Objective:To compare the effectiveness and cost between laparoscopic transabdominal preperitoneal repair(TAPP)or totally extraperitoneal repair(TEP)and open Lichtenstein repair for inguinal hernia.Methods:PUDMED,EMBSE,MEDALINE,CAJ FULL-TEXT DATABASE were used to search the published clinical randomized controlled trials(RCTs)about Lichtenstein repair and TEP or TAPP from 1990 to 2004.All the related data matched our standards were abstracted for Meta-analysis by Revman 4.2.The evaluation criteria included operation time,total perioperative complications,recurrence rate and treatment fee.Results:1 763 patients of 12 RCTs were included into the analysis.Among them 605 TAPP and 265 TEP were in laparoscopic group,945 patients were in open group.Meta-analysis showed operative duration was significantly longer in laparoscopic group.The overall perioperative complication rate and recurrence rate were relatively equal between the two operation procedures.But some of the studies showed laparoscopic repair needed high treatment fee and could bring some special complications.Conclusions:Open Lichtenstein repair is suitable for most patients for its significantly lower treatment fee,faster and easier operation skill,and can use local anesthesia been performed in day surgery clinical practices.For the recurrence and bilateral inguinal hernia,laparoscopic repair may be a good choice.

1 临床资料 患者67岁,男性,因尿黄伴皮肤瘙痒1个多月入院.既往无特殊病史.查体:皮肤、巩膜重度黄染,剑突下深压痛.B超示:胆囊壁增厚,胆囊结石,肝内胆管扩张约0.6 cm,胆总管下段占位,右肾结石双肾小囊肿;PTC造影示胆总管下段梗阻,考虑肿瘤所致.

Objective To discuss the preventions and handlings of complications in endoscopic thyroidectomy via breast approach. Method The results of endoscopic throidctomy via breast approach by using ultrasonically activated scalpel were studied. Result 200 cases underwent endoscopic thyroidectomy via breast approach, in which 194 cases were performed successfully. There was no serious complication occurred during the procedures. The main postoperative complications included one case of thyroid crisis, one case of transient dullness, and 2 cases of transient hoarseness. After 1 to 20 months follow-up, no recurrence occurred. Conclusions It is important for surgeon to have detailed acknowledgement in the anatomy of thyroid gland, skillful manipulation of procedure and the experiences of open procedure in preventing and decreasing the complications of endoscopic thyroidectomy via breast approach.

目的探讨腹腔镜胆囊切除术中不使用钛夹的技术,观察其临床效果.方法800例腹腔镜胆囊切除术术中采用镜下打结、线圈套扎及超声刀技术处理胆囊动脉或胆囊管完成手术;对照组采用钛夹夹闭胆囊动脉与胆囊管完成腹腔镜胆囊切除术326例,比较临床效果.结果800例全部顺利完成,无中转开腹.免钛夹组手术时间较长(P＜0.01),术后肠道功能恢复时间、术后住院时间等恢复指标两组类似,两组均无术后大出血、胆瘘等并发症发生.结论借助镜下打结、线圈套扎及超声刀技术,腹腔镜胆囊切除术可以不使用钛夹,手术安全可靠.

目的比较腹腔镜胆囊切除术逆行法与顺行法的临床效果.方法将219例腹腔镜胆囊切除术患者分为逆行法组(96例)与顺行法组(123例),分别使用逆行法与顺行法完成手术,比较其治疗效果.结果219例全部顺利完成,无需中转开腹.手术时间A组(37±12)min,B组(35±7)min,出血量A组(3.4±2.5)ml,B组(3±1.5)ml,两组间差异均无显著性(P均＞0.05).钛夹使用病例数A组66例,B组121例,两组差异有显著性(P＜0.01).结论腹腔镜胆囊逆行切除法不延长手术时间、不增多出血量,易掌握、更安全.

目的:评价国产吻合器行痔上黏膜环切术(Procedure for Prolapse and Hemoorrhoid,PPH)治疗Ⅲ～Ⅳ度脱垂性内痔疗效.方法:对238例Ⅲ～Ⅳ度脱垂性内痔行国产吻合器行痔上黏膜环切术治疗.结果:术中出血约6～18 mL,平均9 mL;手术时间8～36 min,平均15 min;术后48 h疼痛评价190人无疼痛(79.83%),35例轻度疼痛(14.7%),13例中度疼痛(5.46%),尿潴留42例(17.65%),其中男性29例,女性13例.吻合口3～4周痊愈,出院后随访3～15个月,平均6.7个月,无复发.结论:国产吻合器行痔上黏膜环切术(PPH)是一种操作时间短,术后并发症少,恢复快痛苦创伤少,复发低,疗效好,相对进口产品治疗费用较低廉的手术方法.

