微创外科技术及器械的创新发展新方向

微创外科在外科领域的应用已经历逾30年高速发展, 微创技术及器械在能量平台、成像设备等领域的持续发展不断促进腹腔镜手术向更精准、更安全进步, 而腹腔镜学科本身的发展也不断反哺微创技术和器械创新。近年, 微创技术及器械的创新发展与当前科技前沿更加紧密结合, 在机器人化、无屏化、智能化、电动化、虚拟化等新理念方面取得创新成果。新时代的微创外科医师需时刻紧盯科技前沿, 时刻思考外科与科技的结合, 将先进科技应用于解决当下外科痛点, 为微创外科的下一步发展注入新活力。     

腹部微创外科的过去、现在与未来

过去的100年,科技进步为外科领域带来了众多新器械、新技术、新观念,以腹腔镜技术为代表的微创手术方兴未艾。光学技术、微型化技术和机器人技术的发展为微创外科开辟了广阔的应用前景,遥控机器人手术、经自然孔道手术和新型手术导航系统将在不远的将来进入临床,使微创外科发生前所未有的变革。本文回顾了微创外科的发展历程,及其在腹部外科的应用现状与发展方向。     

单孔腹腔镜技术在肝胆外科的应用进展

随着外科微创理念的更新、腔镜技术与器械的进步,单孔腹腔镜技术日趋完善,在肝胆外科的应用日趋广泛。本文现对单孔腹腔镜技术在肝胆领域的进展、优势及局限性作一综述。     

肺癌微创外科治疗的现状及进展

1历史和现状 随着器械外科技术的不断完善，推动了微创外科（minimally invasive surgery）技术的迅速发展，至20世纪90年代初诞生的电视胸腔镜外科，对器械外科技术提出了更高的要求，使器械缝合材料、切割技术、安全性保证和应用方便等方面都得到极大的改进，可以很方便快捷、安全有效的应用于各种肺切除术中。自1992年McKenna完成第1例胸腔镜下解剖性肺叶切除术以来，微创和器械外科技术在肺癌外科治疗中的应用日趋广泛，二者相辅相成，共同发展，使肺癌外科技术发生了巨大的变化，同时也成为每一个胸外科医师应该熟练掌握的手术技能之一。     

我国肝癌肝切除技术发展之路

肝细胞癌（以下简称肝癌）是我国常见的一种消化道肿瘤,肝切除手术是早中期肝癌的最主要的治疗手段之一。与发达国家相比,我国的肝切除技术起步相对较晚。经过了几代肝脏外科医师的不懈努力,我国的肝癌肝切除技术取得了令人瞩目的成就。进入21世纪以来,随着外科理念的更新、影像学技术的进步、微创外科的发展以及手术器械的改进,肝癌肝切除领域进展迅猛,主要体现在：术前评估精确化、肝切除技术微创化、肝切除理念标准化以及肝癌肝移植适应证扩大化。作为外科医师应谨记,任何技术的进步和理念的更新都应该从为病人服务出发,对于临床上遇到的每例病人,都是完全不同的个体,需要强调治疗方案选择的个体化和合理化。     

整形与美容外科的微创概念和诊疗范畴研究

在医学领域里,"微创技术"一词的出现至今已有30年历史,微创的概念也逐渐被普通外科、骨科、妇产科、泌尿外科、胸外科、耳鼻喉科等外科领域的学科所认同.因此,微创表述的主要是一种诊疗理念,不单纯特指哪个学科、某种技术或术式[1],而且也并非因"微创外科"一词出现才有微创的诊疗理念.外科领域很多学科有关微创的认识甚至微创的技术应用均远先于"微创技术"一词的出现.就整形外科而言,其诞生之初的基本原则、手术操作基本技术无不显示出微创的观念.可以认为"微创"原则是整形外科的建科之本.然而,当今世界微创观念在外科领域的发展迅速,因此认真总结整形与美容外科领域的微创理念和内涵,明确其诊疗范畴有利于推动整形外科与医疗美容事业的发展.     

