二级脾蒂分离法腔镜脾切除术治疗特发性血小板减少性紫癜

目的介绍该科应用腹腔镜脾切除术治疗特发性血小板减少性紫癜(idiopathic thrombocytopenic purprua,ITP)的经验,以及利用可吸收夹行腔镜下脾蒂处理的体会。方法20例ITP患者,通过解剖二级脾蒂的方法,用可吸收夹夹闭脾血管,完成腔镜脾切除手术。结果20例手术患者,无1例中转开腹,无术后严重并发症,其中16例患者用可吸收夹顺利完成腔镜脾切除,4例患者术中脾蒂改为Endo-GIA切割关闭。结论在具备丰富的腔镜手术经验的基础上,二级脾蒂分离法腔镜脾切除术是一种安全有效的技术,并具有创伤小、恢复快、费用低、并发症少等优点。手术前和手术中需要严格把握手术适应证以及做好相应准备。     

The Endo-GIA stapler for the side-to-side colorectal anastomosis in the Duhamel operation

A new technical modification of the Duhamel operation for construction of the side-to-side colorectal anastomosis is reported. A 2_1/2-year-old boy was duagnosed as having Hirschsprung's disease affecting the rectum and sigmoid colon. A Duhamel operation was performed with three modifications of the technique described by Lester W. Martin: the side-to-side colorectal anastomosis was performed with an Endo-GIA 30 stapler (Auto Suture; United States Surgical Corporation, Norwalk, Conn.) in an inverted V-shaped triangular manner; the remnant of the rectal stump was excited just above the Endo-GIA anastomosis, thus preserving only the rectal ampulla; and the rectal stump was left closed without being anstomosed to the descending colon. The postoperative functional results were excellent 6 months after the operation.This work was supported by Auto Suture, España     

A Two-Step Control of Secondary Splenic Pedicles Using Ligasure during Laparoscopic Splenectomy

Objective: We modified the LigaSure vessel sealing into a two-step technique without using Endo-GIA stapler for the secondary splenic pedicle control in laparoscopic splenectomy (LS). This study evaluated the efficacy and safety outcomes of this technique.Methods: Patients (n = 105) scheduled for elective LS were consecutively and prospectively enrolled, including 24 males and 81 females, with a mean age of 43.6 (range 11-75) years. Following the mobilization of the spleen, the splenic inflow was interrupted by applying a Hem-o-lock clip. LigaSure was used to seal and transect the secondary splenic pedicles adjacent to the pancreatic tail and subsequently in proximity to the spleen.Results: Of 105 patients, 103 patients (98.1%) underwent successful LS, whereas two patients (1.9%) required the conversion to laparotomy. The mean operative time was 100 min, whilst the mean volume of blood loss was 500 mL. No clinically significant morbidities or mortality occurred following LS. An average of 8,000 RMB (range: 6900 to 9000; 1 USD = 6.5 RMB) was saved by using this two-step technique.Conclusion: Secondary splenic pedicles can be successfully controlled in LS by using a two-step technique with the LigaSure vessel sealing system in an economically favorable way.     

免内镜切割闭合器的腹腔镜脾切除术14例报告

目的探讨免内镜切割闭合器的腹腔镜脾切除术的可行性。方法11例特发性血小板减少性紫癜、1例自身免疫性溶血性贫血、1例脾脏脉管瘤和1例脾功能亢进、乙肝后肝硬化病人行免内镜切割闭合器的腹腔镜脾切除术。结果14例患者手术均获成功，手助术式1例。二级脾蒂离断法处理脾蒂2例，圈套器双重结扎法处理脾蒂12例。手术时间80-400min，平均180min。术中出血量20～2000mL，平均350mL。术后住院时间2～21d，平均7d。手术并发症2例（14．29％），其中皮下气肿1例，左侧腹壁广泛淤斑1例。结论腹腔镜脾切除术中通过二级脾蒂离断法或圈套器双重结扎法处理脾蒂，可免内镜切割闭合器的使用，该术式安全、有效。     

两种脾蒂分离方法在门脉高压患者腹腔镜脾切除术中的应用价值比较

目的比较腹腔镜下切割闭合器（Endo-GIA）脾蒂离断法与二级脾蒂血管离断法在门脉高压腹腔镜脾切除中的应用价值。方法回顾性分析34例门脉高压脾肿大行腹腔镜脾切除治疗患者的临床资料,根据手术方法不同分为：A组Endo．GIA处理脾蒂19例,B组二级脾血管离断15例。比较两组手术时间、术中出血量、术后住院时间、术后并发症、住院总费用。结果A、B组手术时间[（144±20）min比（127±8）min]差异无统计学意义（t=0．249,P〉0．05）,B组术中出血、术后住院时间、住院总费用分别为（107±37）mL、（13．8±1．7）d、（3．36±0．36）万元,均少于A组的（229±113）mL、（15．4±2．7）d、（4．23±0．71）万元（t=7．774、2．572、2．930,均P〈0．05）。A组术后并发症均多于B组（均P〈0．05）。结论二级脾蒂血管离断法在门脉高压性肝硬化脾肿大腹腔镜脾切除术中有着胰腺损伤率低、出血少、住院费用少的优点,值得推广。     

Laparoscopic resection of splenic artery aneurysms

Background Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently.Methods A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients.Results One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 ± 12.6 ml, the mean operative time was 187.6 ± 79.2 min, and the mean postoperative length of hospital stay was 1.8 ± 1.3 days. The mean time to a clear liquid diet was 5.3 ± 0.5 h, and the mean time to a regular diet was 1 ± 0 day. The mean duration of narcotic analgesic use was 5.4 ± 1.5 days, and the mean time to resumption of regular activities was 12.7 ± 1.6 days.Conclusions These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.     

腔镜切割缝合器在中低位直肠腺瘤治疗中的应用

目的:探讨在中低位直肠腺瘤手术治疗中,使用腔镜切割缝合器（Endo-GIA）行经肛门直肠局部切除术和传统经肛门直肠局部切除术（TAE）的效果。方法:收集66例TAE和50例应用Endo-GIA经肛门直肠局部切除术的临床资料,就患者一般资料、手术疗效和病理检查结果进行分析。结果:两组手术患者的性别、年龄、肿瘤大小、术后住院时间和并发症发生率差异无统计学意义（p＞0.05）。切除肿瘤距肛缘距离Endo-GIA组[（5.30±1.46）cm]高于TAE组[（3.62±1.31）cm]（P＜0.01）;手术时间GIA组[（30.10±9.61）min]较TAE组[（47.50±13.05）min]缩短（P＜0.01）;中位出血量GIA组5 mL,较TAE组20 mL明显减少（P＜0.01）。结论:与传统经肛门局部切除术相比,应用腹腔镜切割缝合器经肛门局部切除中低位直肠腺瘤出血量少,切除范围广,操作省时简便。     

腹腔镜肝左外叶切除规范化手术方案的探讨

目的探讨完全腹腔镜肝左外叶切除的手术方案,制定相对安全、速度更快的规范化手术方案。方法回顾性分析2008年1月至2010年10月48例行完全腹腔镜肝左外叶切除术患者的临床资料,所有患者断肝前均未常规进行左肝静脉的游离阻断,均采用内镜切割闭合器处理肝蒂。结果48例患者均成功完成手术。术后住院时间为3～9d。2例患者发生胆漏,引流5d后痊愈,未发生腹腔内感染、大出血等并发症,无死亡病例。结论内镜切割闭合器进行肝左外叶切除简便、易行,有望成为腹腔镜肝左外叶切除的规范化手术方案。