2017年 · 第32卷第12期

Abdominal wall hernia repair is one of the most commonly performed procedures by general surgeons. Since 1993, LeBlanc et al.^[1]After the first report of laparoscopic ventral and incisional hernia repair (LVHR), LVHR has proven to be a safe, effective and reasonable treatment option for patients with abdominal wall hernia, and has been applied in the repair of various abdominal wall hernias in the past 10 years. Compared with open surgery, LVHR has the advantages of fewer incision complications, faster recovery of intestinal function, shorter hospital stay, and more aesthetic incisions. However, as one of the postoperative complications of LVHR that cannot be ignored-postoperative abdominal wall bulge has been rarely mentioned in the past 20 years, and should attract everyone's attention.

At present, laparoscopic thyroid surgery is used in the treatment of benign thyroid diseases and early (cN0) differentiated thyroid cancer^[1,2]。 However, in the more cutting-edge and difficult cervical lymph node dissection, total laparoscopic surgery is still controversial. From January 2014 to December 2015, we tried to perform cervical lymph node dissection with total laparoscopy combined with modified McFee incision approach (assisted with single upper neck dermatographic incision), and completed 23 cases of cN1 thyroid cancer surgery, and achieved satisfactory results.

Great saphenous varices are the most common vascular diseases, with an incidence rate of 20% to 40% in adults^[1]。 endovenous laser ablation (EVLA) for the treatment of large saphenous varices has the advantages of less trauma, good curative effect and quick recovery^[2]The recommended anesthesia is local tumescent anesthesia (LTA), but the disadvantage of this anesthesia is that the intraoperative analgesic effect is not satisfactory. Our previous study found that the use of femoral nerve block (FNB) combined with LTA can better relieve the pain during EVLA surgery, so this study was designed to compare the analgesic efficacy and safety of FNB combined with LTA and LTA alone in EVLA surgery for great saphenous varices.

The incidence of accessory spleen accounts for about 10% to 30% of the total population, usually without clinical symptoms, more than accidental findings during imaging examinations, and does not require special treatment. The accessory spleen is mostly located near the splenic hilum, and about 17% occurs in the tail of the pancreas^[1]。 intrapancreatic accessory spleen (IPAS) completely located in the pancreatic parenchyma is rare in clinical practice, and is often misdiagnosed as pancreatic space-occupying lesions and treated by surgery. In recent years, 3 cases of IPAS were surgically removed in our department, which are reported in combination with the literature as follows.

Patch infection is a serious complication after hernia repair. Once the patch is infected, clinical management is very difficult. It is often necessary to reoperate to remove the patch, which causes mental pain and financial burden to patients. From November 2010 to December 2015, 12 patients with mesh infection and infected sinus tract of abdominal wall after incisional hernia surgery were treated in our hospital with debridement and infected mesh removal. The report is now as follows.

The traditional treatment for varicose veins of lower limbs is high ligation and stripping of the great saphenous vein. In the past 10 years, minimally invasive treatment methods such as laser, radiofrequency and other endovascular treatments have become more and more popular. Although these therapies are effective, they are easy to damage the saphenous nerve during the treatment process, and numbness and sensory impairment will occur in the affected limb after operation, which will have a huge impact on the patient's life^[1]。 In this study, restrictive varus exfoliation and intracavitary laser combined with foam sclerotherapy were used to treat varicose veins of lower limbs, and the saphenous nerve injury was significantly reduced. The results of the study are reported below.

inferior vena cava (IVC) filters have been widely used in clinical practice. In the United States, a total of 224,700 IVC filters were used in 2012^[1]The use of IVC filters in China is also on the rise. Recyclable IVC filters have been more and more used in clinical practice, and there is a tendency to replace permanent IVC filters. We discussed and analyzed the value of routine IVC angiography after Aegisy IVC filter removal, so as to provide relevant data reference for the development of Aegisy IVC filter removal procedure in clinic.

