Laparoscopic splenectomy with a vessel sealing device

When compared with open splenectomy, laparoscopic splenectomy was associated with fewer complications, however, with more hemorrhagic complications. Furthermore, the mean operative time for laparoscopy was significantly longer than for the open procedure. Vessel sealing systems are represented as decreasing operative time and blood loss in several surgical procedures. The aim of this study is to evaluate the blood loss and operating time of laparoscopic splenectomy with a vessel sealing system. We evaluated 19 laparoscopic splenectomies with a vessel sealing device, particularly focusing on operative blood loss and operating time. Patients were operated in the right lateral decubitus position usually with three ports. In all cases, dissection of the spleen and sealing of hilar vessels and short gastric vessels were performed with a vessel sealing system. No clips, sutures, or monopolar–bipolar diathermy were used. Mean operative blood loss was 88ml (range 20–400?ml) and mean operative time was 107 minutes (range 45–230?minutes). Both results were better than those of most series of laparoscopic splenectomy performed with endostaplers or endoclips. Laparoscopic splenectomy with a vessel sealing system is safe for all vascular controls in laparoscopic splenectomy and can lead to less blood loss. This technique removes the disadvantage of longer operating times for laparoscopic as compared to open splenectomy.     

Principles and initial experience of a new device for dissection and hemostasis.

Electrosurgery is a commonly used technology in laparoscopy. Electrosurgical devices are being used in many medical subdisciplines in order to coagulate, cut, and ablate tissue and to produce hemostasis. The latest advance in electrosurgery is the introduction of novel simultaneous hemostatic sealing and cutting bipolar devices that minimize force by delivering energy as high current and low voltage output. One of these systems is the Gyrus Plasma Trissector (GPT), (Gyrus Group PLC, Gyrus International, Ltd.UK), a novel radiofrequency (RF) system based on bipolar technology, which consists of a proprietary PlasmaKinetic (PK) generator and specific instruments, designed as a system. The instrument consists of a 17 mm long gold-coated curved jaw with a ceramic insulated cutting element. The PK system uses high-powered pulsed bipolar energy to produce a plasmakinetic field around the working elements and is designed to operate at temperatures that allow effective tissue dissection but result in minimal collateral damage and adherence to tissue. The GPT was used with the Gyrus G400 WorkStation generator in laparoscopic radical prostatectomies (LRP). Our initial experience with this novel bipolar device demonstrates it to be safe and effective in dissection and hemostasis. The GPT permits us to act quickly when bloody fields are present, improves coagulation, reduces or eliminates sticking, seals large vessels such as dorsal vein complex (DVC) and allows secure grasping and dissecting of tissue. The urologist is familiar with electrosurgery, as we have become comfortable using GPT to dissect, cut, and coagulate tissue. We feel that the GPT can be used in a variety of laparoscopic procedures in urology.     

腹腔镜脾切除术中出血及周围脏器损伤的预防及处理

目的:探讨腹腔镜脾切除术中出血及周围脏器损伤的预防和处理方法。方法:共纳入32例行腹腔镜脾切除术的患者,术前均进行影像学检查,评估脾血管走行及解剖变异;术中预处理脾动脉,精准解剖脾门,悬吊脾门。结果:32例患者中,31例顺利完成腹腔镜脾切除术,手术时间87~190 min,平均(128±90)min;术中出血量110~790 ml,平均出血量(358±34)mL。术后2例出现无症状性胰漏。结论:在腹腔镜脾切除术中,脾动脉预处理及脾门悬吊等技术值得推广应用。     

手助腹腔镜脾切除(附8例报告)

目的探讨手助腹腔镜脾切除的可行性和安全性。方法对特发性血小板减少性紫癜（idiopathicthrombocytopenic purpera，ITP）3例，脾血管瘤1例，海洋性贫血1例，再生障碍性贫血1例，肝硬变脾肿大、脾功能亢进2例，采用手助腹腔镜行脾切除术。结果8例手助腹腔镜脾切除获得成功，平均手术时间为148min，平均出血量370mL，平均脾重478g。术后全组均未发生严重并发症，术后平均住院日为9d。结论手助腹腔镜脾切除是安全可行的，降低手术难度，有效控制出血，缩短手术时间，是值得选择的微创脾切除方式。     

