老爸论文 – 立委NLP频道

Medicine Lecture Notes

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Medicine Lecture Notes

【立委按】老爸的医学生涯电子版另开辟【教育园地】专栏，整理刊载老爸医学生涯中所做的医学讲座、代表性手术记录以及对后生传帮带方面的资料。相信这些资料对于同行和后学自有其参考价值。在老爸一路向上的医学生涯中，职称上最高的一级当然是主任医师的评定。材料中，五例四类手术例案是九四年申报主任医师的必备附件之一。当然，申报成功还要加上省级至全国核心期刊发表论文五篇以上、专业英文笔试合格、医学教学能力（例如下面的医学讲座）及临床领导经验等综合考核评价。

[Editor’s Comment] Dad’s electronic version of his medical career has a separate column entitled [Education Garden], which collates and publishes medical lectures given by Dad in his medical career, records of representative surgeries and information on mentoring epigenetic patients. I believe these materials have their own reference value for peers and postgraduates. In dad all the way up in the medical career, title on the highest level, of course, is the chief physician evaluation. Among the materials, five cases with four types of operations were one of the necessary accessories for reporting to the chief physician in 1994. Of course, the success of the application also requires the comprehensive assessment and evaluation of more than five papers published in provincial to national core journals, qualified professional English written examination, medical teaching ability (such as the following medical lectures) and clinical leadership experience.

1. Yellow resistance related clinical problems

1 Jaundice–syndrome. Pre-liver (hemolytic), hepatocellular, and post-liver (obstructive). mixed type

2 Yellow resistance-intrahepatic capillary duct–small bile duct–hepatobiliary duct–common hepatic duct–common bile duct … obstruction.

3 Internal medicine jaundice—surgical jaundice: internal and external hepatic obstruction. (15%-20% difficult to identify)

4 Diagnostic procedures and methods of yellow resistance: clinical, laboratory tests, X-ray, B-US, CT, MRI, PTC, ERCP, radionuclide (isotope iodine 131, De99) imaging, selective angiography … liver biopsy, laparotomy …

5 Three elements of diagnosis—yellow stalk or not–location and degree of obstruction–cause of obstruction.

6 the characteristics of surgical jaundice: (1) Biliary colic (Charcot triad, Ranold pentalogy); Painless progressive jaundice is often suggestive of cancer. (2) Physical examination: The right upper abdomen or the whole abdomen shows peritoneal irritation sign and swollen gallbladder. (3) Laboratory tests: bilirubin +85.5umol/L and direct/total bilirubin > 35% or “biliary enzyme separation”, AKP↑ and urine bilirubin+and urobilinogen-. (4) Common causes: cholelithiasis, biliary parasites, bile duct stenosis, cancer, inflammation and pancreatic cancer, inflammation, hilar metastatic cancer, Mirizzi snidrome (5) Internal medicine jaundice that needs to be excluded—for example, viral hepatitis, drug-induced liver damage, idiopathic jaundice of pregnancy, sclerosing cholangitis …

7 Surgical jaundice treatment: strive for early surgery.

8 For preoperative jaundice reduction (especially malignant terrigenous jaundice—liver and kidney, coagulation function, gastric mucosa damage, and immunologic hypofunction, with blood bilirubin of 170umol/L). Methods: (1) External drainage technique —— PTCD, U-tube, cholecystostomy, choledochostomy. (2) Internal drainage technique—biliary and intestinal drainage.

9 Surgeries

9.1 Stone removal+external and internal drainage (T-tube drainage, pelvic biliary-intestinal drainage, Roux-Y, diseased hepatectomy …)

9.2 Pancreas cancer resection: Whipple and Child surgery

1、阻黄的有关临床问题 (讲稿提要)

1 黄疸 —— 症候群。肝前 (溶血性)、肝细胞性、肝后性 (梗阻性)。混合型

2 阻黄 —— 肝内毛细胆管 – 小胆管 – 肝胆管 – 肝总管 – 胆总管 … 梗阻。

3 内科黄疸 —— 外科黄疽: 肝内、外梗阻。(15%-20%难以鉴别)

4 阻黄的诊断程序和方法: 临床、化验、X线、B-US、CT、MRI、PTC、ERCP、核素 (同位素碘131、得99) 显象、选择性动脉造影 … 肝活检、剖腹探查…

5 诊断三要素 —— 梗黄与否 – 梗阻部位、程度 – 梗阻原因。

6 外科黄疸的特点:

(1) 胆绞痛 (Charcot三联征、Ranold五联征); 无痛性进行性黄疸常提示癌症。
(2) 查体: 右上腹或全腹呈腹膜刺激征、肿大的胆囊。
(3) 化验: 胆红素+85.5umol/L 且直接/总胆红素 >35%或“胆酶分离”、 AKP↑、尿胆红素 +、尿胆原 –。
(4) 常见原因: 胆石症、胆道寄生虫、胆管狭窄、癌、炎症及胰癌、炎、肝门转移癌、Mirizzi Snydrome
(5) 需除外内科黄疸 —— 如: 病毒性肝炎、药物性肝损害、妊娠特发性黄疸、硬化性胆管炎 ……

7 外科黄疸的治疗: 力争早期手术。

8 关于术前减黄问题 (尤其恶性梗黄 —— 肝肾、凝血机能、胃粘膜损害及免疫功能低下等，血胆红素在170umol/L)。方法: (1) 外引流技术 —— PTCD、U管、胆囊造口、胆总管造口术。(2) 内引流技术 —— 胆肠内引流。

9 手术

9.1 取石术+外、内引流术 (T管引流、盆式胆肠内引流、Roux-Y、
病肝切除…)

9.2 胰癌切除: Whipple、Child手术2. Complications of most gastric resection

1 Recent complications

1.1 intraoperative injuries: common bile duct, pancreas, and middle colon artery.

1.2 Postoperative gastric bleeding

1.2.1 Recent—incomplete hemostasis, and open ulceration.

1.2.2 7–10 days after surgery (secondary hemorrhage)–most cases can be self-stopped.

1.3 Leak of duodenal stump (Billroth-II type): (1) poor suture, (2) obstruction of jejunal afferent loop, (3) local poor blood supply.

1.4 3-4% anastomotic emptying disorders

1.4.1 Full anastomosis.

1.4.2 Output loop.

1.5 Input loop syndrome (Formula B-II)

1.5.1 Chronic simple partial obstruction (technical factor) —— Braun anastomosis, Roux-Y anastomosis (30-40Cm).

1.5.2 Causes of acute strangulation complete obstruction (excluding pancreatitis): (1) Input/output junction (high pressure—necrotic perforation), (2) Input loop is too long—internal hernia. Treatment: emergency operation.

1.6 Surgical exploration of output loop obstruction (barium meal examination). Causes: retrocolonic—mesangial foramen narrowing, anterior to the colon—internal hernia.

1.7 Postoperative acute pancreatitis 1% (abdominal amylase—diagnosis). Causes: trauma, sphincter of Oddi spasm, afferent loop obstruction, decreased postoperative protease inhibitor secretion. Treatment: Surgical drainage.

2 Long-term complications

2.1 causes and mechanisms of “dumping” syndrome: ① high pressure in the small intestine—intestinal distension—intestinal hormones such as 5-hydroxytryptamine—accelerated peristalsis and vasodilation—decreased blood volume, k ↑– gravity pulling the residual stomach—stimulating visceral nerves—epigastric and cardiovascular symptoms. Treatment: Surgery to avoid small residual stomach, large anastomosis, diet, posture adjustment, drugs: antihistamine or anti-acetylcholine, anti-spasm and sedatives or anti-5- hydroxytryptamine and other drugs, surgery: aims to reduce the speed of food directly into the jejunum (narrow the anastomosis, change B-11 to B-I type, gastroduodenal jejunal interposition.

2.2 Hypoglycemia syndrome: mechanistic food-rapid-small intestine-blood glucose-insulin-blood glucose treatment: slight food intake.

2.3 Mechanism of basic reflux gastritis: it is caused by the difference in PH of the gastrointestinal tract. The procedure was chan to Roux-Y or plus Braun for that purpose of reducing reflux of intestinal fluid to the stomach.

2.4 Loss of function of pylorus in food mass ileus—coarse fiber, ropy—simple obstruction of small intestine.

2.5 Anemia

2.5.1 Iron deficiency-caused by low acid in the stomach, iron supplement.

2.5.2 Giant cell sex—lack of internal factors, V-B12, folic acid, liver preparations.

2.6 Malnutrition is generally normal.

2.7 Surgical failure of an anastomotic ulcer (Zollinger-Elison syndrome).

1999-5-8 wuhu changhang hospital

2、胃大部分切除的并发症 (讲稿摘要)

1 近期并发症

1.1 术中损伤: 胆总管、胰腺、结肠中动脉。

1.2 术后胃出血

1.2.1 近期 —— 止血不彻底、溃疡旷置。

1.2.2 术后7~10天 (继发性出血) —— 多可自止。

1.3 十二指肠残端漏 (Billroth-Ⅱ式): (1) 缝合不佳,(2) 空肠输入袢梗阻，(3) 局部血供不良。

1.4 吻合口排空障碍 3-4%

1.4.1 全吻合口。

1.4.2 输出袢。

1.5 输入袢综合征 (B-Ⅱ式)

1.5.1 慢性单纯性部分梗阻 (技术因素) —— Braun式吻合、Roux-Y 式吻合(30-40Cm)。

1.5.2 急性绞窄性完全性梗阻 (剔除胰腺炎) 原因: (1) 输入、出交叉 (压力过高—— 坏死穿孔)，(2) 输入袢过长 —— 内疝，治疗: 急症手术。

1.6 输出袢梗阻 (钡餐检查) 手术探查。原因: 结肠后 —— 系膜孔缩窄、结肠前 —— 内疝。

1.7 术后急性胰腺炎1% (腹液淀粉酶 —— 诊断)。原因: 创伤、Oddi 括约肌痉挛、输入袢梗阻、术后抑蛋白酶分泌减少。治疗: 手术引流。

2 远期并发症

2.1 “倾倒”综合征原因和机理: ① 小肠内高压 —— 肠管膨胀 —— 5-羟色胺等肠道激素 —— 蠕动增快和血管扩张 —— 血容量降低，K↑ —— &重力牵拉残胃 —— 刺激内脏神经 —— 上腹和心血管症状。治疗: 手术避免残胃过小、吻合口过大，饮食、体位调节，药物: 抗组织胺或抗乙酰胆碱、抗痉挛和镇静剂或抗5-羟色胺等药物，手术: 旨在减少食物直接进入空肠的速度 (缩小吻合口、改B-11为B-I式、胃十二指肠空肠间置。

2.2 低血糖综合征：机理食物 —— 快速 —— 小肠 —— 血糖↓ —— 胰岛素↓ —— 血糖↓ 治疗: 稍进食物。

2.3 碱性返流性胃炎机理: 胃肠PH差异致使。改手术为Roux-Y或加 Braun，目在减少肠液向胃返流。

2.4 食物团肠梗阻幽门失功能 —— 粗纤维、粘稠 —— 小肠单纯梗阻。

2.5 贫血

2.5.1 缺铁性 —— 胃内低酸致使，补铁。
2.5.2 巨细胞性 —— 内因子缺乏，V-B12、叶酸、肝制剂。

2.6 营养不良一般还正常。

2.7吻合口溃疡手术失败 (胃切除不足，Zollinger-Elison syndrome)。

1999-5-8芜湖长航医院

3. Large intestinal cancer

1 Colon and rectum anatomy: The colon is 150Cm in length and can be divided into cecum, ascending colon, transverse colon, descending colon and sigmoid colon. The rectum was about 12.5Cm long, connected with the anal canal (3–4 cm) under the sigmoid colon, and the retroperitoneal fold was 7.5Cm away from the anal margin.

2 Anatomical and physiological characteristics of colon and rectum: (1) The blood supply is that the terminal artery is poorer than the small intestine; (2) The intestinal wall is thin; (3) There are many enteric bacteria’s, with high infection; (4) Absorbing water makes the feces form.

3 Once the colorectal cancer is definitely diagnosed, surgical treatment should be performed as soon as possible. Of course, comprehensive treatment should also be considered. Colorectal cancer has liver metastasis, but if the primary cancer and mesangial lymph node metastasis can still be completely removed, and the metastatic lesions touched in the liver are single, and it is not difficult to locally resect the site, the primary cancer can also be resected and the intrahepatic metastatic lesions can be resected at the same time, which can result in a long-term remission for some patients and a survival period of 5 years or more for a few patients. Cancer at the junction of straight and B accounts for 60% of all colorectal cancers.

4 Operating technical principles of radical resection of colorectal cancer: in order to prevent hematogenous dissemination and local planting of cancer cells during the operation as much as possible, the operation on cancer should be light and squeezing should be avoided; Before free cancer, the pathways of cancer cell intestinal implantation and hematogenous metastasis were blocked first.

5 Intestinal preparation before surgery: Preoperative preparation of the colon (intestine) is an important measure to reduce intraoperative pollution, prevent postoperative infection of the abdominal cavity and incision, and ensure good healing of the anastomosis. The purpose of intestinal preparation is to empty the feces in the colon without flatulence, and the number of intestinal bacteria will be reduced. Bowel preparation method: The colon is cleaned during the operation by regulating diet, taking laxative and cleaning the bowel.

Total fluid was administered three days before surgery, and Folium sennae 30g was orally administered. Fluid was infused for three times a day, 1500-2000ml per day. Or 25 grams of magnesium sulfate one day before surgery, twice a day.
Three days before surgery, metronidazole 0.5 was given orally four times per day and norfloxacin 0.2 was given four times per day.
Clean enema (soapy water) one night before operation, and clean water enema again the next morning.

6 Colonic surgery includes right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoidectomy; Rectal resection includes anterior rectal resection (Dixon’s technique), pullout resection (Bacon’s technique), abdominoperineal resection (Miles’s technique), and retrosacral approach (Klarsks’s technique).

7 Surgical procedures:

The bowel was ligated with a cloth tape, including the marginal vessels, at 10cm each from the proximal and distal sides of the margin of the cancer to block the bowel
The arteries and veins that were ready to be cut were exposed at the root of mesangium. They were ligated and cut separately. From then on, the mesangium was gradually cut to the intestinal part that was to be cut. (Digital pressure test can be performed before cutting to visually preserve intestinal blood supply)
Free the intestinal segment including cancer and resect it.
After intestinal anastomosis, the operation area was rinsed with sterile distilled water in order to destroy the exfoliated cancer cells.

8 Postoperative complications:

If the course of the disease is long and there are symptoms of incomplete obstruction, the intestinal preparation may not meet the requirements, and once the abdominal cavity is polluted during the operation, it will cause abdominal infection.
Due to intestinal wall edema and different degrees of intestinal dilatation, anastomotic leakage or anastomotic stenosis caused by large anastomotic tension is easy to occur after colorectal resection.
colorectal resection, abdominal itching, easy to cause abdominal bowel adhesion.
During the operation, it is easy to bleeding or cause accidental injury of other organs, such as ureter, duodenum, pancreas, and inferior vena cava.
Abdominal incision is large, and incision infection is easy to occur.

9 Post-operative treatment:

Pay attention to blood pressure, pulse and respiration within 48 hours after operation.
pay attention to intra-abdominal hemorrhage and wound bleeding.
Remove the catheter after 48 hours of retention after operation.
pay attention to the supplement of liquid, nutrition and electrolyte every day.
a large number of broad-spectrum antibiotics.

April 8, 2005 Li Mingjie Yu Changhang Hospital

3、大肠癌

1 结、直肠解剖:

结肠长度150Cm，可分盲肠、升结肠、横结肠、降结肠、和乙状结肠; 直肠长约12.5Cm, 上接乙状结肠下连肛管 (肛管 3-4Cm)，其腹膜反折部距肛缘7.5Cm。

2 结、直肠解剖、生理特点: (1) 血供为终末动脉较小肠差，(2) 肠壁薄，(3) 肠内细菌多，感染性高，(4) 吸收水份使粪成形。

3 结、直肠癌一旦明确诊断后应尽早地施行手术治疗，当然，还应考虑综合性治疗。

结、直肠癌虽已有肝转移，但如原发癌及系膜淋巴结转移癌尚可完全切除，而肝内触及的转移灶为单个, 且其所在部位做局部切除困难不大时，也可以切除原发癌的同时，将肝内转移灶切除，部分病人可因此而获得较长时间的缓解，少数病人尚可有5年或更长的生存期。

直、乙交界处癌占全部大肠癌的60%。

4 结、直肠癌根治术的操作技术原则: 为了尽可能防止术中癌细胞的血行播散和局部种植，对癌肿的操作要轻，避免挤压; 游离癌肿前，先阻断癌细胞肠腔内种植和血行转移的途径。

5 手术前的肠道准备:

结肠的术前准备 (肠道) 是减轻术中污染，预防术后腹腔和切口感染，以及保证吻合口良好愈合的重要措施。肠道准备的目的是使结肠内粪便排空，无胀气，肠道细菌数量随之减少。

肠道准备方法:
主要是通过调节饮食，服用泻剂及清洁肠道，达到手术时结肠“清洁”的目的。

(1) 术前三天进全流质，同时口服番泻叶30克冲服，三次/日，每天补液1500-2000ml。或术前1天服硫酸镁 25 克，二次/日。

(2) 术前三天口服灭滴灵 0.5，四次/日，加氟哌酸 0.2，四次/日。

(3) 术前一天晚上清洁灌肠 (肥皂水)，次日晨再行清水灌肠。

6 结肠手术分右半结肠切除、横结肠切除、左半结肠切除、乙状结肠切除; 直肠切除分为直肠前切除 (Dixon术式)、拉出切除 (Bacon术式)、腹会阴联合切除 (Miles术式)、经骶后入路 (Klarsks术式) 等…….

7 手术步聚:

(1) 在距癌肿缘远近侧各10cm处，将肠管包括边缘血管在内，以布带扎紧以阻断肠

(2) 在系膜根部显露准备切断的动静脉，分别结扎，切断，自此开始逐步切断系膜至拟切断的肠管部。(切断前可指压试行，以视保留肠管血运)

(3) 游离包括癌肿在内的肠段，予以切除。

(4) 肠吻合完毕后，用无菌蒸馏水冲洗手术区，以期能破坏脱落的癌细胞。

8 术后并发症:

(1) 若病程长，有不全梗阻症状，肠道准备工作可能达不到应有的要求，术中一旦腹腔受到污染后，会引起腹腔感染。

(2) 由于肠壁水肿，又有不同程度肠管扩张，结、直肠切除后，吻合易发生吻合口瘘或因吻合口张力大引起吻合口狭窄。

(3) 结、直肠切除，腹腔搔扰性大，易引起腹腔肠管的粘连。

(4) 术中易出血或引起其他脏器的误伤如输尿管、十二指肠、胰腺、下腔静脉等。

(5) 腹部切口大，易发生切口感染。

9 术后处理:

(1) 术后48小时内注意血压、脉搏、呼吸。

(2) 注意腹腔内出血和伤口出血。

(3) 术后保留导尿48小时后拔除。

(4) 每天注意液体、营养和电解质的补充。

(5) 大量应用广谱抗菌素。

April 8, 2005 李名杰于长航医院

4. Umbilical disease

1 Umbilical embryology – body pedicle: umbilical artery-lateral umbilical ligament (2); Umbilical vein-umbilical intermediate ligament (1); Vitelline canal; Urachal.

