Objective:To explore the application effect of case-based learning (CBL) teaching model on the clinical teaching of standardized residency training of hepatobiliary surgery.Methods:The study selected 46 residents as the research objects who attended the standardized residency training program from January 2015 to December 2016. All the residents were randomly divided into control group ( n=22) using the traditional teaching method and experimental group ( n=24) using CBL teaching method. After the training, the teaching effect was evaluated by the assessment of theoretical knowledge and clinical skills and questionnaire survey between the two groups. Results:The theoretical knowledge and clinical skills of the residents in the experimental group were significantly better than those in the control group after training [ (85.2±5.9) vs. (81.2±5.6) , (85.0±5.8) vs. (81.4±3.9) ]. The questionnaire survey showed that the total satisfaction of the experimental group with CBL teaching method combined with 3D visualization technology was significantly higher than that of the teaching method of the control group (95.8% vs. 72.7%) .Conclusion:The CBL teaching method with 3D visualization technology is worth popularizing and applying in the education of standardized residency training.

Objective:To explore the application effect of three-dimensional visualization teaching in resident training in pancreatic surgery.Methods:A total of 68 trainees for standardized resident training in pancreatic surgery of our hospital were selected from January 2016 to June 2018. The traditional teaching method is used in the control group, while the three-dimensional visualization technology is used in the observation group on the basis of traditional teaching methods.Results:There was no significant difference in the scores of basic theoretical knowledge examination, but the results of clinical knowledge and the excellent rate of imaging examination in the observation group were significantly higher than those in the control group [(80.4±10.0) vs (74.6±10.7), 76.5% vs 52.9%], the difference was all statistically significant (all P<0.05). The results of questionnaire survey showed that the satisfaction of the students in the observation group was significantly higher than that in the control group (94.1% vs 76.5%, P<0.05). Conclusions:The application of three-dimensional visualization technology is helpful to iprove clinical examination results, imaging examination results and overall satisfaction.

目的 探究腹腔镜疝修补术与开放式无张力疝修补术治疗成人腹股沟疝的具体治疗效果.方法 本次实验选取2015年6月～2016年6月医院接收的214名成人腹股沟疝患者作为本次实验的研究对象,按照双盲性原则将这些患者平均的分为实验组和对照组,各107名.对照组患者主要是采取开放式的无张力疝修补术,实验组患者主要是采取腹腔镜疝修补术.实验结束之后,对比两组患者的实际治疗效果以及患者对治疗的满意程度.结果 实验结束之后,实验组患者总的治疗效率为95.6％,对照组患者总的治疗效率为87.5％,差异有统计学意义(P<0.05).实验组患者术后并发症的发生率要明显的低于对照组患者,实验组患者对治疗方式的满意程度要明显的高于对照组患者,差异有统计学意义(P<0.05).结论 根据实验的结果可以明显的看出,使用腹腔镜疝修补术治疗成人腹股沟疝的治疗效果极好,并且患者对治疗方式满意程度也要明显的高于对照组患者,所以说腹腔镜疝修补术治疗方式值得在临床治疗上推广和使用.

目的 探究开腹手术与腹腔镜胆囊切除术治疗胆囊结石患者的临床效果,评价不同手术方案的临床应用意义.方法 62例胆囊结石患者,根据入院顺序分为对照组和实验组,每组31例.对照组患者采用开腹手术进行治疗,实验组患者采用腹腔镜胆囊切除术进行治疗.比较两组患者的结石清除率、术后并发症发生情况及各项临床指标.结果 实验组患者结石清除率为90.32％,与对照组的83.87％比较差异无统计学意义(P>0.05).实验组患者术后并发症发生率为6.45％,低于对照组的25.81％,差异具有统计学意义(P<0.05).实验组患者手术时间、下床活动时间以及住院时间短于对照组,术中出血量少于对照组,差异具有统计学意义(P<0.05).结论 将腹腔镜胆囊切除术应用于胆囊结石患者的治疗中,能降低患者术后并发症发生率,同时也有助于改善患者的各项临床指标,值得推广使用.

Objective To explore the value of medical three-dimensional visualization technology in preoperative precise assessment for hepatocellular carcinoma (HCC).Methods The clinical data of 24 HCC patients were analyzed retrospectively from Jan 2015 to Dec 2016 in our department.Thin-layer 320-slice CT scaning was performed and data stored in the form of DICOM.Three dimensional reconstruction and simulated hepatectomy were conducted,and correlation test analysis was performed.Results The volume of simulated resected liver was (565 ± 296)ml,while the actual liver resection volume was(523 ± 252)ml.There was no significant difference between the predicted and the actual values (t =1.734,P ＞ 0.05).The actual liver resection volume was positively correlated with the predicted liver resection volume (r =0.920,P ＜ 0.05).The stimulated resection margin was (1.2 ± 0.6)cm,while the actual resected tumor margin was (1.0 ± 0.5) cm.There was no significant difference between the predicted and the actual values (t =1.853,P ＞0.05).The actual margin was positively correlated with the predicted one (r =0.956,P ＜ 0.05).Conclusion The three-dimensional visualization technology has a certain degree of clinical value in the preoperative evaluation of HCC.