旋切器在腹腔镜下脾切除术中的应用体会

目的探讨外伤性脾破裂在腹腔镜下脾切除术中应用旋切器进行取脾的可行性及临床价值。方法回顾性分析该院2014年6月-2016年6月因外伤性脾破裂行腹腔镜脾切除术的10例患者的临床资料。结果其中9例患者在旋切器配合下完成手术,1例因难以控制的出血中转开腹,旋切器配合腹腔镜脾切除术组中手术时间95~170 min,术中出血量300~800 ml,自体血回输400~1 200 ml,术后住院天数8~14 d,术后随访3~24个月无严重相关并发症发生。结论在旋切器配合下行腹腔镜脾切除术安全可行,无需大范围扩大腹壁切口,具有创伤较小、恢复快等的特点,多适用于外伤及良性脾脏病变而需行脾切除的病例,值得临床推广与应用。     

Laparoscopic total gastrectomy for advanced gastric cancer in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare congenital anomaly. Generally, laparoscopic surgery is difficult to perform in patients with SIT because of both the potential challenges associated with unexpected vascular anomalies and the lack of standardized strategy for handling such cases. This is the first report of laparoscopic total gastrectomy with lymph node dissection for advanced gastric cancer in a patient with SIT. A 79‐year‐old man with SIT was diagnosed with advanced gastric cancer. We performed laparoscopic total gastrectomy with modified D2 lymph node dissection (D2 without splenectomy) and esophagojejunal anastomosis using an overlap method involving retrocolic Roux‐en‐Y reconstruction. The total operating time was 232 min, and blood loss was 110 mL. There were no postoperative complications. In summary, laparoscopic total gastrectomy for gastric cancer can be performed safely, even in a patient with SIT.     

Laparoscopic near-total splenectomy: a single-center experience of a standardized procedure

Abstract

Background: Near-total splenectomy (NTS) represents an innovative and effective surgery technique for spleen disease, reducing the risk of severe infections and thromboembolic events after total splenectomy. The authors reported a laparoscopic near-total splenectomy (LNTS) surgical experience following the optimal results of the open approach, describing a standardized and effective minimally invasive technique with the purpose of preserving a minimal residual spleen.

Material and methods: From November 2006 to September 2016, 15 patients with splenic and hematologic disease underwent LNTS, according to a laparoscopic procedure developed by the authors. The end criterion was to conserve a remanent spleen of 10–15?cm³ in size.

Results: Patient age ranged between 18 and 59 years. Mean operative time was 70?±?20?min. Mean hospital stay was 3.46 (range 3–7) days. One complication occurred during the surgery for a lesion of the inferior polar artery with need of a total splenectomy. No conversion to open surgery was necessary.

Conclusions: LNTS is a safe and effective technique for the management of splenic and hematologic disease with a low intra- and post-operative complication rate, and it can minimize the late sequelae of secondary splenectomy. However, it requires further studies with more cases to evaluate its role.     

Dissection efficiency during laparoscopic oesophageal dissection

Advanced techniques in laparoscopic surgery have led to an increased need for appropriate training in instrument handling and dissection. Recent developments in computer video technology have facilitated critical analysis of surgical technique. Video deconstruction of oesophageal hiatal dissection during six laparoscopic fundoplication procedures was undertaken. The procedures were performed by surgeons with a wide range of surgical experience, and the investigators analysing performance were blinded to their level of training. Sequential five‐second video segments were analysed in detail by 3 investigators. A taxonomy list was developed to describe individual types of movement. The number and time per movement was assessed and a degree of efficiency was assigned. An efficient movement was defined as one that advances the dissection towards a recognised goal. The total oesophageal dissection time varied from 10?minutes (min) to 25?min (mean 16?min). The mean number of actions performed was 173 (range 120–272). A mean of 7?min was spent separating tissues (range 5–13), with 6?min spent grasping and positioning tissue (range 3–8). The amount of time spent in inefficient movement varied from 3 to 14?min (mean 7?min). The greatest variation between operators was seen in the efficiency of tissue separation when using dissecting instruments. Inexperienced operators spent a lot more time performing additional movements such as scope cleaning, observation and instrument exchange. This technique of video deconstruction can identify key areas for improvement. This could be used for trainee assessment and to provide constructive feedback. Future development in this area could enhance training in advanced laparoscopic techniques.     

