ObjectiveTo compare the safety and clinical outcomes of isolated aortic valve replacement (AVR)through right anterior minithoracotomy (RAMT)and conventional median sternotomy. MethodsFrom March 2006 to March 2013, 169 patients underwent isolated AVR in Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine. Among them, 42 patients received AVR via RAMT (RAMT group)including 30 males and 12 females with their age of 59.31±8.30 years. And 127 patients received AVR via conventional median sternotomy (conventional surgery group)including 89 males and 38 females with their age of 60.02±5.93 years. There were 75 patients with aortic valve stenosis (AS), 42 patients with aortic regurgitation (AR)and 52 patients with AS+AR. Postoperative outcomes were compared between the 2 groups. ResultsThere was no statistical difference in preoperative clinical characteristics between the 2 groups. All the patients successfully received isolated AVR. 153 patients received mechanical prosthesis and 16 patients received bioprosthetic valves. Fifty-two patients received 21 mm valves, and 117 patients received 23 mm valves. Cardiopulmonary bypass time and aortic cross-clamping time of RAMT group were significantly longer than those of conventional surgery group (P < 0.001). But mechanical ventilation time, length of postoperative ICU stay and hospital stay of RAMT group were significantly shorter than those of conventional surgery group (P < 0.001). Postoperative thoracic drainage, intraoperative and postoperative blood transfusion of RAMT group were significantly less than those of conventional surgery group (P < 0.001). In conventional surgery group, 2 patients underwent reexploration for bleeding and 2 patients had wound infection postoperatively. Two patients died postoperatively, both in conventional surgery group, including 1 patient with low cardiac output syndrome and multiple organ dysfunction syndrome, and another patient with prosthetic valve endocarditis secondary to sternal wound infection. ConclusionCompared with conventional median sternotomy, RAMT is safe and efficacious for patients undergoing isolated AVR with minimal surgical injury, better postoperative recovery and cosmetic outcomes.
Objective To explore the variation about the application of fast-track surgery and laparoscopy in treatment for colorectal cancer in recent years． To investigate the probability of combining protocols of the two for treatment for colorectal cancer. Methods The clinical and basic literatures of related researches about colorectal treatment of laparoscopy and fast-track surgery were collected and reviewed. Results Compared with the traditional treatment modalities, both of fast-track surgery and laparoscopy used for the treatment of colorectal cancer have better clinical effects. Conclusions Fast-track surgery and laparoscopic techniques used for the treatment of colorectal cancer are feasible, but the combination of the two should be confirmed by further randomized controlled trials.
ObjectiveTo summarize the clinical experience of 180 general surgeries under da Vinci surgical system. MethodsFrom January 2009 to October 2010, 180 patients with hepatopancreaticobiliary and gastrointestinal disease underwent robotic surgeries by using da Vinci surgical system. The case distribution, intra-and post-operative data were analyzed. ResultsA total of 171 patients had underwent total robotic surgeries and nine patients converted to hand-assisted procedure (5.0%, 9/180). The surgery for hepatic portal was performed in 63 cases of patients, including surgery for hilar cholangiocarcinoma in 36 cases, gallbladder carcinoma in 10 cases, complex calculus of intrahepatic duct in 12 cases, and iatrogenic biliary duct injury in 5 cases. The pancreatic surgery was performed in 44 cases of patients, including pancreatoduodenectomy in 16 cases, distal pancreatectomy in 6 cases, medial pancreatectomy in 1 case, pancreatic cyst-jejunum anastomosis in 1 case, and palliative surgery in 20 cases. Hepatic surgery was in 19 cases and gastrointestinal surgery in 12 cases of patients. Other procedures were in 42 cases of patients, including common bile duct exploration and removing the stone, retroperitoneal lymph nodes dissection, and splenectomy, etc. All of ten cases of patients with obstructive suppurative cholangitis received emergency surgery by the robot and postoperative infection symptoms were controlled, and shock was corrected quickly. No death occurred during the perioperative period. Postoperative complications occurred in 12 cases (6.7%, 12/180) and 2 cases died (1.1%, 2/180). Conclusionsda Vinci surgical system can carry out all kinds of general surgery, especially complicated and difficult hepatobiliary and pancreatic surgery, which improves the development of minimally invasive surgery.