目的探讨超声刀在腹腔镜肠粘连松解手术中的应用.方法应用超声刀行腹腔镜肠粘连松解术治疗粘连性肠梗阻29例.结果 29例均顺利完成手术,无中转开腹.2例因肠管间广泛致密粘连而致分离中肠管破裂,但均在腹腔镜下修补成功.手术时间30～150 min.术后无肠漏、出血或腹腔感染等并发症.术后3～7 d出院,随访1～24个月,未见有腹痛、腹胀等复发症状.结论与电刀相比,超声刀的应用使腹腔镜肠粘连松解手术安全性更高,创伤更小,手术时间更短,而且使术后肠粘连肠梗阻复发的机会更少.

为探讨腔镜甲状腺切除术皮下全体吸收对机体影响,我们对初期23例因甲状腺疾病施行经胸部途径腔镜甲状腺手术患者的血气进行对比研究.

OBJECTIVE To evaluate the clinical application of laparoscopic vertical banded gastroplasty (LVBG) for morbid obesity. METHODS Four patients undergoing LVBG were evaluated by comparison of the preoperative and postoperative morbidities and body weights. RESULTS Laparoscopic surgery was successfully performed in all the 4 cases without laparotomy. The average operative time was 210 min without intraoperative or postoperative complications. In the 24-month follow-up, the body weight was reduced by over 50% of the excessive weight. CONCLUSION LVBG is an effective and safe treatment for morbid obesity.

腔镜手术是以"孔"代"口"的一种典型微创外科手术技术,我们认为将其称为腔镜微创外科手术比较合适,它以小穿刺口代替大切口,从而减少腹壁体神经的损伤(腹部为T6～L2)以及损伤引起的疼痛刺激;同时医生手不进入腹腔,采用细小器械在具有放大镜作用下的腹腔镜直视下操作,减少了对腹腔内器官的损伤与干扰,继而减轻了引起机体内一系列应激反应的水平,如C-反应蛋白、白介素-6(IL-6)等的增高或减少,达到了少痛或无痛,所以术后病人恢复快、效果好、并发症少,而且具有手术疤痕小、美观的优点.

1临床资料 患者男,17岁,体重136 kg,体重指数43,住院号:168387.2001年6月29日手术.患者取平卧位,术者位于患者两腿之间,第一助手位于患者左侧,建立气腹后,于腹壁置5个套管,用超声刀在胃左动脉第二分支以外分离肝胃韧带,在浆肌层和迷走神经胃后支之间分离胃后壁,分离后用线型切割器于距食管胃交界1 cm处分次将胃底部横行切断,造成一个30 ml的小胃;提起大网膜和横结肠找到Treitz韧带,将一根25 cm长的布带由Trocar送入腹腔,测量Treitz韧带以下的Roux肠袢长度50 cm,用线型切割器切断空肠后,在断端远端100 cm处缝线作标记.

OBJECTIVE To discuss the method, the advantages and disadvantages of endoscopic thyroidectomy. METHODS Endoscopic thyroidectomy via areola of breasts approach was performed in 150 patients, including 41 cases of thyroid adenoma, 64 cases of nodular goiter, 40 cases of Graves' disease, and 5 cases of thyroid carcinoma. RESULTS The endoscopic thyroidectomy was successfully carried out in 144 cases, including tumor dissection in 32 cases, one lobe partial thyroidectomy in 54 cases, two lobe partial thyroidectomy in 19 cases, subtotal thyroidectomy in 37 cases of Graves' disease, and radical thyroidectomy in 2 cases of thyroid carcinoma. The operative time length ranged from 50 to 270 min (mean 80 min). There were no complications such as damage to recurrent laryngeal nerve or parathyroid glands. Postoperative hospital stay ranged from 3 to 7 days (mean 4 days). The post-operative following-up for 1 approximately 13 months indicated that all the patients were satisfied with the cosmetic results and the same curative effects as conventional surgery were obtained. However, the operations were converted into open surgery in 6 cases. CONCLUSIONS Endoscopic thyroidectomy is a safe and effective method of thyroid surgery. Since all the minimal incisions are on concealed parts of the body, the obvious cosmetic effect of this method is guaranteed.

1病例资料 患者,女,18岁.因"反复右上腹部疼痛伴皮肤巩膜黄染3年"入院.查体:皮肤、巩膜明显黄染,腹平软,右上腹扪及一约10 cm×8 cm×8 cm包块,边界欠清,质中,轻度压痛.CT示胆总管囊状扩张,胆囊泥沙样结石、胆囊炎.血生化示ALT 202u/L、TBIL 32.1 mmol/L、DBIL 21.5 mmol/L,血淀粉酶118 u/L,尿淀粉酶1 640 u/L.临床诊断:1先天性胆总管囊肿(1型).

目的探讨有胆囊切除术史的腹腔镜胆总管切开取石术的可行性.方法回顾分析12例有胆囊切除史的腹腔镜胆总管切开取石术,其中伴开腹胆囊切除术7例,腹腔镜胆囊切除术3例,开腹胆囊切除术加胆总管切开取石术2例.取同期无腹部手术史的腹腔镜胆总管切开取石术36例作对照比较,所得数据选用t检验.结果全部手术成功,无中转开腹,无术后并发症.有胆囊切除术史组手术时间较长,术中出血,术后住院时间两组类似.结论胆囊切除术后的腹腔镜胆总管切开取石术可行,值得进一步探索.