2 IgY duct deformity

2.1 Complete patent of vitelline duct — vitelline duct fistula (navel-gut fistula).

2.2 Partial patent yolk sac

2.2.1 Umbilical region — umbilical sinus

2.2.2 Middle part — yolk sac cyst

2.2.3 Bowel — Meckel diverticulum

2.3 Umbilical mucosal residue — umbilical cord (umbilical polyp)

2.4 Residues of vitelline tubule and its vascular fibrotic zona — umbilical enterozona

3 Urachal malformation

3.1 Urachal fistula-patent

3.2 Partial Closure

3.2.1 Umbilical region — urachal sinus

3.2.2 Middle part – urachal cyst

3.2.3 Bladder region-bladder diverticulum

4 Vascular malformations — persistent vitelline canal, urachal and umbilical blood vessels

5 Diseases of navel itself — umbilical hernia, omphalocele, infection, endometriosis, epithelial neoplasm, etc

4、脐部疾病 (讲稿提要)

1 脐部胚胎学 —— 体蒂: 脐动脉–脐外侧韧带(2); 脐静脉–脐中间韧带(1); 卵黄管; 脐尿管。

2卵黄管畸形

2.1 卵黄管完全未闭 —— 卵黄管瘘 (脐肠瘘)。

2.2 卵黄管部分未闭

2.2.1 脐部 —— 脐窦

2.2.2 中间部 —— 卵黄管囊肿

2.2.3 肠部 —— 麦克耳憩室 (Meckel diverticulum)

2.3 脐部粘膜残余 —— 脐茸 (脐息肉)

2.4 卵黄管及其血管纤维化索带残留 —— 脐肠索带

3脐尿管畸形

3.1 脐尿管瘘 —— 未闭

3.2 部分未闭

3.2.1 脐部 —— 脐尿管窦

3.2.2 中间部 —— 脐尿管囊肿

3.2.3 膀胱部 —— 膀胱憩室

4 血管畸形 —— 永存的卵黄管、脐尿管及脐部的血管

5 脐本身疾患 —— 脐疝、脐膨出、感染、子宫内膜异位症、上皮赘生物等

5. Congenital biliary malformations

1 Congenital biliary atresia (divided into six types)

bilioenteral drainage (50 cases +44 cases only, omitted)

2 Congenital choledochal cyst

2.1 Etiology:

2.1.1 Abnormal development of autonomic nerves in the terminal wall of common bile duct (similar to the etiology of Hirschsprung’s disease)

2.1.2 Development disorder of common bile duct itself — weak duct wall (similar to the cause of congenital primary hydronephrosis)

2.1.3 Viral infection – obstruction/weak wall – dilatation-cyst

2.2 Pathology:

2.2.1 Extrahepatic (majority): cystic dilatation of common bile duct, diverticulum

2.2.2 Intra-hepatic (Caroli’s cyst)

2.2.3 Mixed type (rare)

2.3 Symptom: three major symptoms (usually appear when the patient is three years old, but usually sees doctors later); abdominal pain 60%, lump 90%, jaundice 70%, fever 30%, pale feces, gallbladder pigment urine, intussusception perforation peritonitis and abnormal liver function.

2.4 Diagnosis: (i) three major Intermittent symptoms, (ii) ultrasonic diagnosis, (iii) abdominal X-ray or barium meal examination cholangiography. (iv) cyst puncture.

2.5 Treatment:

2.5.1 Cystectomy — Roux-Y cholangioenterostomy (difficult and with high mortality).

2.5.2 Cyst – duodenal anastomosis (easy and effective): low position, large incision (6Cm), and mucosa aligned suture.

2.5.3 Cyst – jejunal Roux-Y anastomosis.

2.5.4 External drainage of cysts (emergency transition).

2.5.5 Treatment of intrahepatic cyst: hepatectomy

3 Congenital gallbladder malformation

3.1 Abnormal number

3.1.1 Absence of gallbladder – 0.07% – predisposing to bile duct stones.

3.1.2 Double gall bladders – 0.025% of the double gall bladders are more prone to lithiasis and inflammation.

3.2 Location abnormality

3.2.1 intrahepatic gallbladder – 10% more children, with gradual emigration later on.

3.2.2 Left subtalar gallbladder

3.2.3 Right retrohepatic gallbladder

3.3 Morphological abnormalities

3.3.1 Biliary gall bladder – mediastinal membrane in the gall bladder.

3.3.2 bilobar gallbladder – bottom separation.

3.3.3 Leg sac diverticulum

3.3.4 gourd-shaped gallbladder

4 Abnormal adhesion — free gallbladder.

5 Abnormal tissue structure — ectopic tissue: pancreas and gastric mucosa.

Treatment points of radical resection of colon cancer

Training material VIII

Treatment points of radical resection of colon cancer

结肠癌一旦明确诊断后应尽早地施行手术治疗，但手术治疗是治疗原则中的一部分，还应考虑综合性治疗。横结肠癌应采取横结肠切除术，切除范围应包括肝曲和脾曲的整个横结肠，还应包括胃结肠韧带的淋巴结组，然后行升结肠和降结肠端端吻合术，倘若两端张力大而不能吻合，可切除升结肠、盲肠和回肠末段，然后作回肠与降结肠吻合术。

结肠癌虽已有肝转移，但如原发癌及系膜淋巴结转移癌尚可完全切除，而肝内触及的转移灶为单个，且其所在部位做局部切除困难不大时，也可以切除原发癌的同时，将肝内转移灶切除，部分病人可因此而获得较长时间的缓解，少数病人尚可有5年或更长的生存期。

Surgical treatment should be performed as soon as possible after a definite diagnosis of colon cancer, but surgical treatment is part of the principle of treatment and comprehensive treatment should also be considered. Transverse colon cancer shall be subjected to transverse colon resection, which shall cover the whole transverse colon of liver curve and spleen curve as well as the lymph node group of gastric-colon ligament. Then end-to-end anastomosis of ascending colon and descending colon shall be performed. In case the tension at both ends is large enough for anastomosis, the ascending colon, cecum and terminal ileum may be excised, followed by anastomosis of ileum with descending colon.

Although colon cancer has liver metastasis, for example, primary cancer and mesangial lymph node metastasis cancer can still be completely excised, and the metastatic foci touched in the liver are single, and when it is not difficult to locally resect the site, the primary cancer can also be excised and the intrahepatic metastatic foci can be excised at the same time, which can result in long-term remission for some patients, and survival time of 5 years or more for a few patients.

Principles of operation technique in radical resection of colon cancer;

prevent in the process of surgery as much as possible cancer cells hematogenous spread and local planting.
avoid extrusion during the operation of cancer with care.
before freeing the cancer, block pathways to prevent the cancer cells planting in the intestinal cavity and the blood metastasis.

Intestinal preparation before surgery:

Preparation before colectomy is an important measure to reduce intraoperative contamination, prevent postoperative infection of the abdominal cavity and incision, and ensure good healing of the anastomosis. The purpose of intestinal preparation is to empty the feces in the colon without flatulence, and the number of intestinal bacteria will be reduced.

Intestinal preparation method:

The colon is cleaned during the operation by regulating diet, taking laxative and cleaning the intestinal tract.

Three days before surgery, only liquid food is taken, at the same time take 30g oral senna, three times a day, giving 1500-2000 ml of fluid infusion every day.
Three days before surgery, patients are orally administrated with 0.5 metronidazole four times per day and 0.2 norfloxacin four times per day.
One night before operation, perform a clean enema (with soap and water), do it again the next morning with water.

Surgical procedures:

The bowel is blocked with a cloth tape, including the marginal vessels, at a distance of 10cm from each side of the tumor margin.
The arteriole and vein ready to be cut are exposed at the root of mesangium, which was then ligated and cut off respectively. From then on, the mesangium is gradually cut off to the intestinal part which is to be cut off too.
Free the bowel segment with cancer, and remove it.
After the intestinal anastomosis, rinse the operation area with sterile distilled water, in order to be able to destroy the dropped-off cancer cells.

Postoperative complications:

Due to the long course of disease and incomplete obstruction symptoms, intestinal preparation may not meet the requirements; once the abdominal cavity during the operation is polluted, it can cause abdominal infection.
Because of the intestinal wall edema, and different degrees of bowel expansion, with transverse colon resection, the colon end-to-end anastomosis is easy to incur compound mouth fistula or anastomosis stenosis caused by anastomosis tension.
Transverse colectomy leads to abdominal itching, easy to cause abdominal bowel adhesion.
Transverse colectomy is more difficult than that for right or left hemicolectomy, and it is prone to bleeding or accidental injury of other organs, such as ureter, pancreas and inferior vena cava.
abdominal incision is fairly big, prone to incision infection.

Postoperative treatment:

pay attention to blood pressure, pulse, breathing within 48 hours after surgery
pay attention to intra-abdominal hemorrhage and wound bleeding
remove the catheter after 48 hours of postoperative retention
pay attention to supplement liquid and electrolyte every day
doses of broad-spectrum antibiotics

Treatment of recurrent ulcer after subtotal gastrectomy

Training material VII

Treatment of recurrent ulcer after subtotal gastrectomy

多发性溃疡的发生机制目前尚不完全明了，但有以下几种原因可促使溃疡复发。

一、与手术有关的因素

1、输入袢过长: 约占复发性溃疡病因的3%左右，一般要求应在屈氏韧带下 6-10cm 最为合适。

2、胃切除过少: 一般认为切除过少，不能切去足够的壁细胞，因此，切除胃约在 75% 的组织实属必要。

3、胃窦粘膜存留: 复发性溃疡中有 9% 的病人有胃窦粘膜存留，如第一次手术时剩下 l cm 的胃窦粘膜都有可能发生溃疡复发。

4、由于不适当的选用 Roux-y 吻合，或空肠近袢间侧侧吻合，分流了胃肠吻合区中和酸的胰液和胆汁，增加了溃疡复发机会。

5、用不吸收的丝线缝合吻合口，轻者可致炎症，重者可能溃疡或形成吻合口糜烂。

6、手术中引起胃肠粘膜的损伤，或剪除胃肠粘膜过多。

7、碱性返流性胃炎，由于胆汁返流入胃，致胃酸分泌增加，损害胃粘膜屏障，胆盐与胆酸在胃内亦可破坏溶酶体膜，导致溃疡发生。

The mechanism of multiple ulcerations is currently not fully understood, but there are several reasons why they may recur.

factors related to surgery:

Excessive length of afferent loop: it accounts for about 3% of the causes of recurrent ulcer. The general requirement is that 6-10cm below the ligament of Treitz is the most appropriate.
Too little gastrectomy: It is generally considered that the resection is too little to remove enough parietal cells. Therefore, it is necessary to remove about 75% of the stomach tissue.
Preservation of gastric antrum mucosa: The gastric antrum mucosa is preserved in 9% of patients with recurrent ulcer. For example, the gastric antrum mucosa with the thickness of l cm left during the first operation may have ulcer recurrence.
Roux-y anastomosis or lateral jejunal anastomosis between proximal loops is inappropriately selected, which shunts the neutralized pancreatic fluid and bile in the gastrointestinal anastomosis area and increases the chance of ulcer recurrence.
The anastomosis shall be sutured with non-absorbable silk thread. In mild cases, the anastomosis may be inflamed, while in severe cases, the anastomosis may be ulcerated or eroded.
cause damage to the gastrointestinal mucosa in the operation, or cut off too much gastrointestinal mucosa.
alkaline reflux gastritis, due to bile reflux into the stomach, increase gastric acid secretion, damage the gastric mucosal barrier, bile salts and cholic acid in the stomach can also destroy the lysosomal membrane, leading to the occurrence of ulcers.

Gastric antrum G cell proliferation.
Gastric seminoma or pancreatic ulcer syndrome accounts for about 1.8% of recurrent ulcers.
Ulcer drugs, such as salicylate type, indomethacin, baotaisong, corticosteroids, reserpine, etc. may lead to ulcer recurrence.

Surgical treatment of recurrent ulceration after subtotal gastrectomy:

The recurrence of ulcer is a fundamental failure of the previous operation, so great caution should be exercised during the reoperation to avoid further failure. First of all, the diagnosis should be clear, to better understand the previous operation, carefully observe the recent x-ray barium meal film, pay special attention to whether the residual stomach is too much, followed by gastroscopy, to determine the diagnosis and the location of the lesion, and pathological diagnosis, all these are very important, and also make sure to rule out the possibility of gastric cancer.

About the principle of reoperation:

The principle of retaking the surgery is to correct the defects of the first surgery. During the surgery, we should first explore whether the stomach is left uncut too much, whether the afferent loop is too long, and whether there is gastric antrum left. We should carefully explore the pancreas to exclude pancreatic ulcer and choose different surgery methods according to different situations. For pancreatic ulcer, the surgical methods include simple tumor resection and total gastrectomy. However, in most cases, the tumor is not easy to be found due to its small size, or it is difficult to remove the multiple affected parts, so total gastrectomy is the best policy. After total gastrectomy, the tumor loses its target organ and will most likely degenerate.

Treatment of carcinoma of pancreas head and carcinoma of ampulla (DRAFT)

Training material V

Treatment of carcinoma of pancreas head and carcinoma of ampulla

首先施行胆囊切除术，在切除胆囊的同时应探查胆总管和胰腺头部的病灶大小，侵犯的范围和周围有无与大血管的粘连侵犯等情况。除此以外，还应探查腹主动脉旁淋巴结等。根据手术探查情况，决定手术术式和手术方法。

如探查胰头癌己有广泛转移而无法切除时，可考虑施行胆总管空肠 Roux-y 吻合术，从而解除病人的黄疸问题，减少病人的痛苦和延长病人的生存期，如胆总管已有癌肿侵犯，胆囊又无法保留，则应给予肝总管切开置入T型管引流术。如术中证实无远处转移，病灶尚可活动，应考虑施行胰十二指肠切除术，但应根据以下情况进行选择。

凡诊断为壶腹部周围癌，临床上又无手术禁忌症时，均应力争一期手术切除。如病人长期有严重的黄疸，周身情况不佳，不能耐受一期手术时，可行二期切除手术。但二期手术可能由于腹腔粘连或癌肿转移固定，给手术带来困难。

术前准备:

1、黄疸病人因肝功能受到一定损害，凝血机制往往不佳，术前注射 GS、Vc、Vk1 和辅酶Q10等改善肝功能和凝血机能，促进出、凝血时间恢复正常，以免术中、术后出血，如有重度黄疸或合并胆道感染高烧者，应分期手术，即第一次开腹探查行胆囊造瘘术，或胆总管切开T型管引流术，待2-3周后黄疸消退，再行根治性切除手术。

2、老年体弱、贫血和低量白血症的病人，应适当输新鲜血，有助于凝血机制的改善, 口服胰酶类助消化药物。配血400ml x 3以备术中应用。

3、为了预防和治疗胆道感染，注射广谱抗菌素等。

4、术前一天给予配血 400mmlx3，以备术中应用。

5、术前应邀请麻醉科会诊，请麻醉科医师根据病人的具体情况选择麻醉的种类和方法。

6、术前应与病人家属说明病情及手术的必要性，以及手术中、术后可能出现的各种并发症，甚至发生死亡的可能，取得完全同意后并以签字为凭，方可考虑手术。

7、术前静滴20% Albumin 50 ml。

关于胰十二指肠切除手术步骤问题：

胰十二指肠切除手术步骤比较复杂，手术难度也较大，术中、术后并发症也较多，但可归纳为以下几个程序。

第一，进入腹腔后首先是探查有无远处转移和肿瘤局部的移动性，以及癌肿的原发灶是否来自胰头。

第二，如癌肿原发灶來自胰头，应进行试行分离，最后确定癌肿是否能被切除，同时还需进一步检查癌灶和腔静脉、腹主动脉、门静脉、肠系膜上静脉之间有无实质性浸润，以便最后确定肿瘤能否被切除，如确定癌肿能够根治切除时，便开始切断肝总管、胃、胰腺和空肠。

第三，切除病灶，最后切断钩状突，病变切除之。

第四，重建消化道，按胰、胆、胃或胆、胰、胃的顺序和空肠之间各别吻合。

胰十二指肠切除术式有以下几种，供手术时选择釆用：whipple 法 Child法 Cattel 法。

胰十二脂肠切除术的注意事项：

1、决定能否做胰十二指肠切除术的关键问题有二：（1）胰头后面与腔静脉、腹主动脉之间有无癌肿浸润现象。（2）胰腺后面与门静脉和肠系膜上静脉之间有无癌肿浸润。若其中之一有癌肿浸润时，则不适应做胰十二指肠切除术。

2、处理胰头、体与肠系膜上静脉之间小静脉时，应先结扎后切断，以免出血，如一旦出血，应立即以手指压住出血点，和肠系膜上静脉的上下两端，吸尽血液，看清损伤部位，准确钳夹止血，切勿盲目钳夹造成损伤。

3、胃的切除范围，一般在1/3-1/2不等。

4、胰瘘是胰十二指肠切除术后最危险的并发症，其发生率很高（20%-30%左右），一旦发生，往往有生命危险，必须加强预防措施，减少此一并发症的发生。

术后处理：

1、术后如血压平稳，可取半卧位。

2、腹腔引流管接计量瓶，记录24小时引流量，并观察其性状，如无其他特殊情况发生，一般在术后5-7天拔除引流管。

3、禁食, 持续胃肠减压，静滴 5% GS 和补充电解质、Vc、VB、Vk1 等，一般持续 4-5天，，待肠鸣音恢复后，拔除胃管开始进流质饮食。

4、广谱抗菌素的应用。

5、为了促进创口早期愈合，术后间隔补充血浆或全血，或 20% Albumin 50 ml。

6、注意口腔护理，鼓励病人作有效的咳嗽，并协助病人不断排痰，以防止合并胸膜炎和肺内感染或肺不张等并发症。

7、术后一周内要严密观察有无腹膜炎发生，如有腹膜炎发生，应及时给予引流

First of all, cholecystectomy should be performed. At the same time of cholecystectomy, the size, extent and periphery of lesions in common bile duct and pancreatic head should be explored, as well as whether there is adhesion invasion with large blood vessels. In addition, the para-aortic lymph nodes should also be explored. According to the surgical exploration, decide the surgical operation and surgical method.

