腹腔镜下膀胱尿道单针连续吻合法动物模型的建立和应用

目的 建立模拟膀胱尿道单针连续吻合法训练的动物模型.方法 体质量30 kg左右的巴马小型猪20只,速眠新10 mg/kg诱导麻醉,3.5%戊巴比妥钠0.25 g/kg术中维持.取仰卧位经脐点穿刺导入CO2制备气腹,放置3个工作套管.游离出尿道蒂,取末端小肠作为代膀胱.按照腹腔镜下膀胱尿道单针连续吻合法步骤完成吻合.6名具有腹腔镜体外模拟训练经验的学员参加培训,根据手术时间评估学员的学习曲线.结果 6名学员在该模型上均成功完成腹腔镜下膀胱尿道单针连续吻合法的各项操作技术.每只模型猪可行3次手术,学员平均接受10次膀胱尿道单针连续吻合法训练,平均手术时间第1次(55.5±10.4)min,第10次(22.4±4.8)min,2次手术时间比较差异有统计学意义(P＜0.01).结论 小猪模型末端小肠替代膀胱,反复利用游离尿道蒂可提供多次训练机会,能够使学员尽快掌握腹腔镜下膀胱尿道单针连续吻合法的操作技术.     

食管癌切除术颈部机械吻合与手工吻合的疗效分析

目的 评价机械吻合与手工吻合在食管癌切除术颈部吻合中的应用价值.方法 本研究回顾性分析2010年1月至2012年1月四川省肿瘤医院收治的187例食管癌患者的临床资料,根据行食管癌切除术后颈部吻合的方式不同分为机械吻合组(98例)和手工吻合组(89例),比较两组患者吻合时间、总手术时间、术后开始进食时间、住院时间、术后并发症发生率及食管残端癌阳性率的差异,计量资料采用t检验,计数资料采用x2检验或Fisher确切概率法.结果 机械吻合组患者吻合时间、总手术时间、术后开始进食时间及住院时间分别为(7.8±1.4)min、(227±60) min、(6.3±0.9)d、(14±4)d,短于手工吻合组的(28.5±2.3) min、(301±81) min、(8.4±1.0)d、(22±9)d,两组比较,差异有统计学意义(t=75.44,7.14,7.71,7.41,P＜0.05);机械吻合组患者术后吻合口瘘发生率为1％ (1/98),低于手工吻合组的8％(7/89),两组比较,差异有统计学意义(P＜0.05);两组吻合口狭窄发生率分别为5％ (5/98)和7％ (6/89),两组比较,差异无统计学意义(P＞0.05);机械吻合组无食管残端癌,手工吻合组食管残端癌阳性率为4％(4/89),两组比较,差异有统计学意义(P＜0.05).结论 机械吻合在食管癌颈部吻合中不仅能缩短吻合时间、总手术时间及住院时间,而且能降低吻合口瘘发生率和食管残端癌阳性率.     

直线切割闭合器在腹腔镜膀胱癌根治术肠道吻合中的应用

目的探讨直线切割闭合器在腹腔镜膀胱癌根治术肠道吻合中的临床应用价值。方法对56例膀胱癌患者施行腹腔镜根治性全膀胱切除术,其中31例行传统手工肠道端端吻合,25例使用直线切割闭合器行肠道侧侧吻合。比较两组的肠吻合时间、手术时间、术中失血量、术后进食时间及术后肠梗阻发生率。结果与传统手工吻合组相比,直线切割闭合器吻合组肠吻合时间短(10.2±1.6minvs28.1±5.3min,P0.05),术后进食时间早(3.0±0.8dvs4.3±1.4d,P0.05),总体手术时间、术中出血量、肠梗阻发生率无明显差异(P0.05)。结论在腹腔镜膀胱癌根治术中使用直线切割闭合器操作简便、可明显缩短肠吻合时间和术后禁食时间,值得临床推广应用。     

