that may occur during laparoscopic hernioplasty, we carried out a systematic analysis of our collected results. The aim was to identify risk factors and to develop useful modifications of the surgical technique and the instrumentation used. Since we first introduced laparoscopic hernioplasty in our clinic, we have carried out standardised, prospective documentation of relevant data from all consecutive operations in an electronic database. We performed a systematic analysis of access-related complications and their possible influencing factors, taking into special account the type of instruments used, port-site and prior intra-abdominal operations. Between April 1993 and March 2000, 4857 consecutive patients received a total of 6023 laparoscopic hernia repairs. In 510 patients three-edged, sharp trocars were used and in 4347 patients conical obturators were used to insert the port. The incidence of access-related complications was 0.9% (44/4857) in the total collection (incision hernias 0.5%, bleeding from abdominal-wall vessels 0.2%, bowel injury 0.06%, wound infections 0.06%). Injuries to intra-abdominal or retroperitoneal vessels were not observed. A differentiated analysis of the various trocar types, taking into consideration the number of inserted ports, showed that for incisions outside the linea alba the incidence of bleeding from abdominal-wall vessels was 12 times higher (0.7%, 7/1020 versus 0.06%, 5/8694). The incidence of incision hernias increased significantly (1.2%, 12/1020 versus 0.02%, 2/8694; p = 0.03) when three-edged trocars were used, as opposed to conical obturators. Our results demonstrate that, outside the linea alba, three-edged trocars should no longer be used for portinsertion. The results of our differentiated analysis of laparoscopic hernia repairs, taking into account the type of obturator, the port-site and number of ports inserted, also can be applied to other laparoscopic operations.     

Instruments for gasless laparoscopic surgery

Summary

In addition to physiological consequences of the pneumoperitoneum, there are many technical disadvantages. Specially designed instruments for laparoscopic procedures using CO₂ gas insufflation and valved trocars with small diameters are expensive, delicate and often single-use items. Besides restricting the surgeon's freedom of movement they lead to a lack of tactile sense and their handling requires a lot more practise compared to conventional instruments. For gasless laparoscopy we use a planar lift system (Origin^?), to attain a sufficient extension to the abdominal wall. The gasless technique allows the use of every laparoscopic instrument without exception, which originally was designed for a pneumoperitoneum. In addition conventional instruments, used in open surgery, can be employed with simple valveless trocars. Instruments without any comparable laparoscopic equivalent can be used. The disadvantage in using instruments designed for conventional surgery is that in their development ergonomic criteria for a laparoscopic application have not been considered. We developed a special instrument set where instrument length, shape and joint position have been designed to fit the needs of gasless laparoscopy. The combination of laparoscopic and ergonomically adapted conventional instruments may lead to progress in the technique of laparoscopic surgery.     

Specially designed curved reusable instruments for single-access laparoscopy: 2.5-year experience in 265 patients

Minimally invasive surgery has been expanded recently by an increasing interest in single-incision, single-port, single-access laparoscopy (SAL). The main drawbacks of this laparoscopic approach include the clashing of the instruments and/or the crossing of the surgeon's hands due to the single-access site and an increase in the cost of the procedures due to the use of disposable materials. Furthermore, one of the rules of laparoscopy, which is to maintain the surgeon's two effectors at the right angle using the optical system as the bisector of this angle, is frequently lost during SAL. To solve these problems, curved reusable instruments for basic and advanced procedures in SAL have been developed based on this laparoscopic principle. The technique consists of the placement of a standard 11-mm reusable trocar, a 10-mm standard rigid scope, and the insertion of curved reusable instruments transabdominally without trocars. The 2.5-year experience in 265 patients is reported here.     

后腹腔镜上尿路手术中腹膜破裂的原因及处理

目的探讨后腹腔镜上尿路手术致腹膜破裂的原因及处理方法。方法对2010年2月—2013年10月收治并行后腹腔镜上尿路手术致腹膜破裂14例的临床资料进行回顾性分析。结果本组行根治性肾切除术5例,肾上腺肿瘤切除术3例,单纯肾切除术、肾部分切除术、肾输尿管全长切除术各2例。腹膜破裂的时间分别为切开侧锥筋膜时3例,建立后腹腔间隙、盲穿腹侧穿刺套管、分离肾脏腹侧粘连处腹膜、分离肾上腺腹侧、器械插入误伤腹膜各2例,清理腹膜外脂肪时损伤腹膜1例。通过Hem-o-lok夹直接夹闭(9例)、腹腔套管排气(5例)、缝合(4例)、手助腹腔镜(1例)等方法处理,恢复腹膜后手术空间,均顺利完成手术。结论掌握好处理腹膜破裂的技巧并及时处理,可减少手术时间,避免并发症的发生,有利于顺利完成手术。     