If extensive metastasis of carcinoma in the head of pancreas cannot be resected during exploration, Roux-y choledochojejunal anastomosis can be considered, in order to relieve the patient’s jaundice, reduce the patient’s pain and prolong the patient’s survival time. If there is invasion of common bile duct carcinoma and the gallbladder cannot be preserved, T-tube drainage through incision of common hepatic duct should be performed. If it is confirmed during surgery that there is no distant metastasis and the lesion is still mobile, pancreaticoduodenectomy should be considered, but the choice should be made according to the following circumstances.

All patients diagnosed with periampullary cancer and without clinical contraindication to surgery, should strive to a surgical resection. If the patient has severe jaundice for a long time and has poor general condition and cannot tolerate the primary operation, the secondary resection can be performed. However, the second-stage operation may be difficult due to abdominal adhesion or cancer metastasis fixation.

Preoperative preparation:

Patients with jaundice suffer from certain damage to liver function and often suffer from poor clotting mechanism. Pre-operative injection of GS, Vc, Vk1 and coenzyme Q10 can improve liver function and clotting function, promote bleeding and restore clotting time to normal so as to avoid intraoperative and postoperative bleeding. In case of severe jaundice or patients with concurrent biliary tract infection and high fever, staged operation should be performed, i.e., the first laparotomy and fistulization of gallbladder or T-tube drainage of common bile duct incision. After the jaundice disappears two to three weeks, radical resection should be performed.
the elderly, weak, anemia and low volume of patients with hyperlipidemia, should be appropriate to lose new blood, help to improve the clotting mechanism, oral trypsin digestive drugs. Blood matching 400ml x 3 for intraoperative application.
in order to prevent and treat biliary tract infection, injection of broad-spectrum antibiotics, etc.
one day before surgery with blood 400mmlx3, for intraoperative application.
preoperative anesthesia department consultation should be invited, please anesthesiologists according to the specific situation of the patient to choose the types and methods of anesthesia.
preoperative should explain the condition with the patient’s family and the necessity of surgery, and surgery, postoperative complications may occur, and even the possibility of death, after obtaining full consent and with signature, can consider surgery.
Intravenous 20% Albumin 50 ml is given before operation.

Problem about surgical procedures of pancreaticoduodenectomy:

Pancreaticoduodenectomy is a complicated procedure with great surgical difficulty and many intraoperative and postoperative complications, but it can be summarized into the following procedures.

First, after entering the abdominal cavity, we first need to explore whether there is distant metastasis and local mobility of the tumor, and whether the primary tumor of cancer comes from the head of pancreas.

Second, if the primary tumor of cancer comes from the head of pancreas, we should try to separate it and finally determine whether the cancer can be removed. At the same time, we need to further check whether there is any substantial infiltration between the cancer and vena cava, abdominal aorta, portal vein and superior mesenteric vein, so as to finally determine whether the tumor can be removed. If it is determined that the cancer can be completely removed, we will start to cut off the common hepatic duct, stomach, pancreas and jejunum.

Third, resection of the lesion, and finally cut off the uncinate process, the lesion resection.

Fourthly, the digestive tract is reconstructed by anastomosis between pancreas, gallbladder, stomach or gallbladder, pancreas, stomach and jejunum in that order. There are several types of pancreaticoduodenectomy, and the whipple method, Child method and Cattel method are optional for operation.

Precautions of pancreaticoduodenectomy:

Two key issues determine whether or not pancreatoduodenectomy can be performed: (i) Whether there is cancer infiltration between the posterior part of pancreatic head and vena cava and abdominal aorta. (ii) There is no cancer infiltration between the back of pancreas and portal vein and superior mesenteric vein. Pancreaticoduodenectomy is not appropriate if one of them has invasion.
processing of pancreatic head, small vein between the body and superior mesenteric vein, should be cut off after ligation, in order to avoid bleeding, such as once bleeding, should immediately with finger pressure bleeding point, and the upper and lower ends of the superior mesenteric vein, absorb blood, see the damage location, accurate clamping hemostasis, do not blind clamp damage.
the scope of gastric resection, generally in 1/3-1/2.
Pancreatic fistula is the most dangerous complication after pancreaticoduodenectomy. Its incidence is very high (about 20%-30%). Once it occurs, it is often life-threatening. Preventive measures must be strengthened to reduce the occurrence of this complication.

Postoperative treatment:

such as stable blood pressure after surgery, desirable half a lie.
The abdominal drainage tube was connected with a metering bottle, and the 24-hour drainage volume was recorded and observed. If no other special circumstances occurred, the drainage tube was generally removed 5-7 days after surgery.
Fasting, continuous gastrointestinal decompression, intravenous drip of 5% GS and supplement of electrolytes, Vc, VB, and Vk1, etc., generally for 4 to 5 days. After the borborygmus recovers, the gastric tube is removed and the fluid diet is started.
the application of broad-spectrum antibiotics.
To promote early wound healing, plasma or whole blood, or 20% Albumin 50 ml was added at intervals after surgery.
pay attention to oral care, encourage patients to make effective cough, and to assist patients with continuous expectoration, in order to prevent combined pleurisy and pulmonary infection or atelectasis and other complications.
within a week after surgery to closely observe the presence of peritonitis, if there is any peritonitis, should be given timely drainage.

术后开发症：

1、胰瘘，多发生在术后5-7天，病人出现腹痛、腹胀、高烧、巩膜黄染和引流量增多现象，应考虑为胰瘘的发生。胰瘘发生后一般采取保守治疗，但必须给于支持疗法。

2、内出血。腹腔出血偶有发生，可给予止血剂的应用、输血等治疗，如有活动性出血，经保守治疗无效时，应给予再次手术止血。

3、腹腔内感染。腹腔内感染也是一种严重的并发症，一旦发生，应首先采取保守治疗。如有脓肿形成，应给予及时的手术引流，除应给予抗菌素治疗外还应给于输血，或血浆，或 20% Albumin。

4、胆瘘，很少发生，一旦发生，应充分地进行引流和体外营养液的补充。

Postoperative development:

Pancreatic fistula occurs more than 5 to 7 days after operation. The patient suffers from abdominal pain, abdominal distension, high fever, scleral yellowing and increased drainage volume. The occurrence of pancreatic fistula should be considered. Conservative treatment is usually adopted after the occurrence of pancreatic fistula, but supportive therapy must be given.
Internal bleeding. Abdominal bleeding occurs occasionally, and can be treated with hemostasis, blood transfusion, etc. If there is active bleeding, and the conservative treatment is ineffective, reoperation shall be performed to stop bleeding.
Intra-abdominal infection. Intra-abdominal infection is also a serious complication that should be treated conservatively first. If an abscess is formed, prompt surgical drainage should be given and, in addition to antibiotic therapy, blood transfusion or plasma, or 20% Albumin.
biliary fistula, rarely occurs, once occurs, should be fully drainage and supplement of nutrient solution in vitro.

Treatment of cardiac cancer

Training material VI

Treatment of cardiac cancer

胃癌在临床上一旦确诊，应考虑尽快地施行手术治疗，但术后还应结合病人的实际情况，采取综合性治疗如化疗、中医中药治疗、免疫治疗等。

胃体癌、胃底癌、贲门癌或全胃癌的癌肿应施行全胃切除术，在临床上根据手术切除的彻底性分为根治性全胃切除术及姑息性全胃切除术。另外根据是否同时切除其他脏器，又可分为单纯性胃切除术和联合脏器切除术两种。全胃切除术的切除范围通常包括全胃，十二指肠球部食管下端的一部分、大网膜、小网膜及胃脾韧带，并在根部结扎，切断胃的所属血管，以清除胃周围转移淋巴结，这就是单纯性全胃切除术。有时脾门及胰腺上缘有转移的淋巴结，需同时将脾及胰尾切除，也有时癌侵及了横结肠或肝左叶，需将部分横结肠或肝左叶一并切除，这就是联合切除术。

是否需作全胃切除术，术前有时难以决定，往往需在剖腹后，根据病变部位，癌肿扩散程度及机体状况等方面来判断。其原因是，凡用胃大部分切除术不能根治，而只有切除全胃才能根治的胃癌才考虑全胃切除术。要慎重选择全胃切除术的适应症，尽量少采用姑息性全胃切除术，尤其是姑息性联合切除术，以免带来不良后果。

手术原则是: 操作时应从周边向中心进行，并在根部结扎，切断胃的所属血管，切断端距癌瘤边缘要有一定的安全距离 (一般在5cm)，操作中用纱布包裹肿瘤井保护腹腔，以做到清除胃周围转移淋巴结，并防止癌细胞扩散。

全胃切除术消化道重建有以下几种方法 (略)。

术后井发症;

1、吻合口瘘：是全胃切除术后最重要并发症，多在术后 5-7 天，即开始进食时出现，如体温上升，脉搏增快，烦躁不安并有腹痛及恶心等症状时，应想到吻合口瘘的可能。一旦确诊应行腹腔引流，同时作空肠造瘘补给营养，加大抗菌素应用。

2、膈下感染: 由于创伤大，腹腔有时受到污染后而出现感染，一般在术后一周后有持续体温升高，血象高，有呃逆现象，往往通过X线摄片或 BUS 检查而定诊断。

3、腹泻：多发生在老年病人，常为消化不良性稀便，病人很快消瘦，主要是由于老年病人消化能力减低，加之全胃切除以后，消化与吸收的机能更加减退，食物刺激小肠使其蠕动增强所致。

4、反流性食管炎: 是一个晚期并发症，主要表现为胸骨后烧灼样疼痛、呃逆、向口腔反流苦水，给予稀盐酸合剂，症状可缓解。

5、营养障碍：主要表现为逐步消瘦及贫血，全胃切除后食物不能充分与胆汁、胰液混合，而且迅速进入空肠，影响消化与吸收。

6、吻合口狭窄: 主要是在吻合时，吻合口内翻过多所致，或因疤痕收缩而引起，或因吻合口过小等均可发生。一旦发生后，可行扩张术或再次手术。

Once gastric cancer is clinically diagnosed, surgical treatment should be considered as soon as possible, but combined with the actual situation of patients after surgery, comprehensive treatments such as chemotherapy, traditional Chinese medicine treatment, immune treatment, etc. should be taken.

Total gastrectomy should be performed for cancers of gastric body cancer, gastric fundus cancer, cardiac cancer or whole gastric cancer. According to the completeness of surgical resection, total gastrectomy is divided into radical gastrectomy and palliative total gastrectomy clinically. In addition, according to whether other organs are resected at the same time, the disease can be divided into simple gastrectomy and combined organ resection. Total gastrectomy usually covers the whole stomach, part of the lower esophagus of the duodenal bulb, the greater omentum, the lesser omentum, and the gastric and splenic ligaments, and ligation is performed at the root to cut off the blood vessels belonging to the stomach in order to remove the metastatic lymph nodes around the stomach. This is pure total gastrectomy.

Sometimes there are metastatic lymph nodes at the splenic hilus and superior margin of pancreas, and the spleen and pancreatic tail need to be removed at the same time. Sometimes the cancer invades the transverse colon or left lobe of liver, and part of the transverse colon or left lobe of liver needs to be removed together. This is called combined resection. Whether total gastrectomy is required is sometimes difficult to determine preoperatively, and often depends on the site of the lesion, the extent of tumor spread, and the body condition after laparotomy. The reason for this is that total gastrectomy is considered for gastric cancer which cannot be cured by most gastrectomy, but only by resection of the whole stomach. The indications of total gastrectomy should be carefully selected, and palliative total gastrectomy, especially palliative combined gastrectomy, should be avoided as much as possible to avoid adverse consequences.

The principle of surgery:

the operation should be performed from the periphery to the center, and ligation should be performed at the root. The blood vessel of the stomach should be cut off, and the cut end should be a certain safe distance (generally 5cm) from the edge of the tumor. The abdominal cavity should be protected by wrapping the tumor well with gauze during the operation, so as to clear the metastatic lymph nodes around the stomach and prevent the spread of cancer cells. There are several methods for digestive tract reconstruction after total gastrectomy (omitted).

Postoperative diseases:

Anastomotic fistula: It is the most important complication after total gastrectomy. It usually occurs 5 to 7 days after surgery, when food is eaten. For example, when the body temperature rises, the pulse increases, the patient is agitated, and there are symptoms such as abdominal pain and nausea, the possibility of anastomotic fistula should be considered. Once diagnosed, abdominal drainage should be performed, together with jejunostomy for nutritional supplement and increased application of antibiotics.
Hypophragmatic infection: Due to large trauma, the abdominal cavity is sometimes infected due to contamination. Generally, the patient has a continuous increase in body temperature, high hemogram, and hiccup after one week after surgery, which is often diagnosed through X-ray film or BUS examination.
Diarrhea: It mostly occurs in the elderly patients, often causing indigestion and loose stool. The patients soon lose weight, mainly due to the reduced digestive ability of the elderly patients. In addition, after the total gastrectomy, the digestive and absorption functions are further reduced, and food stimulates the small intestine to enhance its peristalsis.
Reflux esophagitis: It is a late complication mainly manifested as post-sternal burning-like pain, hiccup, and bitter water regurgitating into the mouth. The symptoms can be relieved after administration of dilute hydrochloric acid mixture.
Nutrition disorder: It is mainly characterized by progressive emaciation and anemia. After total gastrectomy, food cannot be fully mixed with bile and pancreatic juice, and quickly enters the jejunum, thus affecting digestion and absorption.
Anastomotic stenosis: It is mainly caused by excessive turnover in the anastomosis during anastomosis, or caused by scar contraction, or due to excessively small anastomosis. Once it has occurred, dilatation or reoperation may be performed.

Indications of splenectomy and effects on body after splenectomy (DRAFT)

Training material IV

Indications of splenectomy
and effects on body after splenectomy

一、脾切除术指征

(一) 血液病

血液病与脾外科的关系甚为密切，1887年 Spencer 首先为遗传性球形细胞增多症作脾切除术。从此为外科脾切除治疗血液病揭开了新的一页。但对血液病患者进行选择性脾切除或急症脾切除术、以及术前准备、手术时机等，与一般疾病所行脾切除不同，有其特殊性。

1、遗传性球形红细胞增多症 (Hereditary Spherocytosis, HS) 又称家族性溶血性贫血或先天性溶血性黄疸。本病属常染色体显性遗传。凡是确诊HS者临床有贫血与脾大，都应行脾切除治疗。Williams、Schwartz 等均指出，确诊为HS后即使轻型患者，都是脾切除指征，脾切除作为HS的主要治疗方法，并有显著疗效，已被国内外学者公认。由于幼儿手术后易发生感染，故在4岁以下儿童不宜施行脾切除。

2、遗传性椭圆形红细胞增多症 (Hereditary Elliptocytosis, HE) 亦属常染色体显性遗传疾病，临床上无任何症状者可不予治疗，如有贫血、脾大与溶血性黄疸的重型病例，应行脾切除治疗。

3、地中海贫血为遗传性血红蛋白合成障碍性疾病，脾切除对减轻溶血和减少输血量有帮助。脾切除对 α 型地中海贫血有较好疗效，HbE-β 型则差，中科院血研所对29例 α 地中海贫血患者行脾切除术，术后 Hb 明显升高，但术前Hb在 80g/L 以上者，术后 Hb 上升不显，提出因 Hb 在 80g/L 以下者适合手术治疗。同时对11例 β 型地中海贫血患者行脾切除术，其疗效均不如α型。α型地中海贫血脾切除手术指征: (1) 年龄在3岁以上; (2) Hb 在 80g/L 以下; (3) 脾亢伴全血细胞减少; (4) 51Cr 红细胞寿命缩短，脾肝比值 >2，脾定位指数增高者。

4、自体免疫性溶血性贫血 (Autoimmune Hemolytic Anemia, AHA) 是一种后天获得性溶血性贫血，系机体免疫功能紊乱，而产生了能破坏自身正常的红细胞的抗体所致。？？？原理主要是去除了产生破坏自身红细胞或血小板抗体的主要场所，故温抗体型原发性 AHA 适合于脾切除治疗，而冷抗体型 AIHA 的溶血主要发生在血循环或肝脏中，故不适合脾切除治疗。脾切除指征: (1) 药物治疗无效或长期用药，停药后复发者；(2) 合并血小板减少的 Evans 综合症，皮质激素等治疗效果不满意者; (3) 51Cr 同位素体表测定，红细胞主要在脾脏潴留破坏者；(4) 单纯 IgG 型 Coombs 试验阳性脾切除效果佳。国内外报道脾切除疗效一般在 60% 左右。

5. 原发性血小板减少性紫癜 (Idiopathic Thrombocytopenic Purpura, ITP)
本病的发生与自体免疫有关，血小板上均吸附有免疫球蛋白 G，这种带有免疫球蛋白的血小板在胆及肝内被巨噬细胞提前破坏，破坏的部位 2/3 病人在脾。故而多数病例脾切除后血小板计数可迅速上升，关于 ITP 脾切除的疗效报道甚多，有效率在 80% 左右，对于急性 ITP 患者是否行急症脾切除术，意见不甚一致。一般认为，急性 ITP 患者用强的松、大剂量静脉输注丙种球蛋白等无效，出血危及生命时，可进行紧急脾切除术; 慢性 ITP 患者的脾切除指征: (1) 在病程达6个月以上，经用激素或免疫抑制等治疗而未缓解者; (2) 血小板计数低于 25×103/L，有颅内出血或其他脏器大出血者: (3) 激素或免疫抑制剂等药物治疗效果不佳或长期需用较大剂量激素维持者；(4) 对激素或免疫抑制剂应用有禁忌者；(5) 51Cr 标准检查血小板主要在脾脏？？破坏者。

6. 慢性再生障碍性贫血 (Chronic Aplastic Anemia, CCA) Mitchell指出对 CCA 选择性脾切除是有益的，可以减轻溶血，延长血小板寿命和减少输血。CAA 选择脾切除手术指征: (1) 骨髓增生较好，红系偏高，合并溶血而内科治疗无效者；51Cr 测定红细胞或/和血小板寿命缩短，脾脏破坏为主的。中科院血研所对28例 CAA 患者行脾切除治疗，有效率为 65.2%。

7. 慢性粒细胞性白血病 (Chronic Myeloid Leukemid, CML) 70年代，一些学者认为急变细胞在脾脏较多，脾切除可以防止 CML 急性变。但近年来研究，脾切除不能防止 CML 急变，也无何益处。目前对 CML 患者除非巨脾引起机械压追症状、脾亢，龙其是伴有血小板减少者，一般不再主张脾切除术，因为脾切除并不能延长生存或延缓急变的发生。

8. 毛细胞性白血病 (Hairy Cell, HCL) 当伴有脾肿大和脾功能亢进时，是外科脾切除指征。Jansen 认为在以下情况，手术效果较好：(1) 脾在肋缘大于等于4cm; (2) 脾在助缘下 1-3cm，但 Hb<85g/L 或 Hb85-120g/L, pt≤50×109/L; (3 ) 脾摸不到，但Hb<85g/L，pt≤50×109/L.

