微创技术在胸腰椎结核中的应用进展

微创技术已经广泛应用于脊柱退行性疾病、肿瘤及骨折等疾病的治疗中,微创技术治疗胸腰椎结核措施包括经皮穿刺置管引流以及持续灌注冲洗、胸腔镜或腹腔镜下手术治疗以及通道辅助小切口手术治疗等。该文就近年来微创技术在胸腰椎结核中的应用进展作一综述。     

微创手术治疗胸椎结核60例疗效分析

目的 评价微创手术治疗胸椎结核的临床效果.方法 对60例胸椎结核患者采用腋下小切口技术进行胸椎结核前路病灶清除、植骨融合及内固定术,评价其疗效.结果 60例患者手术均成功,术后无并发症,术后神经功能获1～3级改善.结论 腋下小切口技术治疗胸椎结核效果确切,且较为安全.     

一期前路病灶清除后路内固定治疗胸腰段结核合并巨大脓肿

目的 探讨胸腰段椎体结核合并有巨大寒性脓肿行一期前路病灶清除,椎管减压,后路内固定植骨融合的疗效.方法对1999-01～2005-12间收治的22例胸腰椎结核合并有巨大寒性脓病例,采用同期前路病灶清除,后路椎弓根螺钉内固定,自体植骨融合治疗.结果术后随访6～24个月,平均9个月,22例脊柱结核患者均治愈,症状消失,无局部结核复发,植骨全部骨性融合,融合时间为5～7个月,后凸矫正率达80%.结论在胸腰椎结核手术中,后路内固定和前路病灶清除与植骨可同期进行,能有效地稳定病椎,部分矫正畸形,消灭病灶,缩短卧床时间.     

脊柱结核的外科治疗体会

1985～1996年,我们对350例脊柱结核患者行外科手术治疗,现总结分析如下。1 临床资料 本组男184例,女166例。年龄12～69岁,平均41岁。病史1个月至8年。病灶位于颈椎5例(1.4％),胸椎106例(30.3％),胸腰椎40例(11.4％),腰椎135例(39％),椎体附件4例(1.1％)。其中合并截瘫30例(颈椎结核2例,胸椎结核24例,胸腰段结核4例),肺结核30例(胸椎结核22例,腰椎结核8例)。2 手术入路及术式 5例颈椎结核中,2例经颈椎前侧入路行病灶清除(1例同时行颅骨牵引),2例经后路行椎板减压并颅骨牵引术,1例单纯行颅骨牵引术。胸椎结核经胸腔入路病灶清除98例,经胸膜外(包括肋骨横突切除)病灶清除8例,其中同时行椎间髂骨植骨3例,应用带蒂肋骨椎间植骨2例。胸腰段脊柱结核经一侧肾切口清除病灶。腰椎结核行改良倒八字切口病灶清除。椎体附件结核经后正中切口病灶清除。脊柱结核合并截瘫者行前侧减压18例,侧前方减压8例,全椎板切除减压4     

后路椎弓根系统内固定侧前方病灶清除植骨融合治疗胸腰椎结核

对14例胸腰椎结核施行患者后路椎弓根系统固定、侧前方病灶清除、植骨融合术。术后随访15～36个月，平均26个月。切口均一期愈合，胸腰椎结核全部治愈，脊髓功能损害逐渐恢复，脊柱后突畸形得以矫正。认为本术式是手术治疗胸腰椎结核的有效方法。     

一期前路病灶清除植骨选择性病椎内固定术治疗胸腰椎结核疗效观察

目的 探讨一期前路病灶清除植骨选择性病椎内固定术治疗胸腰椎结核的疗效.方法 对18例胸腰椎结核患者行一期前路病灶清除植骨选择性病椎内固定术治疗,术前抗结核治疗2周,术后规则抗结核治疗1 a.随访了解患者神经功能恢复情况,观察植骨融合情况,比较手术前后cobb角变化.结果 手术顺利,术中无大血管及神经损伤,手术切口均一期愈合,无窦道形成,随访时间1～3a.术后1个月ESR开始下降,术后3～6个月降至正常,植骨块术后6～7个月融合,无移位和吸收,全部骨性愈合,短期随访期间无1例出现内固定松动脱出,无结核病灶复发.末次随访融合节段后凸角4°±2.5°,与术前比较,P＜ 0.05.6例有神经功能障碍患者术后神经功能Frankel分级恢复均达到E级.结论 一期前路病灶清除植骨选择性病椎内固定术治疗胸腰椎结核能有效重建脊柱的稳定性,在病椎局部植入钛质内固定材料对疗效无显著影响.     

