21世纪骨科微创技术发展的评价

微创技术是20世纪后半叶兴起的一项新的外科技术.自从1985年英国泌尿外科医生Payne和Wickham首次提出"微创外科(minimally invasive surgery,MIS)"的概念[1],1987年法国医生Mouret成功施行了世界首例腹腔镜胆囊切除术[2]以后,"微创外科"才逐渐被广泛接受.目前微创外科技术还没有确切的定义,通常是指以最小的侵袭和最小的生理干扰达到最佳外科疗效的一种新的外科技术[3],它不是独立的新学科或新的分支学科,而是一种比现行的标准外科手术具有更佳的内环境稳定状态、更小的手术切口、更轻的全身反应、更少的瘢痕愈合、更短的恢复时间、更好的心理效应的手术[4].     

微创外科的发展与21世纪的外科学

微创外科（ｍｉｎｉｍａｌｌｙ ｉｎｖａｓｉｖｅ ｓｕｒｇｅｒｙ）是近２０年来高速发展的新兴学科,而它的主体－－内镜外科（ｅｎｄｏｓｃｏｐｉｃ ｓｕｒｇｅｒｙ）却经历了漫长曲折的发展过程,可追溯至２００年前内镜的起源。内源“ｅｎｄｏｓｃｏｐｙ”一词起源于希腊语,“ｅｎｄｏ”指内部之意,风镜外科在相当长的一段时期处于停 滞状态,直到１９７８年第一例腹腔镜胆囊切除术（ＬＣ）问世,才进入了一个高速发展的新纪元＾〔１〕。内镜外科的发展和形成大致经历了４个阶段。     

微创外科与外科微创化——21世纪外科的主旋律

一、从生物进化角度对外科微创化的思考创伤是动物在自然界中经常遇到的事件。在人类社会中 ,外科手术给身体造成的创伤 ,同样破坏了人机体的内环境稳定。为了生存 ,在亿万年的生物进化过程中 ,机体建立起对创伤的适应性反应 ,现时称之为全身炎症反应 (ＳＩＲ)。创伤反应的目的是重新恢复内环境稳定。当创伤达到一定程度 ,它将不是局部的而是全身性事件 ,亦即所谓 :“牵一发而动全身”。创伤是影响物种生存的一个重要的自然因素。哺乳类动物通过修复创伤来维持种系生存。人类继承动物界远祖的遗传特性 ,包括对创伤的适应性反应。 185 9年达…     

浅谈21世纪外科的发展

现代外科学奠基于１９世纪４０年代，经历一个多世纪以来的发展，先后解决了手术疼痛、伤口感染、止血及输血。从萌发到成熟，形成了雄厚的基础理论和积累了丰富的实践经验。２０世纪末期由于显微外科技术的进展、各种纤维光束内镜的出现，计算机技术，特别是生物工程技术...     

21世纪外科的发展与前景

传统普通外科的极盛时代 2 0世纪过去了 ,年长的外科学家都曾见证 ,2 0世纪后半期外科学的迅速发展 ,在这短短的 5 0年中 ,新的领域的开拓、新的“禁区”被打开 ,使人眼花缭乱。外科学的发展带来了医疗上的巨大成就 ,例如人工心肺机的发明、心脏血管外科的发展、临床器官移植的成功、重症ICU的建立、创伤、感染的代谢研究、肠外营养支持的应用、癌症外科治疗、微创外科思潮的兴起 ,均标志着外科学所取得的巨大成就。而这种技术上的发展 ,随着相关学科的尖端科技的发展而加速。 2 1世纪的外科将更是缤纷多采的 ,微创外科思潮的兴起 ,将在多…     

虚拟人体将为微创外科增添新的技术

“虚拟人体”还是一个较新的学术名词。目前这个领域的理论和技术研究尚不成熟 ,不过其中已有一部分在医学教育及临床工作中 ,初步得到开发和应用。我注意到 ,在本刊 2 0 0 3年第一期的会讯中 ,“2 0 0 3年全国微创外科新进展学术研讨会”的通知里 ,在邀请海内外知名专家介绍最新技术的内容中 ,已经出现了“虚拟外科手术”这个项目。说明数字化虚拟人体的初步研究 ,正为微创外科增添新的技术。微创外科以其创伤小、康复快的特点 ,得到医学界的重视和患者们的欢迎。这个新兴分支学科 ,之所以能够得到迅猛的发展 ,与新设备、新材料、新技术、…     

