| The prevalence rate of gastrointestinal diseases especially gastrointestinal tumors is increasing in recent years.With the development of surgical technique,the minimal trauma on the basis of the most radical cure is the ideal result by operation method,which is the ultimate pursuit of all surgeons.The current methods include traditional laparotomy and laparoscopy in the surgical treatment of gastrointestinal tumors,to some extent,they are opposites under this unified purpose.However,due to the disadvantages of traditional methods,such as maximal operative trauma,unaesthetic appearance and more postoperative complications,laparoscopy,which is also called minimally invasive surgery--often become the first choice for surgeons and patients.But the standard laparoscopic surgery still has some limitations in the clinical application which limits its application in the complex surgery,characterized by long learning curve,high technical difficulty,long operative time,incomplete lesion detection,the lack of tactile function,and lack of incision for some certain surgical specimens to be complete removed,etc.To make up for the inadequacy of laparoscopy,foreign researchers invented a kind of hand-assist device,a new operation method has been proposed and developed.Which is called Hand-assisted laparoscopic surgery(HALS)HALS need to cut a 6-7 cm long incision that allows an assist hand(generally left hand)into the abdominal cavity cooperating with laparoscopic instruments operated by right hand and assistant to finish more complex operations with maintained pneumoperitoneum.The participation of assist hand can reduce the complexity and technical difficulties of laparoscopic surgery,shorten the learning curve and the operation time.The assistance of hand aids doctors to touch blood vessel position and stop bleeding correctly,decrease blood loss and make the surgery more safe.For all these advantages,HALS makes up for the standard laparoscopic operation,possessing broader surgical applications.The first kind of hand-assisted device-"Lapdisc",made by Johnson company,US,consists of pedestal and lid.Domestic and international surgeons conducted many kinds of HALS operations including gastrointestinal tumor surgeries.There were other kinds of hand-assist devices invented and employed.The advantages and disadvantages of HALS were realized.Due to the limited operative vision and expensive cost,besides,the assist hand in abdominal cavity is compressed and limited,it is not accepted by the majority of surgeons and patients.Only 2-3 domestic top three hospitals have brought in and employed,therefore,limiting the application of this technology,especially in primary hospitals.I am the main researcher of The Gastrointestinal Surgery Research Group,The Second Hospital Of Hebei Medical University,we designed a kind of laparoscopic hand assisted device and obtained the national patent,patent number: 201220661287.9.The hand-assisted device we designed overcomes the shortcomings of lapdisc,not only making the HALS operation more convenient,but also making pneumoperitoneum well maintained while equipment or hand going into the abdominal cavity without leakage.It offers the interchange between laparotomy,laparoscopy,and HALS whenever necessary,We name this improved surgical procedure using our novel device Three United Larparoscope Surgery(TULS).This paper aims to introduce our self-developed hand-assisted device and analyze the series of TULS operation conducted by the device,including 3 cases of gastric cardia carcinoma surgery by TULS from January 2014 to February 2014;100 cases from January 2014 to January 2017,including 38 cases of TULS,30 cases of laparotomy and 32 cases of laparoscopy-assisted surgery.With all these clinic cases,we analyzed and evaluated clinical application prospect of TULS in the treatment of intestinal obstruction through the case of sigmoid colon obstruction surgery.Through the above analysis and research,the safety,feasibility and clinical application prospects of TULS are discussed and evaluated,By demonstrating the significance of TULS in the clinical application,we hope to provide an additional surgical option for surgeons,so that more patients can benefit from it.Part one Design and clinical evaluation of the patent handassisted de-vice.Objective: Introduce the structure of our self-developed hand-assisted device and clinical evaluation.Methods:Our self-developed hand-assist device has obtained national patent,it is made of medical plastic,rubber or silicone and other polymer materials,and consists of an outer elastic ring,a sealed connection sets,an inner elastic ring and a sac-like sealed sleeve.It overcomes the shortages of the Lapdisc device,with a simple