9. 戈谢病 (Gaucher 病) 多见于幼儿，属常染色体隐性遗传。Mitchell 指出伴脾肿大，脾功亢进是脾切除指征，但脾切除对此病仅是一种对症治疗，可以缓解由于脾功能亢进引起的全血细胞减少等症状，并非能解决先天性家族性类脂代谢的紊乱。

10. 骨髓纤维化症 (Myelofibrasis, MF) 原发性MF的脾切除指征为: (1) 疼痛性脾肿大；(2) 巨脾引起机械性压追症状; (3) 脾功能亢进全血细胞明显减少和难以控制的溶血; (4) 需经常输血或用皮质激素治疗，骨髓涂片尚见部分造血灶，特别是年轻病人。Benbasat 收集了英、法、德文中 321 例 MF 患者脾切除资料，约 64% 患者手术有治标作用，输血量减少，出血倾向和腹痛减轻。但病人于术后可出现代偿性肝肿大，对于合并活动性肝病和 pt 计数偏高者，不适宜脾切除术。

11. 何杰金氏病 (Hodgkin’s Disease, HD) 某些脾脏受累伴脾亢者可以行脾切除术。Mitchell 提出临床分期 IA、IB 和 A 的病例可考虑脾切除或作为剖腹探查的一部分手术，剖腹探查进行肝脏和淋巴结活检并切除脾脏，可以查明腹腔淋巴结受累程度及病变累及范围，便于提出针对性的治疗方案; 同时脾切除还可使患者发热、乏力等全身症状获得缓解，并可解决脾亢和增强对放疗或化疗的耐受性。

T his is the traditional viewpoint of spleen cutting which has lasted for two to three hundred years: “The spleen is not necessary for life. The spleen can be removed at will.” With the development of modern medicine, as well as the in-depth exploration and research on the function of the spleen, it has been gradually found that the spleen has non-negligible immune functions such as anti-infection and anti-cancer. Therefore, selective and effective splenectomy has become a trend of the times. However, to systematically understand the general view of spleen function and the adverse effects on the body after splenectomy, and to correctly grasp the indications of splenectomy are the key to ensure the quality of splenic surgery.

“脾脏并非生命所必需，脾可以随便切除。” 这便是历时二、三百年的传统切脾观点。随着现代医学的发展，以及对脾脏功能深入探索和研究，已陆续发现脾脏具有不可忽视的抗感染、抗癌等免疫功能。因此，选择性有效保脾手术已成为一种时代的倾向。但系统地了解脾脏功能的全貌及去脾后对机体有哪些不利的影响，正确地掌握脾切除的指征，这便是保证脾外科质量的关键之关键。

A, splenectomy indications

(1) Hematopathy

Hematological diseases are closely related to splenic surgery. In 1887, Spencer first performed splenectomy for hereditary spherocytosis. A new page was opened for surgical splenectomy to treat hematological diseases. However, selective splenectomy or emergency splenectomy for patients with hematological diseases, as well as preoperative preparation and operation timing, are different from splenectomy for general diseases and have their own particularities.

Hereditary Spherocytosis, HS) is also known as familial hemolytic anemia or congenital hemolytic jaundice. The disease is autosomal dominant. Splenectomy should be performed for all patients diagnosed with HS who have anemia and splenomegaly in clinic. Williams and Schwartz et al. pointed out that even mild patients after the diagnosis of HS were indications of splenectomy. Splenectomy as the main treatment of HS, with significant efficacy, has been recognized by scholars both in China and abroad. Splenectomy is not recommended for children under 4 years of age due to the susceptibility of infants to infection after surgery.
Hereditary elliptic erythrocytosis (HE) is also an autosomal dominant disease, and it can be treated without any clinical symptoms. In case of severe anemia, splenomegaly and hemolytic jaundice, splenectomy should be performed.
thalassemia for hereditary hemoglobin synthesis disorder, splenectomy to reduce hemolysis and reduce the amount of blood transfusion. Splenectomy had good curative effect on α thalassemia, while HbE-β type was worse. The Institute of Blood Research of Chinese Academy of Sciences performed splenectomy on 29 patients with α thalassemia. The Hb post-surgery increased significantly. However, for the patients with Hb above 80g/L before surgery, the Hb post-surgery did not increase significantly. It was proposed that the patients with Hb below 80g/L were suitable for surgical treatment. At the same time, splenectomy was performed on 11 patients with β -thalassemia, and the curative effects were not as good as those of α-thalassemia. Indications of splenectomy for α -thalassemia: (1) Aged over 3 years old; (2) Hb is below 80g/L; (3) Hyperactivity of spleen with pancytopenia; (4) 51Cr shortened red blood cell life, spleen-liver ratio > 2, and increased spleen positioning index.
Autoimmune Hemolytic Anemia, AHA) is an acquired hemolytic anemia caused by the production of antibodies against red blood cells that can destroy the body’s normal function due to the body’s immune dysfunction. ? ? ? The principle is to remove the main place where the antibodies that destroy your red blood cells or platelets are produced. Therefore, warm antibody type primary AHA is suitable for splenectomy, while cold antibody type AIHA hemolysis occurs mainly in the blood circulation or liver, so it is not suitable for splenectomy. Indications of splenectomy: (1) patients who failed to respond to medication or took medication for a long time, and relapsed after drug discontinuation; (2) Patients with Evans syndrome complicated with thrombocytopenia, and patients with unsatisfactory therapeutic effects such as corticosteroids; (3) 51Cr isotope body surface measurement shows that red blood cells are mainly in the spleen retention destroyer; (4) Splenectomy with positive IgG-type Coombs test was effective. It has been reported in China and abroad that the curative effect of splenectomy is generally about 60%.
Idiopathic thrombocytopenic purpura (ITP) The occurrence of this disease is related to autoimmune. Immunoglobulin G is adsorbed on the platelets. The platelets with immunoglobulin G are damaged in advance by macrophages in the gallbladder and liver. The damage site is 2/3 in the spleen. Therefore, in most cases, the platelet count can rise rapidly after splenectomy. There are many reports on the efficacy of splenectomy for ITP, with the effective rate of about 80%. There are different opinions on whether to perform emergency splenectomy for patients with acute ITP. It is generally considered that prednisone and high-dose intravenous immunoglobulin are ineffective for patients with acute ITP, and emergency splenectomy can be performed when bleeding is life-threatening. Indications for splenectomy in patients with chronic ITP: (1) those who have been treated with hormones or immunosuppression for more than six months without remission; (2) Patients with platelet count less than 25×103/L and intracranial hemorrhage or massive hemorrhage of other organs: (3) patients who had unsatisfactory therapeutic effects of drugs such as hormones or immunosuppressants, or who needed to maintain a large dose of hormones for a long time; (4) the hormone or immunosuppressive agent application taboo; (5) Platelet detected by 51Cr standard is mainly in spleen? ? Saboteurs.
Chronic aplastic anemia (CCA) Mitchell pointed out that selective splenectomy for CCA was beneficial to reduce hemolysis, prolong platelet life and reduce blood transfusion. Indications for splenectomy for CAA: (1) patients with good bone marrow hyperplasia, high erythroid, and hemolysis, for which medical treatment was ineffective; 51Cr determination of red blood cells and/or platelets life expectancy, spleen damage. The Institute of Hematology of the Chinese Academy of Sciences performed splenectomy on 28 patients with CAA, and the effective rate was 65.2%.
Chronic myeloid leukemia (CML) In the 1970s, some scholars believed that there were more acute transformation cells in the spleen, and splenectomy could prevent acute transformation of CML. However, it has been proved in recent years that splenectomy cannot prevent CML from sudden change and is of no benefit. At present, for patients with CML unless the massive spleen causes symptoms of mechanical chase and hypersplenism, and the massive spleen is accompanied by thrombocytopenia, splenectomy is generally no longer advocated because splenectomy cannot prolong survival or delay the occurrence of sudden changes.
Hairy cell leukemia (HCl) is an indication for surgical splenectomy when accompanied by splenomegaly and hypersplenism. Jansen believed that the surgery had better effects under the following conditions: (1) The spleen was larger than or equal to 4cm at the costal margin; (2) The spleen is 1–3 cm below the synergic edge, but Hb<85g/L or HB85–120 g/L, Pt ≤ 50 × 109/L; (3) The spleen was not palpable, but Hb<85g/L, Pt ≤ 50 × 109/L.
Gaucher disease occurs more frequently in young children and is autosomal recessive. Mitchell pointed out that with splenomegaly, hypersplenism was the indication for splenectomy, but splenectomy was only a symptomatic treatment for the disease, which could alleviate the symptoms such as pancytopenia caused by hypersplenism, rather than solve the congenital disorder of familial lipid metabolism.
Myelofibrasis, MF) The indications of splenectomy for primary MF are as follows: (1) Painful splenomegaly; (2) Giant spleen causes mechanical chase after symptoms; (3) The pancytopenia of hypersplenism and uncontrolled hemolysis; (4) Regular blood transfusion or corticosteroid treatment is needed, and partial hematopoietic foci are still observed on bone marrow smear, especially for young patients. Benbasat collected 321 cases of MF patients with splenectomy data in English, French and German, about 64% of the patients have palliative effect, reduce the amount of blood transfusion, bleeding tendency and abdominal pain. However, the patient may develop compensated hepatomegaly postoperatively, and splenectomy is not appropriate for patients with combined active liver disease and high pt counts.
Hodgkin’s Disease, HD): splenectomy can be performed for some patients with splenic involvement and hypersplenism. Mitchell proposed that for cases with clinical stages IA, IB and A, splenectomy or surgery as part of laparotomy could be considered, and laparotomy with liver and lymph node biopsy and splenectomy could be performed to identify the extent of abdominal lymph node involvement and the lesion involvement, so that targeted treatment could be proposed. At the same time, splenectomy can also relieve the patients’ systemic symptoms such as fever and fatigue, solve the hypersplenism and enhance the tolerance to radiotherapy or chemotherapy.

(二) 脾功能亢进

主要由于肝硬变导致门静脉高压而引起充血性脾肿大，巨脾在血吸虫性肝硬变时尤为多见。周围血细胞减少是由于脾红髓增生时其正常滤过及储存功能呈病理性亢进时所致。脾切除可使周围血液恢复正常。我国大量晚期血吸虫病人行脾切除后 4-5 年的随访结果，生车率达94%。对肝炎后肝硬化或所谓的班替氏病患者的巨脾应根据脾功能亢进程度，静脉曲张有无及全身情况慎重考虑单纯脾切除或与其它分流及断流手术合用，若患者因任何原因造成显著脾肿大有压迫症状或有脾梗塞、脾破裂之危险者也可考虑脾切除。

B. hypersplenism

Congestive splenomegaly is mainly caused by portal hypertension due to cirrhosis, and splenomegaly is particularly common in schistosomal cirrhosis. The decrease in peripheral blood cells is due to the pathological hyperfunction of the normal filtration and storage functions of the splenic red pulp when it proliferates. Splenectomy can normalize the surrounding blood. According to the 4–5 year follow-up results of a large number of people with advanced schistosomiasis in China after splenectomy, the car-bearing rate has reached 94%. Splenectomy alone or in combination with other shunting and devascularization procedures should be carefully considered in patients with post-hepatitis cirrhosis or so-called Banteay’s disease whose massive spleen is in accordance with the degree of hypersplenism, the presence of varicose veins and the general condition. Splenectomy may also be considered in cases where the patient suffers from any cause of marked splenomegaly with symptoms of compression or a risk of splenic infarction or splenic rupture.

(三) 脾破裂

脾切除曾一直是治疗损伤的唯一治疗方法。但自1952年 King 报告了儿童脾切除术后发生爆发性感染 (Overwhelming postspleenectomy infection, OPSI) 引起了人们对脾切除术的重新认识。随着对脾脏生理功能研究的深入，各种脾手术兴起，诸如脾修补术、脾部分切除术等，这些手术保留了脾脏功能，但需要一定的技术水平、经验及术后严密观察。总的原则是抢救生命第一、保留脾脏第二，即在保证生命安全的前提下，尽可能保留脾脏或保存 (或保存一部分) 脾功能，既不要不管损伤程度如何，一律采用切脾治疗，又切忌不顾病人安危而强行保脾治疗。必须根据病情及本医院技术力量，制定适合于自己的单位的切脾适应证，切忌千篇一律，以保证疗效。一般来说，全切除术的适应证：(1) IV 度破裂伤，全脾破裂或广泛性脾实质破裂，脾脏血供完全中断；(2) 有威胁生命的多发伤；(3) 病情重、血压不稳定；(4) 脾缝合术不能有效的止血。

C. Spleen rupture

Splenectomy has always been the only treatment for injury. However, the outbreak of fulminant infection (OPSI) after splenectomy in children reported by King in 1952 has aroused new understanding of splenectomy. With the deepening of research on the physiological function of the spleen, various splenic operations have arisen, such as splenic repair and partial splenectomy, which preserve the spleen function but require a certain technical level, experience and close observation after surgery. The general principle is to save life first and preserve the spleen second, that is, on the premise of ensuring the safety of life, to preserve the spleen or preserve (or preserve part of) the spleen function as much as possible. The spleen cutting treatment should be adopted regardless of the degree of injury, and the spleen conservation treatment should not be forced regardless of the safety of the patient. According to the condition and the technical strength of our hospital, an indication suitable for spleen resection in our unit must be formulated, and no one in common is required to ensure the curative effect. In general, the indications of total resection: (1) Degree IV rupture injury, whole spleen rupture or extensive splenic parenchyma rupture, and complete interruption of splenic blood supply; (2) There are multiple life-threatening injuries; (3) Severe illness and unstable blood pressure; (4) Spleen suture cannot effectively stop bleeding.

二、脾切除术后对机体的影响

(一) 免疫功能低下

脾脏是一个重要的免疫器官，脾脏对机体提供的免疫保护作用是终生的，对婴幼儿和儿童尤其显得重要。脾脏有如一个滤器对侵入血流中的颗粒抗原如细菌首先可发挥机械清除及滤过作用。脾脏还可以产生具有强大调理作用的IgM，经过调理的抗原才易被脾内外吞噬细胞所吞噬。脾脏产生的 Tuftsin，能有效促进多形核细胞吞噬。实验证明半脾切除之后，脾清除能力下降 25%，脾动脉结扎后下降 50%，脾切除后脾清除作用消失。

脾切除后最主要的并发症是由免疫功能低下引起的感染，因为: (1) 脾脏是制造 IgM 的重要场所，感染后首先是 IgM 的增高 (初级免疫反应)。IgM的半衰期只有5天，脾切后 IgM 很快下降，故可发生对感染的免疫应答功能低下；(2) 丧失了脾的“滤器”功能; (3) 不能制造吞噬作用激素，备解素及非特异性调理素，吞噬细胞的吞噬及清除细菌的功能明显减退。据统计外伤而切除脾脏的病人出现凶险的脾切除术后感染 (OPSI) 的危险是正常人群的50倍。因特发性血小板减少症，后天性溶血性贫血，何杰金氏病和其他血液病而施行脾切除者，其出现 OPSI 的危险性更大。

II. Effects on body after splenectomy

(a) low immune function

The spleen is an important immune organ. The immune protection provided by the spleen is lifetime, especially important for infants and children. The spleen acts as a filter for the mechanical clearance and filtration of particulate antigens such as bacteria that invade the bloodstream. The spleen can also produce IgM with a strong conditioning effect, and the conditioned antigen is easily swallowed by the phagocytes inside and outside of the spleen. Tuftsin produced by the spleen can effectively promote the phagocytosis of polymorphonuclear cells. Experiments showed that after hemisplenectomy, the splenic clearance decreased by 25%, and that after splenic artery ligation it decreased by 50%. The splenic clearance disappeared after splenectomy. The most important complication after splenectomy is infection caused by low immune function because: (1) The spleen is an important place for the production of IgM, and the first complication after infection is the increase of IgM (primary immune response). IgM has a half-life of only five days, and it decreases rapidly after splenectomy, so a low immune response to infection may occur. (2) Loss of the “filter” function of the spleen; (3) Can’t produce phagocytic hormone, properdin and non-specific opsonin; the phagocytosis of phagocytes and the function of removing bacteria are decreased obviously. The risk of a dangerous post-splenectomy infection (OPSI) is calculated to be 50 times higher in patients with traumatic splenectomy than in the normal population. Splenectomy for idiopathic thrombocytopenia, acquired hemolytic anemia, Hodgkin’s disease, and other hematological disorders is associated with a greater risk of developing OPSI.

(二) 血液流变学改变

脾切除后由于细胞碎片，Howell-Jolly小体，Heinz 小体及其他代谢产物无法清除，红细胞内粘度升高，红细胞变形能力降低，因而脾切除术后血液粘度升高。脾切除对血小板的影响包括数量的增加和聚集性的增强。脾切除后约13%的病人血小板可超过100万，持续数月甚至数年，造成血小板增多症。血液和血浆粘度升高，加之血小板数量增加和功能增强，使机体处于一种高凝状态，这是术后血栓和栓塞发生的基础。有报道脾切除后死于闭塞性血管疾病和缺血性心脏病的比例增高，如迁移性血栓性静脉炎，深静脉血栓形成，冠心病等。

任何手术创伤都可导致血液流变学改变，但一般手术后的改变主要在术后近期，而远期大多恢复至术前水平。脾切除术后的上述改变则是持续的，因此对脾切除术后血液流变学指标和血小板聚集性明显增强者，以及血小板数量大于 400×109/l 者要采取预防措施，对原有心、脑血管疾病者更应引起重视。

(b) The changes of blood rheology

After splenectomy, the blood viscosity increased due to the inability to remove cell debris, the Howell-Jolly bodies, the Heinz bodies, and other metabolites, as well as the increased intracellular viscosity of erythrocytes and the decreased deformability of erythrocytes. Effects of splenectomy on platelets include an increase in number and aggregation. In about 13% of patients after splenectomy, platelets can exceed 1 million and last for months or even years, causing thrombocytosis. The increased viscosity of blood and plasma, together with the increased number and function of platelets, places the body in a hypercoagulable state, which is the basis for postoperative thrombosis and embolism. It has been reported that the proportion of patients who die from occlusive vascular disease and ischemic heart disease after splenectomy is increased, such as migratory thrombophlebitis, deep vein thrombosis, and coronary heart disease.