Laparoscopic and open splenectomy for idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura(ITP) is an immune disorder, which causes an acute or chronic thrombocytopenia, and may result in potentially life-threatening hemorrhage. Splenectomy is one of the treatment options that needs to be weighted in the treatment of ITP, particularly in cases that have shown response failure to medical modalities such as prednisone, or anti-D globulin therapy. However, because open splenectomy (OS) requires more surgical invasiveness, surgical treatment had not been accepted for many patients with ITP. Recently, laparoscopic splenectomy(LS) is being accepted as an effective alternative to OS in treating ITP. The most important parts of this method are, mobilization of the spleen by dissection of the splenic ligament, and the blocking of blood circulation to the spleen by division of the hilar arteries and veins. The procedure is as follows: (1) The patient is in a right lateral decubitus position. (2) The resection of the splenic ligament is made by an ultrasonic coagulating dissector. (3) The splenic hilum is dissected with an auto-stapler. (4) The freed spleen is contained in a nylon bag and extracted. Laparoscopic splenectomy is a feasible and safe for patients with ITP.     

3种止血方法对卵巢基质血流及激素水平的影响

目的比较3种止血法对卵巢基质血流及激素水平的影响。方法选择2012年5月-2015年10月接受腹腔镜下卵巢肿瘤剥除术的90例患者为研究对象,根据术中创面止血方式不同随机分为3组,A组患者采用单极电凝止血、B组患者采用双极电凝止血、C组患者采用缝合止血,比较3组手术情况、卵巢基质血流和血清性激素水平。结果 A和B组手术时间明显短于C组(t=6.81,7.49,P0.05);术后6个月时,B和C组两组卵巢窦状卵泡数(AFC)、基质血流收缩期峰速(PSV)、舒张期最低血流(EDV)均明显高于A组(t=3.79,5.90,3.02,6.82,7.75,3.00,P0.05),血清黄体生成激素(LH)、促卵泡生成激素(FSH)明显低于A组,雌二醇(E2)明显高于A组(t=10.20,8.49,14.70,11.10,9.21,15.56,P0.05),且B和C组两组基质血流、血清激素水平比较差异无统计学意义(P0.05)。结论腹腔镜卵巢肿瘤剥除术双极电凝止血法有助于减轻手术创伤,维持卵巢基质血流相对稳定,保护卵巢储备功能。     

手助腹腔镜与开腹脾切除加门奇断流术对机体免疫功能和创伤反应影响临床研究

目的 :研究手助腹腔镜和开腹脾切除加门奇断流两种术式对机体免疫功能及创伤反应的影响 ,探讨其差异及新术式的可行性。方法 :监测 5 0例 (手助腹腔镜及开腹各 2 5例 )肝硬变、门静脉高压症患者术前、术后第1天 ,术后第 3天的外周血淋巴细胞 (PBL)亚群、C -反应蛋白 (CRP)、白细胞介素 6 (IL - 6 )和肿瘤坏死因子(TNF)的变化并进行对比研究。结果 :开腹组术后第 3天成熟的T淋巴细胞 (CD3 )、辅助性T细胞 (CD4)、CD4与抑制性T淋巴细胞 (CD8)比值较术前明显下降 (P <0 .0 5或P <0 .0 1)。且两组相比较开腹组明显低于手助腹腔镜组 (P <0 .0 1)。开腹组术后第 1天或 /和术后第 3天CRP、IL - 6、TNF较术前明显升高 (P <0 .0 1)。且两组比较开腹组明显高于手助腹腔镜组 (P <0 .0 1)。结论 :手助腹腔镜组对机体免疫及细胞因子水平影响较小 ,这构成手助腹腔镜组脾切除加断流术术后恢复较快及创伤反应小的病理、生理基础 ,同时也证明了该新术式治疗肝硬变、门静脉高压症的可行性及优越性。     

Novel approach of laparoscopic and endoscopic cooperative surgery (LECS) for cholecystectomy

Background: Endoscopic submucosal dissection (ESD) techniques, such as generating an artificial space between digestive tract layers for safer dissection, were thought to be safer for the resection of organs in cholecystectomy. We investigated whether combinations of endoscopic techniques and laparoscopic techniques could be performed more safely and rapidly.

