电热手术刀在妇产科手术中的应用

目的：观察新型电热手术刀在妇产科手术中的应用效果。方法：对６５ 例需手术的妇产科病人,用新型电热手术刀做手术,与同期用普通手术刀（２５ 例） 和高频电刀（２０ 例） 做手术进行比较。结果：电热手术刀可在锋利切割组织的同时快速止血,止血作用类似于高频电刀;和普通手术刀相比,电热手术刀能明显减少出血量,加快手术速度,且无脂肪液化,无刀片粘连,切口愈合良好,热损伤轻微。结论：电热手术刀结合了普通手术刀和高频电刀的优点,适合在妇产科手术中推广使用。     

An effective device to keep the sternum open

(Received for publication on Oct. 6, 1997; accepted on July 7, 1998)     

Vascular anatomy of the pancreaticoduodenal region: A review

Vascular anatomy of the pancreaticoduodenal region has been the subject of numerous studies. However, several essential areas of confusion remain in interpretation of the vascular configuration. We note and discuss three key points in relation to this confusion: (1) a missing vascular arcade, (2) a rearrangement of the arcade by collateral and/or transverse vessels, and (3) a solitary vessel without an accompanying comites vein or artery. In addition, we consider that different interpretations as well as varying reported incidences depend on different "thresholds" when observations are made. Consideration of new aspects of vascular anatomy of the pancreaticoduodenal region is required for further improvement of surgical procedures. In terms of the selection of lymph node resection procedure, we discuss mainly the inferior arterial origin. Special attention should be paid to the ligation of inferior arteries because of the high incidence of the common trunk formation of the upper jejunal and inferior pancreaticoduodenal arteries. With regard to duodenum-preserving pancreatic head resection for benign tumors, our observations are introduced in view of either arterial or venous configuration. First, a communicating artery between the anterior and posterior arterial arcades is noted because of its possible critical role in blood supply to the papilla of Vater. Second, a venous drainage route from the duodenum to the retroperitoneal space in "normal" specimens is described. Received for publication on June 17, 1998; accepted on July 27, 1998     

Gastro-Gastric Fistulas and Marginal Ulcers in Gastric Bypass Procedures for Weight Reduction

Background: Gastro-gastric fistulas and marginal ulcers are frequent and serious complications of gastric compartmentalization procedures for obesity. Methods: The authors analyzed 810 patients after 911 operations for gastro-gastric fistulas and marginal ulcers over an 8-year period. All patients underwent a form of gastric bypass, in which a pouch is constructed along the lesser curvature of the stomach. The outlet of the pouch was restricted with a prosthetic band. In the first 189 patients (Group I), the pouch and stomach were stapled in continuity or partially divided. In the next 222 patients (Group II), segments were stapled and separated by transection. In the remaining 492 cases (Group III), in addition to transection of the stomach, a limb of jejunum was interposed between the pouch and excluded stomach. Stapled anastomoses were done in Group I and II patients and a portion of Group III patients. The remaining patients underwent hand-sewn anastomosis. Results: Gastro-gastric fistulas occurred in 49% of the patients in Group I, 2.6% of those in Group II, and 0% of those in Group III. In stapled anastomosis, the incidence of marginal ulceration in Groups I, II, and III were 8.5%, 5.4%, and 5.1%, respectively. In a subset of Group III patients, in whom a two-layer, hand-sewn anastomosis was done, the incidence was 1.6% when the outer layer was not absorbable and 0% when both layers were absorbable. Conclusions: Gastro-gastric fistulas and marginal ulcerations are likely the result of breakdown of the mucosa resulting from migrating staples and other foreign material. Lack of integrity of the gastric lining facilitates the action of the gastric digestive process. Transection of gastric segments with interposition of jejunum prevents gastro-gastric fistula formation. An intact serosa appears to block the digestion of bowel wall by gastric enzymes. Our early data suggest that the use of absorbable sutures at the gastrojejunostomy significantly decreases the incidence of marginal ulceration.     