21世纪骨科领域新技术--微创外科

近年来,微创技术在骨科领域的应用日益广泛。骨折治疗的观念正在由生物力学向生物学微创固定转变,关节镜介导的微创技术在临床上的应用取得了惊人的发展,内镜介导的微创脊柱外科治疗技术显示了良好的发展前景,四肢和脊柱疾患的经皮微创技术取得了长足进步,计算机辅助的手术导航系统、手术模拟系统、远程会诊和远程机器人遥控手术等微创技术受到了广泛的关注,将微创技术应用于显微外科,已成为减少供区破坏、保存美观的有效手段。新的影像技术和介入放射技术的发展,为微创技术在骨科领域的应用提供了强有力的手段,激光、射频消融、微波、冷冻、聚焦超声等新的治疗手段和纳米技术、基因治疗的发展及组织工程研究的深入为骨科疾患的微创治疗拓展了更为广阔的发展空间。因此,21世纪的微创外科具有诱人的前景,可望成为骨科领域新的生长点。     

上颈椎微创外科技术及其适应证

近年来,微创脊柱外科手术在我国较广泛地开展,特别是经皮手术和内窥镜下手术,取得了不少经验,也存在一些问题。本刊特邀请国内本领域专家就相关问题进行讨论,供同道参考。     

脊柱外科的微创意识、微创观念与微创技术

外科学是一门主要依靠手术治疗疾病的学科。脊柱外科为外科学的一个分支学科。脊柱外科手术一般组织创伤大．操作风险高。保护健康组织、恢复机体功能是脊柱外科的治疗目的，也是必须遵循的基本原则。以最小的创伤达到最佳的疗效，可以理解为微创脊柱外科的内涵。微创脊柱外科的发展在欧美发达国家已融入远程医学．远程微创手术疑难病例会诊、手术方案的制定以及由机器人实施远程遥控手术已进入现实生活。我国少数先驱者在计算机仿真研究领域中也取得了可喜的进展，但更多的脊柱外科医生还是在临床工作中从传统手术中探索微创脊柱外科的途径。我国微创脊柱外科技术与发达国家出现差距的主要原因是：缺乏明确的微创意识，缺乏坚定的微创观念和扎实的微创技术。     

从微创技术到微创观念——今日外科与明日外科

微创外科与外科微创化思潮已成为当前21世纪外科的潮流，微创的理念是：①减少创伤量的总和，包括机械、生理、心理、精神上的不良刺激，因而覆盖整个围手术期；②减轻过剧的应激反应；③调控创伤反应的过程；④改善创伤愈合。以腹腔镜外科为核心技术的微创外科随着微创外科观念的深入，正不断地扩展、深入，并与传统的开放手术外科融合，正在形成21世纪外科的新模式。肝、胆、胰外科是腹部外科中创伤最大的手术，自然亦可能从微创外科获得最大的益处。     

Ergonomic testing of two different types of handles via virtual reality simulation

Background Ergonomics in laparoscopic surgery is an unsolved problem. Deficiencies of the instrument handles are well-known and described in several reports and studies. Today, virtual training modules for laparoscopic surgery are available. The aim of this study was to evaluate the ability of a virtual reality (VR) simulator to determine the ergonomic properties of two different laparoscopic instrument handles. Methods Two different types of handles, a ring and an axial handle from Richard Wolf, were used to perform the short clip and cut task of the Xitact 500 LS simulator. The task was repeated every 2 days for a period of 5 weeks. After every trial the volunteers were asked structured questions about their preferences while using the two handles. Results The axial handle was superior or equal to the ring handle in all criteria. Learning curves over the entire time and day by day were similar. No differences were found for travel distances and error rates, but task times were different for both handles. The subjects preferred the axial handle at the end of the study. Conclusion It is possible to determine differences in ergonomics of handle design with a VR trainer. In this study, the Richard Wolf axial handle was superior to the ring handle.     