Any surgical trauma can lead to hemorheological changes, but generally the changes after surgery are mainly in the short term after surgery, and most of them return to the preoperative level in the long term. The above changes after splenectomy are persistent, so preventive measures should be taken for patients with significantly enhanced blood rheology indexes and platelet aggregation after splenectomy, and for patients with platelet number greater than 400×109/l, and more attention should be paid to patients with original cardiovascular and cerebrovascular diseases.

三、脾切除术后并发症

脾切除术虽为一中等手术，但并发症却相当多，也有很高的死亡率，根据 Thaeton 统计一家医院 2417 例脾切除总的并发症为 39%，住院死亡率为 10%，危险性相当于或高于全胃切除术。脾切除术后合并发症可根据发生时间的不同分为早期合并症及晚期合井症。

III. Complications after splenectomy Splenectomy is a medium-sized operation, but it has many complications and a high mortality rate. According to Thaeton, the total complication rate of 2417 cases of splenectomy in a hospital is 39%, and the mortality rate in hospital is 10%. The risk is equal to or higher than that of total gastrectomy. The combined complications after splenectomy can be divided into early complications and late complications according to the time of occurrence.

(一) 早期合井症

1、出血术中及术后数内最常见的严重合并症是出血，由于脾上极与胃底距离很近，胃短血管处理不当断端出血是常见的。又如胰尾有时延伸直达脾门，因顾忌伤及胰腺，脾蒂缝扎不牢，或处理脾蒂伤及脾静脉可造成难以控制的出血，门脉高压症尤其是血吸虫性巨脾，周围粘连重且有大量侧支循环，切除脾后膈面及后腹膜常有大量出血和渗血，如止血不完善，不彻底常于术后井发出血。

2、膈下积液、膈下脓肿脾床止血不彻底，导致小量积血，或有淋巴液积聚等原因继发细菌感染而成，胃底损伤可导致胃漏，膈下积液及脓肿，胰尾损伤可导致胰漏、脓肿、胰腺囊肿及胰腺炎。

3、血小板计数过高少数脾切除后可发生严重血小板增高，甚至达 1000×109/L 以上，这种情况多为一过性。

4、左侧胸腔积液及肺炎常见于巨脾尤其是伴有门静脉高压，隔下广泛静脉侧支形成及淋巴管扩张者，因局部创伤，低蛋白血症，术后长期卧床，呼吸运动锻炼不足者。

5、脾热问题脾切除患者术后常出现较长时间发热，短者2周左右，长者可达数月之久。抗生素治疗效果不佳，可笼统称为脾热，其实不同患者的脾热应该有其具体原因，除局部感染外，切脾后免疫功能低下，及脾静脉血栓形成也是常见原因。当然有部分的病例查不出原因，且应用抗生素效果不明显，而经一时期后体温慢恢复正常，人们称之为“不明原因”发热。

(1) Early commingling of wells

The most common serious complication of hemorrhage during and after operation is hemorrhage. Due to the close distance between the superior pole of the spleen and the fundus of the stomach, it is common to have terminal hemorrhage due to improper treatment of short gastric vessels. For another example, the tail of pancreas sometimes extends as far as the splenic hilus. For fear of hurting pancreas, the pedicle of spleen cannot be firmly sutured, or uncontrolled bleeding can be caused by treating the injury of splenic pedicle and splenic vein. Portal hypertension, especially schistosomiasis splenomegaly, has severe peripheral adhesion and a large number of collateral circulation. The resection of the posterior diaphragmatic surface and retroperitoneum of the spleen often results in massive bleeding and bleeding. For example, if the hemostasis is not perfect, the bleeding will not be completely released in the postoperative well.
The hemostasis of the spleen bed for subphrenic effusion and subphrenic abscess is not complete, resulting in a small amount of blood accumulation, or secondary bacterial infection caused by lymph accumulation. Gastric fundus injury can lead to gastric leakage, subphrenic effusion and abscess, and pancreatic tail injury can lead to pancreatic leakage, abscess, pancreatic cyst and pancreatitis.
Platelet count is excessively high. A few patients may suffer from severe thrombocytosis after splenectomy, even reaching more than 1000 × 109/L. This condition is mostly transient.
Left pleural effusion and pneumonia are common in splenomegaly, especially in patients with portal hypertension, extensive collateral formation of inferior septal veins and lymphangiectasia. Due to local trauma, hypoproteinemia, the patients stay in bed for a long time after operation and have insufficient respiratory exercise.

(二) 晚期井发症

1、血栓栓塞性并发症少数病人切除后发生迁移性血栓性静脉炎或严重的深静脉血栓形成及血栓栓塞后井发症，特别是溶血性贫血及骨髓增生异常的病人脾切除后容易发生危险的血小板计数过度上升，必须密切监视病人必要时尽早采用抗凝剂或抗血小板积聚药物治疗。

2、副脾问题据国内外报道，14-30% 的切脾手术患者有副脾，全脾切除后，如遗留副脾在体内，可以完全取代脾脏的功能，甚至原来的溶血或血小板减少症等疾病的复发或疗效不佳，当再次手术切除副脾后症状便可消失。

3、脾切除术后暴发性感染 (OPSD) 早在1919后 Morris 已指出脾切除后可增加感染的局感性，并对滥行脾切除提出警告，但当时未被其他学者所重视，直到 1952 年 King 报告100例儿童球状血球性贫血脾切除后5例发生严重败血症、2例死亡，才引起人们的注意，并命名为“脾切除后暴发性感染（OPSD）”，也有人们称为“脾切除后败血症”。OPSI 的发病年率是 1.45%, 为正常情况感染死亡的 200 倍，OPSI 可发生在切脾后几周至几年之间，而发生越早，死亡率越高，但多发生在切脾后两年内，而且在儿童及患血液病患者中发病幸则更高。

(2) Late onset of well logging

thromboembolic complications occurred in a small number of patients after resection of migratory thrombophlebitis or severe deep vein thrombosis and thromboembolism after well hair disease, especially hemolytic anemia and myelodysplastic patients after splenectomy is prone to dangerous platelet count excessive rise, must closely monitor the patient as soon as possible when necessary using anticoagulant or antiplatelet accumulation drug treatment.
The accessory spleen problem According to the reports in China and abroad, 14-30% of patients undergoing splenectomy have an accessory spleen. After total splenectomy, if the accessory spleen is left in the body, it can completely replace the function of the spleen. Even the original hemolysis, thrombocytopenia and other diseases recur or the curative effect is poor, and the symptoms can disappear after the accessory spleen is resected again.
Post-splenectomy fulminant infection (OPSD) As early as after 1919, Morris pointed out that splenectomy could increase the local sensitivity of infection and warned against indiscriminate splenectomy, but it was not noticed by other scholars at that time. It was not until 1952, when King reported that five of the 100 cases of children with globocytic anemia developed severe septicemia and two died after splenectomy, which was called “OPSD”, or “septicemia after splenectomy”. The annual incidence rate of OPSI is 1.45%, which is 200 times of the death caused by normal infection. OPSI can occur in weeks to years after splenectomy. The earlier it occurs, the higher the death rate will be. However, it mostly occurs within two years after splenectomy, and the incidence rate is even higher in children and patients with hematological diseases.

Surgical treatment of thyroid cancer

Training material III

Surgical treatment of thyroid cancer

甲状腺癌在病理方面可简单地分为三类:

1、乳头状腺癌: 在临床上最常见，恶性程度较轻，主要是转移至颈部淋巴结。

2、腺泡状腺癌: 恶性程度中等度，主要经血运转移，至骨和肺部。

3、未分化的单纯癌: 恶性程度甚高，极早转移至颈部淋巴结，也可经血运转移至骨和肺部，预后较差。

甲状腺癌在临床方面，手术处理的疗效是符合于病理分类的:

1、在乳头状腺癌，如果切除原发患的同时，将颈部淋巴结仔细、彻底地加以清除，五年治愈率可达90%以上。

2、在腺泡状腺癌，如果颈部淋巴结已有转移，大多已有远处转移，因此即使彻底清除了颈部淋巴结，也不能增高手术疗效。

3、未分化的单纯癌，发展甚快，一般在发病后2-3个月即出现压迫症状 (疼痛、声嘶，呼吸困难) 或远处转移，强行手术切除，不但无益，而且可加速癌细胞经血运的扩散，因此如果怀疑为恶性甚高的单纯癌，可先行穿刺作活组织检查证实之，治疗则以放射为主。

手术切除乳头状腺癌或腺泡状腺癌，一般在气管内麻醉下进行，操作步骤与甲状腺部分切除相同，但要注意以下几个问题:

1、切口要宽大，胸锁乳突肌前缘要剪开，显露就好。

2、不可损破内层被膜，当然也不宜应用丝线穿扎腺体作牵拉用，以防止癌细胞种植在切口中。

3、不保留腺体背面部分，而切除全部腺体，但应尽量保留甲状旁腺，也应尽量不损伤喉返神经，如果癌肿局限在一叶的腺体内，可将患叶的腺体连同甲状腺峡部全部切除之，如果癌肿已侵及左右两叶，就需将两叶腺体连同甲状腺峡全部切除之，但至少应保留一侧的甲状旁腺，不使术后发生严重的手足抽搐，甲状腺内层被膜的完整与否 (被癌组织穿破与否)，对原发癌的能否完全切除，具有决定性的意义。

在切除原发癌肿后，接着就应仔细、彻底地清除患侧的颈部淋巴结。

1、清除颈外侧部的淋巴结组织。

2、颈总动脉和颈内静脉深面的淋巴结，

3、再清除气管前，甲状腺峡部以上的淋巴结。

4、然后再清除甲状腺后气管旁，喉返神经周围的以及上纵隔内的淋巴结，同时切除胸锁乳突肌和其他重要组织 (一侧的颈内静脉和颈总动脉等) 是无需的，并不能增高手术疗效。

如果已有远处转移，对局部可以全部切除的腺癌不但应将患叶的腺体全部切除，患侧的颈部部淋巴结加以清除，同时还应切除健叶的全部腺体，这样一方面可防止由于原发癌的发展、增大而发生压迫性症状，另方面可试用放射碘 131 来治疗远处转移。腺癌的远处转移只能在切除整个甲状腺后，才能撮取放射性碘，如果远处转移，撮取放射性碘量极低微，则在切除整个甲状腺后，由于垂体前叶促状腺激素的分泌增多，反而促使远处转移迅速发展，对这种试用放射性碘无效的病例，应早期给予足够量的甲状腺制剂，以抑制促甲状腺素的产生，远处转移可因此而缩小，至少不再继续发展，手术中可能要施行气管切开以保持呼吸道通畅。

Thyroid cancer in pathology can be simply divided into three categories:

Papillary adenocarcinoma: It is the most common adenocarcinoma in clinic, with mild malignancy, mainly involving metastasis to the cervical lymph nodes.
Alveolar adenocarcinoma: The malignancy is moderate, and it is mainly transferred through blood supply to bone and lung.
undifferentiated simple carcinoma: the malignancy is very high, and it metastasizes to the cervical lymph nodes very early, or it can metastasize to the bone and lung through blood supply, with poor prognosis.

Clinically, the efficacy of surgical treatment of thyroid cancer is in line with the pathological classification:

in the papillary adenocarcinoma, if the resection of the primary disease at the same time, the neck lymph nodes carefully and thoroughly removed, five years the cure rate can reach more than 90%.
n acinar adenocarcinoma, if the cervical lymph nodes have metastasized, most of them have distant metastasis. Therefore, even if the cervical lymph nodes are completely removed, the surgical efficacy cannot be improved.
undifferentiated pure cancer, development is very fast, generally in 2 to 3 months after the onset of the compression symptoms (pain, hoarseness, dyspnea) or distant metastasis, forced surgical resection, not only useless, and can accelerate the spread of cancer cells through the blood supply, so if it is suspected to be very high malignant pure cancer, can first puncture for biopsy confirmed, treatment is given priority to with radiation.

Surgical resection of papillary adenocarcinoma or acinar adenocarcinoma, generally under endotracheal anesthesia, the operation steps are the same as partial thyroidectomy, but should pay attention to the following questions:

incision to wide, sternocleidomastoid muscle leading edge to cut open, show.
do not damage to break the inner capsule, of course, also should not use silk thread wear tie gland for pulling, in order to prevent cancer cells planted in the incision.
The back part of the gland is not preserved, and all the glands are excised. The parathyroid should be preserved as much as possible, and the recurrent laryngeal nerve should not be damaged as much as possible. If the cancer is confined to one lobe of the gland, all the glands in the lobe together with the thyroid isthmus can be excised. If the cancer has invaded the left and right lobes, the two lobe glands together with the thyroid isthmus should be excised completely. However, at least one side of the parathyroid should be preserved, so that no severe convulsion of hands and feet occurs after the operation. Whether the inner capsule of the thyroid is intact or not (worn out by the cancer tissue) is of decisive significance for the complete resection of primary cancer.

After resection of the primary cancer, careful and thorough removal of the cervical lymph nodes on the affected side should follow.

remove the lateral cervical lymph node tissue.
the common carotid artery and internal jugular vein deep lymph nodes,
before the removal of trachea, thyroid isthmus above the lymph nodes.
After that, the paratracheal lymph nodes around the recurrent laryngeal nerve and the lymph nodes in the upper mediastinum should be removed. Meanwhile, the sternocleidomastoid muscle and other important tissues (internal jugular vein and common carotid artery on one side) should be removed. This is unnecessary and cannot increase the curative effect of the operation.

If there is distant metastasis, the local adenocarcinoma can be completely removed not only should be the gland of the diseased leaves all resection, the affected side of the neck lymph nodes to be removed, at the same time should also remove all the glands of the healthy leaves, so on the one hand can prevent due to the development of primary cancer, increase and oppressive symptoms, on the other hand can try radiation iodine 131 to treat distant metastasis. Distant metastasis of adenocarcinoma can only take radioactive iodine after the whole thyroid gland is resected. If the distant metastasis takes radioactive iodine with extremely low amount, then after the whole thyroid gland is resected, the distant metastasis will develop rapidly because of the secretion increase of thyroid-stimulating hormone in anterior pituitary gland. In the case that radioactive iodine is ineffective for trial use, thyroid preparations with sufficient amount should be given early to inhibit the production of thyrotropin. The distant metastasis can shrink because of this, and at least it will not continue to develop. Tracheotomy may be performed during the operation to keep respiratory tract unobstructed.

Extrahepatic biliary injuries

Training material II

Extrahepatic biliary injuries

The vast majority of extrahepatic biliary injuries are iatrogenic, and they have been increasing in recent years, with an incidence rate at about 2–3% (1 out of 300–500 gallbladder surgeries). Of the iatrogenic bile duct injuries, 90% are found in cholecystectomy, 5% in common bile duct exploration, 3% in subtotal gastrectomy, and 2% in duodenal diverticulum resection. In the operation of portacaval shunt and pancreas, if the biliary tract injury is not detected and treated in time during the operation, the consequences are often very serious, which must arouse the surgeon’s high attention.

1. Factors causing iatrogenic bile duct injury

1.1 Anatomical factors: There are many anatomical variations of biliary tract, and ignorance of them is likely to cause biliary tract injury.

The cystic duct is too short, or even the neck of the gallbladder is directly connected with the common bile duct, these are likely to lead to the procedure error in mistaking the common bile duct as the cystic duct during ligation.
The cystic duct is too long and it runs parallel to the common bile duct. Tightly clinging to the common bile duct, it flows downward into the common bile duct in the rear of duodenum or head of pancreas. It is easy to cause accidental injury to the common bile duct when separating the cystic duct.
When the cystic duct opens from the right hepatic duct or the right hepatic duct flows into the cystic duct, the right hepatic duct is liable to be injured by mistake if the situation is not identified well.
If the cystic duct is not in the normal position and passes around behind or before the common hepatic duct by 180 and 360 degrees, flowing into the common hepatic duct while both the cystic duct and he common hepatic duct are in the same connective tissue capsule, it is prone to inflammatory adhesion. In such situations, the common hepatic duct may be easily injured by mistake when attempting to separate them by force.
When the pathway of gallbladder artery or right hepatic artery is abnormal, hemorrhage occurs due to injury during operation. Common hepatic duct and common bile duct can be injureddue to clamping or suture hemostasis in a hurry.

1.2 Pathological factors

Acute inflammation, congestion, edema and adhesion lead to unclear local anatomical relationships, fragile tissue, easy damage can be caused by pulling, clamping and separation during the surgery.
When chronic inflammation occurs repeatedly, scar adhesion can cause bile duct shift (scar contraction and traction). If the operator fails to pay attention, forced separation will easily cause biliary tract injury.

1.3 improper operation technology and errors:

The incision is too small, resulting in poor exposure, organ traction and bile duct shift.
When the gallbladder is removed, excessive traction result in damages to the common hepatic duct or common bile duct wall.
If there is bleeding from the gallbladder artery or right hepatic artery during the operation, blindly clamping or sewing causes damages.
Local inflammatory scar adhesion, with unclear anatomical relationships, forcibly separating at hepatic hilus or Calot trigone can cause injury.
Exploration of biliary tract or stone removal with excessive force can cause laceration of hepatic duct or lower segment of common bile duct, or a puncture in bile duct wall.
The posterior wall of common bile duct is accidentally injured when the common bile duct is cut open.
With ulcer of corpus callosum in duodenal bulb, scar contraction, shortening of the interval between pylorus and common bile duct, forced separation during subtotal gastrectomy is likely to cause common bile duct damage.
Many vascular forceps are reserved deep and not removed with timely ligation, the injury is caused easily by “touching” or “bumping” with the vascular forceps.。

1.4 Attention required to the cultivation of surgeons’ skills:

Accidental injury follows the lack of strong sense of responsibility, carelessness, and failure to conduct meticulous dissection to identify the relationship between the cystic duct and common hepatic duct while removing the cyst.
Over-pursuing speed, blind separation, and massive ligation are all possible causes for the injury.
In case of accidents during operation, the operator is not self-possessed and operates blindly in panic.

2 Clinical manifestations

Some cases of bile duct injury are found during the operation and treated in time, but most cases are only definitely diagnosed after the operation when the following symptoms and signs start to appear.

2.1. Abdominal pain: pain in the right upper abdomen spreading to the whole abdomen, with peritoneal irritation. Distending pain in liver area, increased internal pressure of bile duct with ligated bile duct.

