泌尿外科腹腔镜手术的术中并发症及处理

腹腔镜技术是外科手术进入微创时代的一个里程碑,自从20世纪90年代Clayman等[1]首次报道经腹途径腹腔镜下肾切除术以来,腹腔镜技术在泌尿外科手术中的应用便得到了飞速发展,目前单孔腹腔镜（LESS）、三维（3D）腹腔镜以及机器人辅助腹腔镜等崭新技术的相继涌现,让腹腔镜手术又进入了一个新纪元[2].腹腔镜手术的增多、手术范围的放宽以及手术难度的增加,必然导致腹腔镜手术并发症的增加,文献报道总发生率为14.6%～22.1%,其中术中并发症占4.7%[3-4].提高对腹腔镜手术术中并发症的认识与应付技能,探讨其原因及处理原则,有助于泌尿外科医师更好地完成手术,尽可能减少或避免这些并发症的发生.本文就泌尿外科腹腔镜手术常见的术中并发症及其处理技巧阐述如下.     

泌尿外科腹腔镜并发症的分级评估及危险因素分析

目的:评估泌尿外科腹腔镜手术常见并发症的分级及其危险因素。方法:选择2014年3月~2016年5月在郑州大学第一附属医院泌尿外科接受腹腔镜手术治疗的1 138例患者作为研究对象,对患者年龄、性别、体重指数(BMI)、疾病级别、高血压病、血糖、肺部疾病和既往腹部手术史等临床资料进行分析,同时分别采用Stava分级系统评估术中并发症级别,Clavien-Dindo分级系统评估术后并发症,进而解析泌尿外科腹腔镜手术并发症的影响因素。结果:单因素分析表明:BMI、疾病级别、血糖、既往腹部手术病史与患者术中术后出现并发症有关(P0.05)。多因素分析结果显示疾病级别及血糖是影响患者术中术后出现并发症的独立危险因素(P0.05)。结论:疾病级别及血糖是影响患者术中术后出现并发症的独立危险因素。     

经脐单孔腹腔镜技术在泌尿外科手术中的应用体会

目的:探讨经脐单孔腹腔镜技术在泌尿外科手术中的应用价值。方法:分别采用悬吊式及气腹式经脐单孔腹腔镜技术,2例行精索静脉高位结扎术,1例行肾囊肿去顶减压术,1例行肾上腺切除术,分别记录围手术期并发症、手术时间、术中出血量、术后肠蠕动恢复时间、住院时间、随访情况等。结果:4例手术均获成功,无围手术期并发症发生,随访1个月～2年,无切口疝等并发症发生。结论:经脐单孔腹腔镜技术在泌尿外科手术中安全、可行,美容效果突出。随着手术实践的增加及器械的完善改进,经脐单孔腹腔镜技术在泌尿外科手术中必将占有一席之地。     

泌尿外科腹腔镜手术并发症的处理策略

自泌尿外科进入微创时代以来,微创概念已深深植入泌尿外科医师和患者心中,其中腹腔镜技术作为微创技术的主要组成部分应用日益广泛。当前泌尿外科腹腔镜已从原有单纯器官切除术发展到高难度重建手术。虽然与传统开放手术相比,腹腔镜手术具有切口小、术后恢复快和美观度好等优点,但亦存在操作复杂、学习曲线长等不足。因此避免泌尿外科腹腔镜手术的并发症,总结其相关处理策略非常必要。本文结合当前泌尿外科腹腔镜手术的临床实践,将腹腔镜手术并发症的处理策略总结如下:术前准备,治疗个体化,术中术后的相关策略等。     

泌尿外科传统腹腔镜手术严重并发症的分析(附2800例报告)

目的:总结泌尿外科传统腹腔镜手术的严重并发症,分析其类型、原因、发病率、治疗措施及预后,以提高手术安全性.方法:回顾分析1999年10月至2011年3月施行2 800例泌尿外科传统腹腔镜手术的临床资料.总结与腹腔镜操作相关的严重并发症,分析与穿刺、气腹、术中操作及术后相关并发痘的发生原因、处理对策.结果:2 800例手...     