structure,easy to operate and clearly revealed.it combines the advantages of three surgical methods: conventional laparotomy,hand-assisted laparoscopic surgery and laparoscopic surgery.To verify the airtightness of pneumoperitoneum,we conducted an experiment with 4 rabbits,observing the changes of pneumoperitoneum pressure during experiment.In addition,authorized by the hospital ethics committee,we have applied the device to 20 cases of clinical surgery assessments,which shows the clinical feasibility and application prospects of this improved hand-assist device.Results:We installed pneumoperitoneum with the self-developed hand-assisted devices on four intravenous anaesthetized rabbits.The pneumoperitoneum pressure of group A was 200 mm Hg while group B 150 mm Hg,during experiment,the heart rate and the breathe of the rabbits kept smooth.After one hour,the pneumoperitoneum pressure of group A was 197 mm Hg.Two hours later,195 mm Hg;three hours later,193 mm Hg;four hours later,192 mm Hg;five hours later,190 mm Hg.While the results of group B were 149 mm Hg,147 mm Hg,146 mm Hg,145 mm Hg,143 mm Hg.Thus we can conclude that regardless of high abdominal pressure or proper abdominal pressure,the pneumoperitoneum pressure was steady and the fluctuations were small.We had well finished 20 cases of operations in the treatment of TULS with the self-developed hand-assisted device.There were no complications such as infection of incision,the patients were all smooth discharged.During the operation and the conversion,pneumoperitoneum kept well,the hand in the abdominal cavity was flexible and did not feel much compressed,the operation field exposed well,decreased operation difficulty,and we achieved the transition of laparotomy and laparoscopy during surgery.Conclusions: The hand-assisted device we invented overcomes the shortages of the Lapdisc device,with a simple structure.It can finish a flexible operation with easy conversion,The operating region is clearly revealed and the cost is lower,By the pneumoperitoneum pressure experiment of 4 rabbits and 20 cases of clinical operations,we can conclude that the device is safe,feasible and has a bright clinical application prospect.Part two Report of 3 cases of TULS in radical resections of gastric cardia carcinoma.Objective: Evaluate the safety & feasibility,cancer radical effect and postoperative efficacy of TULS in radical resections of gastric cardia carcinoma by summarizing the results of 3 cases in the treatment of TULS.Methods:A retrospective analysis of clinical information on 3 cases of gastric cardia carcinoma in the treatment of gastric cardia radical surgery by TULS admitted From January 2014 to February 2014 was done.the operative time,amount of bleeding,number of lymph nodes removed,time to flatus after surgery,rate of postoperative complications,hospital stay and expense were included.Results:Three operations were completed with TULS without complications such as incision infection,postoperative bleeding,anastomotic leakage,or adhesive intestinal obstruction.The number of lymph nodes removed was 22,25,21,which meets the surgical guide standard.Three months after discharge,there were no tumor recurrence or metastasis during the follow ups.Conclusions:TULS gets the same feasibility and tumor radicality in the treatment of radical operation of gastric cardia carcinoma as Laparotomy.However,it is more accurate by exploring the abdominal situation with both laparoscope and surgeon’s hand.We can deal with different situations timely and safely.Part three A comparative study for the treatment of advanced gastric cardia cancer with TULS,laparotomy and laparoscopy-assisted surgery.Objective:By comparing the results of treatments in TULS,laparotomy and laparoscopy-assisted surgery,we evaluate the safety,feasibility,effect of radical cure and postoperative efficacy of TULS in radical resection of gastric cardia carcinoma.Methods:A retrospective study on 100 patients with advanced gastric cardia cancer admitted from January 2014 to June 2015 was done.There were 38 cases of TULS,30 cases of laparotomy and 32 cases of laparoscopy-assisted surgery.Statistical comparisons between three treatment groups in operative time,incision length,amount of bleeding,number of lymph nodes dissected,time to flatus after surgery,rate of postoperative complications,hospital stay and expense were made.Results:The comparison of group TULS and group laparoscopicassisted: average operating time:(189.58±16.49min)VS(256.25±15.55min)(P<0.05);intraoperatve blood soss:(93.4±45.3m1)vs(99.1±51.7ml);venting time:(2.3±0.4d)vs(2.2±0.4d);hospital stay:(8.9±1.1d)vs(9.5±1.4d);length of incision:(8.1±0.5 cm)vs(8.1±0.6cm),The comparison of group TULS and group