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

Background  Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation. Methods  A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education. Results  The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence. Conclusions  In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.     

Technical skills assessment as part of the selection process for a fellowship in minimally invasive surgery

Introduction

Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates’ technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice.

Materials and methods

Prospective study. Eight surgeons, applying for a fellowship position in minimally invasive surgery (MIS), performed a previously validated assessment curriculum using a Virtual-Reality Laparoscopic Trainer (LapSim^® 3.0, Surgical Science, Gothenburgh, Sweden). Technical performance was evaluated using criteria registered by the simulator, i.e., time, error score, and efficiency of movements score. Candidates performed all the tasks in easy end medium level until reaching predefined criteria. If proficiency criteria were not achieved on easy or medium level after nine repetitions the test was considered as failed. Additionally, all applicants underwent an interview by two independent attending surgeons. Each applicant received a grade on a ten-point scale.

Results

Five out of the eight candidates failed the technical skills assessment test. One candidate failed to achieve proficiency criteria on easy level, one on medium, and three on difficult level. Evaluation scores, based on the interview of the candidates showed a good interrater reliability (Cronbach’s α = 0.8). There was no significant correlation between the interviewers rating, and the applicants technical skills demonstrated during the test on the VR trainer (Spearman’s ρ = 0.182, p = 0.696).

Conclusions

Evaluations by senior surgeons are reproducible and reliable. The introduction of technical skills assessment has the potential to improve the current method of candidate selection, making it more valid, objective, and transparent.     

微创时代胃肠外科的发展趋势

The development of science and technology dramatically promotes the application of minimally invasive technique in the field of gastrointestinal surgery.Today,almost all kinds of gastrointestinal operations can be accomplished through or with the assistance of a laparoscope.Compared to traditional open surgery,lapm'oscopic surgery,which is accomplished by experienced surgeons.can leads to a similar or even better surgical outcome.Although the endoscopic technique was firstly invented as a diagnostic method,its application has expanded to many different medical areas.Now,endoscopic gastrointestinal polypectomy is extensively applied in primary hospitals.Moreover,endoscopic mucosal resection and endoscopic submucosal dissection are also ca~ied out in many large medical centers in China.More and more patients are benefiting a lot from the minimally invasive technique.As the concept of minimally invasive technique is widely accepted,minimally invasive surgery will be a major aspect in the development of gastrointestinal surgery.As a contemporary gastrointestinal surgeon,it is imperative to handle the minimally invasive technique proficiently.     

微创手术平台与微创手术方式的未来走向

近30年来,随着能量平台、器械平台、显像平台三大手术平台的发展,微创外科有了突飞猛进的提升。以结直肠癌手术为例,手术方式的五要素都有着不同程度的发展：手术入路经历了"从大到小"的过程;切除范围从单纯肠段切除到根治术或扩大根治术,再到注重保留器官功能的手术;随着对正常淋巴引流方向和肿瘤淋巴转移特点的认知,淋巴结清扫愈趋规...     

Challenges to the development of complex virtual reality surgical simulations

Virtual reality simulation in surgical training has become more widely used and intensely investigated in an effort to develop safer, more efficient, measurable training processes. The development of virtual reality simulation of surgical procedures has begun, but well-described technical obstacles must be overcome to permit varied training in a clinically realistic computer-generated environment. These challenges include development of realistic surgical interfaces and physical objects within the computer-generated environment, modeling of realistic interactions between objects, rendering of the surgical field, and development of signal processing for complex events associated with surgery. Of these, the realistic modeling of tissue objects that are fully responsive to surgical manipulations is the most challenging. Threats to early success include relatively limited resources for development and procurement, as well as smaller potential for return on investment than in other simulation industries that face similar problems. Despite these difficulties, steady progress continues to be made in these areas. If executed properly, virtual reality offers inherent advantages over other training systems in creating a realistic surgical environment and facilitating measurement of surgeon performance. Once developed, complex new virtual reality training devices must be validated for their usefulness in formative training and assessment of skill to be established.     