2.2. Jaundice: complete ligation of bile ducts and aggravation of jaundice in the early stage. Partial ligation of bile duct, with stricture of bile duct causes mild jaundice or no jaundice temporarily. Bile duct injury or stenosis is often followed by bile duct infection and jaundice.

2.3. External biliary fistula: when the abdominal drainage tube is placed, a large amount of bile may flow out.

2.4. Cold and fever: common manifestations of biliary peritonitis or secondary cholangitis, leading to shock in severe cases.

2.5. Laboratory tests: white blood cells increase and neutrophils increase. Serum bilirubin and alkaline phosphatase may increase.

3. Diagnosis:

3.1. During the operation: The diagnosis rate during the operation accounts for 15–20% of all diagnoses according to the statistics. When seeing bile on the operation wound (seeable when using clean gauze to wipe the wound) or observing liquid leakage in bile duct flushing, the operator needs to carefully check for a clear diagnosis, with timely treatment. Intra-operative cholangiography may assist in the definitive diagnosis in those difficult cases (situations like bile duct rupture, broken end or bile duct sutured).

3.2. In postoperative hospitalization: the diagnosis is not difficult according to the typical clinical manifestations.

3.3. After discharge from hospital: it refers to partial ligation with injury of common bile duct. Usually there are no obvious symptoms in the near future after operation. The wound heals in one stage. There are no signs of biliary peritonitis because the bile duct injury is non-open. Jaundice does not occur either because there is no obstruction of the biliary lumen. However, several months or even years later, due to the injury, stenosis, infection, and cicatricial stenosis, the bile duct gradually becomes thinner, and the biliary flow is no longer smooth, repeated episodes of biliary tract infection appear. This is easily misdiagnosed as “residual stones” in clinical practice, and the definitive diagnosis is indeed difficult. Percutaneous transhepatic cholangiography is an important means to assist examination.

4. Treatment

Once the diagnosis is established, it should be actively treated.

4.1. Timely treatment when injury is found during the operation. When found within 24 hours after the operation, perform emergency surgical treatment when the organization is still healthy, with no serious infection, edema, adhesion. More specifically:

In cases where the injury is small in scope, and there is no or little tension in the anastomosis, transverse suture should be performed with the distal T-tube supporting drainage. The tube should be kept for no less than three months after operation.
In cases with transverse injury (on common bile duct), with local inflammation insignificant, without tension after anastomosis (including Kocher incision and loosening duodenum), end-to-end anastomosis can be performed, with a T-tube placed at the distal end to support draining the wound. The tube shall be placed for 3–6 months after operation.
In cases with numerous common bile duct injuries (especially with injuries larger than 2cm), with high tension after anastomosis, treatment is a challenge, with high risk of failure. Ligation of common bile duct at the distal end and internal biliary-intestinal drainage at the proximal end (Roux-y technique) can be performed to save the case.

4.2. If bile duct injury is found recently after operation, we should try our best to operate within 7–10 days. The operation can be expected to be successful within 7 days after operation. After more than 10 days, local congestion, edema, fragile tissue, adhesion, unclear anatomy, difficult operation, and low success rate, we should first external biliary drainage, and then operate after the inflammation subsides for 3–6 months.

2. 术后近期发现胆管损伤，宜力争在 7-10 天内手术，术后7天内手术可望获得成功。在10天以上，局部充血、水肿，组织脆弱、粘连，解剖不清，操作难度大，成功率低，宜先行胆道外引流，待炎症消退 3-6 个月后再手术。

3. 术后后期诊断胆管损伤性狭窄，也应争取早期手术。因反复发作胆管炎，肝功能损害，继发胆汁性肝硬化，门静脉高压死于上消化道出血或肝昏迷，故应创造条件，争取尽早修复重建。

● 胆肠内引流，肝外胆管较长且扩张，行胆肠 Roux-y 吻合。

● 高位胆管狭窄，肝外胆管较短已无吻合余地，则可行左肝内肝管空肠 Roux-y 吻合术，但应明确左右肝管汇合通畅方可施行。

“Y”吻合旷置肠段在 40-60cm 左右，基本上可无逆行胆道感染发生。

4.3. Early operation should be carried out for the diagnosis of bile duct injury stenosis in the late stage after operation. Because of repeated attack of cholangitis, liver damage, secondary biliary cirrhosis, portal hypertension died of upper gastrointestinal bleeding or hepatic coma, so we should create conditions for early repair and reconstruction. (i) Choledocho-intestinal drainage, long and dilated extrahepatic bile ducts, and choledocho-intestinal Roux-y anastomosis was performed. (ii) If the high bile duct is narrow and the extrahepatic bile duct is short and there is no room for anastomosis, Roux-y left intrahepatic hepatic hepatic jejunal anastomosis may be performed, but it should be clear that the left and right hepatic ducts are confluent and unobstructed before implementation. The size of the “Y” anastomosed open bowel segment is about 40–60 cm, and basically no retrograde biliary tract infection occurs.

1. 适当的切口，良好的麻醉, 肌肉松驰，暴露良好，必要时延长切口或果断改硬膜外阻滞为全麻。

2. 术中应仔细辨认胆囊动脉、胆囊管、肝总管、胆总管的行径和关系，因肝外胆道变异较多，一切组织在未弄清鲜剖关系之前，切勿盲目钳夹、结扎、切断。

3. 争取顺行切除胆囊，但若炎症、水肿、严重粘连、Calot 三角解剖困难，不应强行分离，应改行从胆囊底部开始剥离的逆行法切除胆囊。若仍困难，不得己时则可行胆囊大部切除术，同样可达到切除胆囊之目的。

4. 在两针牵引线间切开胆总管探查时，二针缝线距离不宜过大，以免后壁一同被牵拉，切开时尖刀系“切割开”胆总管前壁而非“刺入”前壁，以免造成后壁损伤。

5. 胃大部切除术，若遇胼胝性十二指肠球部溃疡，由于炎性粘连、疤痕收缩，解剖关系改变，胆总管–幽门间距离缩短，在幽门上方分离时慎防损伤胆总管，在估计困难时应果断改行溃疡旷置 Bancroft 术，可避免误伤胆总管。

6. 术中遇胆囊动脉出血，应采用左手食指置 Winslow 孔内。左拇指在前压迫肝十二指肠韧带，吸净出血后，松开压力观察出血处进行止血，切忌盲目钳夹，缝扎，导致误伤。

7. 探查胆总管下端或左右肝管，(探查，取石) 用力不宜过大，动作不应粗暴，以免造成胆管或括约肌撕裂基至形成戳穿胆管壁造成假道。

8. 熟悉胆道解剖变异，术中时时警惕医源性胆道损伤的可能性，认真、细致操作，摒弃医源性胆道损伤的因素，预防胆管损伤的发生。认织胆管损伤的表现，及时正确处理，使胆管损伤给病人带来的危害降到最低限度，普外科医师在胆囊手术上失误还是比较多的，开好一个胆囊不难，一辈子工作中做好每一个胆囊亦非易事! 同行们，愿我们共同努力。

5. Prevention

Prevention is more important than treatment.

5.1. The appropriate incision, good anesthesia, muscle relaxation, good exposure, when necessary to extend the incision or decisive change epidural block for general anesthesia.

5.2. During the operation, the behaviors and relationships of gallbladder artery, cystic duct, common hepatic duct and common bile duct should be carefully identified. Due to more variation of extrahepatic biliary ducts, all tissues should not be clamped, ligated and cut off blindly before the fresh section relationship is clarified.

5.3. For anterograde cholecystectomy, but if the inflammation, edema, severe adhesion, difficult to dissect the Calot triangle, should not be forced to separate, should be diverted from the bottom of the gallbladder stripping retrograde cholecystectomy. If it is still difficult and inappropriate, subtotal cholecystectomy can be performed, which can also achieve the purpose of gallbladder resection.

5.4. When cutting the common bile duct between the two traction wires for exploration, the distance between the two stitches should not be too large, so as to avoid the posterior wall being pulled together. When cutting, the sharp knife “cuts” the anterior wall of common bile duct rather than “pierces” the anterior wall, so as to avoid the damage to the posterior wall.

5.5. For subtotal gastrectomy, in case of callosal duodenal bulbar ulcer, due to inflammatory adhesion, scar contraction, and changes in anatomical relationship, the distance between common bile duct and pylorus is shortened, so we should be careful to prevent damage to common bile duct when separating above pylorus. When estimation is difficult, we should resolutely switch to ulcer exclusion Bancroft technique to avoid accidental damage to common bile duct.

5.6. In case of gallbladder artery bleeding during the operation, the left index finger should be used to place the Winslow foramen. The left thumb was used to compress the hepatoduodenal ligament in the anterior direction, and after the hemorrhage was sucked out, the pressure was released to observe the bleeding site for hemostasis. It is forbidden to clamp and sew blindly, resulting in accidental injury.

5.7. Explore the lower end of the common bile duct or left and right hepatic duct, (exploration, stone) force should not be too big, the action should not be rough, so as not to cause bile duct or sphincter tear base to form puncture bile duct wall cause false way.

5.8. Be familiar with the anatomical variation of biliary tract, intraoperative always alert to the possibility of iatrogenic bile duct injury, careful and meticulous operation, abandon the factors of iatrogenic bile duct injury, prevent the occurrence of bile duct injury. Recognize weave bile duct damage performance, timely and correct treatment, make bile duct damage to the patient’s harm to a minimum, general surgeons mistakes in gallbladder surgery or more, open a gallbladder is not difficult, a lifetime work to do a good job in every gall bladder is not easy! Colleagues, may we make joint efforts.

New concept of modern surgical blood transfusion

Training material I

New concept of modern surgical blood transfusion

Clinical significance of blood transfusion:

Improve hemodynamics, increase the oxygen content, and maintain the oxidation process;
Supplement plasma protein to maintain osmotic pressure and blood volume;
Increase nutrition to improve the body biochemical function;
Correct the clotting mechanism, to prevent bleeding;
As it contains a variety of antibodies, the body’s ability to resist disease can be improved.

Disadvantage of traditional blood transfusion method:

Whole blood is infused regardless of the blood component the patient needs. For example, whole blood is transfused to control hemorrhage (due to coagulation factor deficiency or thrombocytopenia) or control infection (due to granulocyte deficiency), but the whole blood contains limited coagulation factors, platelets or white blood cells, so it is difficult to achieve the expected goal by transfusion of whole blood. Unless a large amount of whole blood is used, the transfusion of large amount of whole blood can increase blood volume and heart burden, and even cause death due to heart failure, pulmonary edema, and severe cases. In addition, infusion of certain undesired components resulted in adverse reactions.

传统输血方法弊端:

不管患者需要什么血液成分都输注全血。如: 为了控制出血 (因凝血因子缺乏或血小板减少) 或控制感染 (因粒细胞缺乏) 等而输注全血，但全血中所含凝血因子、血小板或白细胞数量有限，输注全血很难达到预期目标，除非用大量全血，而输用大量全血可增加血容量，增加心脏负担，甚至心力衰竭、肺水肿、严重者造成死亡。此外，某些不需要的成分输注后导致不良反应。

The concept of modern blood transfusion: The broad definition includes not only the transfusion of whole blood, various blood cell components and their derivatives, plasma and plasma protein products, but also the transfusion of various blood-related components produced by modern biological technology, such as various hematopoietic factors and plasma protein components produced by DNA recombination technology, and various blood substitutes. The concept of modern blood transfusion also extends from input to removal, that is, the removal of extra or pathologically changed blood cells or other blood components from a patient, such as therapeutic apheresis and plasma exchange.

现代输血的概念:

其广义的定义，已不仅是全血、多种血细胞成分及其衍生物、血浆和血浆蛋白制品的输注，也包括以现代生物技术生产的各种与血液相关的成分，如: 以DNA重组技术生产的种种造血因子和血浆蛋白成分，以及各种血液代用品的输注。现代输血的概念，还从输入延伸到去除，即去除患者血液中多余的或发生病理变化的血细胞或其他血液成分，如治疗性血细胞单采术和血浆置换术等。

I. Component blood:

transfusion Whole blood refers to blood collected into containers containing anticoagulants or preservative solutions and obtained without any processing. In the world, 450ml whole blood is generally considered as a unit, while 200ml whole blood is considered as a unit in China.

Whole blood infusion has the following disadvantages:

The preservative solution prescription of whole blood preservation is only designed to preserve red blood cells, so as long as the blood is extracted, the function of some components begins to be lost.
Because only albumin in red blood cells and plasma is preserved in whole blood, other components such as platelets, white blood cells, the main coagulation factors in plasma and complement have rapidly or gradually failed. Therefore, its therapeutic effect can only temporarily supplement red blood cells and blood volume to prevent hemorrhagic shock.
Even if blood is transfused immediately after blood collection, it is impossible to exert the functions inherent to several main components in whole blood because these components do not reach an effective dose in the allowed amount of blood transfusion.
The sterility of whole blood is guaranteed by the aseptic operation of the blood collection process (including the storage and preparation of blood sampler and blood transfusion device). Practice has proved that “sterile”, it is impossible to reach 100%; Blood products, which can be heated and treated with organic solvents or surface decontaminants by means of microporous membrane filtration techniques, are characteristically “sterile”, and component blood transfusions have been developed to overcome these shortcomings.

一、成分输血

全血即血液采入含有抗凝剂或保存液的容器中，不作任何加工，即为全血。国际上一般以450ml全血为1单位，我国将200ml全血定为1个单位。

全血输注具有如下缺点: (1) 保存全血的保存液处方仅是为保存红细胞而设计的，因此只要血液一经采出，其中某些成分的功能即开始损失。(2) 因为全血中所保存的只是红细胞和血浆中的白蛋白，其他成分如血小板、白细胞、血浆中的主要凝血因子和补体等均已迅速或逐渐失效。故其治疗效果，只能暂时补充红细胞和血容量，防止失血性休克。(3) 即便采血后立即输血，也不可能发挥全血中几个主要成分固有的功能，因为在许可的输血量中这些成分达不到一个有效剂量。(4) 全血的无菌性是靠采血过程 (包括采血器、输血器的储备和准备) 的无菌操作来保证的。实践证明，“无菌”，不可能达到100%；而血液制品 (可借助微孔滤膜过滤技术，加热以及用有机溶剂或表面去污染剂处理) 却可保征“无菌”，因此，为克服以上缺点，出现了成分输血。

Advantages of component transfusion:

improve curative effect: component transfusion is to carry out what components are lac and what components are added to patients, in particular, that blood component can be purified to obtain a blood product with high concentration, high efficiency and convenient storage and transportation, the same blood components of a plurality of blood donors are mixed together to form an effective therapeutic dose, and the curative effect is remarkably improved after infusion.
Reducing reaction: The blood composition is complex, and whole blood transfusion can cause various adverse reactions in the recipient. The diseases transmitted by blood transfusion are even more terrible. Component transfusion can avoid transfusion reaction caused by inputting unnecessary blood components. Currently, blood cells separator can be used to separate blood components from one blood donor for transfusion, and other components can be recycled to the blood donor, which can obviously reduce transfusion reaction and reduce transmission diseases. In the elderly, patients with infantile weight and original cardiac insufficiency can reduce blood transfusion volume and cardiovascular load.
Reasonable use: component transfusion refers to the transfusion of different components of blood to different patients with multiple purposes in one blood. If the various components in whole blood are infused regardless of the needs of patients, the required components are relatively insufficient, and the unnecessary components will be wasted. (4) Economy: using more than one blood can not only save blood, but also reduce the economic burden of society and individuals.

成分输血的优越性:

(1) 提高疗效：成分输血是对患者进行缺什么成分，补充什么成分，特别是可以将血液成分提纯，得到高浓度、高效价，便于保存、运输的血液制品，把多个献血者的同一血液成分混合在一起，成为一个有效的治疗剂量，输注后显著提高疗效。

(2) 减少反应：血液成分复杂，输全血可使受血者发生各种不良反应，再加输血所传播的疾病更可怕。采用成分输血，可避免输入不必要的血液成分所致的输血反应，目前可用血细胞分离机单采一个献血者的血液成分进行输血，而将其他成分回输给献血者，这就可明显减少输血反应及减少传播性疾病。对老年人，儿重及原有心功能不全患者可减少输血容量，降低心血管的负荷。

(3) 合理使用：成分输血是将血液不同成分，输给不同患者，一血多用，如果不考虑患者是否需要，将全血中的各种成分均予输注，所需成分又相对不足，不需要的成分将造成浪费。

(4) 经济：一血多用，既节省血源，又减轻社会、个人的经济负担。

Types of red blood cell products: (I）Oligoplasmic blood，（ii）Concentrated red blood cells，（iii）Substituting plasma blood or crystal salt red blood cells，（iv） Oligoleukocyte red blood cells，（v）Scrubbing red blood cells，（vi）Frozen red blood cells: suitable for the storage of rare blood group and own blood，（vii）Young red blood cells.

Platelet products: （I）Platelet-rich plasma，（ii）Platelet concentrates，（iii）WBC-less platelets.

红细胞制品种类：1. 少浆血 2. 浓缩红细胞 3. 代浆血或晶体盐红细胞 4. 少白细胞的红细胞 5.洗涤红细胞 6. 冰冻红细胞: 适于稀有血型和自身血的贮存 7. 年轻红细胞。

血小板制品：1. 富含血小板血浆 2.浓缩血小板 3. 少白细胞的血小板。

血小板保存: 温度以22℃（上下2度）保存，PH值为6.5-7.2。

Platelet preservation:

The temperature was kept at 22 C (2 C above and below) with a PH of 6.5-7.2.

2. Autotransfusion

In recent years, due to the attention paid by social and medical circles to the transmission of blood transfusion diseases, especially the hepatitis and AIDS after blood transfusion, autotransfusion has risen to an important position, and it is considered to have the following advantages:

the transmission of blood transfusion diseases such as viral hepatitis, AIDS and cytomegalovirus can be avoided;
The alloimmune reaction caused by red blood cells, white blood cells, platelets and protein antigens can be avoided;
hemolytic fever, allergy or graft-versus-host reaction sensitized by immune action can be avoided;
The error accident of allogeneic blood transfusion can be avoided;
The unused blood can be transfused to other patients who need transfusion, which increases the blood supply and source.
patients with autotransfusion because of repeated bleeding, can stimulate red blood cell regeneration, make the patient after surgery hematopoietic speed faster than before;
The collection and long-term preservation of self blood can provide blood storage for patients with rare blood group when they need blood transfusion;
Autoblood collection can provide blood for surgery in remote areas without blood supply conditions;
Some acute internal bleeding, such as rupture of spleen, liver and ectopic pregnancy, can be reinfused under strict conditions without need of anticoagulation (fibrin blood), thus leading to emergency rescue.

