两种外科疾病的腹腔镜联合手术

目的:探讨腹腕镜在同时治疗两种外科疾病的作用。方法:用腹腔镜行胆囊切除的同时施行阑尾切除术36例。结果:除4例因阑尾严重粘连或后位阑尾、腹腔镜难以找到阑尾改行右下腹麦氏切口切除阑尾外,其余32例均获成功,手术时间最短36分钟,最长90分钟,住院天数2～7天,平均4.2天、无手术并发症发生。结论:腹腔镜同时治疗两种外科疾病能明显减轻病人的痛苦,减少院天数,降低治疗费用,具有良好的发展前途。

Exophytic inflammatory myofibroblastic tumor of the stomach in an adult woman:A rare cause of hemoperitoneum

Inflammatory myofibroblastic tumor （INT） of the stomach in adults is extremely rare, with unpredictable prognosis. We present a 55-year-old woman with a gastric IMT. She experienced sudden abdominal pain 4 d previously. Physical examination showed mild abdominal tenderness in the hypogastrium, but no palpable abnormal abdominal mass. Abdominal CT showed a mass of approximately 8 cm in the gastrocolic ligament. On laparoscopic exploration, unexpected hemoperitoneum of approximately 1.5 L of blood was found, and an exophytic gastric mass of approximately 10 cm, appeared from the anterior wall of the gastric body along the greater curvature. Laparoscopy further showed that non- clotting blood in the abdominal cavity seemed to be from the gastric tumor. After conversion to open surgery for more precise evaluation of the cause of hemoperitoneum and the large friable tumor, gastric wedge resection, including the tumor, was conducted. The final diagnosis was consistent with IMT that originated from the gastric wall.

Recent advances in celiac disease

Celiac disease now affects about one person in a hundred in Europe and North America. In this review, we consider a number of important and exciting recent developments, such as clinical associations, HLA-DQ2 and HLA-DQ8 predispositions, the concept of potential celiac disease, the use of new imaging/endoscopy techniques, and the development of refractory disease. This review will be of use to all internists, pediatricians and gastroenterologists.

COMPLICATIONS IN LAPAROSCOPIC GYNECOLOGIC SURGERY

Objective. To investigate retrospectively the complications and associated factors of gynecological laparoscopies. Methods. 1 769 laparoscopic surgeries were carried out from January 1994 to October 1999 at our department. The procedures included 1421 surgeries of ovary and tube, 52 myomectomies and 296 cases of laproscopic-assisted vaginal hysterectomy (LAVH). A total of 312 patients had a history of prior laparotomy (176%). Results. Complications occured in 34 cases, the overall complication rate was 192%. Unintended laparotomies occured in 6 cases(034%). 12 complications were associated with insertion of Veress needle or trocar and creation of pneumoperitoneum, including 5 severe emphysema and 7 vascular injuries, this figure represents 353% of all complications of this series. Five intraoperative complications (147%) occured during the laparoscopic surgery (3 severe bleedings, one bladder injury and one skin burn of leg caused by damaged electrode plate), laparotomy was required in four of these cases. Seventeen complications occured during postoperative stage: 2 intraperitoneal hemorrhages needing laparotomy, 2 bowel injuries, 4 nerve paresis and 9 febrile morbidities. Conlusions. Operative gynecologic laparoscopy is associated with acceptable morbidity rate, but can not be overlooked. Complication rate seems to be higher in advanced procedures such as LAVH.

Ultrasound-guided Transversus Abdominis Plane Block Improves Postoperative Analgesia and Early Recovery in Patients Undergoing Retroperitoneoscopic Urologic Surgeries:A Randomized Controlled Double-blinded Trial