探讨老年急性胆囊炎的临床特点和行腹腔镜胆囊切除术(LC)的手术技巧.回顾性分析2013年1月—2016年12月收治的54例老年急性胆囊炎施行LC的临床资料.术中采用手术技巧包括:胆囊后三角解剖、Rouviere沟解剖定位、吸引器钝性解剖、胆囊大部切除等.所有患者无胆管损伤发生,无术后大出血及胆瘘.中转开腹4例,其中1例因粘连过于致密,解剖结构辨认不清;1例合并Mirizzi综合征;2例胆囊管结石.术后3例合并肺部感染,4例切口感染,1例中转开腹形成切口疝.老年急性胆囊炎病情复杂,术前要有充分地认识,术中多种手术技巧的合理应用,采用LC治疗老年急性胆囊炎是安全有效的.

目的 探讨腹腔镜下胆道镜联合钬激光治疗肝内外胆管结石的疗效及应用价值.方法 回顾性分析我院收治的60例肝内外胆管结石患者分为对照组与观察组,每组各30例.对照组行腹腔镜下胆道镜+网篮取石,观察组行腹腔镜下胆道镜+钬激光碎石,比较其临床疗效.结果 对照组结石完全取尽25例(占83.3％),平均手术时间(135±32) min,平均住院时间(8.0±3.1)天,中转开腹手术2例;术后残余结石4例,后经T管窦道用胆道镜取出,术后胆漏3例.观察组结石完全取尽28例(占93.3％),平均手术时间(100±25) min,平均住院时间(8.2±3.3)天,无中转开腹手术,术后残余结石1例,后经T管窦道用胆道镜取出,术后无胆漏等并发症发生.观察组在术后结石残留率、术后胆漏发生率、平均手术时间上均优于对照组,差异具有统计学意义(P＜0.05).结论 采用腹腔镜下胆道镜联合钬激光碎石治疗肝内外胆管结石术中取尽率高、并发症发生率低、疗效确切.

Liver surgical diseases are characterized by its complicated condition,a variety of anatomical variation,and more difficult to understand the two-dimensional image,so it's necessary to change our traditional clinical practice teaching model.Three-dimensional visualization teaching is an effective teaching method.This article summarizes the application of three-dimensional visualization teaching in surgical clinical practice of liver surgery in our hospital.The results showed that the three-dimensional visualization teaching could improve the learning efficiency of the interns,inspire the students to study,deepen the understanding of liver surgery and contribute to the learning of liver imaging and future clinical work.The conclusion is that the threedimensional visualization teaching is worth popularizing in the clinical practice teaching of liver surgery.

Objective To investigate the efficacy of laparoscopic cholecystectomy (LC) in the treatment of elderly patients with cholecystolithiasis and choledocholithiasis after endoscopic retrograde cholangio-pancreatography (ECRP)/ endoscopic sphincterotomy (EST).Methods A total of 56 elderly patients with cholecystolithiasis and choledocholithiasis after ERCP/EST followed by LC in our hospital were included into the current study.Their clinical data were collected for retrospective analysis.Results ERCP/EST followed by LC was successfully carried out in 53 patients (94.6％).After surgery,there were 8 patients reporting hyperamylasemia,including 2 patients with acute light pancreatitis,who were recovered after conservative therapy.Also,3 patients were converted to open surgery (5.7％).No serious complications occurred.Conclusions ERCP/EST followed by LC is a safe,effective and feasible surgical approach for elderly patients with cholecystolithiasis and choledocholithiasis.

外伤性软组织血肿是一类临床常见的损伤,处理不及时或不当,可能继发感染等多种并发症,及时、有效的治疗至关重要.治疗方法一般分为非手术治疗和手术治疗,但均存在不足,非手术治疗恢复较慢,且较大血肿难以完全吸收;手术治疗切口大,局部麻醉效果不佳,创伤相对较大[1].因此,在保证治疗效果的同时减轻创伤成为必要.笔者采用回顾性病例系列研究分析2011年1月-2015年 12月经皮穿刺置管溶栓引流治疗16例外伤性软组织血肿患者的临床资料,探讨其治疗效果.

