减少手术创伤始终是妇科肿瘤手术快速康复的决定性因素

减少手术创伤始终是快速康复的决定性因素,这一点在目前的加速康复外科研究尤其是复杂手术,如妇科肿瘤手术中尚未得到充分重视。尊重学习曲线、全面规划手术方案、总结失利经验、开展前瞻性研究是解决此问题的主要方案。本文着重讨论妇科肿瘤手术创伤对术后加速康复的影响及可能的改进措施。     

腹腔手术后重症患者心肌损伤的危险因素

目的探讨腹腔手术后重症患者心肌损伤的发生情况及可能的危险因素。方法回顾性分析北京大学人民医院2017年1月至2019年1月腹腔手术后重症患者的一般临床资料及心肌损伤情况,收集并观察基础病史、术中(手术时间、是否急诊手术、术中出血>800 ml和术中低血压等)及术后指标(改良氧合指数、血乳酸、急性肾损伤和术后24 h内使用升压药情况等)。根据术后是否发生心肌损伤,将患者分为心肌损伤组和非心肌损伤组,采用Logistic回归分析腹腔手术后重症患者心肌损伤的危险因素。结果在纳入的803例腹腔手术后重症患者中,心肌损伤发生率为17. 2%(138/803),而急性心肌梗死发生率仅为0. 9%(7/803)。单因素分析显示,慢性肾功能不全病史、手术时间、急诊手术、术中低血压、术后24 h内使用升压药、高APACHEⅡ评分及术后即刻急性肾损伤与术后重症患者心肌损伤相关(P<0. 05)。多因素回归分析显示,急诊手术(OR=3. 14,95%CI:1. 76～5. 60,P<0. 001)、术后24 h内使用升压药(OR=2. 26,95%CI:1. 23～4. 15,P=0. 008)、APACHEⅡ评分(OR=1. 05,95%CI:1. 01～1. 09,P=0. 008)和术后急性肾损伤(OR=3. 18,95%CI:1. 78～5. 69,P <0. 001)与腹腔手术后重症患者发生心肌损伤独立相关。结论重症患者腹腔手术后心肌损伤发生率高,急诊手术、术后24 h内使用升压药、高APACHEⅡ评分和术后急性肾损伤是导致腹腔手术后重症患者发生心肌损伤的独立危险因素。     

激光角膜矫正术中所用激光波长的选择

用分光光度计测定了12例兔角膜和1例人角膜的吸收光谱,结果表明波长小于300nm的准分子激光和波长在1.88μm～2.64μm,2.36μm～40μm的激光,均可对角膜进行切割并可望用于激光角膜矫正术。     

Different Expression of Mitochondrial and Endoplasmic Reticulum Stress Genes in Epicardial Adipose Tissue Depends on Coronary Atherosclerosis

The aim of our study was to analyze mitochondrial and endoplasmic reticulum (ER) gene expression profiles in subcutaneous (SAT) and epicardial (EAT) adipose tissue, skeletal muscle, and myocardium in patients with and without CAD undergoing elective cardiac surgery. Thirty-eight patients, 27 with (CAD group) and 11 without CAD (noCAD group), undergoing coronary artery bypass grafting and/or valvular surgery were included in the study. EAT, SAT, intercostal skeletal muscle, and right atrium tissue and blood samples were collected at the start and end of surgery; mRNA expression of selected mitochondrial and ER stress genes was assessed using qRT-PCR. The presence of CAD was associated with decreased mRNA expression of most of the investigated mitochondrial respiratory chain genes in EAT, while no such changes were seen in SAT or other tissues. In contrast, the expression of ER stress genes did not differ between the CAD and noCAD groups in almost any tissue. Cardiac surgery further augmented mitochondrial dysfunction in EAT. In our study, CAD was associated with decreased expression of mitochondrial, but not endoplasmic reticulum stress genes in EAT. These changes may contribute to the acceleration of coronary atherosclerosis.     

