悬吊式与传统腹腔镜子宫肌瘤挖除术的临床疗效对比

目的对比悬吊式与传统腹腔镜在子宫肌瘤切除术中的临床效果,探讨子宫肌瘤切除的最佳术式。方法 2006年12月～2012年1月,选择60例子宫肌瘤患者,随机分为2组,由同一手术组医师分别采用悬吊式(悬吊组)及传统腹腔镜(传统组)完成挖除子宫肌瘤手术,比较两组手术时间、术中出血量,中转开腹情况,住院天数,术后并发症及复发情况。结果悬吊组与传统组比较,手术时间短、术中出血量少、术后并发症少(P<0.05)。悬吊组均成功完成手术,无中转开腹;传统组有2例中转开腹。两组住院天数无统计学差异(P>0.05)。随访3～12个月,平均10.5个月,悬吊组无复发,传统组有3例复发,两组复发率比较,差异有统计学意义(P<0.05)。结论悬吊式较传统腹腔镜在子宫肌瘤挖除术中有独特的优势,手术时间短,出血少,无并发症及复发,值得在临床大力推广应用。     

腹壁提升免气腹腹腔镜手术

目的：探索一种免除CO2气腹的腹腔镜手术方式。方法：设计一种器械－腹壁提升器，采用机械升降牵拉的方法提升腹壁形成腹腔手术空间，完成腹腔镜胆囊或阑尾切除。手术在连续硬膜外麻醉下进行。结果：使用腹壁提升器免气腹的方法成功完成20例胆囊切除，8例阑尾切除。胆囊切除平均手术时间62min、阑尾切除平均手术时间45min。术后恢复顺利。结论：腹壁提升器免气腹腹腔镜手术是一种全新、实用、可行、安全的微创手术方法，避免了气腹腹腔高压和全麻的诸多并发症，扩展了腹腔镜手术的应用范围，有较大的临床推广价值。     

Dispersal of tumour cells within the peritoneal cavity during laparoscopy

Summary

Disagreement exists about whether laparoscopy results in dispersal of tumour cells during laparoscopic cancer surgery and whether this results in the development of port-site metastases. Recent experimental work suggests that CO₂, but not He, insufflation promotes the development of port-site metastases, suggesting that metabolic or immunological factors might also contribute to this problem. This study investigated whether insufflation results in an initial redistribution of tumour cells; and looked at the contribution of mechanical insufflation factors for the development of port-site metastases. A suspension of radio-labelled cancer cells was introduced into the left upper quadrant of the peritoneal cavity of 17 Dark Agouti rats, which underwent laparoscopy with CO₂ pneumoperitoneum, gasless laparoscopy, or laparotomy. Surgery continued for a further 30 min, after which the rats were killed and the radioactivity present on the peritoneal surface of the anterior and lateral abdominal wall, and the laparoscopy port sites, was determined by scanning standardised samples of the abdominal wall with a y counter. There was less contamination of the abdominal wall from laparotomy than laparoscopy, irrespective of technique. No differences in contamination between the two laparoscopy groups could be demonstrated. Contamination of the port sites was similar except at the site through which the cells were originally introduced, where a greater radioactivity concentration was seen following gasless laparoscopy. This study suggests that it is not the use of gas insufflation during laparoscopy which is responsible for redistribution of tumour cells from a tumour site, but that redistribution is related to some other aspect of the laparoscopic environment. It is possible, when this finding is considered alongside previously reported studies, that a metabolic or immune disturbance, due to other properties of CO₂ insufflation, could cause this problem. This possibility is being investigated further.     

妇科悬吊式腹腔镜的围手术期配合

目的探讨妇科悬吊式腹腔镜的手术配合方法。方法通过配合妇科悬吊式腹腔镜手术,熟悉了悬吊式腹腔镜的手术配合特点、器械使用和与气腹法手术的比较。结果10例手术顺利完成,未中转开腹。结论悬吊式腹腔镜手术更安全,术前准备好各项器械物品,协助摆放患者体位,熟练掌握各种仪器的性能和手术操作步骤是手术配合的重要环节。     

Gasless laparoscopy versus conventional laparoscopy in uterine myomectomy: a single-centre randomized trial