Femoral hernia is relatively rare in clinic, accounting for about 2% ~4% of external abdominal hernias^[1]It is more common in women over the age of 40. The occurrence of femoral hernia is related to the increase of intraabdominal pressure, weakness of transverse fascia and enlargement of femoral ring^[2]。 The occurrence of femoral hernia after inguinal hernia surgery is more rare, and the experience in its diagnosis and treatment is relatively insufficient. We collected the clinical data of 227 patients with femoral hernia admitted to our hospital from June 2006 to December 2015, and analyzed and summarized the clinical data of 38 patients with a history of ipsilateral inguinal hernia surgery, which are now reported as follows.

Surgery remains the main treatment for extrahepatic bile duct stones. At present, in most hospitals, the main treatment for choledocholithiasis is exploration and lithotomy of the common bile duct, and postoperative T-tube drainage. Nowadays, more and more hospitals tend to suture the common bile duct in one stage. We collected 64 clinical cases of common bile duct exploration by laparoscopy combined with cholangioscopy, including 33 cases in the primary suture group and 31 cases in the T-tube drainage group, which are now reported as follows.

Surgical treatment of diabetes has been included in the guidelines for diabetes treatment, among which malabsorption surgeries, including Roux-en-Y gastric bypass (RYGB) and bilioopancreatic diversion (BPD) have better weight loss and hypoglycemic effects. In this study, the advantages and disadvantages of the two surgical procedures were compared by meta-analysis, so as to provide reference for the choice of surgical treatment of type 2 diabetes.

In 2016, our center treated a patient with massive liver cancer, and performed laparoscopic liver resection combined with the concept of enhanced recovery after surgery (ERAS), and achieved good results, which are reported below.

A 28-year-old woman accidentally found a right axillary mass at 12 weeks of pregnancy, about the size of a faba bean, without tenderness. Because she was untreated during pregnancy, the mass gradually increased. 5 days after delivery, the diameter of the mass was about 20.0 cm, nearly the size of the baby's head, and she was admitted to hospital for further diagnosis and treatment. Physical examination: a huge mass was seen in the right axilla (Figure 1), the surface is smooth, purple-red, varicose veins can be seen on the surface skin, soft in texture, without tenderness, and the skin temperature is normal. Ultrasound examination: huge heterogeneous hyperechoic visible subcutaneously in the right axilla (Figure 2), with a larger diameter of approximately 11.7 cm, CDFI: a short rod-shaped blood flow signal can be seen inside, and a venous blood flow spectrum can be seen. Right axillary mass resection was performed on 16 Nov 2016. Intraoperative findings: The tumor was oval, 15.0 cm ×14.5 cm ×11.0 cm in size, most of the cut surface was gray-red and light brown, medium in quality, with a little fat around it. Pathological report: (right axillary mass) accessory breast tissue, heavy infarction, lobular hyperplasia, duct dilation (Figure 3)。

A 59-year-old female complained of "stomach body mass found on physical examination for 1 year and epigastric discomfort for 6 months". Physical examination showed no abnormalities. Serum tumor markers were normal. Gastroscopy showed that the small curve of the stomach body deviated from the anterior wall of a broad-base submucosal bulge, the surface was smooth, and the touch was fixed (Figure 1)。 Endoscopic ultrasound showed that the lesion was located in the submucosa, growing into the cavity, showing mixed echoic changes, the size was 13.6 mm ×10.4 mm, and the boundary with the muscularis propria was not clear. CT examination showed that the small curved side of the stomach was like round soft tissue density shadow, and the boundary was not clear. Laparoscopic exploration showed a slight bulge of the serous layer at the anterior wall of the stomach body. One needle was sutured around the tumor as an index, and then the gastroscope entered the gastric cavity. It was found that the gastric body was small curved to the anterior wall of the tumor, and sutures could be seen beside the tumor. After laparoscopic and gastroscopic localization of the mass, the suture was lifted and the mass was removed with an ultrasonic scalpel. The specimens were removed orally using a gastroscope snare. The results of frozen pathology showed that ectopic submucosal pancreatic tissue. The stomach wall was continuously sutured in full thickness, and the wound was well sutured after gastroscopy again. The gastric cavity was pumped by gastroscope, and the suture effect was satisfactory under laparoscope. The operation time was 1 h 15 min, with intraoperative bleeding of 20 ml. Postoperative pathological examination results: the mucosa on one side of the stomach wall was slightly raised, and a yellow mass was seen on the section, 2.0 cm ×2.0 cm ×1.0 cm in size; Under light microscope, ectopic pancreatic tissue mainly in gastric submucosa, partly located in muscle propria, ectopic pancreatic duct located in the deep layer of gastric wall, duct dilatation with ductal epithelial hyperplasia (Figure 2)。