胸、腰椎结核前路病灶清除植骨融合内固定术的护理配合

目的 总结31例胸、腰椎结核患者前路病灶清除+植骨融合+内固定术的护理配合经验.方法 做好术前心理护理及术前常规准备,术中密切观察生命体征,正确搬运病人及摆放体位,医护密切配合.结果 31例手术顺利完成,无并发症出现.术后切口均Ⅰ期愈合,植骨均获融合.结论 前路病灶清除植骨融合手术是治疗胸、腰椎结核较理想的方法,认真做好术前准备及术中紧密而完善的配合是保证手术顺利成功的重要环节.     

微创椎弓根螺钉内固定术的治疗进展

微创椎弓根螺钉内固定术是一项新的脊柱微创技术。近年来逐渐应用于胸腰椎骨折、腰椎失稳等疾病的治疗,并得到推广应用,其具有切口小、创伤小、出血少、术后恢复快等优点。该文就其临床应用进展进行综述。     

胸腰椎结核病灶清除加内固定术围手术期的护理

近年来胸腰椎结核发病率明显上升，人们逐渐认识到脊椎稳定性的维护与重建是决定胸腰椎结核远期疗效的关键，也是预防胸腰椎结核复发的重要因素。胸腰椎手术中应用植骨内固定能够解决病灶清除术后由于骨质缺损过多而造成的脊柱不稳定的问题，因此内固定手术的开展越来越被人们所重视。自2004年10月1日至2005年4月31日，我院骨科采用结核病灶清除加内固定术治疗胸腰椎结核16例均取得良好效果，现将围手术期护理体会介绍如下。     

小切口单纯脓肿清除治疗脊柱结核112例分析

目的 探讨小切口单纯脓肿清除引流术治疗脊柱结核合并腰大肌脓肿及流注脓肿的方法、疗效及其临床意义。方法 112例脊柱结核病人在全身抗结核药物治疗的支持下，用局麻或氯胺酮全麻。小切口单纯行寒性脓肿清除术，清除脓液、干酪及肉芽组织，同时局部脓腔用大量生理盐水冲洗，术后低位放置脓腔引流管。结果 脓肿清除术后患者结核中毒症状明显好转，102例一期治愈，5例术后形成脓腔积液，3例术后瘘管形成，2例术后复发行第二次手术。结论 小切口单纯脓肿清除创伤小、手术时间短。脓肿能很好地清除干净，对脓肿毒性反应强、体质差不能耐受大手术、或骨性病灶破坏轻是一个较好的治疗方法，减小了手术风险及患者负担。     

脊柱结核的微创手术治疗进展

脊柱结核是最常见的肺外结核,可导致骨质破坏、脊柱后凸畸形、脊髓神经受压损伤、甚至截瘫等。目前,微创手术作为针对脊柱结核的治疗方法越来越受到重视,包括各种影像学技术实时监控引导下经皮穿刺置管引流、内镜辅助下治疗、微创切口下治疗脊柱结核等一系列微创手术。作者就脊柱结核微创手术治疗的研究进展进行综述。     

Moving beyond the boundary: the emerging role of video-assisted thoracic surgery for bronchoplastic resections

Sleeve resections with parenchymal sparing should be attempted whenever possible when operating a central lung cancer rather than performing a pneumonectomy. Long-term results conclusively favored sleeve procedures in improved survival, quality of life, reduced loss in lung function, and improved operative mortality. Therefore, all surgeons should own this technique in their surgical armamentarium. In the last two decades, the minimally invasive surgical approach has slowly gained positions in Thoracic Surgery and now more and more patients ask for a minimally invasive procedure when surgery is required. This technical revolution in thoracic surgery advocates that almost every open procedure could be done in video-assisted thoracic surgery (VATS). Nevertheless, like all other minimally invasive procedures, VATS sleeve lobectomy has a long learning curve. With the skills and the experience derived from major VATS procedures, these demanding surgical operations may also be performed with a minimally invasive approach.     