二、自身输血

近几年来，由于社会和医务界对输血的疾病传播，特别是输血后肝炎和艾滋病的关注，自身输血已上升到一个重要位置，认为它具有以下优点: (1) 可以避免输血的疾病传播，如病毒性肝炎、艾滋病、巨细胞病毒等；(2) 可以避免红细胞、白细胞、血小板以及蛋白抗原产生的同种免疫反应; (3) 可以避免由于免疫作用而致敏的溶血发热，过敏或移植物抗宿主反应; (4) 可以避免发生输同种异体血的差错事故；(5) 自身血没有用完可以输给其它需要输血的患者，增加了血液供应和来源; (6) 自身输血患者由于反复放血，可以刺激红细胞再生，使患者手术后造血速度比手术前快；(7) 自身血的采集和长期保存，可为稀有血型患者需输血时提供贮血；(8) 自身血采集可为无供血条件的边远地区外科手术提供血源；(9) 某些急性内出血，如脾、肝及宫外孕破裂等，在严格条件下可回输且无需抗凝(脱纤维蛋白血)，可达到应急救命。

Frequency of blood collection:

采血频次: 动员蛋白质进入血浆，便血浆容量恢复到正常所需的最长时间为72小时，因此，除了特殊情况外，采血频次应当是两次间隔不少于3天，最好采血至手术前一周，至少应截止在手术前72小时进行，一般允许采4-5单位血液。

The maximum time required for mobilizing protein to enter plasma and restoring plasma volume to normal is 72 hours. Therefore, except for special circumstances, the frequency of blood collection should be no less than 3 days at the interval between two times. It is best to collect blood one week before surgery. Blood collection should be conducted at least as of 72 hours before surgery. Four to five units of blood are generally allowed.

3. Surgical blood transfusion

三、外科输血

外科输血目的有二: 一是纠正血容量; 二是纠正某种血液成分的缺乏。

外科输血特点:

1、失血量大。失血量估计可从以下几方面进行: 心率、动脉血压、尿量、中心静脉压、红细胞压积。

2、输用库血多。一般库血指采集 24h 后的血制品。(血小板止血功能明显下降、凝血因子的活性下降、血K变化，PH值)

3、输血速度快。

Surgical blood transfusion has two purposes: one is to correct blood volume; the second is to correct the lack of a blood component.

Surgical blood transfusion features:

large amount of blood loss. The amount of blood loss can be estimated from heart rate, arterial blood pressure, urine volume, central venous pressure, and hematocrit.
There is much blood in the transfusion reservoir. General blood storage refers to the blood products after 24h collection. (significant decrease in platelet hemostatic function, activity of coagulation factors, blood K change, PH value)
blood transfusion speed is fast.

(一) 外科输血准则:

1、对腹腔实质脏器手术及血管损伤手术，宜常规用粗针头开放两条静脉通道，确保输血速度。静脉穿刺部位可选择前臂、肘前及头静脉，以利于所补充的血液从上腔静脉回至右心，防止下肢输血而从腹腔内血管破裂处进入腹腔。

2、应量出为入，丢多少补多少，速度宜快不宜慢。

3、大量输血时 (>3000ml)，库血与新鲜血 (贮存<24h) 的比例应为3:1，比例2:1则更佳。

4、严重肝功损害者，如总蛋白量 <45g/l、白蛋白 <25g/l 或白球比例倒置应适当补充血浆或白蛋白，术前应争取血红蛋白高于 100g/l，红细在 3×1012/l 以上，血清总蛋白在 60g/l，白蛋白在30 g/l 以上。

5、因血小板减少引起出血者，也应输入浓缩血小板。

6、腹腔内实质脏器及血管创伤时，腹腔可存留大量血液，严格条件下可回输; 脾切除后也可回收部分脾血。

3.1. Surgical blood transfusion guidelines

3.1.1. to the abdominal cavity parenchyma organ surgery and vascular injury surgery, appropriate convention with thick needle open two venous channels, to ensure the speed of blood transfusion. The forearm, anterior elbow and cephalic vein can be selected for venipuncture, so as to facilitate the return of supplemented blood from the superior vena cava to the right heart and prevent blood transfusion of the lower limb from entering the abdominal cavity through the vascular rupture in the abdominal cavity.

3.1.2. should be within our means, lost how much how much, speed should be fast shoulds not be slow.

3.1.3. For massive blood transfusion (> 3000ml), the ratio of pooled blood to fresh blood (stored < 24h) should be 3:1, and the ratio of 2:1 is better.

3.1.4. severe liver damage, such as total protein content < 45g/l, albumin < 25g/l or white ball ratio inversion cases should be appropriate to supplement plasma or albumin, preoperative hemoglobin should be higher than 100g/l, fine red in more than 3 x 1012/l, serum total protein in 60g/l, albumin in more than 30 g/l.

3.1.5. bleeding caused by thrombocytopenia, also should input platelet concentrate.

3.1.6. In case of trauma to the parenchymal organs and blood vessels in the abdominal cavity, a large amount of blood may remain in the abdominal cavity, which may be transfused under strict conditions; Partial splenic blood can also be recovered after splenectomy.

3.2. preoperative preparation and component transfusion

Many patients are accompanied by anemia before operation. The degree of anemia varies. Of course, in severe cases, hemoglobin must be added to a certain level before the operation can be tolerated. The preoperative hemoglobin level should be reached depends on the comprehensive evaluation of the patient.

Animal experiments have shown that left ventricular function is inhibited when the blood protein concentration falls below 100g/l, but oxygen uptake, mixed venous oxygen tension, and coronary sinus oxygen tension remain unchanged until the hemoglobin falls to 70-80 g/L. This indicates that when the hemoglobin concentration is maintained above 70 to 80 g/L, most operations can still be performed as usual. The hemoglobin level of 70-80g/l requires normal heart, lung, liver and kidney functions, and any organ dysfunction requires a corresponding increase in hemoglobin level. It has been found that patients with septic shock have the highest survival rate when the hemoglobin concentration is maintained at 125 to 150 g/L, while patients with acute respiratory failure have a significant reduction in mortality when the hemoglobin concentration is maintained at 130 to 160 g/L. Therefore, for patients with organ dysfunction, the level of hemoglobin supplementation depends on clinical conditions.

However, due to the improvement of anesthesia methods and the improvement of anesthesia level, the requirements for hemoglobin can be specific and flexible to master according to the patient’s situation, anesthesia methods and surgical characteristics. For patients who urgently need surgery for acute hemorrhage, immediate surgery should be performed to stop bleeding and blood transfusion should be performed simultaneously with the surgery.

(二) 术前准备与成分输血

许多患者术前都伴有贫血，其程度不等，当然严重者一定要补充血红蛋白到一定水平后方可耐受手术。对于术前血红蛋白究竟应该达到什么水平，要视接受手术者的情况综合评定。

动物实验表明，当血蛋白浓度降至 100g/l 以下时，左心室功能受到抑制，但直至血红蛋白降至70-80g/l 前，氧摄取率、混和静脉血氧张力及冠状窦氧张力仍保持不变。这表明，当血红蛋白浓度保持在 70-80g/l 以上时，绝大部分手术仍可照常进行。70-80g/l 的血红蛋白水平，要求有正常的心、肺、肝、贤功能，任何脏器功能的不全，均要求相应提高血红蛋白水平。有人发现，脓毒性休克患者，当其血红蛋白浓度保持在 125-150g/l 时存活率最高，急性呼吸衰竭患者当其血红蛋白浓度保持在 130-160g/l 时死亡率可明显下降，因此伴脏器功能不全者，补充血红蛋白到什么水平依临床而定。

但目前由于麻醉方法的进步和麻醉水平的提高，对于血红蛋白要求可以根据病人情况、麻醉方法、手术特点而具体、灵活掌握。对于急待手术的急性出血病人，应立即手术止血，并在手术同时输血。

(三) 外科输血新概念

输血、麻醉、无菌曾被认为促进外科发展的三大要素。有了输血的保证，使手术范围大大扩大，正确掌握术中输血可以迅速纠正失血量，保证手术的成功及病人的安全，输血对外科的发展起到越来越重要的作用。但由于外科输血具有输血量大，输用库血多，输血速度快的特点，输血的并发症发生率相对较高，已越来越受到外科医生的重视，特别是近十多年来对输血的深入研究，外科输血的概念已有了很大的变化，成分输血、自体输血等均有较大的进展。

1、“失血补血”概念的变化

在外科领域，由于手术范围的扩大，术中失血量大，而需要补充血容量机会增多。血量丢失，当然是失血性休克的主要原因，因此“失血补血”的概念曾长期为术者所遵循，以致大量输入血液而忽视细胞外液的补充，致使休克后肾功能衰竭的发生机会增多。近年来大量实验和临床观察表明，严重创伤或复杂的手术，不但丢失全血，而且也使大量功能性细胞外液转移到第三间隙，并使血液浓缩。即使有低血容量休克的病人，输入全血也不如先输入类似细胞外液的晶体溶液见效迅速。所以一般成人手术，失血量在500ml以内，仅补充3倍量晶体液 (如乳酸钠林格液、林格液或生理盐水) 即可满足要求。失血量在500-1000ml，还应追加一半胶体溶液 (如羟乙基淀粉、右旋糖酐等)。失血量超过1000ml，才需要同时输全血或浓缩血细胞。现在已一致认识到失血时不必过早大量输血，应先以代血浆及晶体液扩充血容量使血液稀释，这样还可增加心输出量，降低周围血管阻力，血流速度加快，增加组织灌注，同时还可防止微循环血流障碍。因此临床上改变了“失血补血”概念。

3.3. New concept of surgical blood transfusion

Blood transfusion, anesthesia and sterility were once considered as the three main factors to promote the development of surgery. With the guarantee of blood transfusion, greatly expand the scope of surgery, correctly grasp the intraoperative blood transfusion can quickly correct blood loss, ensure the success of the operation and the safety of the patient, blood transfusion to the development of surgery plays an increasingly important role. However, because surgical blood transfusion has the characteristics of large blood transfusion volume, large amount of transfused blood and rapid blood transfusion, and the incidence of complications of blood transfusion is relatively high, it has attracted more and more attention from surgeons. In particular, through the in-depth research on blood transfusion over the past decade, the concept of surgical blood transfusion has changed greatly, and great progress has been made in component blood transfusion and autologous blood transfusion.

3.3.1. Change of the concept of “blood loss and enrichment”

In the field of surgery, due to the expansion of the scope of the operation, the amount of blood loss during the operation is large, and the chance of needing to supplement blood volume is increased. Loss of blood volume is, of course, the main cause of hemorrhagic shock. Therefore, the concept of “blood loss and blood enrichment” has been followed by surgeons for a long time, so that a large amount of blood was input while extracellular fluid supplement was ignored, resulting in an increased incidence of renal failure after shock. In recent years, a large number of experiments and clinical observations have shown that severe trauma or complicated surgery not only loses whole blood, but also causes a large amount of functional extracellular fluid to be transferred to the third space and causes blood concentration. Even in patients with hypovolemic shock, the introduction of whole blood is not as effective as the introduction of a crystalloid solution resembling extracellular fluid. Therefore, for general adult surgery, the blood loss should be within 500ml, and only three times of crystal solution (such as sodium lactate Ringer’s solution, Ringer’s solution, or normal saline) can be replenished to meet the requirements. The blood loss ranged from 500 to 1000 mL, and half of the colloidal solution (such as hydroxyethyl starch and dextran) should be added. The amount of blood loss exceeded 1000ml, and the simultaneous transfusion of whole blood or concentrated blood cells was required. It has now been unanimously recognized that it is not necessary to conduct a large amount of blood transfusion prematurely during blood loss; instead, plasma and crystalloids should be replaced to expand the blood volume to dilute the blood, which will also increase cardiac output, reduce peripheral vascular resistance, accelerate blood flow, increase tissue perfusion, and prevent microcirculatory blood flow disturbance. Therefore, that concept of “blood los and blood enrichment” was changed clinically.

2、自体输血

自体输血有近百年历史，但近十余年来的临床和实验研究进展较快，技术设备有较大改进，适应范围不断扩大。今已公认为有临床实用价值的治疗方法，自体输血可解决急需输血而血源短缺的困难，无输血反应，并发症少，无传播的危险。更重要的是不产生对红细胞，白细胞、蛋白抗原等血液成分的免疫反应。人们公认自体输血不需化验血型及交叉试验，能及时有效地将丧失血液重新利用，自身的红细胞活力较库血好、运氧能力高。输后红细胞能立即发挥良好的携氧能力。自体输血主要适应于 (1) 胸腔心血管外伤性手术; (2)肝、脾破裂，异位妊娠破裂，肠系膜血管破裂等腹腔出血; (3)体外循坏心内直视手术，主动脉瘤手术等某些择期手术。近年来已发展到术前数天，或麻醉前采集病人血液，用电解质或血浆增量剂补充血容量的“血液稀释法”。血液稀释疗法主要是通过静脉输液，降低患者红细胞压积和血液粘度，加速血流，改善微循环和组织供氧，以达到治疗目的。在外科手术中应用血液稀释技术，还可以大大节约手术中输血量和减少输血并发症的发生。

3.3.2. autologous blood transfusion

Autologous blood transfusion has a history of nearly one hundred years. However, clinical and experimental research has made rapid progress in the past ten years, with great improvements in technical equipment and an ever-expanding scope of application. It has been recognized as a treatment with clinical practical value. Autologous blood transfusion can solve the difficulty of blood shortage due to urgent need of blood transfusion. There is no transfusion reaction, few complications and no risk of transmission. It is more important not to produce immune response to red blood cells, white blood cells, protein antigens and other blood components. It is generally recognized that autotransfusion does not need blood type tests and cross tests, can timely and effectively reuse the lost blood, and has better red blood cell viability and oxygen transport capacity than reservoir blood. After transfusion, red blood cells can immediately exert good oxygen carrying capacity.

Autotransfusion is mainly suitable for (i) thoracic cardiovascular traumatic surgery; (ii) Liver and spleen rupture, ectopic pregnancy rupture, mesenteric vascular rupture and other abdominal hemorrhage; (iii) Some elective operations such as extracorporeal circulation followed by open heart surgery and aortic aneurysm surgery. In recent years, “hemodilution” has been developed in which a patient’s blood is collected several days before surgery or before anesthesia, and blood volume is supplemented with electrolytes or plasma extenders. Hemodilution therapy is mainly through intravenous infusion, reduce the patient’s hematocrit and blood viscosity, accelerate blood flow, improve microcirculation and tissue oxygen, in order to achieve the purpose of treatment. Application of hemodilution technique in surgery can also greatly save blood transfusions during surgery and reduce the occurrence of transfusion complications.

3、成分输血

近年来，输血疗法已进入成分输血。成分输血是把全血或血浆用物理的和/或化学方法分离并制成较纯和较浓的各种制品以供临床应用。传统的输血方法是不问病人确实需要什么而千篇一律输血，这样不仅浪费血液，而且还使病人冒不必要的风险。成分输血优点是 (1) 提高输血效果，减轻心脏负担；(2) 减少对不需要的血液成分的反应; (3) 可以达到一血多用，节约用血的目的。成分输血是现代医药和输血发展的必然进程。外科成分输血主要是输用浓缩红细胞。目前对于体循环血容量的恢复和维持，有较好的血浆代用品 (羟乙基淀粉、左旋糖酐等) 或晶体溶液，但都不具有携氧功能，常需要补充红细胞。因此，浓缩红细胞是外科成分输血最常用的，在输血先进的国家，全血的使用已减少到总输血量的20%以下，而浓缩红细胞用量 >80%。

输红细胞为主的输血疗法具有科学性，可行性和一定的先进性，是外科输血的必然趋势。对于接受大手术或严重创伤治疗者，如果血小板低于 50×109/l，为预防术中异常渗血，术前宜预防性浓缩血小板输血，使血小板数升至100×109/l以上。因骨髓功能衰竭引起的血小板减少症，如癌肿化疗或放疗、急性白血病发作期、再生障碍性贫血等，血小板数可低达30×109/l，一般尚不致自发性出血。但如果决定手术，则宜预防性浓缩血小板输血。大量 (15-20单位) 输注冷藏库血，血小板功能几乎完全丧失，更可出现稀释性血小板减少，亦宜输注较大量浓缩立小板预防出血。

自七十年末，血浆已被广泛用于各种中毒疾患的治疗，血浆用于术中清除中毒性休克，并用以补充某种可能缺少的成分，如术中输用新鲜冰冻血浆，含有各种血浆凝血因子。血浆衍化物有血浆蛋白溶液、白蛋白、因子VIII、IX以及丙种球蛋白等。值得注意的是国内冻干血浆的应用过多，最不合理的是用于扩血容量和补充营养。血浆的最大危险是传染肝炎、艾滋病和其他传染病。血浆的不良反应较多、特别是荨麻疹和过敏反应。血浆的组成复杂，一些蛋自可以致敏病人产生抗体，另外也是极大的浪费。因此不论是新鲜冰冻血浆或冻干血浆不可轻易多用。

3.3.3. component blood transfusion

In recent years, transfusion therapy has entered component transfusion. Component transfusion refers to the physical and/or chemical separation of whole blood or plasma and preparation of various purer and thicker products for clinical application. The traditional method of blood transfusion is to transfuse the blood without asking the patients what they really need. This not only wastes blood, but also makes patients take unnecessary risks. Component blood transfusion has that advantage of (1) improving blood transfusion effect and reduce heart burden; (2) reducing reaction to unwanted blood components; And (3) the purposes of multipurpose with one blood and saving blood can be achieved. Component blood transfusion is an inevitable process of modern medicine and blood transfusion development. Surgical component transfusions are primarily transfusions of packed red blood cells. At present, there are good plasma substitutes (hydroxyethyl starch, dextran, etc.) or crystal solutions for the recovery and maintenance of systemic circulating blood volume, but none of them has oxygen-carrying function, and erythrocyte supplementation is often required. Therefore, packed red blood cells are the most commonly used for surgical component transfusion, and in countries with advanced transfusion, the use of whole blood has been reduced to less than 20% of the total transfusion volume, while the use of packed red blood cells is greater than 80%. The transfusion therapy based on red blood cell transfusion is scientific, feasible and advanced to a certain extent, which is the inevitable trend of surgical blood transfusion. For patients undergoing major surgery or severe trauma treatment, if the platelets are less than 50×109/l, in order to prevent abnormal bleeding during the operation, preoperative prophylactic platelet concentrate transfusion is recommended to increase the platelet count to more than 100 × 109/L. Thrombocytopenia caused by bone marrow failure, such as cancer chemotherapy or radiotherapy, acute leukemia onset, aplastic anemia, platelet count can be as low as 30×109/l, generally does not cause spontaneous bleeding. However, if surgery is decided, prophylactic platelet concentrate transfusion is advisable. If a large amount (15–20 units) of blood is infused into the refrigerator, the platelet function will be almost completely lost, and dilutive thrombocytopenia may occur. It is also advisable to infuse a relatively large amount of concentrated riser to prevent bleeding. Since the end of the seventy, plasma has been widely used in the treatment of a variety of poisoning disorders, plasma used to remove toxic shock during the operation, and to supplement some may be missing components, such as the operation with fresh frozen plasma, containing a variety of plasma coagulation factors. Plasma derivatives include plasma protein solutions, albumin, factors VIII, IX, and gamma globulin. It should be noted that the application of lyophilized plasma in China was excessive, and the most unreasonable one was for blood volume expansion and nutritional supplement. The greatest danger of plasma is the spread of hepatitis, aids and other infectious diseases. There were many adverse reactions in plasma, especially urticaria and allergic reaction. The composition of the plasma is complex, some eggs can produce antibody sensitization patients, in addition is also a great waste. Therefore, whether fresh frozen plasma or lyophilized plasma cannot be easily used.