Material and methods: Laparoscopic and endoscopic cooperative-cholecystectomy (LEC-chole) and conventional laparoscopic cholecystectomy (Lapa-chole) were performed in six dogs. Operation time was defined as the time from the creation of the first port to the retrieval of the resected gallbladder (GB); and GB bed dissection time was the time from local injection of natural saline to the clipping of the cystic duct. The main roles of the endoscope in LEC-chole were to obtain a sufficient cutting space via local injection of natural saline to the GB bed and to monitor the operative view without laparoscopic camera, thus omitting the umbilical port.

Results: The operation times were 60?±?18.3?minutes for LEC-chole and 95?±?7.0 for Lapa-chole (p?=?.036). The GB bed dissection times were 31?±?8.54?minutes in LEC-chole and 50.6?±?7.37?minutes in Lapa-chole (p?=?0.048). There were significant differences in liver damage and bleeding (p?=?0.116), but there were no significant differences in one-month survival.

Conclusions: The application of LEC-chole may be expanded to cholecystectomy.     

腹腔镜脾切除术

该文报道了5例脾功能亢进患者行腹腔镜脾切除术的初步体会。从1996年4月～1997年3月，行腹腔镜脾切除术5例，全部获成功。平均手术时间为3．8h（2．8～5h），平均水中失血650ml（50～1200ml），术后翌日恢复流质饮食，无术后并发症，平均水后住院7d（5～10d）。腹腔镜脾切除术具手术创伤小和恢复快的优点，但其手术时间较长和水中失血较多。腹腔镜牌切除术可适用于需脾切除的血液病患者。推荐左前侧厦里手术径路。     

腹腔镜脾切除术脾蒂处理方法探讨

目的探计腹腔镜脾切除术(laproscopic splenectomy,LS)中处理脾蒂的方法。方法回顾性分析36例腹腔镜脾切除手术病例(包括16例腹腔镜下脾切除联合断流手术)的临床资料。了解脾蒂处理的方法及技巧。结果36例病人中有1例中转开腹,35例均顺利完成腹腔镜脾切除术或腹腔镜脾切除联合断流手术,19例腹腔镜脾切除平均手术时间为165min,术中平均失血87mL,术后平均禁食时间1.5d,术后平均住院时间6d。16例腹腔镜脾切除联合断流手术平均手术时间268min,术中平均失血800mL,手术后平均禁食时间为2.5d,手术后平均住院时间8d。结论腹腔镜脾切除及腹腔镜脾切除联合断流手术是安全且效果良好的手术,手术成功的关键是术中仔细操作,控制脾蒂,防止大出血。     

En-bloc stapling of the splenic hilum in laparoscopic splenectomy.

Vascular staplers or clips for sectioning of the splenic artery and vein are the procedure of choice in laparoscopic surgery. There are some concerns about the possible complications such as pancreatic injury, arteriovenous fistula (AVF) formation and portal or splenic vein thrombosis related to stapler usage. Hence this study was aimed to evaluate the safety and advisability of en-bloc mass stapling of the splenic hilum. A retrospective chart review was performed of 17 consecutive children undergoing laparoscopic splenectomy between June 2003 and June 2005 by a single surgeon. A routine four-trocar technique was used in all patients. Vascular isolation was achieved with an Endo-GIA (powered vascular linear stapler) without individual dissection of the splenic artery and vein. Doppler ultrasonographic evaluation was performed in order to search for a possible portal or splenic vein thrombosis and arteriovenous fistula formation in all patients one year after the operation. En-bloc stapling of the hilum was successfully performed in all children. No immediate or short-term complications related to en bloc stapling were observed. There were no arteriovenous fistula formations and splenic or portal vein thrombosis related to the previous operation with a mean follow-up of 21 months (12-36 months). En-bloc stapling can thus be safely performed in pediatric laparoscopic splenectomy with no related short-term vascular complications.     