腹腔镜下输尿管膀胱再植术动物模型的建立方法

目的 建立训练腹腔镜下输尿管膀胱再植术的动物模型. 方法 10只体质量30kg左右小型雌性猪作为实验动物,氯氨酮(10 mg/kg)诱导麻醉,3.5%戊巴比妥钠(0.25 g/kg)术中维持.取仰卧位经脐点穿刺导人CO2制备气腹,放置3个工作套管.游离子宫角以替代扩张的输尿管.按膀胱外黏膜下隧道法(Lich-Gregoir)标准步骤进行手术.4名具有腹腔镜体外模拟训练经验的学员参加培训,根据手术时间评估学员的学习曲线. 结果 能够在该动物模型上成功完成腹腔镜下输尿管膀胱再植术的各项操作技术,每侧可进行2次手术.学员接受10次输尿管再植术训练后,平均手术时间从最初的(170±10)min降至(90±4)min(P<0.01),学员均能熟练完成腹腔镜下输尿管膀胱再植术. 结论 该模型利用子宫角替代扩张输尿管提供多次训练机会,能使学员掌握膀胱外黏膜下输尿管膀胱再植术的腔内操作技巧和手术方法.     

胰十二指肠切除术中胰肠吻合方式的选择策略

目的 评价胰肠吻合方式选择策略在胰十二指肠切除术中应用的临床效果.方法 回顾性分析2007年6月至2012年6月第四军医大学西京医院收治的455例行胰十二指肠切除术患者的临床资料.对于胰管直径≥4 mm的患者采用胰管空肠黏膜吻合术(胰管空肠黏膜吻合组,210例);对于胰管直径＜4 mm的患者,其胰肠吻合术式由胰腺残端直径和空肠管腔口径决定,空肠管腔口径＜胰腺残端直径者选择改良Child胰肠吻合(改良Child胰肠吻合组,140例),空肠管腔口径≥胰腺残端直径者选用捆绑式胰肠吻合(捆绑式胰肠吻合组,105例).比较分析各组临床疗效及术后并发症发生率.计数资料采用x2检验,计量资料采用t检验.结果 胰管空肠黏膜吻合组的胰管直径为(4.4±0.7)mm,显著大于改良Child胰肠吻合组的(2.8±0.6)mm和捆绑式胰肠吻合组的(2.3 ±0.7)mm(t =2.25,2.48,P＜0.05).改良Child胰肠吻合组胰腺残端直径为(36 ±5)mm,显著大于捆绑式胰肠吻合组的(21 ±6)mm(t =21.65,P＜0.05).总体胰液漏发生率为8.4％(38/455).3组患者胰液漏、腹腔出血、腹腔感染、消化功能异常、平均住院时间比较,差异无统计学意义(x2=0.53,0.88,1.63,5.34,F=2.53,P＞0.05).结论 在胰十二指肠切除术中根据胰管直径、胰腺残端直径和空肠管腔口径合理选择胰肠吻合方式可取得较好的临床效果.     

腹腔镜胃中上部癌切除术后胃肠道重建方式的选择

目的:总结腹腔镜胃中上部癌切除术后食管与胃或空肠吻合的各种方式,探讨其优缺点及适用范围。方法:2004年5月～2006年11月共行腹腔镜下根治性胃中、上部癌手术95例,4例中转开腹,6例行远端胃大部切除。其余病人中有49例行小切口辅助的食管胃或食管空肠吻合,12例行腹腔镜食管空肠侧侧吻合,25例行腹腔镜食管胃/空肠端侧吻合(含1例因残端癌阳性而中转开腹者)。结果:3组中除腹腔镜食管胃或食管空肠端侧吻合组中有1例因抵钉座放置后残端癌残留而中转开腹外,其余均顺利完成吻合。小切口吻合组术后发生吻合口漏、吻合口出血各1例,均经内科保守治疗痊愈;发生吻合口狭窄1例,经胃镜下扩张后治愈。两个腹腔镜吻合组均无吻合相关并发症。3组吻合平均耗时分别为(50.2±13.6)min、(43.5±10.4)min、(55.4±14.5)min。结论:尽管对于多数病人,在小切口辅助下能安全地完成食管胃/空肠吻合,但对于肥胖、左肝肥大等特殊体型病人,或因进展期贲门癌要求食管切断平面较高者,以采用腹腔镜下吻合为宜。合理地选择吻合方式,是安全、省时及切除充分的手术保证。     