预防后腹腔镜治疗复杂肾囊性疾病术后尿漏的经验总结——附59例报告

目的：总结预防后腹腔镜治疗复杂肾囊性疾病术后尿漏的经验。方法：1997年4月-2008年12月术前诊断为肾囊性疾病的患者59例,予行后腹腔镜肾囊肿去顶术（术后诊断为单纯肾囊肿36例、多囊肾21例、肾盏憩室2例、肾盂旁囊肿2例）。其中2001年后收治的43例均于术前常规予输尿管逆行插管留置导管,术中经输尿管导管注射染料（亚甲蓝）,观察由亚甲蓝显示的集合系统情况,如发现集合系统损伤,即进行相应处理。结果：59例患者均顺利完成手术。术后发生尿漏并发症共5例。应用输尿管逆行插管注射染料技术前、后尿漏发生率分别是25％（4／16）、2％（1／43）,比较差异有统计学意义（P〈0．05）。术后59例随访3个月～8年,复查B超和（或）CT均未见复发。结论：术中输尿管逆行插管注射亚甲蓝可降低后腹腔镜治疗复杂肾囊性疾病术发生尿漏并发症的风险,是预防尿漏的重要措施。     

妇科再次腹腔镜术的探讨——附36例临床分析

目的：探讨妇科再次腹腔镜术的指征。手术时机、处理方法及价值。方法：回顾性分析因妇科疾病行再次腹腔镜术的３６例病人的临床资料。结果：再次腹腔术与首次腹腔镜术间隔时间３个月至６０个月，中位间隔时间为２５个月。１８例（５０％）的再次腹腔镜术指征与首次相同，其中不孕症１４例（原发不孕９例，继发不孕５例），盆腔包块３例，继发性痛经１例。手术指征不一致的１８例中，不孕症３例，盆腔包块４例，绝育１便，异位妊娠６     

后腹腔镜联合尿道电切镜治疗肾盂癌

目的探讨后腹腔镜联合尿道电切镜在肾输尿管全切加膀胱输尿管口袖套状切除的技术要点和可行性。方法采用后腹腔镜联合尿道电切镜行肾输尿管全切加膀胱输尿管口袖套状切除5例。病理类型均为移行细胞癌。结果5例手术均获一次成功，手术时间120-240min，平均150min，术后无并发症，随访3-9个月，无肿瘤复发转移，无切口肿瘤种植。结论后腹腔镜联合尿道电切镜行肾输尿管全切加膀胱输尿管口袖套状切除治疗肾孟癌创伤小、恢复快，疗效可靠。     

泌尿外科后腹腔镜手术的护理研究

目的探讨泌尿外科后腹腔镜手术的护理内容及特点,以提高护理工作效率和质量。方法随机将120例适合手术治疗的患者分为两组,观察组采用后腹腔镜手术,对照组采用传统开放手术。观察两组患者术中出血量、术后卧床时间、带引流管时间、住院天数及术后并发症例数,并进行比较。围手术期采取针对性护理措施。结果观察组较对照组手术具有创伤小、出血少、恢复快、并发症少、住院天数短等优点,差异均具有统计学意义。良好的护理配合可减少并发症,促进病人早日康复。结论某些适宜手术治疗的泌尿外科疾病,采用后腹腔镜进行手术较传统开放式手术具有显著的优越性。积极做好护理工作是手术后患者康复的重要环节。     

The new reusable laparoscopic multi-fire clip-applier for titanium clips

Summary

This article presents a new clip-applier characterized by its reusable construction with interchangeable disposable clip storage magazines containing eight titanium clips. The advantage of this multi-fire clip-applier is evident in laparoscopy under the conditions of pneumoperitoneum because the clips are loaded intra-abdominally. Gas losses as seen during introductions through special trocars when changing the clips outside the abdomen are missing. The authors discuss the technical features of the instrument in detail.     

Comparison of laparoscopic and retroperitoneoscopic approaches to the great vessels in a porcine model

Summary

Conventional laparoscopy has not yet been widely adopted for procedures involving the retroperitoneal organs, due to the problems of adequate bowel retraction and the poor access afforded by the position of the root of the mesentery. Developments in retroperitoneal laparoscopy facilitated by balloon dissection have afforded a new minimally invasive approach to the retroperito-neum. We have compared retroperitoneoscopic and laparoscopic approaches to the great vessels in a porcine model.     