A 71-year-old female was admitted to the hospital because of "hypertension found for 30 years and aggravated for 1 year". It has been found that serum creatinine has increased for more than 1 year, with a maximum of 244 μ mol/L, and frequent heart failure in the past month; He has taken nifedipine controlled-release tablets, losartan potassium hydrochlorothiazide tablets, metoprolol tartrate tablets, terazosin hydrochloride tablets, furosemide tablets and other antihypertensive drugs orally, but his blood pressure is still poorly controlled, with a maximum of 260/90 mmHg. Physical examination at admission: Vascular murmur could be heard in the right kidney area. Renal dynamic imaging: Glomerular filtration rate (GFR) 24.38 ml/min. Renal artery CTA: The left renal artery was completely occluded from the opening to the distal main vessel, and the right renal artery was severely narrowed at the opening (Figure 1)。 The patient had severe stenosis of the right renal artery and a clear diagnosis of occlusion of the left renal artery. Surgical procedure: Left femoral artery puncture was performed by Seldinger method, 6F vascular sheath was implanted, and 5F pigtail catheter was guided by 0.035 ultra-slippery guide wire to the level of thoracic 12 vertebral body of abdominal aorta. High pressure syringe angiography showed that the opening of the right renal artery was severely narrowed, the degree was more than 95%, and the length was about 1.0 cm. The left renal artery and left kidney were not developed (Figure 2)。 The 6F Guiding catheter was replaced to the opening of the right renal artery, the PT2 guidewire was selected into the right renal artery and passed through the stenotic lesion, pre-dilated with a 4.0-20.0 mm balloon, and a 5.0-15.0 mm bulb dilating stent was placed; In the same method, the occlusion of left renal artery was opened to the true lumen of the distal left renal artery by using SIM1 catheter guided by PT2 guidewire, and dilated with a 4.0-20.0 mm balloon, and a 5.0-20.0 mm bulbar stent was placed. Re-angiography showed good stent expansion, smooth blood flow and no residual stenosis (Figure 3)。 Postoperatively, aspirin enteric-coated tablets and clopidogrel bisulfate tablets were given antiplatelet therapy. After 3 months of follow-up, the patient only took compound reserpine triamteridine tablets to reduce blood pressure, and his blood pressure was controlled at about 150/80 mmHg, and his serum creatinine was 105 μ mol/L.

The patient, a 71-year-old female, was admitted for 3 d due to pain and discomfort in the left upper abdomen. Abdominal B-ultrasound: 32 mm ×30 mm irregular hypoechoic solid space-occupying lesion of the pancreas. Upper abdominal CT: A heterogeneous low-density lesion with a cross section of about 3.3 cm ×2.5 cm was seen in the neck and body of the pancreas, with clear boundaries. After enhanced scan, the lesion was significantly enhanced, and the main pancreatic duct was not dilated. The patient had no previous history of abdominal trauma, surgery, acute or chronic pancreatitis attacks, and no history of oral contraceptives. Physical examination showed no abnormalities. Laparotomy showed that the tumor was located at the junction of the neck and body of the pancreas, about 4 cm ×3 cm ×3 cm in size, with intact capsule, cystic solid at touch, and acceptable mobility; No enlarged lymph nodes were found in the hepatoduodenal ligament and mesenteric root. Excision of pancreatic cervical body tumor + distal pancreatic body-jejunostomy was performed at 0.5 cm from the tumor. Postoperative pathology: the lesion section is gray-white gray-red, honeycomb sponge-like; Immunohistochemistry CD34 (+), CD31 (+), D2-40 (-). Diagnosis of pancreatic hemangioma (Figure 1)。 Pancreatic fistula (grade B) appeared postoperatively, which was cured by conservative treatment. After one year follow-up, the general condition was good, and no tumor recurrence was observed.