LigaSure在腹腔镜下巨脾切除中的应用

目的探讨LigaSure在腹腔镜下巨脾切除中的应用价值。方法在手助腹腔镜下完成18例巨脾切除术。应用LigaSure离断脾周韧带及部分脾蒂血管。结果18例手术全部成功。手术150～260min平均180min。术中出血200～2000mL，平均540mL。切除牌重500～2000g，平均910g。术后17例恢复顺利，1例术后肝功能衰竭死亡。结论LigaSure可安全、有效地离断脾周韧带和脾的二级血管，并减少失血和降低手术费用。     

Reduced port laparoscopic splenectomy using a newly developed multichannel port: A pilot study

Abstract

Background: The authors introduce the dual-incision laparoscopic splenectomy (DILS) technique using a specially designed multichannel trocar and report on the surgical outcomes and operative cost of DILS compared with conventional laparoscopic splenectomy (CLS). Material and methods: The medical records of 53 patients who underwent a laparoscopic splenectomy using CLS with four trocars and DILS at our institution were analyzed. Results: There was no statistical difference in operative time between the two groups and the intraoperative transfusion rate of red blood cell substitution was not different between the two groups. In terms of postoperative pain score, hospital stay, and overall complication rate, there were no differences between the two groups. Operative cost was significantly lower in the DILS group compared with the CLS group. Conclusions: DILS is a feasible and cost-effective modality of reduced port surgery in laparoscopic splenectomy.     

腹腔镜巨脾切除术10例

目的探讨腹腔镜巨脾切除术的临床可行性。方法回顾分析作者医院2006年1月~2006年12月10例(其中手助7例)腹腔镜巨脾切除术的临床资料。结果10例腹腔镜下巨脾切除术全部成功,手术时间60~170 min,平均90 min;术中出血100~900 ml,平均350 ml;术后住院5~12 d,平均8.5 d,无术后明显并发症。术后引流留置3~8 d,平均5 d。结论腹腔镜巨脾切除术在临床上是安全可行的。     

食管胃结合部腺癌患者行微创手术中淋巴结的清扫效果

目的探讨腹腔镜下行食管胃结合部腺癌(AEG)根治术中淋巴结的清扫效果。方法选取2014年6月-2015年9月该院收治的105例行开腹或腹腔镜根治术的AEG患者为研究对象,根据手术方式分为微创组(n=70)和开腹组(n=35),比较两组的基线资料、淋巴结清扫结果及围手术期资料。结果微创组的脾门淋巴结清扫总数明显多于开腹组(P0.05)。两组的术中淋巴结清扫总数、阳性数目、阳性患者例数、脾门淋巴结阳性数目和阳性患者例数等比较,差异无统计学意义(P0.05)。微创组的手术时间、术中失血量、切口长度、近端切缘阳性率、胸腹部联合切除率和脾切除率等均明显低于开腹组,近端食管切除长度明显大于开腹组(P0.05)。所有患者术后均未出现死亡,微创组的首次排气时间、首次下床时间、首次进流质时间等均明显低于开腹组(P0.05)。两组的并发症发生率比较,差异无统计学意义(P0.05)。结论与开腹手术相比,腹腔镜AEG根治术在清扫脾门淋巴结方面较有一定优势,且切除的食管更长,胸腹部联合切除率与脾切除率更低,安全可行,值得临床推广应用。     

Leaves from a Doctor's Diary

Tonsillectomies account for 25 per cent of all surgery done in the average general hospital, but there is no uniform technic for the operation. The author advocates a method of dissection and hemostasis which involves five essential elements: (1) endotracheal anesthesia, (2) perfect illumination, (3) an unimpaired view of the operating field, (4) meticulous dissection, and (5) hemostasis by tying.