3D soft-tissue tracking using spatial-color joint probability distribution and thin-plate spline model

Visual tracking techniques based on stereo endoscope are developed to measure tissue motion in robot-assisted minimally invasive surgery. However, accurate 3D tracking of tissue surfaces remains challenging due to complicated deformation, poor imaging conditions, specular reflections and other dynamic effects during surgery. This study employs a robust and efficient 3D tracking scheme with two independent recursive processes, namely kernel-based inter-frame motion estimation and model-based intra-frame 3D matching. In the first process, target region is represented in joint spatial-color space for robust estimation. By defining a probabilistic similarity measure, a mean-shift-based iterative algorithm is derived for location of the target region in a new image. In the second process, the thin-plate spline model is used to fit the 3D shape of tissue surfaces around the target region. An iterative algorithm based on an efficient second-order minimization technique is derived to compute optimal model parameters. The two processes can be computed in parallel. Their outputs are combined to recover 3D information about the target region. The performance of the proposed method is validated using phantom heart videos and in vivo videos acquired by the daVinci^®${\mathrm{daVinci}}^{\circledR }$ surgical robotic platform and a synthesized data set with known ground truth.     

柔性针的运动学建模及实验研究

针对在微创手术中传统采用的钢针的不足,如与组织作用,双方均产生较大变形,造成很大误差,严重影响治疗效果。另外在手术中常常遇到一些重要的组织和器官要避开,传统的钢针无法满足需要。本文采用带斜尖的柔性针,完全利用进针时斜尖与组织的侧向作用力使针轴产生弯转。这样不但可以更精确控制针的轨迹,而且还能绕过障碍物准确达到靶点。本文首先简化了WebsterIII等人提出的柔性针非完整约束系统的自行车模型,提出了自行车前、后轮模型。在此基础上,又提出了更符合实际的带返程度的自行车模型,并进行了运动学建模研究。以实验数据拟合了模型中各参数,同时验证了此模型的合理性和准确性。     

八叉树搜索算法在计算机辅助手术中的应用

讨论基于八叉树的空间搜索与求交算法,包括基于八叉树的单元格分配及求交运算2个步骤。该算法可有效应用于计算机辅助手术,实现解剖标志点的空间定位、距离测量、骨厚测量、三维模型间的干涉与距离检测等。其运算效率较高,具有良好的通用性和扩展性,适用于各类计算机辅助手术规划与手术导航软件。     

虚拟膝关节镜手术中保持单元质量的体网格形变方法

在虚拟膝关节手术中,需要对膝关节进行大范围形变的实时模拟。本文针对四面体网格的膝关节模型,提出了采用LSD度量建立形变能量,然后将带约束的最优化问题转化为不带约束的最优化问题,最后通过带Armijo线性查找的非精确牛顿法求解最优化问题。在求解过程中,通过预估未知点的位置,减少迭代步数,提高了算法的效率。这种方法具有较好的保体积性,同时保证形变后的四面体网格不出现体元翻转和退化。该方法也能推广应用于其它类似的关节弯曲运动的变形中。     

虚拟手术仿真中人体软组织形变技术的研究

对虚拟手术仿真中人体软组织形变技术进行深入研究,利用OpenGL三维图形标准建立了基于质点-弹簧物理模型的虚拟人体软组织形变系统。围绕虚拟手术仿真中人体软组织形变的逼真度和实时性两大要素展开研究,通过对比四边形网格结构提出了改进的基于质点-弹簧模型的正六边形几何拓扑结构,并对软组织形变动力学模型及其数值积分算法、软组织形变力反馈计算模型进行了讨论,针对以往的虚拟手术器械与软组织表面接触时作用点的最近邻质点求取算法存在的不足,提出了改进的求取算法。实验结果表明,改进的算法在模拟软组织形变时具有较好的稳定性和实时性。     

腹腔微创手术机器人末端执行机构的设计和实现

为了提高腹腔微创手术的安全性,设计了一种新型的腹腔微创手术机器人末端执行机构,用于夹持手术器械．根据腹腔微创手术的特点和技术要求,采用轴驱动和平行四杆的运动原理设计定点机构．详细介绍了末端执行机构的机械结构,应用D-H法和矢量代数法给出了各个关节的运动学解公式,研究了控制系统的硬件结构和软件系统,并进行了样机实验．实验表明所设计的末端执行机构具有很好的定点运动效果,能够较好地完成手术规划,满足腹腔微创手术要求．