laparotomy : average operating time:(189.58±16.49min)vs(185.13 ±15.66min);intraoperatve blood soss:(93.4±45.3 m1)vs(264.0±100.3 ml);venting time:(2.3±0.4d)vs(3.0±0.6d);hospital stay:(8.9±1.1d)vs(10.9±1.7d);length of incision:(8.1±0.5cm)vs(24.1±2.0cm).There were no significant differences between TULS,laparotomy and laparoscopy-assisted surgery in number of lymph nodes removed:(24.8±2.3)vs(25.1±2.1)vs(24.8±1.8).Conclusions:For lymph node dissection,there were no significant differences between TULS,laparotomy and laparoscopy-assisted surgery.However,compared with conventional laparotomy,TULS and laparoscopy-assisted surgery were found to be able to minimize incision length,reduce blood loss during surgery,lower postoperative complication rate,and shorten time to flatus and hospital stay.The differences were statistically significant(P < 0.05).The operative time of TULS was significantly shorter than the laparoscopy-assisted(P < 0.05),and was comparable to that of laparotomy.TULS is as efficient as laparotomy in lymph node dissection and shows the advantages of minimally invasive surgery.It can be a novel and promising surgical intervention for treatment of advanced gastric cancer.Part four The surgical application of TULS in the treatment of colorectal cancer.Objective: Evaluate the safety and feasibility,tumor radical effect and postoperative efficacy of TULS in radical resection of colorectal cancer by summarizing the clinical effect.Methods: A retrospective analysis of 32 patients with colorectal cancer admitted from January 2015 to January 2017 was made,including 1 case of transverse colon cancer,12 cases of right colon cancer,9 cases of left colon cancer,4 cases of sigmoid colon cancer,9 cases of rectal cancer,in order to evaluate the efficacy of TULS in the radical resection of colorectal cancer,the operative time,incision length,amount of bleeding,radiation of the tumor,number of lymph nodes dissected,time to flatus after surgery,and the rate of postoperative complications.The efficacy and long-term efficacy after surgery were observed.Results:The 32 patients in the treatment of TULS were operated smoothly with no case conversed to open surgery.The average ages(years-old)of the patients of group right colon cancer,the group left colon cancer,group transverse colon cancer,the group sigmoid colon cancer,the group rectal cancer are: 50,55,53,51;intraoperatve blood soss:170ml,100 ml,80 ml,100 ml;number of lymph nodes dissected: 11,8,17,5;venting time : 5d,6d,5d,7d;length of incision: 6.0cm,6.5cm,6.0cm,5.0cm;operating time: 177 min,185min,170 min,180min;hospital stay: 12 d,13d,11 d,15d;there were no serious complications during follow ups.Conclusions: During the exploration in colorectal cancer surgery by TULS,we achieved the surgical effects such as minimize incision length,less intraoperative bleeding,lower postoperative complication rate,and shorten operative time.The number of the lymph node dissection which indicates the tumor radical effect proved that TULS can meet the surgical guide standard,which is a safe,feasible treatment for colorectal surgeries.Part five The clinical application of TULS in the operation of intestinal obstruction.Objective: Evaluate the clinical application prospect of TULS in the treatment of intestinal obstruction by analyzing the operative procedure and effect of one case of sigmoid colon obstruction surgery.Methods:Analyze the result of 1 case of the treatment with TULS in sigmoid colon obstruction surgery to evaluate the clinical feasibility and foreground in surgical application of TULS in the operation of intestinal obstruction.Results:One case of the treatment with TULS in sigmoid colon obstruction surgery was successful.Operative time: 150 min;intraoperatve blood soss:30ml;Catheter removed in the 1st day,vented in the 2nd day,liquid diets in the 3rd day,pulled out the abdominal cavity drainage tube in the 6th and 8th day.There were no serious complications,suture removed and discharged in the 9th day.Conclusions:It is safe to use TULS to treat the cases of sigmoid colon obstruction,Patients can get the benefits of smaller incision trauma,shorter operating time,more safety,faster postoperative recovery and many other advantages.This surgical method dealing with TULS after intestinal decompression has a general meaning for all kinds of obstruction cases.It possesses the advantages of both traditional laparotomy and laparoscopic surgery in the treatment of intestinal obstruction.For the cases of intestinal obstruction caused by other reasons,the effect remains to be further observed.We recommend this method as a priority option for patients with intestinal obstruction,... |
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