随着互联网技术的进步,远程医学作为一种新型医学技术应运而生.广西医科大学附属肿瘤医院深入贯彻落实健康中国战略,紧紧围绕推进健康广西重点建设任务,以问题为导向,以提升人民健康水平为核心,结合医院承担自治区政府肿瘤防办职能和肿瘤诊疗专科优势,牵头成立广西肿瘤性疾病远程诊疗联盟,探索建立完善远程医疗体系运行机制,为基层群众提供便捷、质优、价廉、可持续的远程医疗服务,有效缓解了医疗资源分布不平衡,促进优质资源下沉,推进分级诊疗制度建设,更好地落实了全区肿瘤防治工作.

普通外科腹腔镜手术方式已经得到同行认可,而腹腔镜手术视频的采集、制作简便,作为教学素材应用到普通外科的临床教学中,可以提高学生的学习兴趣和效率,培养学生的微创外科理念,加深其对局部解剖的直观认识以及手术基本操作技能的掌握.

目的 探讨腹腔镜循肝中静脉左半肝切除术治疗原发性肝癌的安全性和可行性.方法 回顾性分析27例行腹腔镜循肝中静脉左半肝切除术的原发性肝癌患者的临床资料.所有患者术前进行影像学精确评估;术中阻断入肝血流,循肝中静脉平面应用超声刀、双极电凝、Ligasure、Endo-GLA等离断肝组织.结果 27例手术均获得成功,无中转开腹.手术时间(175.1±50.0)min,术中出血量(200.2±55.1)mL,术后住院时间(6.0±2.2)d,术后无腹腔出血、肝功能衰竭等严重手术并发症,无围术期死亡病例.结论 腹腔镜循肝中静脉左半肝切除术安全、可靠,可作为治疗原发性肝癌的一种术式.

目的:探讨腹腔镜左半肝切除模式化手术的可行性及技术难点.方法:选择2013年1月至2017年10月收治的34例左半肝占位患者,均行腹腔镜解剖性左半肝切除术,术中先行入肝血流阻断,再用超声刀、双极电凝等断肝.结果:34例手术均获成功.手术时间平均(164.54±50.32)min,出血量平均(161.67±50.86)mL,无手术并发症发生,术后平均住院(6.30±0.85)d.结论:腹腔镜左半肝切除术的技术越来越成熟,基本上已模式化,可作为治疗左半肝疾病的标准术式.

目的:探讨完全内镜双侧乳晕同侧腋窝径路甲状腺切除术手术(ABBA)的临床效果,并与内镜乳晕胸壁径路甲状腺切除术手术(BAET)进行对比研究.方法:回顾性分析2015年8月-2017年8月138例同一手术者行内镜单侧甲状腺切除术的临床资料,其中行ABBA术54例(ABBA组),行BAET术84例(BAET组).比较两组的手术时间、出血量、手术分离皮瓣的面积、术后第1天引流量、术后住院时间、术后第1天VAS疼痛评分、术后并发症、术后第1天C-反应蛋白(CRP).结果:两组的年龄、手术时间、出血量、术后第1天引流量、肿瘤大小比较无统计学差异(P＞0.05).ABBA组与BAET组的手术时间、出血量、分离皮瓣面积、术后第1天VAS评分、术后并发症、术后第1天CRP及术后住院时间等指标比较均无统计学差异(P＞0.05),随访4～24个月,BAET组18例胸前有疤痕疙瘩,ABBA组对切口美容效果满意.结论:ABBA与常用BAET相比,具有同样的临床效果,是安全可行的,ABBA避免可以胸前的手术疤痕,具有更好的切口美容效果.

Objective To investigate the safety and efficacy of laparoscopy combined with choledochoscopy in treatment of intrahepatic and extrahepatic bile duct stones.Methods A total of 50 patients with intrahepatic and extrahepatic bile duct stones were chose.Among them, 12 cases of cholecystolithiasis complicated with choledocholithiasis were treated with laparoscopic cholecystectomy and T tube drainage;18 cases of cholecystolithiasis complicated with choledocholithiasis and hepatolithiasis were treated with laparoscopic cholecystectomy, common bile duct incision and choledochoscope stone removal combined with T tube drainage;20 cases of common bile duct stones complicated with intrahepatic bile duct stones were treated by laparoscopic common bile duct exploration combined with bile duct stone removal and T tube drainage.Results The stone removal surgery were successful in both 50 cases;postoperative bile leakage occurred in 2 cases, after positive anti-infection and adequate drainage for 8-10 d, the bile leakage stopped;1 cases of postoperative bile duct bleeding were treated with right hepatic artery embolization after conservative treatment failed.There were no deaths, no conversion to open surgery, no significant liver function damage complications.After T tube drainage for 12-14d, cholangiography showed that, 46 patients without residual stones, 4 cases with intrahepatic biliary residual stone(8.0%);after 3-6 months of operate, according the T tube cholangiography, T tube choledochoscopic lithotomy surgery was conducted again.Follow-up for 6-24 months, ultrasound or CT scan showed no stone recurrence.Conclusion Laparoscopy combined with choledochoscopy in the treatment of intrahepatic and extrahepatic bile duct stones have the advantages of fewer traumas, less complications.It is safe and feasible.

