情景模拟法在后腹腔镜肾癌根治术教学中的应用

后腹腔镜手术是泌尿外科微创治疗的重要手段之一,后腹腔镜肾癌根治术是后腹腔镜微创手术的典型术式,高质量地完成后腹腔镜肾癌根治术的教学将有助于提高泌尿外科医师对后腹腔镜手术的理性认识和相关手术技能.我科每年要培训来自西南各地的大批进修生,在近几年的后腹腔镜教学中,我们应用情景模拟法,根据手术中进修医师可能需要扮演的角色,将他们安排在模拟的、逼真的手术环境中,要求其处理术中可能出现的各种临床情景.本文就情景模拟法在泌尿外科后腹腔镜肾癌根治性切除术教学中的经验报告如下.     

后腹腔镜肾癌根治性切除术52例临床体会

目的探讨后腹腔镜肾癌根治性切除术的手术治疗方法和临床体会。方法回顾研究后腹腔镜肾切除术的临床资料。肾脏肿瘤共52例。结果手术均获成功。所有患者均未输血,无腹腔脏器损伤、膈肌损伤、皮下气肿等并发症。手术时间70～180min,平均100min;术中出血50～200ml,平均90ml;引流管拔除时间24～72h;术后12～24h进流食;术后1～2d下床活动;术后6～8d出院。随访1年,患者无肿瘤种植及复发。结论后腹腔镜肾癌根治性切除术具有创伤小、恢复快、出血少、对腹腔脏器干扰少、住院时间短等优点,在手术器械改进和手术技巧熟练的情况下,疗效优于开放手术。具有良好的临床应用前景。     

腹腔镜在胃癌根治术中的应用和研究进展

目前,腹腔镜技术因其优点越来越受到临床医师的重视,具有创伤小、恢复快、术后生活质量高等优点,其应用范围随也逐渐扩大。经多年的临床实践证明其在胃癌患者中的应用效果良好,本文就腹腔镜技术在胃癌的诊断、应用及研究进展等作一综述。     

三维高清腹腔镜在腹腔镜直肠癌根治术中的应用

目的探讨3D高清腹腔镜在腹腔镜直肠癌根治术中的临床应用价值。方法2013年5月-11月,分别采用3D高清腹腔镜（30组）和2D高清腹腔镜（20组）行腹腔镜直肠癌根治术各30例,对比2组在手术持续时间、术中失血量、住院费用等方面的差异。结果3D组手术持续时间为（2．4±0．6）h,2D组为（3．0±0．8）h,差异有统计学意义（P=0．002）。3D组术中失血量（70±14）ml,2D组（80±16）ml,差异无统计学意义（P=0．013）。住院费用3D高清腹腔镜组（6．3±1．2）万元,2D高清腹腔镜组（6．5±1．3）万元,两组相比无统计学上差异（P=0．538）。结论3D高清腹腔镜能提供清晰的三维立体视觉,良好的深度感,可实现精确操作,缩短手术时间和减少出血量。3D高清视野下能更快地提高外科医生的腹腔镜手术操作能力。     

超声刀在泌尿系统后腹腔镜手术中的应用

探讨后腹腔镜技术治疗泌尿系统疾病的微创方法。方法应用超声刀经后腹腔镜途径对14例肾囊肿和6例肾上腺疾病患者进行手术治疗。其中原发性醛固酮增多症4例,无功能腺瘤1例,原发性肾上腺结节状增生1例;14例肾囊肿病例中5例为单侧多发性囊肿,9例为单发性;左肾8例,右肾6例;囊肿直径25～135mm,平均62.3mm。改良了穿刺点和扩张后腹腔的方法,采用超声刀进行分离和切割。结果本组病例应用以上方法全部获得成功,无术中转开腹手术者所有患者术中、术后均未输血。手术时间30min至2.5h。术中平均出血30ml。平均住院时间5.2天。结论有效的后腹腔扩张是进行手术的关键;超声刀具有精确切割和可靠止血的优势,不产生烟雾,提高了手术效率,在泌尿系手术中具有很好的推广前景。     

腹腔镜与传统开腹结直肠癌根治术手术效果对比

目的 分析腹腔镜结直肠癌根治术的微创优势。方法 选取 2015 年4月~2017年2月我院收治的 80 例结直肠癌患者作为研究对象,根据随机数字表法分为对照组和试验组,每组40例。对照组采用开腹结直肠癌根治术治疗,试验组采用腹腔镜结直肠癌根治术治疗,比较两组患者的切口长度、术中出血量、手术时间、肛门排气时间、住院时间以及术后肺部感染、尿路感染、异常出血、吻合口瘘、切口愈合不良并发症发生率。结果 试验组切口长度小于对照组[（6.30±1.24）cm vs （14.80±3.80）cm]、术中出血量少于对照组[（68.45±29.65）ml vs （134.68±35.49）ml]、肛门排气时间[（2.89±1.32）d vs （3.82±1.45）d]、住院时间[（11.47±3.04）d vs （18.62±2.67）d]更短,差异具有统计学意义（P＜0.05）;两组手术时间比较,差异无统计学意义（P＞0.05）;对照组患者并发症总发生人次高于试验组（19 vs 4）,试验组切口愈合不良发生率更低（0/37 vs 7/39）,差异有统计学意义（P＜0.05）。结论 腹腔镜结直肠癌根治术短期疗效确切,具有创伤小,术中出血量少,术后胃肠道功能恢复快,术后并发症少等优势。     