腹腔镜肾切除术两种不同入路的比较

目的比较腹腔镜肾切除术经腹腔入路与经后腹入路的差异。方法2002年6月~2003年12月应用腹腔镜行肾切除术48例,均为重度积水无功能肾患者。完全随机分组,其中23例采用经腹腔入路,25例采用经后腹膜腔入路。随访3个月~1年,作统计分析。结果48例手术均获成功。手术时间经腹腔入路组120~250 min,平均170 min,经后腹腔入路组80~180 min,平均110 min(P<0.05);术中出血量腹腔入路组平均80ml,经后腹腔入路组平均30 ml(P<0.05);经腹腔入路组出现2例阴囊皮下气肿,经后腹腔入路组发生1例腹膜穿孔。结论在重度积水无功能肾的腹腔镜肾切除术中,经后腹腔入路较经腹腔入路更可靠、安全、易操作。     

后腹腔镜联合下腹部小切口治疗肾盂肿瘤

目的 评估腹腔镜联合腹部小切口术式治疗肾盂及输尿管肿瘤的可行性及优缺点,为腹腔镜临床技术的广泛开展提供更多的临床依据.方法 2006 ～ 2009年该院对14例术前临床分期评估为T1、T2期的患者进行了后腹腔镜联合腹部小切口治疗上尿路移形细胞肿瘤,患者年龄50～72岁,平均653岁.术中首先经后腹腔行肾脏切除;然后取下腹部小切口行患侧输尿管开口部分膀胱切除术.切除范围包括患肾、肾上腺、肾周脂肪组织、输尿管及部分膀胱,术中保持输尿管完整,最终通过下腹部切口取出切除患侧肾脏及输尿管.结果平均手术时间4 h(3～4.5 h),平均失血量200 mL(75 ～300mL),患者平均住院时间8d(7～10 d),无明显手术并发症.术后病检均为尿路移行细胞癌,病理分级G1级7例,G2级6例,G3级1例;临床分期均为T2N0M0.术后随访膀胱镜、B超,必要时CT及肾功能等,随访时间9～36个月,平均18个月,3名患者术后出现膀胱移形细胞肿瘤,其余患者随访暂未见异常. 结论 经后腹腔镜联合腹部小切口治疗上尿路肿瘤是一种临床疗效肯定的术式,相对于完全的开放手术,该术式具有创伤小及恢复快等优点.而相对于全腹腔镜下肾盂癌根治术,则易于掌握,故值得推广.     

Laparoscopic left lateral sectionectomy in pediatric living donor liver transplantation by single-port approach: A case report

BACKGROUNDSingle-port laparoscopy has been used in a variety of abdominal operations. We report the first case of single-port laparoscopic left lateral sectionectomy in pediatric laparoscopic living donor liver transplantation.CASE SUMMARYA 28-year-old man volunteered for living liver donation to his daughter who was diagnosed with liver cirrhosis and portal hypertension after the Kasai procedure for biliary atresia. His body mass index was 20.5 kg/m². Liver dynamic computed tomography showed: (1) Left lateral graft volume of 232.76 cm³ with a graft-to-recipient weight ratio of 2.59%; and (2) Right hepatic artery derived from the superior mesenteric artery. A single-port access system was placed through a transumbilical incision, including four trocars: two 12-mm ports for a camera and endoscopic stapler and two 5-mm working ports. Liver parenchyma was dissected by a Harmonic and Cavitron Ultrasonic Surgical Aspirator, while bipolar was used for coagulation. The bile duct was transected above the bifurcation by indocyanine green fluorescence cholangiography. The specimen was retrieved from the umbilical incision. The total operation time was 4 h without blood transfusion. The final graft weight was 233.6 g with graft-to-recipient weight ratio of 2.60%. The donor was discharged uneventfully on postoperative day 4.CONCLUSIONSingle-port laparoscopic left lateral sectionectomy is feasible in pediatric laparoscopic living donor liver transplantation in an experienced transplant center.     