In a single-centre, randomized trial, gasless laparoscopic myomectomy was compared with conventional laparoscopic myomectomy. The study examined feasibility, safety, reliability and post-operative outcomes. Estimated blood loss, duration of surgery, early post-operative outcomes and length of hospital stay were recorded. Compared with conventional laparoscopic myomectomy, gasless laparoscopy resulted in significantly lower intra-operative blood loss (median 100 ml vs 80 ml, respectively) and duration of surgery (median 94 min vs 71 min, respectively). Post-operative abdominal drainage volume was significantly lower after gasless laparoscopy than after conventional laparoscopy (median 100 ml vs 240 ml). There was no significant difference between duration of post-operative fever, post-operative time to flatus or length of hospital stay. Both forms of laparoscopy are suitable for uterine myomectomy, and comparison of these methods showed that gasless laparoscopy had potential advantages over conventional laparoscopy.     

A small animal model for laparoscopic microsurgery training

Summary

Training of the surgeon is one of the main factors in avoiding technical problems and complications during laparoscopic procedures. Because of the demands on skill and restriction of instrument movement within pneu-moperitoneum and the need for 2-dimensional videoendoscopic vision, participation in a training course is recommended. Simulation trainers cannot completely simulate pneumoperitoneum and only represent part of the laparoscopic procedure and therefore pigs are the preferred animal model for surgical laparoscopy because standard instruments can be used and visceral anatomy of the pig is familiar to the surgeon. We report on an inexpensive training concept using the rat model which requires less logistic effort than the comparable course on a large animal would do. Laparoscopic procedures are performed with an increasing degree of difficulty first on an ‘open’ then on the ‘closed’ model simulating all laparoscopic conditions.     

免气腹与CO 2气腹腹腔镜双侧精索静脉高位结扎术的临床疗效比较

目的探讨免气腹与CO₂气腹腹腔镜精索静脉高位结扎术的临床疗效。 方法回顾性分析2010年5月至2016年4月解放军71军医院68例双侧精索静脉曲张患者行腰硬联合麻醉或全麻下双侧精索静脉高位结扎术的临床资料,其中34例行腹壁悬吊式免气腹腹腔镜手术（免气腹组）,34例行经腹CO₂气腹腹腔镜手术（气腹组）。观察症状和体征改变及并发症情况,比较2组手术时间、术后住院时间、肠道功能恢复时间;分别比较气腹组、免气腹组术前和术后9个月的精子密度、精子活动度。 结果2组患者手术均顺利完成,症状、体征均改善,无严重手术并发症。2组手术时间、术后住院时间、肠道功能恢复时间比较,差异均无统计学意义（P均＞0.05）;2组患者术后9个月精子密度与术前比较,差异均无统计学意义（P均＞0.05）,术后9个月精子活动率均较术前增高［气腹组：（78.59±6.50）% vs（74.41±6.95）%,免气腹组：（75.88±7.47）% vs（68.71±7.43）%］,差异具有统计学意义（t=6.549,P=0.013;t=15.770,P＜0.001）。 结论2种微创术式均可准确结扎精索内静脉,疗效确切,切口美观,术后恢复较快。免气腹手术避免了CO₂气腹对呼吸、循环系统的影响,无气腹并发症,可采用椎管内麻醉,作为更经济的术式选择。     

Reduced port laparoscopic splenectomy using a newly developed multichannel port: A pilot study

Abstract

Background: The authors introduce the dual-incision laparoscopic splenectomy (DILS) technique using a specially designed multichannel trocar and report on the surgical outcomes and operative cost of DILS compared with conventional laparoscopic splenectomy (CLS). Material and methods: The medical records of 53 patients who underwent a laparoscopic splenectomy using CLS with four trocars and DILS at our institution were analyzed. Results: There was no statistical difference in operative time between the two groups and the intraoperative transfusion rate of red blood cell substitution was not different between the two groups. In terms of postoperative pain score, hospital stay, and overall complication rate, there were no differences between the two groups. Operative cost was significantly lower in the DILS group compared with the CLS group. Conclusions: DILS is a feasible and cost-effective modality of reduced port surgery in laparoscopic splenectomy.     