Retropublic colpourethropexy with transabdominal anterior and/or posterior repair for the treatment of genuine stress urinary incontinence and genital prolapse

A new operative technique combining retropublic colpourethropexy with transabdominal internal anterior and/or internal posterior repair for the treatment of genuine stress incontinence (GSI) and genital prolapse is described in 75 cases. The overall success rate in correcting GSI was 92.0%, with a 94.8% success rate in the primary surgical group (n=58) and an 82.4% in the secondary group (n=17). Average follow-up has been 1.31 years (range 6 weeks–6 years). There was a 3.4% incidence of residual prolapse. Nine patients also underwent concomitant colpourethropexy. Overall surgical complications include febrile morbidity 4/75 (5.3%), wound infection 1/75 (1.3%), deep vein thrombosis 1/75 (1.3%) and partial ureteric obstruction 1/75 (1.3%). There were no statistically significant changes in multichannel urodynamic studies preoperatively and at 1 year following surgery. Onethird (2/6) of the GSI failures had low MUCP (<20 cm H₂O) prior to surgery and continued so at 1 year follow-up.EDITORIAL COMMENT: Genital prolapse is often present in patients who have GSI. If an operation is performed to correct the GSI, and those areas of weakness in the pelvic support system that are contributing to the genital prolapse are not treated, the genital prolapse will become more severe. In the operation which has been described, the colpopexy sutures will correct any cystourethrocele, and the removal of the wedge of tissue from the anterior superior vaginal wall will correct the cystocele. The removal of the wedge of tissue from the posterior superior vaginal wall will reduce the redundancy of the posterior vaginal fornix, but a culdeplasty of the Moschcowitz or Halban type is recommended to treat or prevent an enterocele and to place the vaginal apex in the hollow of the sacrum. Any coexistent rectocele must always be treated vaginally. If it is not treated, it will appear to be more advanced following elevation of the anterior vaginal wall by retropubic urethropexy and the anterior repair which has been recommended.Genital prolapse is best treated by a vaginal approach. When one must une an abdominal approach, ancillary procedures such as the authors have described should be considered. A bulbous upper vagina is ideal for childbearing but if the apical support system and vaginal wall is weakened it is predisposed to prolapse. If the surgeon, in operating for genital prolapse, which involves the upper vagina, will taper the vaginal apex and support it by obliteration of the cul-desac and shortening and reattachment of the uterosacralcardinal complex, postoperative prolapse will be less likely to recur.     

Surgical management of recurring or metastatic thyroid cancer

The surgical oncologist is sometimes confronted with a patient who was surgically treated for cancer of the thyroid gland and now has recurrent disease. In most instances, additional surgical treatment is indicated. The magnitude of surgery is primarily determined by the amount of tissue removed at the original operation. Surgery for recurrent disease may include completion of total thyroidectomy with dissection of lymphatic tissues in the thyroid compartment or/and neck dissection, preferably modified. Several clinical situations are outlined and discussed.     

The immobilization response in rhesus monkey: a behavioral and electroencephalographic study.

Rhesus monkeys maintained in individual cages are rarely inactive when observed by humans unfamiliar to them. It has been observed that these animals display a greatly reduced behavioral repertoire after they are transferred to primate chairs. The present study used systemic behavioral observations to document those changes and to examine additional changes produced by arm restraint. Chair restraint was associated with a reduction in activity which was intensified when animals were further immobilized by arm restraint. This immobilization produced a reduction of tone in all limbs, a reduction of spontaneous behavior, and the appearance of eye closure. Electroencephalographic (EEG) correlates of the behavioral changes were examined also, using quantitative data generated through power spectral analysis of sensorimotor cortical EEG signals. Immobilization was accompanied by a significant increase in spectral density at 12 to 15 Hz which was most marked at mid and far lateral rholandic recording sites. No other significant changes were seen in the frequency bands studied. When the immobilized animal was alerted with novel stimuli, lower frequencies were attenuated but 12- to 15-Hz activity remained enhanced. These findings indicate that a unique immobilization response is elicited by restraint in the rhesus monkey which is associated with discrete changes in both behavior and accompanying EEG patterns.     

Design and test of a vascular access device

Transarterial left ventricular assist devices (LVADs), such as the Hemopump, IABP, and PUCA-pump, are meant to be introduced into the body via the femoral or axillary artery without major surgery. For certain applications, introduction is performed directly into the aorta via an open thorax procedure. A prototype of a vascular access device has been realized that allows direct access into the aorta as an alternative for the common surgical graft anastomosis suturing technique. The device consists of a metal tube acting as a circular knife to cut a hole in the aortic wall, a screw to store the removed part of the aortic wall, and a plastic tube that is introduced through the hole and tightly connected to the aortic wall. The device could be placed without aortic clamping. The device has been tested on a slaughterhouse porcine aorta. A low-pressurized aorta appeared to be the worst case; thus, two animal experiments in the low-pressurized pulmonary artery were performed. No leakage occurred for pressures between 40 and 300 mm Hg.