超声引导下前锯肌平面阻滞在胸科手术中的应用进展

<正>胸部外科手术常伴随术后疼痛,不仅增加术后肺部并发症的发生,同时延长术后恢复时间。目前常用的胸部区域阻滞镇痛技术各有其局限性[1],近年来一种新颖的胸部神经阻滞技术——超声引导下前锯肌平面阻滞(serratus anterior plane block,SAPB)安全易实行且镇痛效果完善,主要被用于管理前外侧胸壁的疼痛。本文就SAPB的应用解剖、超声引导下不同胸科手术SAPB的入路和方法及其临床效果评价进行综述。SAPB的应用解剖     

超声引导下低位前锯肌平面阻滞对上腹部手术患者术后镇痛及炎症反应的影响

目的 评价超声引导下低位前锯肌平面阻滞(SAPB)对上腹部手术患者术后镇痛及炎症反应的影响.方法 择期上腹部手术患者120例,男69例,女51例,年龄18～65岁,ASAⅠ或Ⅱ级.随机分为三组:对照组(C组,n=39),不行神经阻滞;常规SAPB组(SAPB组,n=40),全麻诱导前超声引导下双侧腋中线第5肋水平前锯肌...     

超声引导下不同阻滞方法的镇痛效果比较

目的比较超声引导下前锯肌平面阻滞(SAPB)与硬膜外阻滞在胸外科术后镇痛效果。方法选取2018年10月至2019年10月于本院择期行胸外科手术患者80例,随机分为前锯肌平面阻滞组(A组)与硬膜外阻滞组(B组),每组40例。于术后3、9、27小时采用数字分级评分法(NRS)评定患者疼痛情况,统计术后24小时内镇痛药用量及不良反应例数用于比较两组术后镇痛效果。结果术后两组NRS评分差异无统计学意义(P0.05);两组术后24小时内镇痛药用量差异无统计学意义(P0.05);A组不良反应发生例数小于B组,差异有统计学意义(P0.05)。结论超声引导下SAPB用于胸外科手术术后镇痛不良反应例数少安全性高,建议在临床推广应用。     

超声引导下前锯肌平面阻滞的研究进展

前锯肌平面阻滞是一种新颖的局部肌肉筋膜阻滞技术,被广泛应用于胸部及腹部手术后的疼痛管理。超声引导下平面阻滞具有可视化、定位准确、安全性高、舒适度高等优点。本文回顾了近年来国内外对超声引导下前锯肌平面阻滞的研究,对前锯肌阻滞的解剖,超声引导下阻滞层面,穿刺入路,不同手术中的应用和使用的药物种类与注射容量方面进行综述,为其临床使用提供参考。     

血府逐瘀汤联合超声引导下行连续前锯肌平面阻滞对单纯肋骨骨折患者镇痛及骨折愈合疗效观察

本研究旨在比较分析血府逐瘀汤联合超声引导下的前锯肌平面阻滞(SAPB)治疗、血府逐瘀汤联合消炎止痛药物治疗以及单独的SAPB治疗对单纯性肋骨骨折患者的疼痛程度和骨折的愈合效果。     

前锯肌平面阻滞与胸椎旁神经阻滞用于胸腔镜手术患者术后镇痛效果的比较

目的比较前锯肌平面阻滞与胸椎旁神经阻滞用于胸腔镜手术患者术后的镇痛效果。方法选择择期行胸腔镜手术患者60例,男38例,女22例,年龄18～65岁,BMI 18～25kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法分为前锯肌平面阻滞组(S组)和胸椎旁阻滞组(T组),每组30例。两组患者均采用支气管插管静脉全身麻醉,术后采用PCIA。S组于麻醉诱导前行超声引导下前锯肌平面阻滞,T组则行超声引导下胸椎旁阻滞,两组均使用0.4%罗哌卡因30ml,阻滞完成后30min使用针刺法测定并记录感觉阻滞平面;记录阻滞操作时间、起效时间、持续时间;记录术后2、4、8、12、24、48h的静息和咳嗽VAS评分;记录首次按压镇痛泵时间、术后48h内镇痛泵有效按压次数、舒芬太尼使用总量和哌替啶补救性镇痛例数;记录阻滞相关并发症、镇痛不良反应发生情况。结果与T组比较,S组阻滞操作时间明显缩短,阻滞持续时间明显延长(P0.01);S组术后12h静息时和咳嗽时VAS评分明显降低(P0.01),S组PCIA首次按压时间明显延长,S组PCIA 48h内按压次数、舒芬太尼使用量明显减少(P0.01),两组气胸、恶心呕吐发生率差异无统计学意义。结论超声引导下前锯肌平面阻滞或胸椎旁阻滞均可为胸腔镜手术患者提供良好术后镇痛,但前锯肌平面阻滞较胸椎旁阻滞作用更持久、操作时间更短、并发症更少,且能有效减少患者术后对阿片类药物的需求量。     