目的:探讨悬吊式免气腹经脐单孔腹腔镜阑尾切除术的可行性及临床应用价值.方法:回顾分析2013年8月至2014年5月为20例患者行悬吊式免气腹经脐单孔腹腔镜阑尾切除术的临床资料,术中使用骨科牵引弓、克氏针自制腹壁悬吊装置及普通腹腔镜操作器械完成手术.结果:手术均获成功,无中转常规腹腔镜手术及开腹手术,手术过程顺利,手术时间40 ～ 70 min,平均(54.0±1.7) min;无腹腔、脐部切口感染,平均住院(6.0±1.2)d,患者均顺利出院.结论:悬吊式免气腹经脐单孔腹腔镜阑尾切除术具有微创及美容的优势,使用普通腹腔镜操作器械也可完成手术,具有临床推广价值.

Objective To study the delayed protective effects of limb ischemia preconditioning(LIPC) on liver ischemia-reperfusion(I-R) injury in rats.Methods Thirty-six SD rats were equally randomized into there groups of S(sham operated),I-R(I-R model) and LIPC(LIPC before I-R).I-R model was established by 70% liver ischemia for 1 hour and reperfusion for 3 hours.LIPC was performed by 5-min ischemia of two posterial limbs for three times.Blood and liver samples were obtained to determine the activity of total superoxide dismutase(tSOD),malondialdehyde(MDA),ALT and AST,liver wet/dry weight(W/D),and the expression of TNF-α.The ultrastructural damage of the liver was observed as well.Results Compared with group I-R,the activities of MDA,ALT and AST were significantly decreased,tSOD level was increased and W/D and the expression of TNF-α were obviously reduced in group LIPC(P0.01).The damage of liver tissue was significantly less in group LIPC than that in group I-R.Conclusion LIPC has an delayed protective effect on liver I-R injury in rats,which is possibly related to an increase of the antioxidant capacity,suppression of liver inflammatory reaction,inhibition of the expression of TNF-α and improvement of liver microcirculation.

Objective To evaluate catheter-directed thrombolysis via the popliteal vein in the treatment of the lower limb acute deep venous thrombosis.Methods From July 2009 to October 2010,32patients of the lower limb acute deep venous thrombosis including 3 patients with concurrent pulmonary embolism underwent uhrasound-guided catheter-directed thrombolysis via the popliteal vein.The thrombolytic catheter was inserted into thrombus,through which urokinase was infused at a dosage of 100 × 104U/d.The venous patency score and the rate of patency improvement were observed by venograms before and after therapy.Results In every patient,the lower limb swell and pulomonary symptoms relieved.The circumferences between affected and normal thigh before and after the thrombolysis were(5.4 ± 1.4)cm and (1.7 ± 1.3)cm(t =9.92,P ＜0.01).The circumferences between affected and normal leg before and after the thrombolysis were(4.1 ± 1.5)cm and(1.5 ±0.7)cm(t =7.65,P ＜0.01).The venous patency score before and after the thrombolysis were(15 ± 4)and(4 ± 3)(t =7.12,P ＜ 0.01).The mean rate of venous patency was 88.21％.In the 3 patients with pulmonary embolism,thrombus was complete dissolved in 1 case and partial dissolved in 2 cases.No major complications occurred in all these patients.29 patients were followed up for 3-12 months.There were no thrombosis relapsed.Conclusions Catheter-directed thrombolysis via the popliteal vein with urokinase for acute lower limb deep venous thrombosis is safe and effective.

目的 探讨腔镜深筋膜下交通支离断术(SEPS)治疗重度下肢慢性静脉功能不全的临床疗效.方法 回顾性分析2008年8月至2010年12月采用SEPS治疗重度下肢慢性静脉功能不全22例患者共26条肢体的临床资料,采用彩色多普勒超声、临床分级和静脉功能评分等方法在术前、术后对患肢静脉交通支离断情况、静脉功能和术后并发症等情况进行分析.对所有患者进行随访,分析手术的近、远期效果.结果 术后所有患肢曲张静脉团消失,局部疼痛缓解,色素沉着减轻；26条肢体术后切口愈合良好,无感染及出血,患肢溃疡在2～6周完全愈合,无溃疡复发及新溃疡形成.22例患者均获得随访,随访时间为5 ～ 16(9.27±2.14)个月.术前与术后3个月CEAP临床评分比较,除色素沉着改善不明显外,其他临床表现如疼痛、水肿、静脉性跛行、皮下脂肪硬化和溃疡等均有明显改善(P＜ 0.05).结论 SEPS安全有效、创伤小、并发症少,复发率低,联合大隐静脉高位结扎及曲张静脉点式抽剥术是治疗重度下肢慢性静脉功能不全的有效方法.

