LC手术治疗胆囊结石嵌顿226例临床分析

目的探讨LC治疗胆囊结石嵌顿的经验。方法回顾性分析我院2004年1月-2008年10月用LC治疗胆囊结石嵌顿226例的临床资料。结果215例成功施行LC,11例中转开腹,1例术后发生胆瘘,2例胆管损伤,无死亡病例,全部患者均痊愈出院。结论由于病例数的累积,术者腔镜技术的不断提高,对于胆囊结石嵌顿,采取适当的个体化方案,LC可作为首选,术后恢复快、痛苦小、并发症少。     

高龄患者后腹腔镜手术的麻醉管理

目的总结伴发全身性疾病的高龄患者后腹腔镜手术麻醉管理的经验。方法回顾性分析2002年10月-2007年1月81例高龄患者（年龄70-86岁,平均74.2岁）后腹腔镜的临床资料,其中有全身性伴发疾病77例,81例手术均在全麻下完成。结果气腹后35例（43.2%）发生高碳酸血症,35例（43.2%）发生酸中毒;41例（50.6%）出现不同程度的高血压。66例（81.5%）在手术室内拔除气管导管,手术结束至手术室内拔除气管插管时间5-50 min,平均15.1 min;1例（1.2%）带气管插管回本病房;14例（17.3%）术后转入ICU。1例（1.2%）术后第3天并发急性心肌梗死死亡。1例术后发生严重谵妄状态。结论高龄患者可耐受后腹腔镜手术高碳酸血症、酸中毒以及气腹后血压升高的风险,但围麻醉期的处理须谨慎。     

LAPAROSCOPIC CHOLECYSTECTOMY: THE EXPERIENCE OF A COMMUNITY HOSPITAL

Background: The practice of laparoscopic cholecystectomy in a community hospital is presented. The morbidity of the procedure is analysed and recommendations for improvement are made. Laparoscopic cholecystectomy was introduced into this 200 bed community hospital in October 1990. All five general surgeons accredited to the hospital agreed to participate in a quality assurance programme to determine the incidence of complications and to make recommendations for improvement. Methods: The records of all 534 patients having laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed, and all complications recorded. Results: Of the 534 cases reviewed in the study 470 were considered uncomplicated and 64 patients experienced a total of 85 postoperative complications. The death of one patient was caused by a pulmonary embolus and another patient experienced a myocardial infarction. Twenty patients has postoperative atelectasis or pneumonia and urinary infection or retention occurred in seven. Complications of laparoscopic cholecystectomy requiring a conversion to open cholecystectomy occurred in eight patients, biliary complications occurred in 18 and 11 patients required re-operation. Conclusions: Three areas of concern were identified. They were the incidence of major biliary injury (0.37% of all cases) and its management, the role of cholangiography. and the incidence and prophylaxis of deep venous thrombosis and pulmonary embolism. Recommendations for improvement in these areas were made.     

From laparoscopic training on an animal model to retroperitoneoscopic or coelioscopic adrenal and renal surgery in human

So far, laparoscopic approaches to kidney and adrenal have been limited because of their retroperitoneal location. We here report eight renal and adrenal endoscopic procedures performed in seven patients: two adrenalectomies for hyperaldosteronism, one adrenalectomy for isolated metastasis from an adenocarcinoma of the lung; two nephrectomies for end-stage infected hydronephrosis, two partial nephrectomies for small circumscribed lesions of the kidney, and one endoscopic resection for pain relief of a voluminous cyst at the kidney. The approach was transperitoneal in two cases and retroperitoneal in five cases using the retropneumoperitoneum insufflation technique. One patient was operated by a combined approach using the retro- and transperitoneal routes. All procedures were successfully completed endoscopically. The retroperitoneoscopic approach of the kidney is safe and does not interfere with the peritoneal organs. Its working space is tenuous, but allows a direct access on the kidney with good exposure of its pedicle. For adrenal surgery, the retroperitoneoscopic dissection is more difficult, because movements of instruments are often impaired by the closeness of the costal margin and the iliac crest. However, in case of difficulties we found it very convenient to switch from a retroperitoneal endoscopic approach to a combined coelioscopic and retroperitoneoscopic operation. Far from excluding each other, both approaches are complementary, particularly for difficult situations (i.e., previous peritoneal or retroperitoneal surgery).     

Apical vault repair, the cornerstone or pelvic vault reconstruction

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.     

An alternative technique for laparoscopic cholangiography

The current methods utilized for laparoscopic cholangiography involve cystic duct cannulation and present practical difficulties and potential hazards. An alternative method for intraoperative cholangiography is described which is easy, quick, and safe. The Kumar clamp (a gift from Sabi Kumar, M.D.) is placed across the infundibulum. A 23-gauge sclerotherapy needle is introduced through a side port in the clamp and directed into the infundibulum. The cholangiogram is obtained prior to any dissection in the triangle of Calot, thereby avoiding iatrogenic common bile duct injuries due to misidentification of the cystic duct or anomalous anatomy. To date no pathology has been missed and no complications have resulted from this technique.     