目的 观察小剂量动脉栓塞化疗(TACE)治疗肝癌的临床效果.方法 将2003-12～2014-08该科159例不能手术单病灶原发性肝癌患者随机分为小剂量TACE组94例(A组)和常规剂量TACE组65例(B组).观察治疗前后两组患者临床症状、肿瘤标志物(AFP)、肿瘤影像学(CT或MRI)、肝功能等变化,评估治疗后临床症状缓解率、肿瘤缩小情况和生存预后.结果 A组、B组治疗后患者的临床症状缓解率分别为76.5％、63.0％,两组比较差异无统计学意义(P=0.065).术后6个月肿瘤缩小有效率A、B组分别为25.5％ (24/94)、29.2％ (19/65),两组比较差异无统计学意义(x2=0.266,P=0.605);A组与B组术前甲胎蛋白阳性例数分别为68例、46例,术后1个月甲胎蛋白下降超过50％的比例分别为55.8％ (38/68)、52.2％(24/46),两组比较差异无统计学意义(x2=0.152,P=0.695);术后1年生存率A组与B组分别为82.9％(78/94)、75.4％ (49/65),两组比较差异无统计学意义(x2=1.378,P=0.240).A组肝功能ALT、AST术后第1、3、5天明显低于B组,差异均有统计学意义,术后第7天A组的ALT、AST基本正常,而B组仍高于正常.结论 小剂量TACE治疗肝癌的疗效与常规剂量TACE无差异,且对肝功能的影响小.

<正>临床路径(clinical pathway,CP)是一组人员共同针对某一病种的治疗、护理、康复、检测等所制定的一个最适当的,能够被大部分患者所接受的照护计划。是既能降低单病种平均住院日和医疗费用,又能达到预期治疗效果的诊疗标准。临床路径管理是公立医院改革重要内容之一。一方面,临床路径管理是改革医疗服务管理机制的重要手段,是推进公立医院改革的重要突破口;另一方面,临床路径管理

胃癌是常见的恶性肿瘤之一,中国是胃癌的高发区[1].目前外科手术仍是治疗胃癌的最主要手段.随着微创治疗学概念的发展,病人治疗后心理和生理上最大限度的康复成为了外科治疗的终极目标.如何在不低于甚至高于传统手术治疗效果的前提下,尽可能地减少病人近期和远期因手术带来的痛苦,已成为广大外科医生日益关心的现实问题,腹腔镜胃癌手术正是基于此理念而开展起来的,并给胃癌的手术治疗注入了崭新的内容.在我国,约90%的病例确诊时已为进展期胃癌,有关进展期胃癌腹腔镜根治术的应用一直是医学界关注的热点.本文就此方面的概况及研究进展综述如下.

Objective:To explore the learning curve of endoscopic thyroidectomy via breast approach.Methods:The clinical data of 101 cases,who underwent endoscopic thyroidectomy via breast approach performed by the same group of surgeons with practice of conventional open thyroidectomy,were analyzed retrospectively.The cases were divided into 2 groups(group A and group B) according to the sequence of operations.Operative time,blood loss,the volume of drainage,time of total and postoperative hospitalization,postoperative complications and analgesic requirements,time of recovery to normal activity of the two groups were compared.Results:There were significant differences between two groups in operative time,blood loss,time of postoperative hospitalization and analgesic requirements.However,the differences about volume of drainage,time of total hospitalization and recovery to normal activity were not statistically significant between two groups.The rate of postoperative complications were 8% in group A and 2.63% in group B,there wasn't statistically significant difference between two groups.1 case in group A converted to open operation and 0 case in group B,the difference was not statistically significant.Conclusions:If the surgeons can complete conventional thyroidectomy proficiently,they can learn skills of endoscopic thyroidectomy via breast approach after performing 25 operations of this kind.

Objective To investigate the methods of the treatmennt and prevention of the complications of laparoscopic cholecystectomy. Methods From August 2003 to December 2008,the data of 561 case of laparoscopic cholecystectomy were analysed.Results Laparoscopic cholecystectomy was successfully performed in 558 of 561 cases(99.47%).There were 4 cases(0.71%) with complicatios .These involved 2 cases(0.36%) with a biliary leak, 2(0.36%)complete transversal injury of the common bile duct. The operative duration was (51.36±20.46)min; The duration for hospitalization after operation was (4.15±1.36)d. Conclusion Laparoscopic cholecystectomy is minimally invasive technique which can be carried out safely and effectively.The complicatios can be minmized by emphasizing prevention and improving the techniques of laparoscopic cholecystectomy.