Changes in abdominal wall thickness during laparoscopy: implications for the use of magnetic assisted surgery

Abstract

Introduction: Recently, magnetic solutions have been proposed to minimize surgical invasiveness. These are comprised of deployable instruments containing magnets which are inserted into the abdominal cavity through a single access point. The manipulation of the internal elements occurs via magnets held on the external surface of the abdominal wall. This technology relies on the magnetic force between the magnets, which is inversely related to the abdominal wall thickness (AWT). The aim of this study was to establish the expected change in AWT from before and after initiation of pneumoperitoneum.

Material and methods: Patients scheduled for laparoscopic procedures were assessed by ultrasound for AWT immediately before and during laparoscopy. Change of AWT during laparoscopy was calculated. Statistical analysis was performed using Student’s t-test.

Results: Thirty-two patients undergoing various laparoscopic procedures were included. Twenty patients were male (62.5%) and ten were morbidly obese (31%). Mean age was 51?years (range 18–76) and average BMI was 28.1?kg/m² (range 19.0–41.0). AWT decreased on average by 15.6% once pneumoperitoneum was initiated in both obese and non-obese patients (p?=?.01).

Conclusion: Our data suggest that following preoperative assessment of AWT with abdominal wall ultrasound, more patients than expected might be candidates for the use of trans-abdominal magnetic devices.     

Laparoscopic single-port Burch colposuspension with an extraperitoneal approach and standard instruments for stress urinary incontinence: Early results from a series of 15 patients

Abstract

Objective:We aimed to investigate the use of single-port laparoscopy in a series of patients undergoing Burch colposuspension with an extraperitoneal approach as an alternative treatment for scarless surgery in stress urinary incontinence. Material and methods: From September 2010 to May 2011 we performed single-port extraperitoneal laparoscopic Burch colposuspension for stress incontinence in 15 patients. Fifteen women who were diagnosed with urodynamic stress incontinence were included in the study. Demographic and clinical data, intraoperative findings, and postoperative course were recorded. Results:The mean age was 45,80 ± 9,91 years (range: 38–70 years). The mean body mass index was 25,67 ± 4.06 kg/m2 (range: 22.23–35.38 kg/m²). The mean operation time and mean blood loss were 40.80 ± 5.94 minutes (range: 30–50 minutes) and 30.67 ± 11.00 cc (range: 10–50 cc), respectively. The single-port laparoscopic operations were technically completed successfully without placement of additional trocars and there were no complications. The cure and improvement rates following laparoscopic Burch colposuspension via single port were 73.3 % and 20 % respectively. Conclusion: Single-port laparoscopic Burch can be an alternative treatment for scarless surgery in stress incontinence. Single-incision laparoscopic Burch colposuspension can offer suitable, effective and safe treatment in women with stress incontinence.     

Access techniques for endoscopic surgery - types of trocars,ports and cannulae - an overview

Trocar systems with different transperitoneal access techniques are indispensable for laparoscopic surgery. The development of laparoscopic surgery has led to the establishment of two different techniques of access to the peritoneal cavity: first, there is the closed establishment of a pneumoperitoneum by direct trocar or by means of a Veress needle puncture of the abdominal cavity; this first 'blind' step of laparoscopy can be facilitated by optical control of the penetration process. The second technique is the open trocar application, first described by Hasson. Generally, trocar systems differ with respect to their reusability and there are also differences in the perforator techniques used. Particularly in single-use trocars, 'safety' perforators are applied, in which a shield protects the cutting device. Perforators can also be blunt, or vary in their cutting characteristics, with dilatation trocars at the extreme end of the scale. The risk of potential lesions to the abdominal wall and intraperitoneal organs is crucial for the evaluation of any given trocar system. When considering both cost aspects and technical details, the reusable steel trocar with a cone-shaped perforator currently appears to be the best compromise.     