超声引导下前锯肌神经阻滞在胸腔镜肺叶切除术中的应用效果分析

目的探讨超声引导下前锯肌神经阻滞(Serratus anterior plane block,SAPB)在胸腔镜肺叶切除术中的应用效果。方法选取本院收治的择期行胸腔镜肺叶切除术的90例患者为研究对象,随机分为试验组和对照组各45例,两组均采用静吸复合全身麻醉,观察组在全身麻醉基础上复合SAPB,两组患者均在手术结束缝皮前开启静脉自控镇痛(PCIA),记录并比较两组患者的麻醉效果、术后24小时QoR-40评分、VAS评分、手术总费用及术后不良反应的发生情况。结果与对照组相比,观察组患者术中及术后24小时舒芬太尼用量及PCIA按压次数均显著减少(P0.05),术后苏醒时间和恢复自主呼吸时间亦显著缩短(P0.05),术后24小时的QoR-40评分、VAS评分均具有显著优势(P0.05);两组患者的手术总费用比较差异无统计学意义(P0.05)。观察组患者术后恶心、呕吐、眩晕等不良反应发生率(13.3%)与对照组(8.9%)相比,差异无统计学意义(P0.05)。结论超声引导下前锯肌神经阻滞(SAPB)麻醉手法能够显著减少胸腔镜肺叶切除术中及术后麻醉药物用量,提高患者全身麻醉术后恢复质量,改善患者术后疼痛情况,且临床应用安全性高,具有较好的临床应用价值。     

超声引导下前锯肌和竖脊肌平面阻滞在微创肺癌根治术中的应用价值

目的 探讨超声引导下前锯肌和竖脊肌平面阻滞在微创肺癌根治术快速康复中的应用价值。方法 回顾性分析2017年5月至2019年11月扬州市江都人民医院收治的120例行微创肺癌根治术患者的临床资料。按照术中麻醉和术后镇痛方案的不同随机分为两组,每组60例。A组为对照组,麻醉方式为全麻插双腔管,镇痛方式为静脉自控镇痛泵镇痛;B组为观察组,麻醉方式为全麻双腔气管插管,镇痛方式为超声引导下前锯肌、竖脊肌平面阻滞+静脉自控镇痛泵镇痛。观察两组患者术中指标、术后镇痛效果及临床相关指标。结果 120例患者均顺利完成手术。两组患者术中心率。血压、血氧饱和度等指标比较无统计学差异（P>0.05）,两组患者术后疼痛评分、术后头昏发生率、术后恶心呕吐发生率、术后肺部感染发生率、术后下床活动时间等指标比较差异有统计意义（P<0.05）。结论 超声引导下前锯肌和竖脊肌平面阻滞具有良好的镇痛效果,可以达到术后快速康复的目的。     

前锯肌平面阻滞与胸椎旁阻滞用于胸外科手术患者术后镇痛效果的Meta分析

目的 比较超声引导下前锯肌平面阻滞(SAPB)与胸椎旁阻滞(TPVB)对胸外科手术患者术后镇痛的效果。方法 检索Cochrane、Pubmed、Embase、Web of Science、中国知网、维普、万方和中国生物医学全文数据库,纳入SAPB与TPVB在成人胸外科手术后镇痛比较的随机对照试验(RCT)。按照Cochrane指导手册选择文献、提取资料及评价研究质量。采用RevMan 5.4进行Meta分析。结果 共纳入8篇RCTs,共计434例患者,其中SAPB组217例,TPVB组217例。两组术后1、2、4、6、12、24、48 h的静息及活动时VAS疼痛评分差异无统计学意义。SAPB组术后48 h内阿片类药物用量明显低于TPVB组(MD=-9.34μg, 95%CI-17.1～-1.58μg,P=0.02),低血压发生率明显低于TPVB组(RR=0.23, 95%CI 0.07～0.76,P=0.02)。结论 超声引导下SAPB与TPVB对胸外科手术患者术后镇痛效果相当,但采用SAPB患者术后阿片类药物用量明显减少、低血压发生率明显降低。     