后腹腔镜技术在腰椎结核手术中的应用

目的：初步探讨后腹腔镜技术在腰椎结核手术中的应用价值。方法：采用后腹腔镜技术对5例腰椎结核患者进行病灶清除及腰大肌脓肿切开引流术。结果：顺利建立后腹腔气腹,成功地清除腰大肌脓肿及结核病灶。手术时问100—150min,出血量均约100ml。本组均获随访,时间7～24个月,均无复发、皮肤窦道及后凸畸形发生。结论：利用后腹腔镜技术结合术中B超行腰椎结核病灶清除手术具有微创、恢复快、清创彻底等优点,具有明显的优势,值得进一步推广。     

后腹腔镜在肾上腺手术中的应用

1资料与方法 1.1临床资料 6例肾上腺肿瘤患者,男4例,女2例,年龄38～65岁,平均47.8岁.术前根据临床症状、实验室检查、彩色多普勒超声及CT检查结果得到诊断,其中原发性醛固酮增多症3例、无功能腺瘤1例、嗜铬细胞瘤2例.肿瘤大小为2.1 cm×2.2 cm～4.3 cm×4.5 cm.     

腋前线切口在肥胖患者后腹腔镜肾根治切除术中的应用

目的 探讨腋前线切口在肥胖患者后腹腔镜肾根治切除术中的应用技巧及临床价值。方法 回顾性分析2015年9月至2022年9月于我院行后腹腔镜肾根治切除术的49例肥胖患者的临床资料,并分为改良组（16例）和传统组（33例）。改良组患者常规放置3枚套管后添加腋前线辅助套管进行手术;传统组患者常规放置3枚套管实施手术。比较2组患者的手术情况及术后恢复情况。结果 2组患者的术中失血量、肾测量最大横径比较,差异无统计学意义（P>0.05）。与传统组比较,改良组患者的手术时间、切口长度、下床活动时间、引流管留置时间及术后住院时间更短/早,术后应用镇痛药物、术后3个月切口感觉异常与切口局部肌肉膨出的患者比例更小,差异有统计学意义（P<0.05）。结论 肥胖患者后腹腔镜肾根治切除术于腋前线添加辅助套管,可以锁定切口起止点,便于助手进行辅助操作,可提升手术流畅度,缩短手术时间,且不增加手术并发症;选择腋前线切口取出肾标本具有保护肌肉、神经,减轻术后切口疼痛及并发症,愈合良好的优点。     

腹腔镜下子宫颈癌根治术的手术配合和护理

目的：探讨腹腔镜下子宫颈癌根治手术的配合及护理方法。方法对我院37例腹腔镜下子宫颈癌根治手术围术期护理、术中配合进行分析和总结。结果37例手术均顺利完成手术,初期10例手术中,其中2例术中转开腹,平均手术时间为(5.6±1.2)h,平均术中出血(245±20)ml;后其27例中,无1例中转开腹,平均手术时间为(4±0.8)h,平均术中出血(155±15)ml。结论通过改进手术体位、加强设备保养和检查并准备备用器械、熟练术中配合、及时处理、有效相关设备故障,能缩短手术时间、减少术中出血,有利于手术顺利进行。     

后腹腔入路与经腹入路腹腔镜下肾部分切除术治疗肾癌效果观察

目的：观察比较后腹腔入路与经腹入路腹腔镜下肾部分切除术治疗肾癌的临床疗效。方法选取我院的肾癌患者36例,根据手术方法分为A组和B组,分别采取后腹腔入路和经腹入路在腹腔镜下行肾部分切除手术治疗。结果两组在住院时间、手术时间及恢复进食时间方面,A组均所用时间均短于B组。结论此法具有良好的效果,且安全性高、创伤小,但后腹腔入路在相关指标因素上要优于经腹入路。     

腹膜后淋巴引流预防宫颈癌术后盆腔淋巴囊肿

目的：探讨宫颈癌术后并发盆腔腹膜后淋巴囊肿的防治方法和疗效。方法：53例IB期宫颈癌患者随机分为A、B两组。在宫颈癌根治性切除后,A组20例阴道残端与盆腔腹膜缝合,盆腔腹膜后完全闭合,腹膜后淋巴不引流;B组33例采用阴道残端部分敞开腹膜后淋巴引流。结果：术后盆腔淋巴囊肿发生率A组为25％、B组为3．3％,两组比较差异有统计学意义（P〈0．05）。结论：宫颈癌根治术后腹膜后引流用于预防术后盆腔腹膜后淋巴囊肿,方法简单、效果可靠,值得临床推广应用。     