腹腔镜前列腺癌根治术中两种膀胱尿道吻合方法的比较研究

目的:比较腹腔镜前列腺癌根治术中两种膀胱尿道吻合方法的患者临床资料,探讨单针体外牵拉缝合方法的效果。方法:回顾性分析95例接受经腹膜外腹腔镜前列腺癌根治术患者的临床资料。根据膀胱尿道吻合方法分为两组;双针连续缝合法组(A组,n=52)和单针体外牵拉缝合法组(B组,n=43)。分别比较两组手术时间、膀胱尿道吻合时间;引流管留置时间、导尿管留置时间、并发症以及手术切缘等指标。结果:与A组相比,B组有较短的手术时间(A组179.9min,B组142.8min,P<0.05)、膀胱尿道缝合时间(A组22.0min,B组12.9min,P<0.05);和较低的吻合口漏尿发生率(A组15.4%,B组2.3%,P<0.05)。但在术后尿道狭窄发生率、引流管留置时间、导尿管留置时间以及手术切缘阳性率等方面两组并无明显差异。结论:腹腔镜前列腺癌根治术中采用单针体外牵引缝合法可以缩短膀胱尿道吻合时间以及总手术时间,同时可以减少吻合口漏尿发生率。     

泌尿外科腹腔镜技能培训模式的初步探索

目的 初步探索合理的泌尿外科腹腔镜技能培训模式. 方法利用模拟训练箱开展腹腔镜基本技能培训.选择20～30 kg的小猪建立腹腔镜下肾部分切除术、肾盂成形术和输尿管再植术3种动物模型,然后开展有针对性的专项手术模拟训练.33名泌尿外科研究生参与培训,其中博士16名、硕士17名.初学者从基本技能培训开始,腹腔镜基本技能达剑合格水平后在动物模型上进行模拟手术培训. 结果 参与2期基本技能培训后,33名学员腹腔镜基本操作技能均达到合格水平.33名学员在完成8次肾部分切除术专项手术训练后,手术时间从(64.0±18.4)min降为(30.9±3.8)min(P<0.01),学员均熟练掌握肾肿瘤切除和肾实质腔内缝合等技术;完成8次肾盂成形术的模拟训练后,平均完成时间由(127.5±17.5)min降为(65.2±7.5)min(P<0.01),学员均能熟练完成无张力的肾盂输尿管吻合并掌握了顺行放置双J管的技巧;完成8次输尿管膀胱再植术的模拟训练后,平均手术时间从(75.8±11.6)min降为(37.7±7.2)min(P<0.01),学员均能熟练完成输尿管的分离、裁剪、缝合等操作.接受系统培训后,15名(45.5%)学员已完成了从模拟训练到临床手术的过渡,在临床开展腹腔镜手术. 结论 腹腔镜基本技能训练设备简单,成本较低,适合于初学者的培养;动物模拟手术可以全真地模拟手术过程,在动物模型上进行专项手术训练町以帮助学员更快掌握腹腔镜手术方法和技巧.基本技能培训与动物模拟手术相结合的模式较适合于腹腔镜技能的培训,有一定的临床推广价值.     

重视团队配合在腹腔镜技能培训中的价值

目的探讨团队配合的训练课程在腹腔镜技能培训中的价值。方法 2012年12月~2014年3月我院普外科卫生部内镜诊疗培训基地共举办培训班4期,培训内容包括腹腔镜基础理论学习、模拟操作训练、动物实体的各种腹腔镜手术操作训练等,在后2期的培训内容中,我们设计并增加与团队配合有关的腹腔镜培训课程,在动物实体的腹腔镜手术训练中,记录4期培训班各组学员的腹腔镜胆囊切除术及脾切除术的手术时间和术中出血量。我们将后两期学习班的学员设为实验组,前两期学员设为对照组,对2组结果进行比较。结果实验组腹腔镜胆囊切除手术时间(63.8±16.8)min,显著短于对照组(82.8±12.5)min(t=2.566,P=0.022);腹腔镜脾切除手术时间(88.7±17.1)min,显著短于对照组(119.0±18.1)min(t=3.442,P=0.004);腹腔镜胆囊切除术中出血量(46.2±12.8)ml,显著少于对照组(96.6±22.5)ml(t=5.507,P=0.000);腹腔镜脾切除术中出血量(91.8±15.3)ml,显著少于对照组(146.9±18.5)ml(t=6.492,P=0.000)。结论增加团队配合训练内容的腹腔镜培训课程更加符合腹腔镜手术的特点,可提高腹腔镜培训的效果,值得推广。     