human immunodeficiency virus (HIV) has been discovered for more than 30 years^[1]Nowadays, HIV has spread around the world, with nearly 40 million people infected. Since 2005, the HIV infection rate has not continued to decline. Instead, the HIV infection rate has increased in 74 countries, including many regions in the Middle East^[2]。 At present, cardiovascular complications in HIV infected people mostly occur in the late stage of infection^[3,4]And the incidence rate was significantly higher than before^[5]With the rapid development of highly active anti-retroviral therapy (HAART), the survival of HIV patients has been continuously prolonged, and HIV complicated with macrovascular disease has become one of the main complications of patients. Its specific pathological mechanism and the relationship with HAART are still unclear.

hilar cholangiocarcinoma (HCC) refers to biliary mucosal epithelial carcinoma that occurs in the upper common hepatic duct, left and right hepatic ducts and their bifurcations. It is a perihilar malignant tumor, which has attracted widespread attention after the characteristics were first described by Klatskin and is also called Klatskin tumor^[1]。 HCC is the most common type of cholangiocarcinoma, accounting for about 50% ~60% of all cholangiocarcinomas^[2]。 Because it is adjacent to the important tissue structure of the hepatic hilar region and has the biological characteristics of transverse spread and longitudinal invasion, it leads to the difficulty of surgery, low resection rate, high recurrence rate and short survival time of HCC. Radical resection is undoubtedly the main way to cure HCC. However, its radical resection rate is only 1/3 of all patients, and its 5-year survival rate is only 20% ~42%. Its treatment is still a huge problem for hepatobiliary surgeons^[3]。 In recent years, with the development of imaging technology, the improvement of surgical skills and the continuous understanding of HCC biological behavior, its prognosis has been significantly improved, but the degree of hepatectomy in different Bismuth types of HCC is still controversial.

deep venous thrombosis (DVT) of lower limbs is a common and difficult peripheral vascular disease in clinical practice. The common causes include venous endothelial damage, slow blood flow, hypercoagulability and iliac vein stenosis^[1,2]。 post-thrombosis syndrome (PTS) is a long-term complication of DVT, often accompanied by venous fibrosis, poor venous compliance and increased venous pressure^[3]。 The clinical manifestations are: limb swelling, chronic pain, skin pigmentation and even skin ulcers that are difficult to heal. Even if DVT patients receive standardized anticoagulant therapy, the incidence of PTS is still as high as 20% ~50% after 2 years, and the quality of life of 100% patients is affected^[4]。 At present, the treatment of PTS is limited and the efficacy is not ideal. Therefore, in-depth research on the molecular mechanism in the development of DVT, and finding new methods for early diagnosis, efficient and safe biological therapy and prognosis evaluation will bring good news to patients.

Danish scholar Professor Kehlet first proposed the concept of enhanced recovery after surgery (ERAS) in 1997^[1]。 This concept is based on evidence-based medicine, and a series of perioperative optimization management measures are adopted to achieve the goal of accelerated recovery. The application research of ERAS has been extended to many surgical fields such as general surgery, thoracic and cardiac surgery, orthopedics, gynecology and urology, and many related research results have been published at home and abroad^[2,3,4,5,6]。 Adult inguinal hernia repair is one of the common operations in general surgery. According to incomplete statistics, the number of tension-free inguinal hernia repair operations in China has reached 1 million every year. Tension-free inguinal hernia repair has the advantages of mild pain and low recurrence rate, but postoperative complications such as scrotal hematoma or effusion, chronic pain, urinary retention and patch infection still cause headaches for surgeons. The Hernia and Abdominal Wall Surgery Group of Shanghai Medical Association Surgery Branch organized Shanghai hernia and abdominal wall surgery experts to jointly formulate the Shanghai Expert Consensus on Accelerated Rehabilitation of Adult Inguinal Hernia after Surgery (2017 Edition) (hereinafter referred to as the Consensus), hoping to speed up the rehabilitation of hernia patients through the concept of ERAS, achieve the purpose of reducing stress, complications, hospitalization, readmission risk and medical expenses, aiming at providing a reference for the standardization and standardization of ERAS in hernia and abdominal wall surgery in China.