Objective To study on the clinical experience of Totally Laparoscopic Extraperitoneal Herniorrhaphy on 46 cases with bilateral inguinal hernia.Methods A retrospective study was carried out on 46 patients with bilateral inguinal hernia who were performed Totally Laparoscopic Extraperitoneal Herniorrhaphy during October 2002 to May 2007.The clinical data of these patients was analyzed.Results 46 patients who were 49-81 ages(mean ages was 65.2),including 15 were bilateral direct hernia and 26 bilateral indirect hernia,5 of one side direct & another side indirect hernia and 9 recurrent hernia.The rate of successful operation was 93.48%,the operation lasted 75-180 min.The mean operating duration was 96min.The patients stayed in hospital for 5-10d.The mean inpatient hospital stay was 8.5d.The mostly complications were scrotum hematomas or seromas,which appeared in 5 cases(10.87%),and the chronic inguinal pain after operation appeared in 1 cases(2.17%),one case had bladder injury(2.17).There was only 1 case of recurrence(2.17%),and no operative death.All the patients were followed up for 6-60 months.Conclusion Totally Laparoscopic Extraperitoneal Herniorrhaphy on the bilateral hernia is safe,good effect and low recurrence rate.It is worth excellent promotion.

Objective To evaluate the feasibility of laparoscopic left liver rescetion.Methods Candidate for laparoscopic left liver rescetion were 28 cases including hepatic hemangioma 3 cases,15 cases of hepatolithiasis,10 cases of primary hepatic carcinoma.Electric-cautery,ultracision were used for left liver transection.Operative procedures includeded anatomical left hepatectomy in 8 case,non-anatomical left hepatectomy 20 cases.1 cases were performed cholecystectomy synchronously.Results Laparoscopic left liver rescetion was successfully performed in all 28 cases.The operative duration was(251.15±40.94)min;The quantity of blood lost during the operation was(422.20±146.01)mL.The postoperative recovery was smooth and good.No complications occurred.The duration for hospitalization after operation was(5.98±0.73) day.Conclusion Laparoscopic left liver rescetion is a prospective and minimally invasive technique which can be carried out safely and effectivel.

2002年1月至2007年2月,我院对35例各种肝胆病变位于肝脏左外叶的病人进行腹腔镜左外叶肝切除,疗效满意,现报告如下.

Objective Laparoscopic pancreaticoduodenectomy(LPD) is one of most difficult laparoscopic operations.It involvs many important organs whose anatomy is complex.The issue of operative approach is worth of investigation.The aim of this article is to expore safe and rapid operative approaches in LPD.Materials and Method During November of 2002 and July of 2007,15 cases of LPD were performed successfully in our centre.11 patients were male,and 4 femal.The age ranged from 35 to 76 years,average 54.9 years.The indications included 7 cases of adenocarcinoma of duodenal papilla,3 cases of adenocarcinoma of ampulla,1 case of papillary adenocarcinoma,1 case of adenocarcinoma of head of pancreas,1 case of endocrine small cell carcinoma,1case of neuroendocrine carcinoma,1 case of adenocarcinma of duodeal papilla and lower common bile duct.We reviewed the operative procedures of 15 cases of LPD to analyze the application of duodenal-wall approach in LPD.Results Most organs and tissues were dissected safely and rapidly along the duodenal wall.The duodenal-wall approach involves the following procedures:①the exploration of inferion vena cava.The retroperitoneum was open along the wall of decending part of duodenum.The duodenum and head of pancreas were dissected to their back side with this approach,and they could be pulled aside to show the inferion vena cava.②the exporation of portal vein.Dissection was continued along the duodenal wall to find the upper part of superior mesenteric vein,and the portal vein could be reached by following the superior mesenteri vein.③the common bile duct was dissected along the upper wall of duodenum.,and the lymph nodes along duodenum and bile duct were cleared.④The stomach was transected after the first part of duodenal was dissected and lifted.Then the celiac artery,common hepatic artery,proper hepatic artery and the gastroduodenal artery could be exposed.⑤the whole assending part of duodenum and proximal jejunum were dissected along the lower side of duodenal wall,and they were pulled to the right epicolic area throug the space behind the superior mesenteric vessels.⑥The vessels between the unciform process of pancreas and portal vein were exposed by pulling the distant duodenum and proximal jejunum to the right epicoli area.Then the unciform process of pancreas could be cut using ultrasonic dissector.Conclusion The duodenal-wall approach is a safe and efficient operative approach in LPD.