不同气腹环境对大鼠系统免疫功能的影响

目的　观察开腹手术和腹腔镜不同气腹环境对大鼠系统免疫功能的影响。方法　将 6 0只雌性S-D大鼠随机分为 4组 :开腹组 ;CO2 气腹组 ;无气组 ;N2 气腹组 ,每组 15只。模拟开腹手术和相应腹腔镜手术时的气腹环境 ,时间为 1h。分别于手术第 0、1、3、7d检测大鼠血液中CD3 、CD4和CDRT细胞的数值变化 ,了解开腹及不同气腹对大鼠系统免疫功能的影响。结果　术后各组CD细胞计数值均明显下降 (P <0 .0 0 1) ,开腹组最低 (P <0 .0 0 1) ;CO2 气腹组居中 (P <0 .0 0 1) ,无气和N2 组间无统计学差异 (P >0 .0 5 ) ,免疫抑制程度最低。开腹组术后恢复最慢 (P <0 .0 1) ;CO2 气腹组居中 (P <0 .0 1) ,无气和N2 气腹组数值基本相同 (P >0 .0 5 ) ,恢复最快。第 7d各组印细胞计数均恢复术前正常水平 (P >0 .0 5 )。结论　CO2 气腹对系统免疫功能抑制程度小于开腹组 ,但大于无气或N2 气腹组 ,术后恢复晚于后两组。     

二氧化碳气腹和无气腹腔镜手术对腹膜形态学的影响

目的:探讨CO2气腹和无气腹腔镜手术对腹膜形态学的影响。方法:对38例子宫肌瘤患者(排除腹膜炎症患者)分别进行CO2气腹腹腔镜手术(有气腹腔镜组,n=20)和无气腹腔镜手术(无气腹腔镜组,n=18),于手术0、30、60、90、120min分别采集壁层腹膜,对其行透射电镜和扫描电镜观察腹膜间皮细胞形态学变化。结果:有气腹腔镜组充气后间皮细胞迅速肿胀,60min时可见腹膜间皮细胞间连接断裂,基底膜裸露,120min时更明显;而在无气腹腔镜组间皮细胞未见明显变化,120min时仅见细胞肿胀。结论:CO2气腹腹腔镜手术与无气腹腔镜手术相比,改变了腹膜的形态学,而且与充气时间有关,可能有利于腹腔内恶性肿瘤的转移     

Intra-operative risk and haemodynamic etfects of the CO2-pneumoperitoneum in laparoscopic surgery

The benetits of minimally invasive surgery led to an increasing rate of laparoscopic procedures in older patients. These patients profit most from the p.op. advantages of laparoscopic surgery. On the other hand they often display cardiovascular risks with the intra-operative risk of the CO₂-pneumoperitoneum still under discussion. Methods: The haemodynamic etfects of CO₂-pneumoperitoneum were investigated. Monitoring included cardiac output (CO), central venous pressure (CVP), pulmonary arterial pressure (PAP) and wedge pressure (PAWP), femoral venous pressure (FVP), intra-oesophageal pressure (IEP), systemic vascular resistance (SVR) and transmural right-atrial pressure (TMP), and was performed in a controlled, experimental model. Results: Establishing the pneumoperitoneum caused initially a 35% decrease in CO. SVR, as an indicator of cardiac afterload, increased clearly. The increased intra-abdominal pressure led to a reduction of venous retlux from the periphery and squeezed the venous reservoir within the abdominal cavity. Cardiac preload was altered, too. The elevated cardiac afterload adapted under pneumoperitoneum. After desufflation cardiac output rose far above normal. Conclusions: These results indicate a strong cardiac stress after insufflation and desufflation. This is caused by the increased intra-abdominal pressure rather than by systemic etfects of resorbed CO₂. Laparoscopic procedures in patients with clinical signs of cardiovascular insufficiency should only be performed with substantial intra-operative monitoring. Otherwise low pressure pneumoperitoneum and/or pressure and gasless laparoscopy could be considered.     

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.     

Ergonomic comparison of laparoscopic hand instruments in a single site surgery simulator with novices

Background: Single-site surgery improves cosmesis but increases procedural difficulty. Enhanced instruments could improve procedural efficiency leading to better patient outcomes. Material and methods: One pair of non-articulating (straight) and two different pairs of articulating laparoscopic instruments were evaluated using a peg-transfer surgical task simulator by premedical college students. The instruments were comparatively tested using task performance measures, ergonomic measures, and participant questionnaires. Results: The straight instrument produced significantly higher task performance scores and lower task times compared to both articulating instruments (p < 0.05). The straight instrument required less muscle activation and less wrist deviation than the articulating instruments to perform the same task. Participants rated the straight instrument significantly easier to use and less difficult to complete the task than with either articulating instrument (p < 0.05 for both). Conclusions: This exploratory study suggests that novices have difficulty using articulating instruments and perform better using straight laparoscopic instruments when first attempting LESS surgical tasks. Although a study with post-graduate medical trainees is needed to confirm these results, trainees should initially practice LESS with non-articulating instruments to gain proficiency at basic laparoscopic tasks. Additionally, redesigning articulating instruments to specifically address the spatial constraints and learning curve of LESS may also improve trainee performance and instrument usability.     

