外科临床实习教学的问题与思考

外科临床实习是医学生实习的重要组成部分,如何通过调动实习生学习的积极性和提高临床带教教师对临床实习教学的重视,来提高外科实习的教学质量,完善实习教学大纲内容和考评体系,是外科临床实习带教教师重点关注和深入研究的课题之一.本文对目前在外科临床实习阶段中普遍存在的问题、影响因素及近年来在外科临床实习教学中的思考和探索进行总结,希望能跟广大临床带教医生交流探讨,为提高临床实习质量提供新的思路和解决方案.     

自体外周血干细胞移植治疗周围神经损伤

背景:关于神经干细胞对周围神经损伤的治疗已有多篇报道,但外周血干细胞对周围神经损伤治疗鲜有报道。目的:探讨自体外周血干细胞移植治疗周围神经损伤使失神经骨骼肌重获神经再支配的临床应用。方法:应用外周血干细胞治疗周围神经损伤6例,同时与周围神经损伤单纯行神经断端吻合或神经移植10例比较。2组患者术后常规肌注鼠神经生长因子一两个疗程,同时给予针灸、理疗、经皮电刺激治疗及功能康复训练。结果与结论:两组患者随访均超过6个月。干细胞移植组运动神经传导速度和感觉神经传导速度的恢复率要明显高于单纯神经吻合组。提示周围神经损伤后给予修复局部用外周血干细胞移植能够使远端失神经骨骼肌早期重新获得神经再支配。     

逆行足内侧隐神经营养血管皮瓣修复足前部皮肤缺损

Objective To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects at forepart of feet. Methods From January 2004 to October 2008,15 cases of skin defects at forepart of feet were repaired with reverse saphenous nerve neurocutaneous flaps. The flap size ranged from 3.5 cm × 3.0 cm to 8 cm ×5 cm. The wounds at donor site were closed with skin graft. Results All the flaps survived completely with no ulcer at the donor site. 10 patients were followed up for 1 ～ 9 months. The skin color and texture were satisfactory. The patients could walk very well. Conclusions It is reliable to repair the skin defects at forepart of feet with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity.     

逆行足内侧隐神经营养血管皮瓣修复足前部皮肤缺损

Objective To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects at forepart of feet. Methods From January 2004 to October 2008,15 cases of skin defects at forepart of feet were repaired with reverse saphenous nerve neurocutaneous flaps. The flap size ranged from 3.5 cm × 3.0 cm to 8 cm ×5 cm. The wounds at donor site were closed with skin graft. Results All the flaps survived completely with no ulcer at the donor site. 10 patients were followed up for 1 ～ 9 months. The skin color and texture were satisfactory. The patients could walk very well. Conclusions It is reliable to repair the skin defects at forepart of feet with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity.     

带蒂腹壁下动脉穿支皮瓣修复大腿肿瘤术后创面

目的 探讨腹壁下动脉穿支皮瓣修复大腿肿瘤切除术后创面的效果.方法 自2002年1月至2009年1月,采用腹壁下动脉穿支皮瓣修复大腿肿瘤切除术后创面15例,皮瓣面积13 cm×10 cm～40 cm×10 cm,血管蒂长11～16 cm.根据缺损区皮肤松弛程度决定采用直接缝合或皮瓣移植修复.结果 术后14例皮瓣全部成活,1例皮瓣远端坏死约4 cm×1 cm,经换药创面痊愈.10例获随访1个月至2年,皮瓣色泽、质地与外形良好,患者行走及下蹲功能很好.结论 带蒂腹壁下动脉穿支皮瓣能修复大腿肿瘤切除术后创面,皮瓣范围大、供区隐蔽,效果理想.     

尺动脉近侧穿支蒂前臂内侧皮神经营养血管皮瓣修复肘部皮肤缺损

目的探讨尺动脉近侧穿支蒂前臂内侧皮神经营养血管皮瓣对肘部皮肤缺损修复的可行性。方法2006年1月至2008年12月,采用尺动脉近侧穿支蒂前臂内侧皮神经营养血管皮瓣转移修复肘部创面患者12例,年龄20～52岁。7例单纯皮肤缺损,5例伴有骨外露,2例伴尺神经缺损。神经缺损采用游离腓肠神经移植桥接,皮肤软组织缺损范围约4.0cm×5.0cm～6.0cm×8.0cm。供区游离植皮。结果12块皮瓣全部存活,皮瓣范围5.0cm×6.0cm～7.0cm×9.0cm。8例获随访(包括电话随访)1个月至2年,皮瓣色泽、质地与外形良好,肘关节可自由活动。2例尺神经缺损病例随访6～10个月,爪形手畸形明显改善。结论尺动脉近侧穿支蒂前臂内侧皮神经营养血管皮瓣可修复肘部皮肤缺损,血供可靠,手术操作简单。     