ObjectiveTo summarize the clinical experience of 58 operations for biliary malignant tumor with da Vinci surgical system. MethodsFrom January 2009 to October 2010, 180 patients with hepatopancreaticobiliary and gastrointestinal disease underwent robotic surgeries by using da Vinci surgical system, including 58 patients with biliary malignant tumor. The case distribution, intra and postoperative data were analyzed. ResultsOf 58 patients, 3 patients with intrahepatic bile duct cystadenocarcinoma received wedge resections of liver. In 36 patients with hilar cholangiocarcinoma, anatomical left hemihepatectomies were performed in 3 cases, resection of extrahepatic duct and gallbladder bridge type biliary revascularization in 3 cases, resection of extrahepatic duct and biliary-enteric Roux-en-Y anastomosis in 14 cases, tumor resection and revascularization of hepatic portal bile duct in 1 case, palliative external drainage of intrahepatic bile duct in 5 cases, and Y-internal drainage of hepatic portal in 10 cases. In 10 patients with gallbladder carcinoma, resection of extrahepatic duct and gallbladder and biliaryenteric Roux-en-Y anastomosis in 2 cases, cholecystectmy in 3 cases, cholecystectmy and external drainage of intrahepatic bile duct in 1 case, cholecystectmy and Y-internal drainage by suspension of hepatic portal in 4 cases. A patient with middle bile duct cancer received radical resection of cholangiocarcinoma and biliary-enteric Roux-en-Y anastomosis. Of 8 patients with distal bile duct cancer, Whipple procedure were performed. Of 58 patients, 2 cases converted to hand-assistant procedure (3.4%). For all patients, operation time was (6.18±1.71) h, blood loss was (116.66±56.06) ml, blood transfusion was (85.55±38.28) ml, ambulation time was (9.10±2.91) h, feeding time was (14.95±4.35) h, and hospital stay was (12.81±4.29) d. Postoperative complications occurred in 8 cases (13.8%), including bile leakage (3 cases), wound bleeding (1 case), pancreatoenteric anastomotic leakage (2 cases), pulmonary infection (1 case), and renal failure (1 case). Of these 8 cases, 6 cases recovered smoothly and 2 cases die of severe pulmonary infection and renal failure after conservative treatment (3 or 4 weeks), therefore, the mortality of patients was 3.4%. In 36 patients with hilar cholangiocarcinoma, 19 cases died (on 2 monthes 4 cases, on 6 monthes 5 cases, on 10 monthes 8 cases, and on 12 monthes 2 cases after operation), 11 cases survival well (gt;26 monthes 4 cases, gt;22 monthes 3 cases, and gt;19 monthes 4 cases), and 6 cases required hospitalization. Of 10 patients with gallbladder carcinoma, 7 cases died (on 3 monthes 1 case, on 5 monthes 1 case, on 8 monthes 1 case, on 11 monthes 3 cases, and on 12 monthes 1 case after operation) and 3 cases survival (gt;17 monthes 2 cases, gt;13 monthes 1 case). In 8 cases undergoing pancreatoduodenectomy, 5 cases died (on 4 monthes 2 cases, on 6 monthes 2 cases, and 10 monthes 1 case after operation) and 3 cases survived well over 2 years. Three patients with intrahepatic bile duct cystadenocarcinoma survived over 1 year. Conclusionsda Vinci surgical system can carry out all kinds of surgery for biliary malignant tumor, especially prominent in the complicated surgeries for hepatic portal, which breaks through the restricted area of laparoscope in hepatobiliary malignant tumor.
Objective To assess the feasibility and adequacy of Harmonic Scalpel in a totally laparoscopic total mesorectal excision (TME) and low,ultralow,colo-anal anastomoses for rectal cancer. Methods Excision of the mesorectum and low，ultralow site anastomoses were performed laparoscopically on 30 patients with low rectal cancer based on the concept of TME. Results All 30 TME were successfully completed by laparoscopic approach, and no one was converted to open procedures. A cholecystectomy and/or an ovariotomy were meanwhile performed laparoscopically for 3 patients with rectal cancer,and 1 patient with chronic cholesyctitis, gallstone,ovarian cyst and torsion of the ovary. The operation time was 155 min (115-320 min). Operative blood loss was 20 ml (5-80 ml).The time of bowel function returned and the time to resume postoperative diet was 1-2 days after the operation. Fourteen patients had postoperative analgesic requirement. Average hospital stay was 8 days (5-14 days) and there were no intraoperative and postoperative complications in all 30 patients.Conclusion Laparoscopic excision of the mesorectum and low,ultralow,coloanal anastomoses with Harmonic Scalpel for low rectal cancer is a perspective minimally invasive technique, which is feasible, safe, effective and has dramatic high rates of sphincter preservation with decreased postoperative pain, rapid recovery.