腹腔镜肾上腺手术热点问题的探讨

自1992年Gagner等首次报道腹腔镜肾上腺手术以来,该项技术得到迅速推广和普及,目前绝大多数肾上腺手术都可以采用腹腔镜完成。早期泌尿外科学者们研究的焦点多集中在腹腔镜手术具有的创伤小、恢复快等优点上,随着腹腔镜技术的广泛应用及研究的不断深入,目前越来越多的学者开始深入研究腹腔镜肾上腺手术适应症及禁忌症的选择,术中及术后并发症的防治,以及手术技术的革新。本文对上述研究方面进行综述,希望能与广大泌尿外科同道对腹腔镜肾上腺手术的现状及未来进行深入的探讨。     

泌尿外科后腹腔镜手术250例临床探究

目的:对泌尿外科病患者采用后腹腔镜手术,通过临床去观察疗效进而体现该手术的使用价值。方法:对我院2010年1月～2012年2月收治的泌尿外科患者中抽取250例作为研究对象,患者都采用了后腹腔镜手术,分析其临床资料报告,并观察患者转开腹原因以及产生并发症原因。结果:242例成功完成手术,1例因为大出血在手术的第2日实施开放手术,1例采用术中膈肌穿孔,3例术后出现切口感染,未出现腹腔内脏器受损现象,无血管破裂及死亡等各种并发症产生,8例采用中转开放手术。采用时,采用后腹腔镜肾切除手术术中及术后出血量都低于开放组。结论:从临床科研究可知,后腹腔镜手术对于肾、肾上腺、输尿管以及精索静脉等疾病治疗非常有效,具备安全、创伤小及术后康复较快等各种有点,是泌尿外科患者手术上的首选方法,值得临床大力推广。     

泌尿外科医生成长路上的腹腔镜基本功

正20世纪90年代以来,腹腔镜技术的迅速发展引领泌尿外科医师进入泌尿外科手术的新时代——微创时代。相比开放手术,腹腔镜手术具有手术损伤小、术野及解剖结构清晰、术后康复快、围手术期并发症少、切口美观和平均住院日短等优势,已经成为泌尿外科手术治疗的主流。目前,几乎所有的泌尿外科手术都可以使用腹腔镜技术来完成。在世界范围内主要的医学中心,微创手术所占的比例已经超过了开放手术。因此,在泌尿外科医生成长的道路上,腹腔     

后腹腔镜在泌尿外科的应用研究（附136例报告）

目的探讨后腹腔镜在泌尿外科的应用价值。方法对136例患者行后腹腔镜手术临床资料进行分析报告，观察136例腔镜组患者中转开腹的原因和发生并发症的原因。并将后腹腔镜手术与传统开放手术在肾切除术中应用进行比较，对2组患者手术时间，术中失血量，术后肛门排气时间和总住院时问进行比较。结果136例中130例成功施行后腹腔镜手术；并发症上腹膜破裂发生率最高，切口感染和膈肌损伤最低，术中中转开腹的原因主要是出血；腔镜组与开放组手术时间相近，术中失血量、术后肛门排气时间和总住院时间腔镜组小于开放组。结论后腹腔镜在泌尿外科应用较传统开放手术优势大，具有安全、微创、并发症少、术后恢复快等优势，值得临床推广。     

腹腔镜技术在泌尿外科手术中的应用(附28例报告)

目的探讨泌尿外科腹腔镜手术的技术和方法，评价腹腔镜技术在泌尿外科手术中的临床价值。方法回顾性分析了28例采用腹腔镜技术诊治的泌尿外科疾病患的临床资料。行肾囊肿去除减压术16例，精索静脉高位结扎术8例，隐睾症定位术4例。结果28例手术成功26例。平均住院4d，术中均未输血，术中术后未出现严重并发症。结论通过腹腔镜能顺利进行多种泌尿外科手术，具有损伤小、痛苦轻、术后恢复快和住院时间短等优点，有良好的临床应用前景。     

INTENSIVE CARE UNIT ADMISSIONS FOLLOWING LAPAROSCOPIC SURGERY: WHAT LESSONS CAN BE LEARNED?