尿道电切镜联合腹膜后镜治疗上尿路移行细胞癌(附15例报告)

目的：探讨尿道电切镜联合腹膜后镜治疗上尿路移行细胞癌的临床效果。方法：联合尿道电切镜、腹膜后镜行肾输尿管切除术治疗肾盂癌9例，输尿管癌6例。结果：15例平均手术时间4h，平均出血80ml，平均住院时间6d，无明显并发症。结论：联合尿道电切镜、腹膜后镜行肾输尿管切除术，具有创伤小、出血少、术后恢复快、并发症少的优点。     

腹膜后腹腔镜手术

目的：探讨腹膜后腹腔镜的应用。方法：应用腹膜后腹腔镜进行２０例手术，包括肾上腺良性肿瘤切除术１２例，肾上腺囊肿开窗术３例，肾囊肿开窗术３例，肾盂旁囊肿开窗术１例，腹膜后淋巴囊肿切除术１例。结果：手术全部成功，无并发症发生，伤口平均长度２．７ｃｍ，术后住院天数５．８ｄ。结论：腹膜后腹腔镜是腹膜后手术的一种新技术，具有损伤少、住院日短、恢复快的优点     

Gerota筋膜内后腹腔镜应用于肥胖患者的体会

目的 探讨Gerota筋膜内后腹腔镜的临床应用价值.方法 36例肥胖患者采用12肋下腋后线孔气囊扩张建立Gerota筋膜内后腹腔间隙,进行腹腔镜肾切除4例,肾囊肿去顶12例,肾盂输尿管上段切开取石17例,离断性肾盂成形1例,肾上腺肿瘤切除2例.结果 35例手术顺利完成,仅1例输尿管结石因术中气腹机故障改开放手术.手术时间20～160 min（平均63.1 min）.术中出血量10～240 mL（平均55 mL）.肾盂输尿管上段切开取石患者,6例术后少许漏尿2～6d（平均3.5 d）.住院时间4～26 d.术后随访35例,2～13个月（平均5.1个月）,未见严重并发症.结论 为减少脂肪组织的干扰,肥胖症患者可在Gerota筋膜内建立后腹腔间隙行腹腔镜手术,简便易行,路径直接,组织分离少,手术时间缩短.     

应用达芬奇机器人切除原发性腹膜后巨大肿瘤的临床研究

目的探讨达芬奇机器人腹膜后巨大肿瘤切除术的安全性和疗效。方法回顾性分析该院5例腹膜后巨大肿瘤行达芬奇机器人手术切除的临床资料,探讨手术技巧,分析并发症与疗效。结果 5例腹膜后巨大肿瘤患者均成功实施达芬奇机器人辅助肿瘤切除术,术后恢复良好,无严重并发症。随访6～33个月,4例无肿瘤复发;1例腹膜后淋巴瘤患者,残余瘤体经化疗后明显缩小。结论达芬奇机器人能安全地完成复杂的腹膜后巨大肿瘤手术,术后并发症少,疗效满意。在熟练掌握机器人操作后,经腹和腹膜后途径均能很好完成手术。     

后腹腔镜技术应用于泌尿外科疾病初步临床分析

目的回顾比较部分泌尿外科疾病应用后腹腔镜技术与开放手术的治疗,总结临床经验,提高后腹腔镜技术水平,逐步扩大后腹腔镜技术在泌尿外科疾病的应用范围。方法采用后腹腔镜技术治疗泌尿系疾病137例(A组),开放手术130例(B组),两组分别就手术时间、出血量、术后排气时间、术后住院日等进行比较。结果两组疗效无显著差异(P0.05),后腹腔镜组术中及术后出血量、平均住院时间均明显少于开放组(P0.05),部分手术时间略长于开放组,有些手术时间短于开放组。结论后腹腔镜技术应用于泌尿外科疾病,途径直接,不会对腹腔镜内脏器造成干扰和污染,且损伤小、痛苦少、康复快、住院时间短。随着不断训练、不断熟练和技术水平的提高加之相关操作器械的更新,部分手术时间的缩短不容置疑,将在泌尿外科领域得到更广泛的应用。     

平卧位腹腔镜下经腹途径双侧腹膜后及盆腔淋巴结清扫术:3例报告并文献复习

目的探讨睾丸癌平卧位腹腔镜下经腹途径双侧腹膜后及盆腔淋巴结清扫术的方法。方法采用经腹途径性腹腔镜下双侧腹膜后及盆腔淋巴结清扫术3例,复习总结国内外相关文献。结果3例手术均顺利,术中分别清扫双侧腹膜后淋巴结22个,及盆腔淋巴10个,术中出血少,术后安返病房。结论腹腔镜下经腹途径双侧腹膜后及盆腔淋巴结清扫范围广,上至肾动脉水平,下至髂总下约2 cm,解剖标志清晰,可达到与开放手术相同的切除范围,仰卧位能同时清扫双侧腹膜后淋巴结及盆腔淋巴,避免中途左右转换体位的麻烦,降低手术风险,可应用于非精原细胞瘤的淋巴结诊断及治疗。