目的探讨腔镜甲状腺切除术的方法、优缺点及安全性.方法采用胸部乳晕入路行腔镜甲状腺切除术150例.其中甲状腺腺瘤41例,结节性甲状腺肿64例,原发性甲状腺机能亢进40例,甲状腺癌5例.结果成功完成手术144例.2例肿瘤位于峡部的患者没有切断舌骨下肌群,手术时间50～270 min,平均80.5 min,甲状腺肿瘤直径7～1 cm.行甲状腺肿瘤切除32例,单侧甲状腺部分切除54例,双侧甲状腺部分切除19例,甲亢行甲状腺次全切除37例,甲癌根治性切除2例,术后2～3 d拔出引流管,无神经或甲状旁腺损伤及其他并发症.术后住院时间3～7 d,平均4.2 d,术后随访1～13个月,疗效理想,病人均对手术美容效果非常满意.中转开放手术6例,其中1例为原发性甲亢开放术后复发,术中见粘连严重,解剖不清;1例为6cm腺瘤,术中分破肿瘤出血;1例峡部肿瘤,术中发现为甲癌并侵犯气管;1例Ⅲ.肿大结节性甲状腺肿,严重粘连;1例甲亢服碘时间不够,术中出血而中转:1例Ⅲ°甲亢太大,手术空间不够中转.结论腔镜甲状腺手术是一种安全的手术方法,和传统的甲状腺手术相比手术效果相同,且将微小切口开在隐蔽位置,具有很好的美容效果,很受患者欢迎,是甲状腺手术的理想手术方法.

目的:总结腹部多脏器和胸腹联合伤急诊腹腔镜手术的优势和局限性.方法:对24例腹部创伤腹腔镜处理中的2例胸腹联合伤、6例腹部多脏器伤病例进行回顾性分析.结果:8例均能在镜下确定有脏器损伤或内出血,其中4例能明确诊断损伤部位,4例未能确定出血部位或遗漏损伤部位.3例镜下完成手术,5例中转剖腹手术.结论:急诊腹腔镜能为腹部损伤患者在诊断和治疗上多提供一条迅速、直观、有效的途径,但对腹部多脏器损伤和胸腹联合伤患者应严格掌握适应证,放宽中转剖腹指征.

完全腹腔镜下行胆管癌根治性切除、胆肠吻合术未发现有文献报道,近期我科成功施行1例,取得了满意的效果,报告如下.

随着腹腔镜外科技术的不断发展与完善,腹腔镜外科手术的手术种类与例数不断增加,腹腔镜结直肠手术也一样,从1990年Jacobs等[1]开展第一例腹腔镜结直肠癌手术以来,经过十多年的发展,已经有越来越多的医生接受并逐渐掌握了腹腔镜手术,开展该手术的医院也越来越多,手术例数也逐渐增加,开展的手术种类基本上包括全部结直肠手术种类,治疗Dukes A～D期的结直肠癌病人.

目的:探讨腹腔镜手术治疗结直肠良恶性病变的应用价值.方法:回顾分析经腹腔镜行结直肠手术103例,其中良性病变17例、恶性病变86例,包括右半结肠切除19例,横结肠切除术8例,左半结肠切除5例,乙状结肠切除12例,先天性巨结肠切除10例,全结肠切除1例,乙状结肠造瘘术2例;直肠前切除术32例,腹会阴切除术12例,直肠悬吊术1例.结果:102例成功完成腹腔镜手术,1例因肿瘤侵犯十二指肠及胰头而中转开腹.手术时间平均146.8min,术后肠功能恢复平均30.6h,术后平均住院7.4d.2例低位直肠癌保肛术后并发吻合口瘘.随访3～90月,平均随访26月,腹腔镜结直肠癌根治术后生存率为89.2%(74/83).结论:腹腔镜结直肠手术具有创伤小、术后恢复快的优点,处理结直肠良性病变优势明显,对结直肠恶性肿瘤治疗,近期疗效尚可、远期疗效评价尚待进一步观察.

目的探讨临床急性下消化道出血的病因及诊治方法.方法对55例下消化道出血手术病例分析,其中小肠出血24例,大肠出血31例.结果下消化道出血原因以肿瘤为最多见,其它病因包括非特异性炎症、克隆氏病、血管畸形等.小肠出血术前确诊率为58.3%,大肠出血确诊率为100%.结论急诊下消化道的诊断以内镜及血管造影为最佳选择,对于部分小肠出血难以确诊者,术中配合肠内镜检查会有满意的效果,若在无肠镜检查条件或出血原因不明确时,可在术中进行分段肠管灌洗以确定出血部位.治疗上则根据不同的出血病因采取相应的治疗方法,避免不必要的盲肠段切除.