Objective To evaluate the effects of ultrasound-guided transversus abdominis plane(TAP) block on postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.Methods This was a randomized,controlled,double-blinded trial.Eligible patients scheduled for retroperitoneoscopic urologic surgeries were randomly assigned to two groups.Group TAP received ultrasound-guided TAP block with 0.5% ropivacaine 20 ml at 30 minutes before surgery,and Group C received TAP sham block with normal saline.All patients received retroperitoneoscopic urologic surgeries under general anesthesia.The primary outcome was the severity of pain after surgery.Secondary outcomes included opioids consumption,analgesics,postoperative nausea and vomiting,time to Foley catheter removal and to passage of flatus,length of post-anesthesia care unit stay and hospital stay.Results Eighty patients completed the study,forty cases in each group.Compared to the Group C,the Group TAP had lower visual analogue scale pain scores within two postoperative days(all P<0.05).They also had less consumption of intraoperative fentanyl(2.0±0.5 vs. 3.8±0.7 μg/kg,P<0.05),reduced incidence of postoperative rescue analgesic usage(12.5% vs. 45.0%,P<0.05),and lower incidence of postoperative nausea and vomiting within postoperative 48 hours(12.5% vs. 25.0%,P<0.05) when compared to the Group C.In addition,Group TAP had a shortened post-anesthesia care unit stay(25±8 vs. 49±12 minutes,P<0.05),and a greater proportion of patients discharged within postoperative three days(57.5% vs. 35.0%,P<0.05).Conclusion Preoperative ultrasound-guided TAP block is an effective technique to improve postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.

胸腔镜与闭式引流在胸腔积液临床检查的应用效果分析

选取我院2014年10月~2015年2月收治的胸腔积液患者24例,采用内科胸腔镜检查进行诊断。与临床常用闭式引流取胸腔积液行细胞病理、影像学进行分析对比,评价其诊断率及临床应用价值。统计结果可以看出,胸腔镜组确诊率为100%（24/24）,闭式引流组确诊率为79.2%（19/24）,胸腔镜组确诊率明显高于闭式引流组,差异具有统计学意义（P〈0.05）。结果 24例患者中胸腔镜下多部位取材的病理活组织检查确诊率为100%（24/24）。总计确诊病例24例,阳性15例（结核12例、肿瘤3例）,慢性炎症9例。闭式引流组24例患者确诊率为66.7%（16/24）。总计确诊16例,阳性10例（结核8例、肿瘤2例）,慢性炎症6例,原因不明8例。内科胸腔镜是一种诊断率高、简便、安全、创口小的诊疗手段,值得广泛应用于临床。

Venous hemodynamic changes of lower extremity during gynecological laparoscopy

Objective: To study the effect of CO2 pneumoperitoneum and the special 30 degree head-down tilt position on the venous hemodynamics in the lower extremity. Methods: Color doplex ultrasound was adopted to evaluate the diameter and blood flow velocity of the right femoral vein of 18 patients undergoing gynecologic laparoscopy under the same pressure of pneumoperitoneum of 12 mmHg. The diameter of femoral vein and the flow velocity were measured; the blood flow volume was calculated based on the equation of Q = vπr2 . Result: After establishment of pneumoperitoneum, the dilation of the femoral vein and the decrease in the velocity and volume can be observed (P < 0.05). And the 30 degree head-down position could increase the flow velocity and volume of the femoral vein and decrease the diameter of the vessel ( P < 0.05). At 30 minutes of the 30 degree head-down tilt position, the blood flow ameliorated compared with that in prone position after the establishment of pneumoperitoneum. After deflation of pneumoperitoneum, the femoral vein remained dilated( P < 0. 05). Conclusion: During laparoscopy, CO2 pneumoperitoneum may result in the dilation of the vein in lower extremity and retar dance of blood flow. The 30 degree Trendlenburg position can ameliorate the blood flow in the lower extremity. The deflation of the pneumoperitoneum cannot eliminate the effect of CO2 pneumoperitoneum on the lower extremity veins, which may predispose deep venous thrombosis after laparoscopy.

Application of Laparoscopy in Gynecological Surgery

Laparoscopic surgery is a recent minimally invasive technological innovation that conforms to the idea of endoscopic surgery. With the rapid development of science and technology, gynecological surgery has been widely used laparoscopic technology, greatly improved the gynecological problems. The survey found that China＇s laparoscopic technology and foreign laparoscopic technology were the same leveL Laparoscopic technology has become more and more mature in recent years, laparoscopic technology in the field of gynecology has been applied year after year, after many clinical trials, gets some experience and progress. This article explores the development of laparoscopic surgery in the field of gynecology and the limitations and solutions to discuss, promoting gynecological development, so that the majority of patients benefit from it.