超声引导下低位前锯肌平面阻滞和腰方肌阻滞用于腹腔镜肾癌根治术的比较

目的比较超声引导下低位前锯肌平面阻滞(SAPB)和腰方肌阻滞(QLB)用于腹腔镜肾癌根治术的应用效果。方法选择行腹腔镜肾癌根治术患者90例,男55例,女35例,年龄18～80岁,BMI 19～28 kg/m~2,ASAⅠ或Ⅱ级。将患者随机分为三组:SAPB联合全麻组(S组)、QLB联合全麻组(Q组)和单纯全麻组(G组),每组30例。记录神经阻滞操作时间、神经阻滞起效时间、神经阻滞范围、神经阻滞相关并发症发生情况。记录术后0.5、2、12、24、48 h静息和活动时VAS疼痛评分。记录术中丙泊酚和瑞芬太尼用量、补救镇痛例数、术后48 h内镇痛泵按压次数及患者镇痛满意度评分。结果 S组阻滞操作时间和阻滞起效时间明显短于Q组(P0.05)。术后0.5、2、12、24 h S组和Q组静息和活动时VAS疼痛评分以及术后48 h活动时VAS疼痛评分明显低于G组(P0.05)。S组和Q组术中丙泊酚和瑞芬太尼用量明显少于G组(P0.05),补救镇痛率明显低于G组(P0.05),镇痛泵按压次数明显少于G组(P0.05),镇痛满意度评分明显高于G组(P0.05)。S组阻滞平面集中在T_6—T_(11),Q组阻滞平面集中在T_7—L_1。结论低位SAPB和QLB均可有效缓解腹腔镜肾癌根治术患者术后早期切口痛,减少术中全麻药物用量以及术后镇痛药物用量。与QLB比较,低位SAPB操作更简单、起效时间短,适宜在临床推广应用。     

胸腰筋膜平面阻滞在脊柱外科手术围术期的应用进展

胸腰筋膜平面（TLIP）阻滞是一种用于腰椎术后镇痛的筋膜间平面阻滞技术。随着超声技术的普及,TLIP阻滞被广泛应用,能提供良好的术后镇痛,减少术中及术后阿片类药物的用量,且操作简单、并发症少。目前TLIP阻滞主要用于腰椎融合术、腰椎间盘切除术以及椎板成型术等腰椎手术的多模式镇痛。此外,TLIP阻滞还可用于微创脊柱外科手术的麻醉,如经皮椎间孔镜手术、经椎间孔入路腰椎椎间融合术和脊髓刺激器的植入等。本文对TLIP阻滞的解剖学基础、作用机制、临床应用及并发症等方面作一综述,以期为脊柱外科手术的麻醉及多模式镇痛提供参考。     

Minimally invasive anterior approach to upper cervical spine: surgical technique

OBJECTIVE: The transoral approach of Spetzler is the classic anterior access to the upper cervical spine that provides direct exposure for anterior decompression of the spinal cord. The risks of infection, the limits in extension, and the postoperative recovery difficulties of transmucosal access suggest the use of an alternative anterior extraoral approach in upper cervical surgery. However, this approach results in complications from nerve palsy because of excessive retraction of the hypoglossal and the superior laryngeal nerves. The goal of this work was to provide anatomic data for an anterior retropharyngeal upper cervical approach through a minimally invasive window below the hypoglossal and the superior laryngeal nerves. METHODS: In two adult cadaveric cervical spines, the anterior approach using the Metrx tubular retractor system through a window between the hypoglossal nerve and the superior laryngeal nerve, as well as below these two nerves, is compared in the exposure of C1 and C2 anteriorly with the aid of an operating microscope. RESULTS: A maximum diameter of the internervous window for the tubular retractor is reached beyond which the superior laryngeal nerve will be excessively stretched. Conversely, the tubular retractor can retract the superior laryngeal nerve superiorly without undue tension. Better proximal exposure is also made possible by angling an end-beveled tubular retractor on the mandible without undue compression on the hypoglossal and superior laryngeal nerves, the marginal mandibular branch of the facial nerve, and the submandibular gland. CONCLUSION: This minimally invasive approach can replace transoral surgery, allowing direct anterior access to C1 and C2 while allowing extension to the lower cervical spine.     

Severe incisional pain and long thoracic nerve injury after port-access minimally invasive mitral valve surgery

The authors describe the occurrence of severe postoperative pain and long thoracic nerve injury after Port-Access minimally invasive mitral valve surgery. The potential for these events and the impact on postoperative hospitalization and rehabilitation are emphasized.     

Thoracoscopic debridement and stabilization of pyogenic vertebral osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.     