Laparoscopic cecal ligation and puncture in the rat

Background: We describe a technique of laparoscopic cecal ligation and puncture (CLP) in the rat analogous to open CLP which may facilitate the study of minimally invasive surgery (MIS) and peritonitis. Methods: Forty-four rats were randomized to either laparoscopic or open CLP and their 3-day mortality was recorded. Autopsies were performed for peritoneal fluid cultures, measurement of the length of ligated cecum, and scoring of the degree of cecal necrosis. Results: Laparoscopic CLP required slightly longer operating times compared to open CLP (average 15.6 vs 13.1 min, p= 0.002). Three-day postoperative mortality was 36.4% and 22.7% for open and laparoscopic CLP, respectively (p= NS). There were no differences in the length of ligated cecum or the cecal necrosis score between the open and laparoscopic CLP groups. Conclusion: Laparoscopic CLP is feasible and produces a fecal peritonitis with similar characteristics to those of traditional open CLP. Received: 3 July 1996/Accepted: 7 January 1997     

Bile duct injury repair: when? what? who?

Laparoscopic cholecystectomy is associated with a two-to-four times higher risk of bile duct injury (BDI) than open cholecystectomy. BDI can lead to significant morbidity and even mortality. The first priority in BDI is to control peritoneal and biliary sepsis and to convert an acute BDI to a controlled external biliary fistula (EBF) — this can be achieved by endoscopic and/ or radiological intervention in most cases. This should be followed by assessment of the extent of injury — both biliary and vascular. Immediate management of BDI recognized during cholecystectomy depends on the type of injury, the condition of the patient, and the experience of the surgeon. For BDI recognized after cholecystectomy, early repair is not recommended, as the results are poor. The EBF may evolve into a benign biliary stricture (BBS), which should be electively repaired by a Roux-en-Y hepatico-jejunostomy. The use of an endoscopic stent as definitive management of BDI is not recommended. Long-term follow-up is essential after the repair of a BBS, as recurrence can occur several years after repair. Recurrent BBS is best treated with endoscopic balloon dilatation. Excellent early and long-term results can be obtained in specialized units at tertiary care referral centers.     

腹腔镜筋膜内子宫切除和开腹子宫全切除临床对照研究

目的 :探讨腹腔镜筋膜内子宫切除术 (CISH)的手术方法和临床效果。方法 :选择CISH患者 6 0例 (腹腔镜组 )与开腹子宫全切除术 6 0例 (开腹组 )为研究对象。术前B超检测两组子宫大小无明显差异 ,术后两组的病理诊断均为良性。结果 :腹腔镜组 6 0例均获成功 ,与开腹组相比 ,腹腔镜组术中出血少 ,术后最高体温低 ,术后用药少 ,患者痛苦小 ,住院时间短 ,术后发热率低 ,术后并发症发生率低。结论 :CISH具有很多微创手术的优点 ,适合良性子宫病变患者。     

A comparison of surgeons' posture during laparoscopic and open surgical procedures

Background: There is increasing recognition of surgeons' physical fatigue in the new ergonomic environment of laparoscopic surgery. The purpose of this study was to determine what the differences are in the movement of the surgeon's axial skeleton between laparoscopic and open operations. Methods: Surgeons' body positions were recorded on videotape during four laparoscopic (LAP) and six open (OP) operations. The percent of time the head and back were in a normal, bent, or twisted position as well as the number of changes in head and back position were tabulated using a computer program. A separate laboratory study was performed on four surgeons ``walking' a 0.5-inch polyethylene tubing forward and backward using laparoscopic and open techniques. The movements of the surgeons' head, trunk, and pelvis were measured using a three-camera kinematic system (Kin). The center of pressure was recorded using a floor-mounted forceplate (Fp). Results: In the operating room surgeons' head and back positions were more often straight in laparoscopic procedures and more often bent in open operations. The number of changes in back position per minute were significantly decreased when the laparoscopic-only part of surgery was analyzed. In the laboratory the subjects' head position was significantly (p= 0.02) more upright and the anteroposterior (AP) and rotational range of motion of the head was significantly reduced during laparoscopy. Subjects' CP was more anterior and there was a significant reduction in the AP range of motion of the CP during laparoscopy. Conclusions: Our study suggests that surgeons exhibit decreased mobility of the head and back and less anteroposterior weight shifting during laparoscopic manipulations despite a more upright posture. This more restricted posture during laparoscopic surgery may induce fatigue by limiting the natural changes in body posture that occur during open surgery. Received: 3 March 1996/Accepted: 2 July 1996