Centers of excellence in minimally invasive gynecology: Raising the bar for quality in women's health

The ＂Center of Excellence＂ concept has been employed in healthcare for several decades. This concept has been adopted in several disciplines; such as bariatric surgery, orthopedic surgery, diabetes and stroke. The most successful model in surgery thus far has been the bariatric program, with a very extensive network and a large prospective database. Recently, the American As-sociation of Gynecologic Laparoscopists has introduced this concept in gynecologic surgery. The ＂Center Of Excellence in Minimally Invasive Gynecology＂ （COEMIG） designation program has been introduced with the goals of increasing safety and efficiency, cutting cost and increasing patient awareness and access to mini-mally invasive surgical options for women. The program may harbor challenges as well, such as human and fnancial resources, and diffculties with implementation and maintenance of such designation. This commen-tary describes the COEMIG designation process, along with its potential benefits and possible challenges. Though no studies have been published to date on the value of this concept in the feld of gynecologic surgery, we envision this commentary to provoke such studies to examine the relative value of this new program.

The Use of 3D laparoscopy in Surgical Operation

Purpose： studying and analyzing the application effect of three dimensional （3D） laparoscopy m surgical operation. Method： We select 126 patients who were diagnosed celiac disease in our hospital between May 2015 and April 2016 as our research subjects. All of these patients have indications for laparoscopic surgery, and we divide them into two groups randomly （observation and control group）. While the observation group is treated by 3D laparoscopic operation system, and the control group is treated by 2D laparoscopic system. During the treatment ,we observe the operation time, intra-operative bleeding and hospitalization time between the two different methods. Result： During the operation, the operation time of observation is （135.5±23.84） minutes and intra-operative bleeding time is （130.2±20. 11） milliliters, which both them are significantly lower than control group （163.8±25.22）min, （146.3±27.42）ml. This difference is statistically significant （P 〈0.05）. On the other hand, there is no obvious difference between observation and conlrol about indwelling catheter time, postoperative hospitalization time and postoperative exhaust time. For the observation, the datum were （2.3±0.31） d, （8.1±1. 32） d, （3.2±0.58） d and they were no statistical significance. Conclusion： Compared with traditional laparoscopic surgery, the image of 3D laparoscopic surgery is more clear and stereoscopic. What＇s more, operators can have a good command of it easily to shorten operation time, which avoid surgery vascular damage and reduce bleeding amounts to some extent. It is a good assistant for clinical use.

About Laparoscopic Surgery Teaching Methods Discussed in this Paper

Surgery as one of the backbone of the clinical medical disciplines, it is a practical subject and the surgery teaching is an important component part of the surgery, is also a medical student to study the surgical aseptic technique and basic knowledge of the surgery and surgical basic skills, the students learned an important part of the theory is applied to clinical practice. Laparoscopy is a new technology, how to apply this new medical technology in surgery, to help students in the limited class hours quickly mastering their own knowledge, this is at present our country facing the most important subject in medical teaching. In view of the present of laparoscopic surgery in school teaching method were discussed and analyzed, and on how to have a purpose, systematic training students to master this skill, and to lay a good foundation of surgical basic skills of students, set up a bridge from slowly towards the classroom teaching of clinical practice.

Application of ultrasonic scalpel in gynecologic operative laparoscopy

Objective To investigate the applied value of the ultrasonic scalpel in gynecologic operative laparoscopy. Methods Gynecologic operations were performed using the ultrasonic scalpel under laparoscopy. Operative bleeding and time, perioperative body temperature and hemogram, and tissue damage were observed.Results Forty-two cases of benign gynecologic diseases were treated with the ultrasonic scalpel under laparoscopy. Among them, there were 4 hysterectomies, 9 ovarian cystectomies, 18 salpingotomies, 4 ectopic pregnancies, 3 myomectomies, 3 adhesiolysis and 1 adnexectomy. The amount of operative bleeding, operating time and the tissue injury were related to the type of operation. The minimual operative bleeding amount, operating time, depth of tissue necrosis, tissue injury score and fibrin deposition score were 24.77±4.71ml, 23.39±3.01 min, 0.22±0.10mm, 0.98±0.21 and 0.38±0.26, respectively. The maximal operative bleeding amount, operating time, depth of tissue necrosis, tissue injury score and fibrin deposition score were 166.7±47.18ml, 127.2±16.99 min, 0.35±0.20mm, 1.25±0.20 and 0.81±0.29, respectively. The levels of body temperature, white blood cells and hemoglobin before and after the operations were not statistically different (P>0.05) except for hysterectomy (P<0.05). Conclusion The ultrasonic scalpel can be safely applied for gynecologic operative laparoscopy and should be used widely.