腹腔镜前列腺癌根治术中采用膀胱颈口荷包缝合联合尿道周围组织重建的早期尿控效果北大核心CSCD

目的探讨腹腔镜前列腺癌根治术中采用膀胱颈口荷包缝合联合尿道周围组织重建的早期尿控效果。方法2020年2月~2021年4月我们在20例腹腔镜前列腺癌根治术中采用膀胱颈口荷包缝合联合尿道周围组织重建。尿道后壁重建:将狄氏筋膜残端与尿道括约肌后壁中线结构缝合,再缝合至膀胱颈后壁筋膜;膀胱颈口荷包缝合及尿道吻合:将膀胱颈口肌层做连续荷包缝合,端端吻合膀胱颈及尿道;尿道前壁重建:将耻骨前列腺韧带与膀胱前壁连续缝合、悬吊尿道。结果20例手术均顺利完成,无中转开放或其他术式。手术时间(200.0±54.9)min,术中出血量(44.3±19.8)ml,术后住院时间(8.9±2.8)d,引流管留置时间(7.6±2.7)d,导尿管留置时间(12.9±2.6)d。术后病理:T2a期1例,T2b期4例,T2c期7例,T3a期5例,T3b期3例;术后标本病理Gleason评分:6分1例,7分9例,8分4例,9分5例,10分1例;切缘阳性率10%(2/20)。拔除导尿管后即刻和术后1、3、6个月尿控良好率分别为70%(14/20)、85%(17/20)、95%(19/20)、100%(20/20)。结论腹腔镜前列腺癌根治术中采用膀胱颈口荷包缝合联合尿道周围组织重建安全、可行,操作容易,患者术后早期尿控恢复满意。     

A novel training model for laparoscopic pyeloplasty using chicken crop

PURPOSE: To create a model for laparoscopic pyeloplasty training using the crop and esophagus of a chicken. The model can be used to simulate the steps taken during laparoscopic pyeloplasty and to help trainees practice laparoscopic suturing skills. MATERIALS AND METHODS: The chicken crop and esophagus were used to simulate the renal pelvis and ureter, respectively. These were exposed by reflecting the skin overlying the neck and thorax. The crop was thoroughly cleaned and filled with water via the esophageal end to simulate the dilated renal pelvis. The chicken was positioned within an indigenously made laparoscopic training box. Laparoscopic pyeloplasty was performed using the dismembered Anderson Hynes technique. The model was used over a period of 1 month by three urology trainees in their final year of training. They were assessed with respect to time needed to complete anastomosis and quality of anastomosis. RESULTS: The mean operative time showed a marked reduction from the second to the fourth attempt. There was also a significant improvement in the quality of anastomosis from the first to the fourth attempt. At the end of four attempts, all trainees were able to satisfactorily complete a good quality ureteropelvic anastomosis in a mean time of 67.7 minutes (range 62-76 min). CONCLUSION: Laparoscopic suturing skills require effective training and constant practice to perfect the technique. Adequate practice on this chicken model shortens the learning curve, makes the trainee more confident of his or her skills, and improves his operative performance.     