Automatic tracking of laparoscopic instruments for autonomous control of a cameraman robot

Background An automated instrument tracking procedure was designed and developed for autonomous control of a cameraman robot during laparoscopic surgery. Material and methods The procedure was based on an innovative marker-free segmentation algorithm for detecting the tip of the surgical instruments in laparoscopic images. A compound measure of Saturation and Value components of HSV color space was incorporated that was enhanced further using the Hue component and some essential characteristics of the instrument segment, e.g., crossing the image boundaries. The procedure was then integrated into the controlling system of the RoboLens cameraman robot, within a triple-thread parallel processing scheme, such that the tip is always kept at the center of the image. Results Assessment of the performance of the system on prerecorded real surgery movies revealed an accuracy rate of 97% for high quality images and about 80% for those suffering from poor lighting and/or blood, water and smoke noises. A reasonably satisfying performance was also observed when employing the system for autonomous control of the robot in a laparoscopic surgery phantom, with a mean time delay of 200ms. Conclusion It was concluded that with further developments, the proposed procedure can provide a practical solution for autonomous control of cameraman robots during laparoscopic surgery operations.     

Robotic-assisted laparoscopy is a feasible method for resection of deep infiltrating endometriosis,especially in the rectosigmoid area

ObjectiveThis study aimed to compare outcomes of mini-invasive surgical treatment of endometriosis, especially conventional laparoscopy with robotic-assisted laparoscopy, and to evaluate the quality of life.MethodsOne hundred three consecutive patients with endometriosis who had surgery from 2014 to 2017 owing to an indication of pain were enrolled in this retrospective study. The majority (n = 77, 75%) of patients underwent conventional laparoscopy and 18 (17%) had robotic-assisted laparoscopy. The quality of life was postoperatively assessed with a questionnaire.ResultsThe rates of parametrectomy (76% vs. 45%,) and rectovaginal resection (28% vs. 4%) were significantly higher in robotic-assisted laparoscopy than in laparoscopy. Additionally, the rate of bowel operations (50% vs. 17%), especially the shaving technique, was higher in robotic-assisted laparoscopy surgery than in laparoscopy (39% vs. 8%). There was no difference in the rate of postoperative complications between laparoscopy and robotic-assisted laparoscopy. Most (91%) of the patients who answered the questionnaire felt that surgical treatment had relieved their pain. In the laparoscopic and robotic-assisted groups, 88% of respondents felt that their quality of life had improved after surgery.ConclusionsThis study suggests that robotic-assisted laparoscopy is a feasible method to resect deep infiltrating endometriosis, especially in the rectosigmoid area.     

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.     

The Minimally Invasive Manipulator: An ergonomic and economic non-robotic alternative for endoscopy?

Introduction: Since the da Vinci robotic system was introduced, it has been reported to have ergonomic advantages over conventional laparoscopy (COV). High investments associated with this system challenged us to design a more economical, mechanical alternative for improvement of laparoscopic ergonomics: the Minimally Invasive Manipulator (MIM). Material and methods: An earlier reported MIM prototype was investigated. Its shortcomings were input for the establishment of design criteria for a new prototype. Results: A new prototype was developed, aiming at improved intuitiveness and ergonomics. The handle and instrument tip were redesigned and the parallelogram mechanism was converted from linear moving parts to mainly rotating parts. Discussion: The new prototype was tested by a panel of experts and novices during an indicative ergonomic experiment. A major advantage of the MIM seems to be the possibility to perform laparoscopic surgery in a sitting position, in line with the working axis, instead of standing at the side of the patient. At an estimated cost level of 10% of the da Vinci system, the MIM can be an economical alternative for the enhancement of laparoscopy ergonomics. However, further development for clinical feasibility is necessary.