Incidence of deep venous thrombosis after gynaecological laparoscopy

Objective To evaluate the incidence of deep venous thrombosis (DVT) after gynaecological laparoscopy.Methods The incidence of DVT was studied in 72 consecutive patients who underwent gynaecological laparoscopy in the Liverpool Health Service between May and September 1997. B-mode ultrasound supplemented by Doppler was used to examine venous patency and intraluminal echoes to diagnose DVT. Sixty-one patients who had pneumoperitoneum less than 60 minutes were classified a minor procedure and 11 who had pneumoperitoneum more than 60 minutes were classified as major procedure. Two Doppler ultrasound scans were planned for every patient. The first one was done within 24 hours and the second was performed on day 7 post-surgery. All 72 patients had the first scan and 40 out of 61 in the minor procedure group and 9 out of 11 in the major procedure had the second scan. Twenty-three patients who did not come for the second scan were followed up by phone.Results No DVT was found in our study.Conclusion This study confirms an impression that gynaecological laparoscopic procedure has a very low incidence of DVT. If it occurs, the diagnosis and treatment must be made as soon as possible so that the fatal complications such as pulmonary embolus can be avoided.

Gasless laparoscopy for benign gynecological diseases using an abdominal wall-lifting system

Objectives: The use of gasless laparoscopy with an abdominal wall-lifting device for benign gynecological diseases was compared to conventional laparoscopy with CO2 pneumoperitoneum. Methods: From February 2007 to July 2007,76 women with uterine and/or adnexal benign diseases and candidates for laparoscopic surgery were recruited in this study. Thirty-two women underwent gasless laparoscopic surgery and 44 women underwent pneumoperitoneum laparoscopic surgery. Results: Diverse pathologies,including adnexal cyst,uterine myoma and ectopic pregnancy,were treated successfully with gasless laparoscopic surgery. Compared with the patients in the pneumoperitoneum group,the similar hospital stay (P=0.353) and intraoperative blood loss (P=0.157) were observed. However,the mean operative time in the gasless group was significantly longer than that in the pneumoperitoneum group (P=0.003). No severe intraoperative or postoperative complications were found in either group,except for one case of laparotomic conversion in the pneumoperitoneum group due to dense pelvic adhesions. The total hospital charges were significantly less in the gasless group than in the pneumoperitoneum group (P=0.001). In 38 cases of ovarian cyst resection,the mean operative time in the gasless group remained longer than that in the pneumoperitoneum group (P=0.017). The total hospital charges were also significantly less in the gasless group than in the pneumoperitoneum group (P<0.001). Conclusion: Our preliminary results demonstrated that the laparoscopic procedure using the gasless technique was a safe,effective method to treat benign gynecological diseases. Moreover,it was easy to master. As a minimally invasive treatment,gasless laparoscopic surgery provides a good choice to patients in the undeveloped regions in China without increasing the patients’ and the government’s burden significantly.

The impact of surgeon choices on costs associated with uncomplicated minimally invasive colectomy:you are not as important as you think

Background:There is increasing public discussion about the escalating cost of healthcare in America.There are no published data regarding the contribution of individual surgeons’choices on the cost of uncomplicated minimally invasive colectomy.Methods:A review of a hospital cost-accounting database of the direct costs related to the index operation and postoperative care of all patients who underwent elective minimally invasive segmental colectomy over a 1-year period was performed.Results:A total of 111 cases were enrolled in this study,18 of which were performed robotically.The average direct cost after minimally invasive colectomy was$5536.The cost of robotic colectomy was 53%greater than laparoscopic($7806 vs$5096,p<0.001).There was no statistically significant difference in overall costs among laparoscopic cases performed by three surgeons($5099 vs$5108 vs$5055,p¼0.987).Average operating room supply costs among the three surgeons were$1236,$1105 and$1030,respectively(p¼0.067),with a standard deviation of$328(6.4%of overall cost).Conclusions:No significant difference in overall costs between surgeons was demonstrated despite varied training,experience levels and operative techniques.Total costs are relatively institutionally fixed and minimally influenced by variations in individual surgeon preferences.