左腋下小切口治疗成人动脉导管未闭30例

目的探讨成人动脉导管未闭(PDA)患者左腋下小切口治疗的安全术式及应用价值.方法采用左腋下胸壁小切口,结扎线从胸降主动脉后方转移,对30例成人(20～35岁)PDA患者进行手术治疗.结果30例均获成功,术后第二天即可下床活动,术后杂音消失,无手术并发症,复查心脏彩超无残余分流,随访未见导管再通.结论该术式具有损伤小、不破坏胸廓连续性、瘢痕隐蔽、安全性高、出血少、疼痛轻、恢复快等优点,符合外科微创原则,手术效果满意,适宜治疗成人PDA患者.     

218例电视胸腔镜手术的回顾分析

目的探讨电视胸腔镜或辅助小切口胸部外科手术的临床应用范围与效果。方法采用电视胸腔镜或辅助小切口完成经胸手术218例,范围包括胸膜、胸膜腔、肺、纵隔、食道、心包、膈肌以及胸部创伤等。结果全组病例均按术前计划进行,无中转开胸,无手术死亡和术后严重并发症发生;术中无输血,均痊愈出院。在肺切除术中,优先选择国产一次性缝合材料,手术费用降低20%~30%左右。结论①胸膜的局限性病变,胸膜腔病变,自发性血胸、气胸、血气胸、肺部表浅的孤立性病变,心包、纵隔、食道良性病变、以及创伤后循环稳定的血气胸、肺裂伤、心包伤、膈肌破裂等是胸腔镜的主要适应症。②电视胸腔镜辅助小切口肺叶切除、全肺切除在一次性缝合材料的配合下,手术安全,在恶性肿瘤手术中有常规器械的互补操作,对淋巴结的清除可达到与开胸手术的相同效果。     

经皮椎间孔镜椎板间入路与椎间孔入路治疗腰椎管狭窄症

腰椎管狭窄症是老年人常见病、多发病。手术方式包括开放手术和微创手术。椎间孔镜以其创口小、疼痛轻及恢复快的特点已成为目前治疗腰椎管狭窄症的微创手术首选器械。其手术入路主要分为经皮椎板间入路和经皮椎间孔入路,然而这两种手术入路各有优缺点及适应证。在实际的临床工作中选择椎间孔镜治疗腰椎管狭窄症时,对不同病理类型的腰椎管狭窄症选用合适的手术入路进行治疗,是达到良好手术效果的前提。     

Single-incision laparoscopic colorectal surgery for cancer: State of art

A number of clinical trials have demonstrated that the laparoscopic approach for colorectal cancer resection provides the same oncologic results as open surgery along with all clinical benefits of minimally invasive surgery. During the last years, a great effort has been made to research for minimizing parietal trauma, yet for cosmetic reasons and in order to further reduce surgery-related pain and morbidity. New techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy (SIL) have been developed in order to reach the goal of “scarless” surgery. Although NOTES may seem not fully suitable or safe for advanced procedures, such as colectomies, SIL is currently regarded as the next major advance in the progress of minimally invasive surgical approaches to colorectal disease that is more feasible in generalized use. The small incision through the umbilicus allows surgeons to use familiar standard laparoscopic instruments and thus, perform even complex procedures which require extraction of large surgical specimens or intestinal anastomosis. The cosmetic result from SIL is also better because the only incision is made through the umbilicus which can hide the wound effectively after operation. However, SIL raises a number of specific new challenges compared with the laparoscopic conventional approach. A reduced capacity for triangulation, the repeated conflicts between the shafts of the instruments and the difficulties to achieve a correct exposure of the operative field are the most claimed issues. The use therefore of this new approach for complex colorectal procedures might understandingly be viewed as difficult to implement, especially for oncologic cases.     