《中国微创外科杂志》稿约

《中国微创外科杂志》是北京大学主办，北京大学第三医院承办，反映国内外微创技术进展的学术期刊。报道普通外科各专业、小儿外科、心胸外科、骨科、运动医学、神经外科、泌尿外科、血管外科、妇科、辅助生殖医学、耳鼻喉科、颌面外科、放射介入科、超声介入科、肿瘤科等领域微创技术的临床实践经验及相关的实验研究，器械的改进与发明。本刊以从事微创外科各领域高中级医务人员为主要读者对象，办刊宗旨为传播微创技术，促进国内外微创外科的技术与学术交流，推动我国微创外科的发展。     

比较性研究的撰写规范

正随着微创外科的迅猛发展,设备、器械更新升级,技术不断提高,微创外科领域新技术新方法层出不穷,操作技巧的技术改进更是各有所长,从传统开腹手术到腹腔镜手术,从三孔到两孔、单孔到经脐或经自然腔道手术和机器人辅助手术,一些以往的禁忌证在一定条件下逐渐变为适应证。新技术的报道可以为国内或国际首例[1～3](需要省级以上单位的     

脊柱微创技术应用现状

在骨科范围内脊柱的微创诊、疗技术的起步虽然略晚于关节镜技术，但近10年来却取得了长足的进步，使人有耳目一新之感。本文简略地介绍了经皮穿刺和内窥镜系统辅助下的两类脊柱微创技术对伤病的诊疗进展情况。鉴于任何一种新技术的发展早期都有可能被过急跟进，从而出现一些问题，故本文比较重点地介绍了有关脊柱微创技术的各种并发症和一些对策，以供初习者参考。为了保证脊柱微创技术达到“微创”的目的，应强调术者需具有脊柱外科的坚实理论和优良技巧基础}有微创技术经验；有高质量的微创器械和先进的影像配套设备。此外，与任何一个外科手术原则一样：严格掌握手术的适应症是取得成功和避免并发症的关键。     

内镜外科在肝胆胰外科中的应用及培训评价

正内镜外科是现代微创外科的组成部分,是多项技术领域的融合,是整合医学理念的体现。内镜外科在肝胆胰外科疾病中的应用最为广泛,发展最为全面。内镜外科技术的推广和普及,需要建立完善的内镜外科医师培训基地和培训体系,建立质量控制体系。内镜外科技术的发展需要多中心合作,多学科整合。一、内镜外科的概念及发展内镜外科技术是现代微创外科技术的重要组成部分,其特点是:经人体自然腔道或人工建立的通道通过软镜(胃肠镜、十二指肠镜、超声内镜、胆道镜、Spyglass等)将操作器械进入病变部位,在内镜直视下或联合X     

Minimally invasive total knee arthroplasty: the importance of instrumentation

MIS TKA is in the early stages of development. There are many opponents who believe that the technique is nothing more than a cosmetic modification of the standard TKA that leads to more complications and less patient satisfaction. It is important to respect these comments and to thoroughly address them. MIS surgery should not be based on the length of the incision or the cosmetic result. The term "minimally invasive" should refer to the extent of disruption of the anatomic structures about the involved joint. In the knee, the MIS approach should not violate the extensor mechanism and should not violate the suprapatellar pouch. MIS should be a capsular approach, and as such it should produce less discomfort and a faster recovery. Modifications of the MIS technique that extend the arthrotomy into the extensor mechanism, violate the suprapatellar pouch, and evert the patella while using a limited incision are not truly minimally invasive. The MIS procedure should allow the patient to recover faster while keeping the incidence of complications at the same or lower levels as the open procedure. There will certainly be a learning curve for this operation and a smaller incision with standard TKA techniques maybe the interim step for the surgeon attempting to master the new approach. MIS TKA must be performed with accurate instruments that are coordinated with the procedure. It is not possible to perform the operation with the traditional instruments that have been made for the open operations. The older instruments do not fit into the knee joint and do not allow visualization of the joint at the same time that the cuts and balancing are performed. The visual appearance is totally different and new. The surgeon must learn a completely new image of the knee joint while continuing to apply the basic principles that have been well established. The instruments are a critical part of this new technology and are central to its success. There is no room for guessing or "eye balling" the bone cuts or the alignment and balancing. Instruments and computer-assisted technology will help advance MIS surgery in the next few years. The results of MIS TKA must be thoroughly studied and compared with the existing literature. The author has tried to advance this development ina logical fashion. The initial step was to design instruments that would allow implantation of the presently accepted knee prostheses. This step has now been completed; however, the operation is not simple and is time consuming. The next step therefore is to change the prostheses to facilitate the surgery. The femoral and tibial components are presently too large for the working incision. They are now being modified so that they can be implanted in two or more pieces. This will permit less soft tissue dissection and work better with the smaller incision. The final step will incorporate computer navigational systems. All of the present instruments are designed with attachments for the appropriate arrays to interact with these systems. Ideally, the computer image will allow precise visualization of the knee, particularly the lateral side. All new surgical approaches and devices must be introduced with the expectation to improve the surgical results. There is no doubt that the final goal of this work should be technical improvement without early clinical failures or complications.     