Background: Laparoscopic surgery has been widely embraced, often without adequate data concerning the range and incidence of complications. In the present series, our experience of complications requiring Intensive Care Unit (ICU) admission following laparoscopic surgery is described. Methods: The records of patients requiring ICU admission at John Hunter Hospital (JHH) following laparoscopic surgery over a 39 month period were retrospectively reviewed by an independent multidisciplinary panel. Results: Twenty-three ICU admissions were identified. Twenty-one followed general surgical laparoscopic procedures and two followed gynaecological laparoscopies. Ten cases were operated on initially at JHH and 13 were transferred from other hospitals. During the study period, 2444 laparoscopic surgical cases were performed at JHH; 725 general surgical procedures (1.37% admitted to ICU) and 1719 gynaecological procedures (no ICU admissions). Twelve cases suffered surgical complications (including five gastrointestinal tract perforations and three biliary tract injuries) and 11 cases were admitted for non-surgical problems. In 75% of surgical complications there was delay in diagnosis of more than 24 h. The duration of ICU stay for surgical complications (16.4 days) was significantly longer than for the non-surgical group (3.9 days). Conclusions: There was a greater likelihood of ICU admission following general surgical rather than gynaecological laparo-scopy. Fifty-two per cent of the admissions were for surgical complications. Surgical complications are characterized by delay in diagnosis and longer ICU admission periods. Strategies to prevent some of these complications are discussed.     

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??Complications and managements after laparoscopic surgery for benign diseases of esophagogastric junction QIN Ming-fang, ZHAO Hong-zhi. Tianjin Nankai Hospital, Tianjin Minimally Invasive Surgery Center, Tianjin 300100, China
Corresponding author: QIN Ming-fang, E-mail:qins88@sina.com
Abstract The most common diseases of benign diseases of esophagogastric junction in daily practice are gastro-esophageal reflux diseases, hiatal hernia and achalasia. The surgical procedures are laparoscopic fundoplication, laparoscopic hiatal repair and laparoscopic myotomy accordingly??which have been proved to be with advantages of less surgical trauma, quicker recovery, safe operation and durable efficacy, etc. Nevertheless, postoperative complications have gained more and more attention. Early postoperative complications are bleeding, GI fistula and pneumothorax, and the late complications include recurrence and other conditions. The prevention is the most important for the treatment of postoperative complications. Correct treatment should be performed as soon as the complication occurred.     

Comparison of the benefits and complications between laparoscopic and open Roux-en-Y gastric bypass surgeries

BACKGROUND: In recent years, there has been an increase in numbers of individuals seeking laparoscopic surgical procedures for obesity. The current study compared the benefits and risks between laparoscopic and open Roux-en-Y gastric bypass (RYGBP) performed at the same center for more than 2,000 patients. METHODS: The study population consisted of 1,077 laparoscopic and 1,198 open RYGBP procedures performed between the years 1999 and 2002. Measurements included population characteristics, anthropometries, complications, and hospital stay. RESULTS: The laparoscopic RYGBP has both advantages and disadvantages. The disadvantages include a longer operative time and a higher incidence of fistulas, internal hernias, and small bowel obstruction. The advantages of the laparoscopic procedure are shorter hospital stay, lower incidence of wound infection, and fewer incisional hernias. Both procedures cause similar changes in body weight, but laparoscopic RYGBP is associated with less lean tissue loss during the early postoperative period. CONCLUSION: Both laparoscopic and open RYGBP are effective in inducing massive weight loss. There are, however, differences in the benefits and risks between the two procedures.     

腹腔镜减重代谢袖状胃手术要点与适应证

腹腔镜袖状胃切除最开始是作为超级肥胖病人的前期手术出现,随后发现单独的腹腔镜袖状胃切除手术可以显著减轻体重和肥胖相关的并发症,并且具有手术难度低,术后并发症少等优点,因此近些年来应用的越来越多。虽然《中国肥胖与2型糖尿病外科治疗指南(2019)》对于腹腔镜袖状胃切除手术要点及适应证进行了进一步的规范,但由于中国开展减重代谢手术时间较短,手术不规范导致的减重效果不佳,严重并发症的情况依然存在。因此手术细节和相关技术要点的进一步优化,必将有利于手术的推广与开展。     

Complications of laparoscopic urological procedures

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.     

Objective evaluation of expert performance during human robotic surgical procedures