5/6肾切除大鼠肾脏微循环改变

目的:观察5/6肾切除大鼠肾脏微循环的改变。方法:实验分为假手术组和5/6肾切除组,平行检测24h尿蛋白、尿蛋白/尿肌酐比值和血肌酐;观察肾组织病理学变化;免疫组化法观察小鼠抗大鼠氨肽酶P(JG-12)染色情况;检测肾组织内皮型一氧化氮合酶(eNOS)和组织型纤溶酶原激活物(tPA)mRNA和蛋白质的表达。结果:5/6肾切除组大鼠出现尿蛋白增多、尿蛋白/尿肌酐比值增加及血肌酐升高;肾组织可见肾小球硬化、肾小管萎缩和间质纤维化;免疫组化示毛细血管密度降低;eNOSmRNA及蛋白质表达减少,tPAmRNA及蛋白质表达增加。结论:5/6肾切除大鼠存在肾微循环障碍及血管内皮损伤。     

B超监测Bard针肾活检术后的腹膜后血肿——110例临床及病理

对110例用Bard针肾活检的患者术后采用B超检查,结果发现腹膜后血肿发生率为10.9%,穿刺针较粗可能是血肿形成的有关因素.采用B超导向下用18G Bard针进行肾活检、改进穿刺技术、对肾功能衰竭者肾活检前用低分子肝素抗凝并加强透析等措施,有可能减少腹膜后血肿的发生.     

Retroperitoneal fibrosis in 27 Korean patients: single center experience

Retroperitoneal fibrosis (RPF) is a rare disease with unclear etiology, which is characterized by chronic non-specific inflammation of the retroperitoneum. This study was performed to investigate the clinical characteristics, laboratory findings, radiologic findings, treatment and outcome in Korean patients with RPF. We retrospectively reviewed medical records of 27 RPF patients who were admitted to Yonsei University Medical Center between 1998 and 2009. Twenty-two patients (81%) were male. The mean age at diagnosis was 56 yr. Nine patients had identifiable risk factors of RPF and three patients had combined autoimmune diseases. Acute phase reactants were elevated in most patients. Rheumatoid factor was positive in 3 of 16 patients (19%) and antinuclear antibody in 4 of 17 (24%). Five of 6 patients who were taken positron-emission tomography showed positive uptake. Glucocorticoids were used in 16 patients (59%) and four of them received combination therapy with azathioprine. After immunosuppressive treatment, the levels of acute phase reactants dropped, and the size of mass also decreased in most patients. In conclusion, the clinical characteristics of RPF in Korean patients are similar with other series except for higher proportion of male. Some patients with RPF have autoimmune features. The effect of immunosuppressive treatment on RPF is good.     

Retroperitoneal laparoscopic ureterolithotomy for upper ureter stones

We evaluated the role of retroperitoneal laparoscopic ureterolithotomy (RPLU) for upper ureter stones. Between February 1998 and July 2004, 12 patients (10 men and 2 women) underwent RPLU for upper ureter stones (mean size 18.1 mm, range 10-25). RPLU was carried out in 5 patients as a salvage treatment after failed shock wave lithotripsy (SWL) (3) and both of failed SWL and ureteroscopy (URS) (2), and in 7 patients as primary treatment for large impacted stones. Total 6 of 12 cases were converted to open surgery. The reason of open conversion was failure of locating ureter due to severe adhesion in 5 cases and vascular injury in 1 case. In 6 successful cases, mean operation time, mean estimated blood loss, and mean postoperative hospital stay were respectively 109 min (90-120 min), 50 mL (10-100 mL), 4.6 days (2-7 days). There was no serious postoperative complication except for one patient who showed delayed urinary leakage but was cured with conservative management. Our experience suggested that RPLU was not easy to perform simply because it was indicated mainly in ureter stones with severe adhesion or after failed SWL and/or URS. Nevertheless, it can be considered as a primary procedure before open ureterolithotomy.     

The anatomical basis for retrorenal extensions of pancreatic effusions: the role of the renal fasciae

Summary Retrorenal extension of pancreatic inflammatory processes are considered to involve invasion of the posterior pararenal space. Analysis of computed tomographic (CT) images demonstrates preservation of posterior pararenal fat in most patients, implicating some other mechanism. We have examined the anatomical basis for these retrorenal extensions in static and functional studies of 12 cadavers using CT imaging, dissection and histological techniques. We observed that the posterior renal fascia was thicker than the anterior, that it could be easily separated into two layers by manual dissection and injections of liquid latex, that the inner (anterior) layer of the posterior fascia was continuous with the anterior fascia and the outer layer continuous with the lateroconal fascia. The point at which the two layers of the posterior fascia separated laterally and the medial extent of the posterior fascia varied considerably in CT scans of 100 patients. These data are interpreted to mean that pancreatic effusions extend posterior to the kidney by separating the two layers of the posterior renal fascia. Presented in abstract form at the second annual meeting of the American Association of Clinical Anatomists, Omaha, Nebraska, June 1985