Training and educational approaches to minimally invasive surgery: state of the art

Current training in minimally invasive surgery (MIS) is inadequate given the demands of patients on practitioners and the number of surgeons and residents who still need to be trained. The training that is provided is neither widespread nor is it standardized, resulting in graduate surgeons with a wide range of competence. There is little guidance in what a training program needs to be effective. We provide a brief review of the state of the art of MIS training with some emphasis given to training methods including perceptual motor training, MIS learning laboratories, virtual reality, evaluation and assessment, cost, simulation fidelity, credentialing, certification, privileging, and ergonomics. We conclude that the state of the art is left wanting.     

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。     

理念革新:微创外科新视角

腹腔镜视觉平台的发展与革新,推动了整个外科从开腹手术到微创手术的理念革新与技术变革。从最初利用烛光反射镜装置窥视人体内部的内镜雏形,到高清、超高清腹腔镜视觉系统,从腹腔镜胆囊切除术,到腹腔镜下包括肿瘤根治手术在内的各类普通外科手术的普及与推广,外科手术因微创技术而发生巨大变革。进入新时代,3D、4K腹腔镜的应用,再次给微创外科带来新视角,从而推动手术朝着精准解剖和功能保护方向发展。未来,新型冠状病毒后疫情时代带来的理念革新,有可能使第5代移动通信技术加持下的虚拟现实技术和机器人手术,及在此基础上的远程医疗与远程教学成为微创外科发展的新视角。     

Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training

SUMMARY BACKGROUND DATA: To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision METHODS: A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. RESULTS: VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. CONCLUSIONS: VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.     

From the operating room of the present to the operating room of the future. Human-factors lessons learned from the minimally invasive surgery revolution

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.     

Entwicklung, Terminologie, Prinzipien und Kontroversen bei der minimal-invasiven Knieendoprothetik

Minimally invasive total knee arthroplasty is a logical and further improvement of the good results achieved with minimally invasive unicondylar knee arthroplasty. The terminology for minimally invasive surgery (MIS) is confusing and comparison of different techniques is therefore difficult. A simple separation between less invasive and minimally invasive techniques will be presented. Besides the approach, minimally invasive surgical principles are very important. MIS in total knee arthroplasty is discussed very controversially at the moment. The preliminary results of these new techniques are very promising. Up to now there is much more feeling then knowing. Important questions (risk-benefit analysis, which technique for which patient and surgeon, education and cost-effectiveness) must be addressed by the proponents of this MIS technique. Step by step learning of these new techniques (evolution instead of revolution) in specific education centres is strongly recommended. Ultimately, patients and surgeons will have to decide whether these new techniques will only be a modern trend or represent the future.     

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.     

微创外科近20年进展及未来发展趋势

腹腔镜微创外科经历了3个发展阶段，即从“要不要做？”到“如何规范做？”，再到“做什么？”。回首过去20年，微创手术已从最初的单纯胆囊切除拓展到胃肠、肝胆胰、减重代谢、疝与腹壁外科等领域，手术量和手术复杂度逐步提高。展望未来，微创外科将更多地结合疾病本身治疗的进步而发展，人工智能、虚拟现实、下一代移动通信传输、肿瘤靶向治疗等技术将助力微创外科的进一步创新。微创外科也将秉承“绿色”理念，实现可持续发展。     

Minimally invasive training in urologic oncology

Use of minimally invasive surgical (MIS) techniques continues to expand in the field of urologic oncology; however, proficiency in these techniques is subject to a learning curve. Current training paradigms have incorporated MIS, but in a non-standardized fashion. Residency work-hour restrictions and ethical concerns may influence efforts to deliver adequate training during a defined residency period. Post-residency fellowships or mini-courses may help urologists gain proficiency in these skills, but are time-consuming and may not provide adequate exposure. Surgical simulation with dry labs and augmentation with virtual reality are important adjuncts to operative training for MIS. The urologic oncologist must be familiar with open and MIS techniques to effectively treat cancer in the least morbid way possible and adapt to the ever-changing field of MIS with dynamic training paradigms.