直视微创心脏外科手术临床应用108例

目的 总结直视微创心脏外科手术临床应用的初步效果和优点.方法 2010年4月至2011年8月,完成直视微创心脏外科手术108例,其中男44例,女64例;平均年龄(44.3±16.4)岁;平均体重(60.0±12.0)kg.二尖瓣置换(MVR) 29例,主动脉瓣置换(AVR) 17例,二尖瓣成形术(MVP)5例,MVR+ AVR 6例,室间隔缺损修补术(VSD)12例,房间隔缺损修补术(ASD) 23例,不停跳直视微创冠状动脉旁路移植术( M1DCAB)9例,MVR+ CABG术1例,部分型心内膜垫缺损矫治术(PECD)2例,Ebstein畸形矫治术1例,三尖瓣隔叶腱索断裂修复术1例.同期手术包括三尖瓣成形术(TVP) 19例,射频消融术11例.除MIDCAB术外,其余手术均在闭式体外循环下完成.2例中转常规开胸完成.结果 体外循环36～260 min,平均(104.4±59.3) min;主动脉阻断0～204.0 min,平均(66.7±52.8)min.心脏停跳下实施手术80例,术后自动复跳74例;气管插管2.0～90.0 h,平均(14.5±11.9)h;ICU 停留4.0～138.0h,平均(18.8±15.3)h;术后住院3.0～24.0天.平均(6.9±2.9)天;切口长度3.5～10.0 cm,平均(5.3 ±1.2) cm;术后第1天引流量(337.6±240.9)ml;未输血者72例,围手术期及出院后近期无死亡,无二次开胸止血和胸骨切口感染者.出院时心功能Ⅰ级94例、Ⅱ级8例、Ⅲ级6例.结论 直视微创心脏外科手术的近期效果良好,手术安全性高,适用范围广;具有创伤小,出血和输血少,切口美观,无胸骨感染,并发症和病死率少等优点.     

Impact of hand dominance,gender, and experience with computer games on performance in virtual reality laparoscopy

Background: The impact of gender and hand dominance on operative performance may be a subject of prejudice among surgeons, reportedly leading to discrimination and lack of professional promotion. However, very little objective evidence is available yet on the matter. This study was conducted to identify factors that influence surgeons performance, as measured by a virtual reality computer simulator for laparoscopic surgery. Methods: This study included 25 surgical residents who had limited experience with laparoscopic surgery, having performed fewer than 10 laparoscopic cholecystectomies. The participants were registered according to their gender, hand dominance, and experience with computer games. All of the participants performed 10 repetitions of the six tasks on the Minimally Invasive Surgical Trainer—Virtual Reality (MIST-VR) within 1 month. Assessment of laparoscopic skills was based on three parameters measured by the simulator: time, errors, and economy of hand movement. Results: Differences in performance existed between the compared groups. Men completed the tasks in less time than women (p = 0.01, Mann–Whitney test), but there was no statistical difference between the genders in the number of errors and unnecessary movements. Individuals with right hand dominance performed fewer unnecessary movements (p = 0.045, Mann–Whitney test), and there was a trend toward better results in terms of time and errors among the residence with right hand dominance than among those with left dominance. Users of computer games made fewer errors than nonusers (p = 0.035, Mann–Whitney test). Conclusions: The study provides objective evidence of a difference in laparoscopic skills between surgeons differing gender, hand dominance, and computer experience. These results may influence the future development of training program for laparoscopic surgery. They also pose a challenge to individuals responsible for the selection and training of the residents.     

微创技术在胆道外科应用的现状

Minimally invasive biliary surgery developed rapidly and laparoscopic cholecystectomy has become the"gold standard"for the treatment of benign gallbladder disease.Combined application of endoscopic and ultrasonic technology improved the diagnosis of biliary diseases.Endoscopic balloon dilation or sphincterotomy of duodenal papilla to remove connon bile duct stones and internal biliary stent placement under ERCP for obstructive jaundice caused by biliary tumors provided safe and satisfactory therapeutic effect.However,in the laparoscopic era,minimally invasive techniques should still be used in conjunction with traditional biliary surgery.Meanwhile,strict indication should be emphasized to avoid the occurrence of complications.