Objective To review the latest comparative research of minimally invasive transforaminal lumbar interbody fusion (TLIF) and traditional open approach. Methods The domestic and foreign literature concerning the comparative research of minimally invasive TLIF and traditional open TLIF was reviewed, then intraoperative indicators, length of hospitalization, effectiveness, complication, fusion rate, and the effect on paraspinal muscles were analyzed respectively. Results Minimally invasive TLIF has less blood loss and shorter length of hospitalization, but with longer operation and fluoroscopic time. Minimally invasive surgery has the same high fusion rate as open surgery, however, its effectiveness is not superior to open surgery, and complication rate is relatively higher. In the aspect of the effect on paraspinal muscles, in creatine kinase, multifidus cross-sectional area, and atrophy grading, minimally invasive surgery has no significant reduced damage on paraspinal muscles. Conclusion Minimally invasive TLIF is not significantly superior to open TLIF, and it does not reduce the paraspinal muscles injury. But prospective double-blind randomized control trials are still needed for further study.
ObjectiveTo compare the effectiveness and changes of sagittal spino-pelvic parameters between minimally invasive transforaminal lumbar interbody fusion and conventional open posterior lumbar interbody fusion in treatment of the low-degree isthmic lumbar spondylolisthesis. MethodsBetween May 2012 and May 2013, 86 patients with single segmental isthmic lumbar spondylolisthesis (Meyerding degree Ⅰ or Ⅱ) were treated by minimally invasive transforaminal lumbar interbody fusion (minimally invasive group) in 39 cases, and by open posterior lumbar interbody fusion in 47 cases (open group). There was no significant difference in gender, age, disease duration, degree of lumbar spondylolisthesis, preoperative visual analogue scale (VAS) score, and Oswestry disability index (ODI) between 2 groups (P>0.05). The following sagittal spino-pelvic parameters were compared between 2 groups before and after operation: the percentage of slipping (PS), intervertebral height, angle of slip (AS), thoracolumbar junction (TLJ), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), spino-sacral angle (SSA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Pearson correlation analysis of the changes between pre- and post-operation was done. ResultsPrimary healing of incision was obtained in all patients of 2 groups. The postoperative hospital stay of minimally invasive group [(5.1±1.6) days] was significantly shorter than that of open group [(7.2±2.1) days] (t=2.593, P=0.017). The patients were followed up 11-20 months (mean, 15 months). The reduction rate was 68.53%±20.52% in minimally invasive group, and was 64.21%±30.21% in open group, showing no significant difference (t=0.725, P=0.093). The back and leg pain VAS scores, and ODI at 3 months after operation were significantly reduced when compared with preoperative ones (P<0.05), but no significant difference was found between 2 groups (P>0.05). The postoperative other sagittal spino-pelvic parameters were significantly improved (P<0.05) except PI (P>0.05), but there was no significant difference between 2 groups (P>0.05). The correlation analysis showed that ODI value was related to the SVA, SSA, PT, and LL (P<0.05). ConclusionBoth minimally invasive transforaminal lumbar interbody fusion and conventional open posterior lumbar interbody fusion can significantly improve the sagittal spino-pelvic parameters in the treatment of low-degree isthmic lumbar spondylolisthesis. The reconstruction of SVA, SSA, PT, and LL are related to the quality of life.
ObjectiveTo assess the feasibility of the treatment of unresectable late pancreatic cancer with laparoscopic choledochojejunostomy and gastric bypass. MethodsFrom June 2000 to December 2003, laparoscopic choledochojejunostomy and gastric bypass were successfully performed in 15 patients with unresectable late pancreatic cancer. Endoscopic nosobiliary drainage (ENBD) was performed before the operation. ResultsAll procedures were completed laparoscopically. Jaundice and hepatic function of the patients were obviously improved after the bypass. Oral nutrition was recovered after operation. The mean operative time was (100±26) min (range 70-200 min); the mean operative blood loss was (60±15) ml (range 30-120 ml); the bowel function recovery was on the 3rd-5th postoperative day; the average hospital stay was (8.1±0.7) days (range 6-13 days). Incision infection ocurred in one patient. No operative complications occurred in other patients. ConclusionTreatment of unresectable late carcinoma of the pancreas with laparoscopic choledochojejunostomy and gastric bypass aided by ENBD is a minimally invasive technique with less postoperative pain，shorter hospital stay, lower procedurerelated morbidity,and better oral nutrition. The life quality of patients with late pancreatic cancer can be obviously improved.