Robotic laparoscopic surgery has revolutionized minimally invasive surgery and has increased in popularity due to its important benefits. However, evaluation of surgical performance during human robotic laparoscopic procedures in the operating room is very limited. We previously developed quantitative measures to assess robotic surgical proficiency. In the current study, we want to determine if training task performance is equivalent to performance during human surgical procedures performed with robotic surgery. An expert with more than 5 years of robotic laparoscopic surgical experience performed two training tasks (needle passing and suture tying) and one human laparoscopic procedure (Nissan fundoplication) using the da Vinci™ Surgical System (dVSS). Segments of the human procedure that required needle passing and suture tying were extracted. Time to task completion, distance traveled, speed, curvature, and grip force were measured at the surgical instrument tips. Single-subject analysis was used to compare training task performance and human surgical performance. Nearly all objective measures (8 out of 13) were significantly different between training task performance and human surgical performance for both the needle passing and the suture tying tasks. The surgeon moved slower, made more curved movements, and used more grip force during human surgery. Even though it appears that the surgeon performed better in the training tasks, it is likely that during human surgical procedures, the surgeon is more cautious and meticulous in the movements performed in order to prevent tissue damage or other complications. The needle passing and the suture tying training tasks may be suitable to establish a foundation of surgical skill; however, further training may be necessary to improve transfer of learning to the operating room. We recommend that more realistic training tasks be developed to better predict performance during robotic surgical procedures and testing the transferability of basic skill acquisition to surgical performance.     

Outcomes of laparoscopic versus open resection of pediatric choledochal cyst

BackgroundUntreated pediatric choledochal cyst (CC) is associated with complications including cholangitis, pancreatitis, and risk of malignancy. Therefore, CC is typically treated by surgical excision with biliary reconstruction. Both open and laparoscopic (lap) surgical approaches are regularly used, but outcomes have not been compared on a national level.MethodsThe Nationwide Readmissions Database was used to identify pediatric patients (age 0–21 years, excluding newborns) with choledochal cyst from 2016 to 2018 based on ICD-10 codes. Patients were stratified by operative approach (open vs. lap). Demographics, operative management, and complications were compared using standard statistical tests. Results were weighted for national estimates.ResultsCholedochal cyst excision was performed in 577 children (75% female) via lap (28%) and open (72%) surgical approaches. Patients undergoing an open resection experienced longer index hospital length of stay (LOS), higher total cost, and more complications. Anastomotic technique differed by approach, with Roux-en-Y hepaticojejunostomy (RYHJ) more often utilized with open cases (86% vs. 29%) and hepaticoduodenostomy (HD) more common with laparoscopic procedures (71% vs. 15%), both p < 0.001. There was no significant difference in post-operative cholangitis or mortality.ConclusionsAlthough utilized less frequently than an open approach, laparoscopic choledochal cyst resection is safe in pediatric patients and is associated with shorter LOS, lower costs, and fewer complications. HD anastomosis is more commonly performed during laparoscopic procedures, whereas RYHJ more commonly used with the open approach. While HD is associated with more short-term gastrointestinal dysfunction than RYHJ, the latter is more commonly associated with sepsis, wound infection, and respiratory dysfunction.Level of evidenceLevel III: Retrospective Comparative Study.     

Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE: We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications. MATERIALS AND METHODS: From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure. RESULTS: Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%. CONCLUSIONS: Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.     

A nation's experience of bleeding complications during laparoscopy

BACKGROUND: Bleeding complications during laparoscopic surgery are rare but probably underreported. The aim of the current study was to elucidate the clinical relevance of bleeding complications and major vascular injuries during standard laparoscopic procedures. PATIENTS AND METHODS: The Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing different standard laparoscopic procedures (1995 to 1997). These data were analyzed with special interest in intraoperative and postoperative bleeding complications and major vascular injuries. RESULTS: In all, 331 patients (2.3%) had intraoperative bleeding complications. Whereas 44 patients suffered from an external bleed of the abdominal wall, the bleeding was internal in the remaining 287. Thirty-three patients with internal bleeding required blood transfusion with a mean blood loss of 1,630 mL. Surgical hemostasis was necessary in 68% of external and 91% of internal bleeds. There were 250 patients (1.8%) with postoperative bleeding complications. External bleeding occurred in 143 patients, and 107 patients developed internal bleeding. External bleeding was mainly treated conservatively (92%), whereas 50% of internal bleeds required further surgical intervention. Major vascular injuries occurred in 12 patients (incidence 0.08%) with open treatment being necessary in all cases. CONCLUSIONS: Bleeding complications are, in fact, common during laparoscopic surgery. Meticulous dissection technique, immediate recognition, and adequate surgical treatment are mandatory for their management.     

Methodological and technological aspects of relaparoscopy

Overall 3457 laparoscopic procedures after open and laparoscopic abdominal operations have been performed including 270 relaparoscopies due to intraabdominal postoperative complications. Basing on their own experience, the authors give methodological and technological recommendations allowing to increase diagnostic and surgical efficacy of relaparoscopy and to reduce the rate of complications.