Simple model for training in the laparoscopic vesicourethral running anastomosis

PURPOSE: To create a simple model for training in the complex technique of laparoscopic vesicourethral anastomosis after radical prostatectomy. MATERIALS AND METHODS: A model simulating the performance of a laparoscopic running urethrovesical anastomosis was fashioned using skin of a supermarket chicken set in a laparoscopic training box. A circular continuous anastomosis was performed, following exactly the technique we use in vivo for performing a vesicourethral anastomosis after laparoscopic radical prostatectomy. Details regarding the use of the right or the left needle holder, needle positioning, precise stitch position, and use of forehand or backhand stitch were strictly respected in order to reproduce the continuous stitch currently done in vivo in our department. The learning curve was analyzed in terms of the time necessary to perform the task and the quality of the anastomosis. RESULTS: The model was created and used by the junior authors during their year of fellowship in advanced laparoscopic urology. The authors had no previous experience with hands-on laparoscopic suturing but have assisted in a great number of laparoscopic radical prostatectomies. The time required for performing the anastomosis on the model declined from 75 minutes initially to 20 minutes after the trainees had performed 20 anastomoses each. After this training, it was possible to create a watertight running laparoscopic vesicourethral anastomosis in patients in a mean time of 40 minutes (range 30-55 minutes). CONCLUSION: This simple model allows the trainee in laparoscopic urology to acquire the skills necessary to perform a laparoscopic vesicourethral anastomosis, one of the most complex steps in laparoscopic radical prostatectomy, as well as to develop dexterity and facility in laparoscopic manipulation of needles, sutures, and fragile tissues.     

Laparoscopic urethrovesical anastomosis: a model to assess surgical competency

PURPOSE: To create a model for the evaluation of resident competency and performance of laparoscopic skills in compliance with Accreditation Council for Graduate Medical Education (ACGME) outcome assessment guidelines for urology residency programs. MATERIALS AND METHODS: A model of laparoscopic interrupted urethrovesical anastomosis was developed using chicken skin from a local supermarket. Eight residents at various training levels utilized a simulator with a camera-operating assistant to practice placing interrupted stitches. The time necessary for completion of an anastomosis and the quality of the anastomosis were documented. RESULTS: The time required to recreate a simulated urethrovesical anastomosis by placing six interrupted stitches declined from an initial mean of 60.75 minutes to 20.5 minutes after each resident had performed 20 anastomoses each. The mean improvement was 39.5 minutes, with one postgraduate year-3 resident demonstrating an improvement of 50 minutes. CONCLUSION: This model can be used by ACGME-certified urology residency programs to assess the laparoscopic skills of residents.     

腹腔镜下次全子宫切除术子宫动脉及宫颈残端不同处理方法的比较

目的比较腹腔镜下次全子宫切除术子宫动脉及宫颈残端不同处理方法的临床效果。方法回顾分析我院2007年6月～2010年12月128例腹腔镜次全子宫切除术,宫颈残端缝合法65例（A组）：术中缝扎子宫动静脉后,切除宫体,宫颈残端连续锁扣缝合;宫颈套扎法63例（B组）：常规套扎子宫动静脉及宫颈,切除宫体后,再次套扎宫颈残端。比较2组手术时间、术中出血量、术后排气时间、术后宫颈残端出血发生率、术后住院时间、住院费用。结果 A组手术时间（63.1±14.0）min与B组（62.4±14.9）min比较无统计学差异（t=0.274,P=0.785）;A组术中出血量（115.2±56.7）ml与B组（128.1±66.2）ml比较无统计学差异（t=-1.185,P=0.238）;A组术后排气时间（31.1±2.7）h与B组（30.2±2.7）h比较无统计学差异（t=1.885,P=0.062）;A组住院费用（14 052.8±918.1）元与B组（14 361.2±891.0）元比较无统计学差异（t=-1.928,P=0.056）。B组术后宫颈残端出血发生率6.3%（4/63）与A组0比较差异无显著性（P=0.056）;B组术后住院时间（6.7±3.1）d较A组（5.8±0.5）d明显延长（t=2.310,P=0.023）。结论腹腔镜下子宫动脉＋宫颈残端缝合法似较宫颈套扎法安全,减少术后宫颈残端出血并发症的发生。     

Molleja de pollo: un nuevo modelo para entrenamiento laparoscópico de la anastomosis uretrovesical