结直肠手术中微创技术和理念的进展

近年来随着微创技术的发展,结直肠外科手术取得了重大进步。内镜技术最初作为一项诊查手段,现已越来越多地用于胃肠道疾病的治疗。其中内镜下粘膜切除术和内镜下粘膜剥离术可用于治疗早期结直肠癌,避免了开腹或腹腔镜手术,且体表不遗留手术疤痕。随着器械的完善和技术的进步,腹腔镜技术也已广泛用于结直肠癌的根治性切除,且大量的临床实践证明其具有良好的可行性和安全性。三维腹腔镜的应用改善了术中的视野,提升了腹腔镜操作的精细程度。机器人手术系统的出现则将外科手术引入一个新时代,远程手术得以成功实施,且更加精细灵活的操作可在腹腔镜下狭小的空间里完成。此外,功能学的微创理念日益受到重视。外科医生不仅仅追求更小的切口和创伤,更开始追求更小的应激反应和更快的术后恢复。本文回顾了近年来微创技术和理念的进展,并对微创外科在结直肠手术中的应用做出了展望。     

Thoracoscopic resection of a pericardial cyst.

The development of new instruments that can be applied endoscopically opens up new possibilities for minimally invasive thoracic surgery. The surgical technique is exemplified by a thoracoscopic resection of a pericardial cyst. The benefits for the patient are impressive: minimization of surgical trauma and postoperative pain, a short convalescence, and an optimal cosmetic outcome.     

The evolving application of single‐port robotic surgery in general surgery

Advances in the field of minimally invasive surgery have grown since the original advent of conventional multiport laparoscopic surgery. The recent development of single incision laparoscopic surgery remains a relatively novel technique, and has had mixed reviews as to whether it has been associated with lower pain scores, shorter hospital stays, and higher satisfaction levels among patients undergoing procedures through cosmetically‐appeasing single incisions. However, due to technical difficulties that arise from the clustering of laparoscopic instruments through a confined working space, such as loss of instrument triangulation, poor surgical exposure, and instrument clashing, uptake by surgeons without a specific interest and expertise in cutting‐edge minimally invasive approaches has been limited. The parallel use of robotic surgery with single‐port platforms, however, appears to counteract technical issues associated with single incision laparoscopic surgery through significant ergonomic improvements, including enhanced instrument triangulation, organ retraction, and camera localization within the surgical field. By combining the use of the robot with the single incision platform, the recognized challenges of single incision laparoscopic surgery are simplified, while maintaining potential advantages of the single‐incision minimally invasive approach. This review provides a comprehensive report of the evolving application single‐port robotic surgery in the field of general surgery today.     

Minimally invasive surgery of small intestine

Since the first laparoscopic surgery was performed by Erick Mühe in 1986, multiple minimally invasive techniques have been developed. The small intestine presents several technical difficulties for the application of these techniques, namely: its size, mobilization inside the abdominal cavity, difficulty defining the site under manipulation and the distension association by an ileo or an occlusion. The development of new technology with better cameras and coagulation equipment such as the Harmonic Scalpel and the Ligasure, cutting linear staplers, have permitted the evolution of surgical techniques for the small intestine. Indications for the use of minimally invasive interventions in the treatment of the small intestine are classified as urgent and elective. Lesions secondary to an abdominal cavity puncture were the first to be treated in the small intestine. Abdominal trauma due to a sharp instrument can also be treated through this method. Intestinal occlusion treated without a great dilation can be solved in 55 to 65% of cases. Crohn's disease various surgical treatments are performed by laparoscopy. Obesity surgical treatments, particularly derivative gastroplasty have been carried out successfully by minimally invasive surgery. Gastrojejunoanastomosis or cystojejunoanastomosis are specialized techniques which are performed with minimal invasion; any kind of digestive or urinary stoma can be performed with these techniques. As the surgeon's surgical skills evolve, surgical minimally invasive indications for the small intestine become wider.