Day zero ambulation under modified femoral nerve block after minimally invasive surgery for total knee arthroplasty: preliminary report

Ambulation in the early postoperative period of total knee arthroplasty is crucial, in order to avoid complications and obtain preferable outcomes. Although a femoral nerve block can provide enough postoperative analgesia after total knee arthroplasty, falling, or other accidents due to motor paresis, are potentially adverse events in patients who have received a conventional femoral nerve block. We devised a modified femoral nerve block to spare voluntary knee extension ability, and clinically applied it to patients who received total knee arthroplasty under minimally invasive surgery. In our new-approach nerve blockade technique, the main targets of the sensory nerves are the saphenous nerves which branch out from the femoral nerve trunk. All the patients rated pain at bed rest between 0 and 3 on a numerical rating scale 3 h after the operation. In addition, the rectus femoris muscle was not affected at all, and the surgically invaded vastus medialis oblique muscle was completely anesthetized. Patients were able to not only actively raise their extremities with their knee in extension, but also to flex the knee in the air without pain or aggravation. On day 0, the patients were able to walk around, with the leg that had been operated upon not giving way. Our anesthetic approach can provide better pain relief than a conventional femoral nerve block, while the patients achieve ambulation on the day of the procedure, following minimally invasive knee surgery.     

2019年度中国微创心血管外科手术统计

近年来,微创心血管外科的发展呈现迅猛势头.为促进我国微创心血管外科紧跟国际发展脚步,国家心血管病专家委员会微创心血管外科专业委员会(Chinese Minimally Invasive Cardiovascular Surgery Committee,CMICS)自成立以来,逐步规范中国微创心血管外科手术数据统计及报告...     

左胸微创切口在儿童干下型室间隔缺损直视修补术中的应用

目的总结左胸微创切口在儿童干下型室间隔缺损(ventricular septal defect,VSD)直视修补术中的应用方法,并评价临床效果。方法回顾性分析2015年10月至2019年4月上海交通大学医学院附属新华医院心胸外科21例干下型VSD儿童的临床资料,其中男13例、女8例,年龄5~13(9.1±2.2)岁,体重22~55(35.6±9.5)kg。VSD最大直径4~15(9.1±3.3)mm,术前合并主动脉瓣右冠瓣轻度脱垂8例,主动脉瓣轻到轻中度关闭不全4例。取左侧第2或第3肋间胸骨旁横切口进胸,股动、静脉插管建立体外循环,阻断升主动脉后,在肺动脉瓣上横行切开肺动脉,根据VSD大小、形态直接缝合或补片修补干下型VSD。出院前及随访常规复查经胸超声心动图评价VSD修补效果及主动脉瓣开闭情况。结果全组患儿均顺利经左胸微创切口完成VSD直视修补术,无转为正中开胸手术者。VSD修补方法:补片修补(n=15),直接缝合(n=6)。体外循环时间45~68(57.1±6.3)min,主动脉阻断时间23~40(32.6±4.7)min,术后呼吸机辅助时间5~9(6.3±1.3)h,术后24 h胸腔引流量33~105(57.5±17.7)mL,术后住院时间5~8(5.7±1.0)d。出院前及随访复查经胸超声心动图提示VSD闭合良好,无VSD残余漏;主动脉瓣轻度关闭不全1例。围术期及随访无死亡病例,无房室传导阻滞、切口愈合不良、胸廓畸形等并发症发生。结论左胸微创切口可安全、有效地应用于儿童干下型VSD直视修补术中,早、中期治疗效果满意。     

Intraoperative neuromonitoring in thoracoscopic excision of brachial plexus schwannoma

Mediastinal schwannoma arising from brachial plexus are rare, but their surgical treatment could be challenging with a minimally invasive approach, given their position. Furthermore, their proximity to brachial plexus nerve fibres raises the risk for postoperative upper limb deficits. A 72-year-old man presented mediastinal schwannoma arising from the T1 nerve root. Complete surgical excision was achieved via video-assisted thoracic surgery with the aid of intraoperative neuromonitoring, and no postoperative neurological deficit developed after the intervention. Using intraoperative neuromonitoring, radical minimally invasive surgical treatment can be safely achieved for mediastinal schwannoma arising from brachial plexus.     

The ALIF concept

The terms ‘minimally invasive’ or ‘less invasive surgery’ have been used recently to describe surgical approaches or operations that are performed with less trauma to anatomical structures on the way to or surrounding the surgical ‘target area’. These types of surgical procedures are usually performed with the help of ‘high-tech’ instruments such as surgical endoscopes or surgical microscopes, modern video techniques and automated instruments. Within the last 10 years, such techniques have been developed in the field of spinal surgery. The application of minimally or less invasive procedures has concentrated predominantly on anterior approaches to the thoracic and lumbar spine. This article describes two anterior approach techniques for performing anterior lumbar interbody fusion (ALIF) through a minimally invasive retroperitoneal or transperitoneal approach. The technical principles are microsurgical modifications of traditional anterior approaches to the lumbar spine. Through small (4-cm) skin incisions, the target area can be exposed. Preliminary results suggest decreased peri - and postoperative morbidity, less blood loss, earlier rehabilitation and acceptable complication rates. The technique is currently used by the author for all patients requiring anterior lumbar interbody fusion.