ObjectiveTo create a simple, inexpensive, and reproducible model that would provide a new training option for performing urethrovesical anastomosis during laparoscopic radical prostatectomy.Material and methodsDesign and experimentation were carried out in 2008. Materials employed included a laparoscopic training box, video camera, monitor, needle holder, sutures, and non-eviscerated chickens weighing more than 2 kilograms. The model was prepared with a new vision of a structure similar to the human pelvis. To create the anastomosis, we used the gizzard (bladder neck) and the rectum (urethra). Once the model was placed in the box, the anastomosis was performed in very similar anatomical conditions to those in real procedures. The anastomosis quality was assessed by means of an impermeability test and transanal endoscopy.ResultsThe operating field is very similar to the human pelvis. Tissues with a quality, texture, and diameter resembling those of the urethra (rectum) and the bladder neck (gizzard) offer the possibility of practicing anastomosis and anterior racket.ConclusionsThe model for urethrovesical anastomosis using the chicken gizzard and rectum is simple, easy, available, inexpensive and reproducible. The anatomy of the chicken and the characteristics of its tissues allow for training under conditions very similar to those present in human cases.     

三站进阶模式在机器人前列腺癌根治术培训中的应用价值

目的探讨体外模型+虚拟现实+实际操作三站进阶模式在机器人辅助前列腺癌根治术培训中的应用价值。 方法第一站：体外模型训练。受训者在体外模型上进行端端吻合培训,使用Test T、Test R两种不同的评价方法对受训者进行评分。第二站：机器人虚拟现实培训。采用虚拟培训技术培训受训者,评价培训前后指标的变化。第三站：机器人体内操作。受训者与对照组医师进行机器人辅助膀胱尿道吻合,应用膀胱注水试验,评价吻合的可靠性。 结果第一站中,6名受训者总体得分显著提高（P=0.004）,由训练前的（50.0±10.5）提高至（79.2±9.7）;吻合时间明显缩短（P<0.001）,由（654.5±24.7）s降至（331.0±36.6）s。第二站中,6名受训者的总体分数显著提高（P<0.001）,由训练前的（35.3±3.1）提高至（86.0±4.2）;吻合时间显著下降（P<0.001）,由（345.5±31.2）s降至（170.0±7.4）s。第三站中,6名受训者在上级医师的指导下均顺利完成膀胱尿道吻合,相比6名对照组医师平均吻合时间由（40.7±8.6）min缩短至（27.5±8.4） min（P=0.023）。在膀胱注水试验中,受训者组未发现吻合口漏水情况,对照组有2例发生漏水情况,由上级医师进行了补救性缝合。 结论三站进阶模式能够快速缩短术者机器人前列腺癌根治术学习曲线,有利于在我国有限的机器人设备情况下推广。     

Single-knot running suture anastomosis (one-knot pyeloplasty) for laparoscopic dismembered pyeloplasty: training model on a porcine bladder and clinical results

Objectives  

The one-knot running ureteropelvic anastomosis is a modification of the single-knot running suture that was previously described for urethrovesical anastomosis. In this study, we present a novel porcine model for laparoscopic pyeloplasty training and report the results obtained in patients who underwent one-knot pyeloplasty.     

A simplified 5-step model for training laparoscopic urethrovesical anastomosis

PURPOSE: We developed a training model and program aimed at improving the skills of urologists with no previous experience in laparoscopy to perform a running suture urethrovesical anastomosis as is done during laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our program is performed on a pelvic trainer with a videolaparoscopic unit and consists of passage of a ligature, intracorporal knotting, intracorporal suturing, linear anastomosis and circular running suture anastomosis. The trainees performed the first 3 tasks during the initial lessons and then advanced to the 2 final tasks. At the end of each lesson time was recorded and progression curve was plotted for each participant for each task. The end point of the study was participant ability to perform an accurate circular anastomosis. Logarithmic regression analysis was used to assess the significance of progression. RESULTS: All 10 urologists who participated in this study showed a rapid and significant decrease in the time required to perform the first 3 tasks accurately. The participants were able to perform a linear anastomosis after 3 to 5 lessons and an accurate circular anastomosis after 5 to 10 lessons. CONCLUSIONS: By using this model and dividing a complicated surgical step to simplified tasks, we were able to improve trainee performance significantly in a short time. A training program for basic and advanced laparoscopic skills should be incorporated into the syllabus of urologists-in-training and available to those who wish to gain experience in laparoscopic surgery.