ObjectiveTo compare early outcomes of the minimally invasive mitral valve surgery (MIMVS) through right anterolateral mini-thoracotomy (ALMT) with conventional mitral valve surgery (MVS), and evaluate feasibility and safety of MIMVS. MethodsFrom January 2011 to December 2013, 120 patients undergoing elective MVS in Nanjing First Hospital were prospectively enrolled in this study. There were 72 male and 48 female patients with their age of 22-71 (42.4±11.0) years. Using a random number table, all the patients were randomly divided into a portaccess MIMVS group (MIMVS group, n=60) and a conventional MVS group (conventional group, n=60). MIMVS group patients received port-access cardiopulmonary bypass (CPB) establishment via femoral artery, femoral vein and right internal jugular vein cannulation through right ALMT 5-6 cm in length. Special MIMVS operative instruments were used for mitral valve repair or replacement. Conventional group patients received mitral valve repair or replacement under conventional CPB through median sternotomy. Perioperative clinical data, morbidity and mortality were compared between the 2 groups. ResultsThere was no death in-hospital or shortly after discharge in this study. CPB time (98.0±26.0 minutes vs. 63.0±21.0 minutes) and aortic cross-clamping time (68.0±9.0 minutes vs.37.0±6.0 minutes) of MIMVS group were significantly longer than those of conventional group (P<0.05). Postoperative mechanical ventilation time (6.0±3.9 hours vs. 11.2±5.6 hours), length of ICU stay (18.5±3.0 hours vs. 28.6±9.5 hours) and postoperative hospital stay (8.0±2.0 days vs. 13.5±2.5 days) of MIMVS group were significantly shorter than those of conventional group (P<0.05). Chest drainage volume within postoperative 12 hours (110.0±30.0 ml vs. 385.0±95.0 ml) and the percentage of patients receiving blood transfusion (25.0% vs. 58.3%) of MIMVS group were significantly lower than those of conventional group (P<0.05). Patients were followed up for 1-24 months, and the follow-up rate was 94.2%. There was no statistical difference in postoperative morbidity or mortality between the 2 groups (P>0.05). ConclusionMIMVS through right ALMT is a safe and feasible procedure for surgical treatment of mitral valve diseases. MIMVS can achieve similar clinical outcomes as conventional MVS, but can significantly shorten postoperative ICU stay and hospital stay, reduce blood transfusion, and is a good alternative to conventional MVS.
ObjectiveTo investigate the effectiveness and safety of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for upper lumbar disc herniation. MethodsRetrospective analysis was made on the clinical data of 26 patients with upper lumbar disc herniation, who were in line with the selection criteria and underwent MIS-TLIF in 14 patients (MIS-TLIF group) and open transforaminal lumbar interbody fusion (OTLIF) in 12 patients (OTLIF group) between December 2007 and May 2012. There was no significant difference in gender, age, disease duration, level of disc herniation, side of disc herniation between 2 groups (P>0.05). The operation time, intraoperative blood loss, postoperative drainage volume, and complications were compared between 2 groups. The clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI) scores. The fusion rate was determined by using CT three-dimensional reconstruction and dynamic lumbar radiography at last follow-up. ResultsPrimary healing of incisions was obtained in both groups. No difference was found in operation time between 2 groups (t=0.858, P=0.399), but MIS-TLIF group had less intraoperative blood loss and postoperative drainage volume than OTLIF group (P<0.05). The average follow-up duration was 34.1 months with a range of 12-50 months. No complication of dural tear, infection, spinal nerve trauma, and implant failure occurred. The VAS scores of lower back pain and radicular pain and ODI scores at preoperation showed no significant difference between 2 groups (P>0.05). The VAS score of lower back pain and ODI score at 1 day after operation in MIS-TLIF group were significantly lower than those in the OTLIF group (P<0.05), but no difference was found in VAS scores of radicular pain between 2 groups (P>0.05). Difference in all scores was not significant at last follow-up between 2 groups (P>0.05). The fusion rate was 92.8% (13/14) in MIS-TLIF group, and was 100% (12/12) in OTLIF group at last follow-up. ConclusionMIS-TLIF is a safe and effective procedure for upper lumbar disc herniation as an alternative to other techniques.