目的 探讨经胭静脉置溶栓导管灌注溶栓治疗急性下肢深静脉血栓形成(DVT)的临床应用价值.方法 对28例急性DVT患者(其中2例合并肺动脉栓塞)在超声引导下经患肢胭静脉穿刺置人溶栓导管至骼、股静脉血栓中进行溶栓治疗,并对溶栓效果进行分析.结果 全组患者溶栓后症状明显改善,下肢肿胀消退,肺部症状缓解.溶栓后患、健侧大腿周径差[(1.72±1.23)cm]明显小于溶栓前[(5.47±1.29)cm),差异有统计学意义(t=12.14,P<0.01),患肢大腿消肿率为91,58%;溶栓后患、健侧小腿周径差[(1.55±0.77)cm]也明显小于溶栓前[(5.04±1.32)cm),差异有统计学意义((t=13.81,P<0.01),患肢小腿消肿率为84.92%.溶栓后静脉通畅评分[(4.34±3.55)分]明显低于溶栓前[(15.23±4.64)分],差异有统计学意义((t=6.42,P<0.01),溶栓后静脉平均通畅率为87.43%.2例合并肺动脉栓塞患者中,1例栓子完全溶解,1例大部分溶解.所有患者均无严重并发症.25例患者获随访,随访1～12个月(平均7.16个月),无一例出现血栓再发.结论 经胭静脉置管溶栓治疗急性DVT是一种安全、有效的治疗方法.

Objective To probe the approach of the diagnosis and treatment of micro hepatocellular carcinoma(MHCC).Methods Through carrying out the secondary prevention of liver cancer and medical examinations at hospitals,liver substantial space-occupying lesion(SOL) less than 2 cm was found in 35 cases with the history of hepatitis liver cirrhosis and the low concentration of AFP.All of them were confirmed as micro hepatocellular carcinoma(MHCC) undergone multiple imageology examinations.Results The resections of liver cancer in 32 of the 35 patients were performed;3 cases treated with the radiofrequency ablation.Three cases recurred 1 year later.Conclusion(1)Carrying out the secondary prevention of liver cancer at hospitals and medical examinations are the foundation of early diagnosis and treatment for MHCC.(2)The diagnosis of MHCC needs comprehensive analysis with case history,imageology examination and the AFP level.(3)It is difficult for the diagnosis of MHCC.Operation and radiofrequency ablation are the first choice.Localization for central type MHCC in operation using b-sonograph is the key point for the safe and thorough removal of the tumor.

收集我院2007年以来26例经内镜下逆行胰胆管造影(ERCP)和十二指肠乳头括约肌切开术(EST)后,因结石巨大或结石嵌顿于管壁,镜下取石失败,随机将其中16例放置鼻胆引流管,经腹切开胆总管取石.10例放置胆管塑料内支架,反复镜下取石,报道如下.

目的 探讨微小肝癌(micro hepatic cellular carcinoma,MHCC)的诊断与治疗.方法 开展肝癌二级预防和健康体检,对AFP低浓度阳性的肝脏实质占位性病变进行联合诊断,对肝脏实质性小占位进行多项影像学检查并结合肝炎肝硬化病史和AFP,发现和诊治31例MHCC.31例MHCC中28例行肝肿瘤切除术,3例行肿瘤射频消融术.结果 31例病理均为肝细胞癌.4例术后1年复发,其余27例存活.结论 开展肝癌二级预防和健康体检是发现和诊断MHCC的基础.MHCC的诊断应结合乙肝肝硬化病史、影像学检查和AFP等进行综合分析.MHCC诊断困难,治疗首选手术和微创消融,对中央型MHCC术中B超定位是安全、彻底切除肿瘤的关键.

Objective To investigate the protective effect of the fast window (FW) of liver ischemic preconditioning (IPC),the second window (SW) of remote (leg) ischemic preconditioning (RPC) and conbined applications of liver and lges IPC to against liver ischemia/reperfusion (I/R) injury in the rat,and to investigate the mechanism of the protection.Methods Rats were randomly divided into five groups (n = 8 each):(1) Sham group (S group),rats without IPC,(2) Rats with 5 min IPC (IPC group);(3) Rat wiht both liver and lower limbs IPC and repeated three times (RPC group);(4) IPC 24 h after RPC group;(5) IR without IP (I/R group);except S group,the rats were subjected to 60 min sustained liver ischemia followed by 180 min reperfusion.All ischemia rats were only subjected to 70% liver ischemia.Finally,blood and liver samples were obtained to determine the activity of ALT and AST,the expressions of TNF-α and HSP70 protein,and liver wet/dry weight (W/D) and pathology.Results All IPC group and RPC group and IPC + RPC group had obviously lower levels of ALT,AST,W/D,TNF-α than that of the I/R group (P ＜0.01),but had obviously higher expressions of HSP70 protein than the I/R group (P ＜ 0.01),howerer,all the indices between IPC group and RPC group and IPC + RPC group had no statistical difference (P ＞ 0.05).Conclusions The FW of the IPC,the SW of the RPC and combined applications can lessen hepatic I/R injury.There is no significant difference in the protective intensity of the 3 motheds.The protective effects possibly are due to suppression of TNF-α production,induction of protein HSP70 expression and improvement of liver microcirculation.