目的:探讨我科完全腹膜外腹腔镜疝修补(totally laparoscopic extraperitoneal herniorrhaphy,TEP)的临床疗效和经验教训。方法:回顾性分析我科2002年10月至2006年10月行TEP的226例病人的临床资料。结果:226例共进行263例次TEP,中转经腹腔腹膜前修补(transabdominal preperitoneal hernia repair,TAPP)5例,TEP手术成功率98.1%。手术时间30~210min,平均手术时间单侧62min,双侧108min。术后无需使用镇痛剂,住院时间5~16d,平均7d。主要并发症为阴囊血清肿或血肿27例(10.3%),术后腹股沟区慢性疼痛4例(1.5%),手术大出血1例,膀胱损伤1例。随访6个月至4.5年,术后复发1例。结论:TEP手术安全,术后疼痛轻,恢复快,复发率低。熟悉镜下腹股沟区解剖标志,掌握手术技巧和原则可提高手术成功率、降低术后并发症和复发率。

Objective To explore safe and rapid operative approaches in laparoscopic pancreaticoduodenectomy(LPD).Method The operative procedures of 17 cases of LPD were retrospectively reviewed and the application of the duodenal-wall approach in LPD was analyzed.Results Most organs and tissues were dissected safely and rapidly along the duodenal wall.Conclusion The duodenal-wall approach is a safe and efficient operative one in LPD.

Objective To explore the clinical effects of Laparoscopic video choledochoiberscopic hepatocholangiolithotomy T-tube drainage(LCHTD)and open choledochoiberscopic hepatocholangiolithotomy T-tube drainage(OCHTD).Method 47 cases of extra-and intra-hepatric bile duct were porformed by LCHTD from Jan.2004 to Aug.2007,meanwhile 50 cases of those same as above were performed by OCHTD.Analyzing the treating effects of these two groups patients.Results Compared between LCHTD group and OCHTD group,the mean operative time was respectively(127.52±23.70)min and(115.41±29.33)min(P>0.05);the quantity of blood lost during operation was respectively(60.00±25.17)ml and(300.20±130.39)ml(P<0.01);Postoperative patients using anodyne was respectively31.91%(15/47)and 88%(44/50)(P<0.01);Gastrointestinal function reactivated time was respectively(25.81±7.80)h and(63.42±17.60)h(P<0.01);The rate of postoperative calculi residual was 4.0% and 6.0% respectively(P>0.05);The incision infection and fat liquefaction rate was respectively 0(0/47)and 16%(8/50)(P<0.01);The expenseses of hospitalization was respectively(26 573.73±6 739.40)yuan and(16 868.95±5 216.25)yuan(P<0.05).Conclusion LCHTD is safe,effective and feasible.Compared with OCHTD,LCHTD has the advantages of mild postoperative ache,rapid recovery,effective,the rate of incision infection and fat liquefaction is reduced,short postoperation hospitalization,mild injury and minimal scar.It is the complement of the modern cosmetic desires.

Objective To conclude clinical experience of totally laparoscopic extraperitoneal herniorrhaphy of 338 cases.Methods A retrospective study was carried out on 292 patients with inguinal hernia who were performed 338 totally laparoscopic extraperitoneal herniorrhaphy between October 2002 and May 2007.The clinical data of these patients was analyzed.292 patients who were 18-91 ages(the average age was 54)were performed 338 totally laparoscopic extraperitoneal herniorrhaphy,including 57 direct hernia and 281 indirect hernia operations.Among 292 patients,246 cases had unilateral hernia and 46 cases had bilateral hernia,including 42 recurrent hernia.Results The rate of successful operation was 98.23%.The operation lasted 25-220min.The average operating duration was 60min for unilateral hernia and 96min for bilateral hernia.The patients stayed in hospital for 4-16d without needing of analgesics.The average inpatient hospital stay was 7d.The mostly complications were scrotum hematoma or seroma,which appeared in 29 cases(9.93%),and the chronic inguinal pain after operation appeared in 4 cases(1.37%),one case had bladder injury.There was only 1 case of recurrence,1 case of surgical bleeding,no operative deaths.All the patients were followed up for 6-60months.Conclusion Laparoscopic totally extraperitoneal inguinal hernia repair surgery was safe,low recurrence rate.To master surgical skills could improve the success rate and reduce postoperative complications and recurrence rate.

随着老年人121的增加,老年人胆囊疾病的患病率不断增多.老年人因为循环、呼吸等器官功能减退,同时合并有多种疾病,因此对手术的耐受力较差.我院2003年8月至2008年1月,对115例60岁以上病人行腹腔镜胆囊切除术(Laparo-scopic cholecystectomy,LC),取得了满意的疗效,报告如下.