扩张皮瓣法外耳再造术矫正先天性小耳畸形

目的探讨扩张皮瓣法联合自体肋软骨支架移植治疗先天性小耳畸形的临床疗效。方法 2008年8月至2010年12月,采用扩张皮瓣法联合自体肋软骨支架移植治疗25例先天性小耳畸形患者。男15例,女10例。年龄6～30岁,平均12岁。术前患者均存在不同程度的小耳畸形。结果术后患者伤口愈合良好,无并发症发生。25例患者均获随访6月～1年。平均随访8月。患者术后再造耳解剖结构清晰,位置、大小、形态与健侧基本一致。结论扩张皮瓣法联合自体肋软骨支架移植矫正先天性小耳畸形疗效可靠,并发症少,易于操作,是修复先天性小耳畸形的简单有效的手术方法。     

皮瓣重建阴囊对家兔生殖功能的影响

目的 通过检测皮瓣重建阴囊后睾丸生精细胞凋亡及增殖细胞核抗原(PCNA)表达情况,以探讨皮瓣重建阴囊后对兔生殖功能的影响.方法 以育龄期新西兰大白兔作为实验动物,雄性动物随机分为实验组(皮瓣重建阴囊组)48只、对照组(皮瓣重建阴囊假手术组)24只和空白组18只.建模后的第3～8周末应用原位末端标记法(TUNEL)检测生精细胞凋亡和免疫组织化学法(SABC法)检测PCNA表达情况;第8周末各组分别对未取睾丸活检的12只雄性家兔与雌兔配对喂养,观察生育情况.结果 凋亡检测结果 :空白组正常睾丸生精细胞的凋亡指数为7.73±4.95.在第3周末实验组凋亡指数为22.59 4-3.04,对照组为21.13±1.68;在第8周末实验组凋亡指数为71.85±2.69.对照组为13.64±2.09.实验组在重建阴囊后3～8周内随着时间延长生精细胞凋亡指数逐渐增加,其凋亡指数明显高于空白组(P＜0.05);在第3周末实验组与对照组凋亡指数比较差异无统计学意义(P＞0.05);在第8周末实验组与对照组凋亡指数比较差异具有统计学意义(P＜0.05);第3周末对照组凋亡指数与空白组比较差异具有统计学意义(P＜0.05);第8周末对照组凋亡指数与空白组比较差异无统计学意义(P＞0.05).PCNA检测即增殖指数检测结果 :空白组正常睾丸生精细胞的增殖指数为43.07±2.25.第3周末及第4周末实验组增殖指数分别为9.32±9.30及12.52±3.87,对照组第3周末为45.69±4.98,实验组第3、4周末增殖指数分别与对照组第3周末及空白组增殖指数比较差异具有统计学意义(P＜0.05);实验组第7周末及第8周末增殖指数分别为46.98±18.92及49.53±9.79,对照组在第8周末为39.90±5.10,实验组第7、8周末增殖指数分别与对照组第8周末及空白组增殖指数比较差异无统计学意义(P＞0.05);对照组增殖指数在第3周末和第8周末分别与空白组增殖指数比较差异均无统计学意义(P＞0.05).配对结果 :空白组、对照组配对后对应母兔均受孕生崽,平均生崽数分别为(6.0±1.28)只、(5.92±1.31)只,两组生崽数差异无统计学意义(P＞0.05);实验组配对后对应母兔均未受孕,与空白组和对照组比较差异有统计学意义(P＜0.05).结论 皮瓣重建阴囊导敛的家兔生殖功能障碍主要是由于生精细胞的过度凋亡所致,生精细胞的增殖能力仪在重建阴囊早期受到一定的影响.而后期则无明显受损表现.     

逆行足内侧隐神经营养血管皮瓣修复足前部皮肤缺损

Objective To investigate the effect of reverse saphenous nerve neurocutaneous flaps for skin defects at forepart of feet. Methods From January 2004 to October 2008,15 cases of skin defects at forepart of feet were repaired with reverse saphenous nerve neurocutaneous flaps. The flap size ranged from 3.5 cm × 3.0 cm to 8 cm ×5 cm. The wounds at donor site were closed with skin graft. Results All the flaps survived completely with no ulcer at the donor site. 10 patients were followed up for 1 ～ 9 months. The skin color and texture were satisfactory. The patients could walk very well. Conclusions It is reliable to repair the skin defects at forepart of feet with reverse saphenous nerve neurocutaneous flaps. It is easily performed with less morbidity.