Level 4 Surgery

Education Campus

Level 4 Surgery

Six Sample Cases

[Editor’s Comments] This part of Education Campus is where the six representative cases of high clinical difficulty are presented, with detailed operation records.  They are: 1. Extended total gastrectomy; 2. Simulated radical surgery for thyroid cancer; 3. Simulated Berne surgery for duodenal rupture; 4. Left lateral hepatectomy, intrahepatic lithotomy and hepatobiliary basin internal drainage; 5. Focal clearance and drainage for acute pancreatitis; 6. Radical surgery for rectal cancer.

Case 1. Extended total gastrectomy

Single operation record of Wuhu Changhang Hospital for Surgery Case 1

Name: Yao XX

Gender: Female

Age: 74

Bed No.: 34

Hospitalization No.: 19052

Operation Date: 1995/4/21

Pre-operation Diagnosis: gastric cardia cancer and esophagus invasion

Post-operation Diagnosis: gastric fundus and cardia and esophagus cancer

Surgery operated: total gastrectomy + splenectomy, esophagojejunostomy (Schlatter’s style).

Operation Time: started at 9am, ended at 4pm

Blood transfusion volume: 1200ml

Surgeon: Mingle Li

Assistant 1: Yang, Zonghua
Assistant 2: Wu, Maowang

Surgical nurse: Qian, Weilin

Anesthesia: continuous epidural block
Anesthesiologist: Chen, Qibin and Wang, Yisen

The gross examination of the specimens after operation showed that the primary cancer focus was located in the posterior wall of small bend near the cardia, involving 1cm at the lower end of the cardia and esophagus and invading the whole layer. Name of pathological specimen sent for examination: whole stomach, distal esophagus, and spleen. Procedure: Supine, chest and abdomen disinfection cloth, sword navel longitudinal incision 25cm long, bite in addition to the xiphoid process. Laparotomy was performed layer by layer and the incision was isolated. There was no ascites in the abdominal cavity and no space-occupying lesion in the liver. There was a little adhesion between pancreas and spleen and the lesion. The mass was located at the small bend of the posterior wall of the gastric fundus and involved the serosal layer, with the size of 10x7x5cm. There was still space between the mass and the liver. No metastasis was found at the pelvic floor and other parts of the abdominal cavity. A total gastrectomy and splenectomy were performed with a double-tube jejunum anterior to the colon and side-to-side anastomosis of the esophagus, plus a Bauwn short circuit between the jejunal afferent and afferent loops. The stomach was free, and the origin of the left gastric artery was cut off by the root of the vena cava. The omentum and the anterior layer of transverse mesocolon were excised, and the duodenum was severed 3cm below the pylorus, sealing the stump. Pancreas-stomach adhesion was separated from under the pancreatic capsule, and the spleen was excised. Acute severance was performed in the space between normal tissues outside the pericardial mass. The peritoneum at the part where the esophageal hiatus was incised was reversely folded, and the left and right vagus nerve trunks were severed. Then the esophagus was bluntly separated and 7cm was dragged down. At this point, the whole stomach has been free. The cancer focus was wrapped and placed for traction. Thus, group (1) (2) (3) (4) (5) (6) (7) (10) (11) (15) of lymph nodes were removed and radical 2 surgery was performed. Jejunum proximal to 20cm was anastomosed with esophagus at 5cm above cardia via anterior ascending colon for lateral end anastomosis. Five needles in seromuscular layer were intermittently sutured and fixed at posterior wall. Jejunum opposite mesangial margin was cut for 3cm and was intermittently sutured with whole layer of posterior wall of esophagus. The feeding channel was cut off at 4cm above cardia, and whole stomach and spleen sent out the operation field. Then whole-layer suture of anterior wall was performed for one week. Esophageal inflammation was fragile and it was easy to avulsion. Tension-reduction suture was conducted carefully, and the anastomosis was sleeved into jejunum a little with two-layer suture without leakage. Jejunum slightly distant from the anastomosis was sutured onto the septal muscle near the hiatus to reduce the tension, and the hiatus was slightly repaired to prevent internal hernia without narrowing. A Braun short-circuit anastomosis between the double loops of jejunum (8cm) was performed 7cm below the anastomosis, and a gastric tube was inserted into the proximal jejunum to facilitate postoperative suction and decompression. The abdominal cavity was washed thoroughly, and the fields were carefully examined without bleeding or leakage. There was no torsional compression of the intestinal loop in place of stomach. The abdominal cavity was immersed in distilled water to destroy the tumor, and after the abdominal cavity was wiped clean, a double cannula was placed under the septum to poke the wound and then led out for fixation. The abdomen was closed in sequence conventionally. The procedure was uneventful and 400ml of blood was lost.

Conclusion of the operation: The advanced gastric cardia cancer involves extra-gastric pancreas, spleen and distal esophagus, and the inflammation of esophagus is fragile. Although the whole stomach, distal esophagus and spleen are resected, and the large and small omentum are removed, as well as the anterior lobe of transverse mesocolon are removed, and the removal range reaches the second lymph node. Although the root 2 operation is achieved, the short-term and long-term prognosis is still not optimistic. Operator, record Li Mingjie 95，4，21

Note: 1 Postoperative pathology (952343) reported poorly differentiated adenocarcinoma of the lateral aspect of the lesser curvature of the cardia, partially mucinous adenocarcinoma, with a lesion of 10 × 7 cm involving the esophagus, cardia, fundus of the stomach, and body of the stomach and penetrating the whole layer. There were seven lymph nodes at the lesser curvature, six metastatic carcinomas, and none of the five lymph nodes at the greater curvature had metastatic carcinomas. Focal mild acute inflammation of spleen. He has survived for half a year and his constitution is relatively thin.

手术后标本肉眼检查所见: 原发癌灶位于贲门附近小弯后壁累及贲门食道下端1cm侵犯全层。
送出检查病理标本名称: 全胃、食道远端、脾。

手术经过:

仰卧、胸腹部消毒铺巾，剑脐间纵切口长25cm，咬除剑突。逐层开腹，切口隔离。

腹腔无腹水，肝无占位灶，胰脾与病灶粘连少许，肿块位于胃底后壁小弯处，侵及浆膜层，大小为10x7x5cm，与肝尚有间隙，盆底及腹腔他处未见转移灶。拟行全胃切除，脾切除，双管空肠结肠前与食道作侧端吻合，加空肠输入出袢间Bauwn短路术。

游离胃周，腔动脉根部切断胃左动脉起始部。切除大小网膜、横结肠系膜前层，幽门下3cm断离十二指肠，封闭其残端。从胰包膜下，分离胰胃粘连，切除脾脏。贲门周围肿块外正常组织间隙作锐性断离。切开食道裂孔处腹膜反折，断离左右迷走神经干，钝性分离食道，拖下7cm。至此，全胃已游离。癌灶予包裹搁置牵引。至此，清除了(1) (2) (3) (4) (5) (6) (7) (10)(11) (15) 组淋巴结，根2手术。

空肠近侧20cm处经结肠前上提与食道在贲门上5cm处作侧端吻合，后壁5针浆肌层间断缝合固定，切开空肠对系膜缘3cm，作与食道后壁全层间断缝合，于贲门上4cm处断食道，全胃+脾送出术野，继而作前壁全层缝合一周，食道炎症脆弱，极易撕脱，仔细减张缝合，二层缝合将吻合口套入空肠少许，无泄漏。再将吻合口稍远处空肠缝于食道裂孔附近隔肌上以减张，略加修补食道裂孔以防内疝，未致缩窄。

吻合口下7cm作双袢空肠间Braun短路吻合8cm，并将胃管置入近端空肠，以利术后吸引减压。

彻底冲洗腹腔，仔细检查创野，无出血及渗漏。代胃之肠袢无扭转压迫，蒸馏水浸泡腹腔灭瘤，拭净腹腔后隔下置双套管戳创引出固定。常规依次关腹。手术经过平顺，失血400ml. 安返病房。

手术结论: 晚期胃底贲门癌累及胃外胰脾及食道远端，食道炎症脆弱，虽作全胃、食道远侧、脾切除，并清除大小网膜，横结肠系膜前叶，清除范围达第二站淋巴结，虽然达到根2手术，但近远期预后仍不乐观。

术者、记录李名杰

95，4，21

注:

1 术后病理 (952343) 报告为贲门小弯侧差分化腺癌，部分为粘液腺癌，病灶10x7cm累及食道贲门、胃底、胃体并穿透全层，小弯处7枚淋巴结，6枚转移癌，大弯5枚淋巴结均无转移癌。脾脏局灶性轻度急性炎。

2 至今半年存活，体质较瘦弱。

Case 2. Simulated radical surgery for thyroid cancer

Single operation record of Wuhu Changhang Hospital for Surgery Case 2

Name: Gao XX
Gender: Female
Age: 47

Bed No.: 34
Hospitalization No.: 18639

Operation Date: 1994/8/30

Pre-operation Diagnosis: metastatic carcinoma of the right thyroid gland

Post-operation Diagnosis: metastatic follicular adenocarcinoma of the right thyroid gland

Surgery operated: modified right cervical lymph node dissection + isthmus resection and left thyroidectomy

Operation Time: started at 9am, ended at 2pm

Blood transfusion volume: 400ml

Surgeon: Mingle Li

Assistant 1: Yang, Zonghua
Assistant 2: Shi, Lianghui
Surgical nurse: Gao, Qingjie

Anesthesia: cervical plexus block
Anesthesiologist: Chen Qibin

Gross examination of the post-surgical specimen revealed a resected mass necropsy showing a typical enlarged lymph node. Pathological report of rapid section of lymph nodes during the operation (Pathology No.944346, Second Municipal Hospital): metastatic thyroid cancer and follicular adenocarcinoma, and the possibility of papillary adenocarcinoma cannot be ruled out. Name of pathological specimen sent for examination: 9 superficial and deep lymph nodes in right neck, thyroid. Procedure: 1 The patient was supine under cervical plexus anesthesia with left head and neck hyperextension. For routine skin sterilization and towel spreading, an “in” incision was made in the anterior region of the right neck, which began 2cm below the right mastoid and ended on the sternum and extended left to the outer margin of the left sternocleidomastoid muscle, 18cm in length. The other incision extended to the right reached the right supraclavicular recess, and the original surgical scar was excised. All the flaps were secretly separated to reach the outer margin of the right trapezius muscle, and the outer margin of the left sternocleidomastoid muscle went up to the lower margin of the mandible and abutted against the sternal notch. 2 The platysma muscle was incised, and the bilateral anterior cervical muscle groups were separated from the cervical midline and transected to expose various lumps and thyroid. No residual remains were observed in the right thyroid lobe. The right common carotid artery, vagus nerve, and internal jugular vein were pushed to the superficial layer by the mass. Nine visible lymph nodes of different sizes were located in the right inferior cervical trigone, the right sternocleidomastoid muscle area, the right supraclavicular fossa, and the anterior cervical trigone, respectively. The largest one was 5cm in diameter, and the smaller one was about 1cm. The lymph nodes were hard in texture, smooth in surface, and not densely adhered. The trachea was moved to the left, but not associated with a mass, and the left thyroid lobe was slightly larger and no obvious nodules were palpable. 3 The right sternocleidomastoid muscle was transected at the middle and lower 1/3 point to improve exposure. First, a lymph node 2cm in diameter was cut from the upper extremely shallow part of a series of lumps and sent for rapid section. The pathological report was thyroid cancer metastasis and follicular adenocarcinoma. The modified right neck lymph node dissection was performed. A total of nine lymph nodes large and small visible to the naked eye were removed during the operation. The intact general A and internal V nerves of the neck, vagus nerve and right accessory nerve were carefully protected. 4 The anatomy of the thyroid gland was continued, and the isthmus and most of the left thyroid lobe were removed, with the size of the posterior medial glandular finger retained. Suture the residual thyroid. 5 The wound cavity was rinsed to perfect hemostasis. One skin tube was inserted and another was poked out of the wound. The anterior cervical muscle group and the severed right sternocleidomastoid muscle were sutured, and the wound was sutured layer by layer and intermittently. 6 Patients were anesthetized satisfactorily during the operation, with clear anatomy, no important vascular and neural damage, less bleeding, silent hoarseness and cough, and were returned to the ward. 7 Although it is a well-differentiated adenocarcinoma, reoperation for cervical lymph node metastasis has occurred, which makes the long-term prognosis difficult to be optimistic.

Performer and Record Li Mingjie 94, 8, 9

Note: 1 Pathological report with regular section on 94/9/2 after operation (Medical record No.944355 of the Second Municipal Hospital): (1) Papillary-follicular adenocarcinoma of thyroid. (2) There are small focal metastases in the “normal” thyroid tissue and (3) most lymph node metastases. 2 The follow-up visit has lasted for more than one year. The patient showed no signs of recurrence or symptoms.

手术后标本肉眼检查所见: 切除之肿块剖检为典型肿大之淋巴结。术中淋巴结快速切片病理报告 (市二院病理号944346): 转移性甲状腺癌、滤泡状腺癌，不排除乳头状腺癌可能。送出检查病理标本名称: 右颈浅深淋巴结计9枚，甲状腺。

手术经过:

1 颈丛麻醉下患者仰卧，头颈部过伸偏左。常规皮肤灭菌、铺巾，右侧颈前区作一“入”形切口，始于右乳突下止于胸骨上2cm左延至左胸锁乳突肌外缘，长18cm，另向右延伸切口达右锁骨上凹，切除原手术疤痕，潜行剥离诸皮瓣达右斜方肌外缘，左胸锁乳突肌外缘，上至下颔下缘，下抵胸骨切迹。

2 切开颈阔肌，从颈中线分离两侧颈前肌群并予横断，显露诸肿块及甲状腺。右甲状腺叶未见残留遗迹，右颈总动脉、迷走神经、颈内静脉被肿块推向浅层，9枚可见之大小不等之淋巴结分别位于右颈下三角区，右胸锁乳突肌区、右锁骨上窝及颈前三角区内，其中最大者为直径5cm，小的为1cm左右，质硬，表面光滑，粘连不致密。气管左移，但与肿块不关联，左甲状腺叶略大，无明显结节可扪及。

3 从右胸锁乳突肌中下1/3分处横断该肌，以改善显露，在一串包块的上极浅处先切取一枚淋巴结直径2cm送快速切片，病理报告为甲癌转移灶，滤泡状腺癌，遂行改良式右颈淋巴清扫术，术中共切除肉眼所见有9枚大小淋巴结，仔细保护颈总A、颈内V，迷走神经、右付神经等未受损伤。

4 继续解剖甲状腺，切除其峡部及左甲状腺叶大部，保留其后内侧腺体指头大小。缝合残余甲状腺。

5 冲洗创腔，完善止血，置皮管一根另戳创引出，缝合颈前肌群及断离之右胸锁乳突肌，分层间断缝合创口。

6 术中麻醉满意，解剖清晰，无重要血管神经损伤，出血少，无声嘶哑及呛咳发生，安返病房。

7 虽为高分化腺癌，但已发生颈淋巴结转移再手术，惜根治过晚，远期预后难以乐观。

术者、记录李名杰
94，8，9

注:

1 术后于 94/9/2 常规切片病理报告 (市二院病检号 944355):
(1) 甲状腺乳头状一滤泡型腺癌。(2) “正常”甲状腺组织内有小灶性转移及 (3) 多数淋巴结转移。

2 术后随访至今已一年余，患者无复发征象，无症状。

Case 3. Simulated Berne surgery for duodenal rupture

Single operation record of Wuhu Changhang Hospital for Surgery Case 3

Name: Li XX
Gender: Male
Age: 29

Bed No.: 22
Hospitalization No.: 18158

Operation Date: 1993/10/7

Pre-operation Diagnosis: duodenal rupture, peritonitis

Post-operation Diagnosis: duodenal descending retroperitoneal injury, peritonitis

Surgery operated: Berne-like operation (intestinal repair, external drainage of common bile duct, gastric antrum resection, gastrojejunostomy, duodenal fistulization, abdominal cavity drainage)

Operation Time: started at 7pm, ended at 11pm

Blood transfusion volume: 400ml

Surgeon: Mingle Li

Assistant 1: Shen, Yaping
Assistant 2: Wu, Maowang
Surgical nurse: Qian, Wailing

Anesthesia: Continuous epidural block
Anesthesiologist: Chen Qibin

样液体，肝十二指肠韧带区及十二指肠降部到右肾周围后腹膜大片水肿、增厚绿染，作Kocher切口，游离十二指降部，该处腹膜后大片疏松组织坏死，充斥胆汁样液体，清理后查出十二指肠降部右后侧破裂1.5cm粘膜外翻，继续寻找其他腹腔后器官未见损伤。

Procedure:

In supine position, routine disinfection was applied to the abdomen. The right longitudinal incision through the rectus abdominis muscle, 18cm in length, was performed subcutaneous hemostasis, and laparotomy was performed in sequence using a shawl.

A small amount of pale green fluid in the abdominal cavity was about 100ml. His stomach and duodenal bulb were normal, his liver looked normal in color and texture, smooth and nodular-free, and his spleen was roughly 500gm in hardness. A small amount of bile-like fluid was accumulated in the omental foramen, and a large area of edema and thickening green stain appeared in the retroperitoneum from the hepatoduodenal ligament area and descending part of duodenum to the periphery of right kidney. A Kocher incision was made to free the descending part of duodenum, where a large area of loose tissue behind peritoneum was necrotic and filled with bile-like fluid. After cleaning, 1.5cm mucosal eversion due to rupture in the right posterior part of descending part of duodenum was found, and no damage was seen in continuing to find other organs after abdominal cavity.

Incision of the common bile duct was performed for decompression, the nipple part was explored. The site of the injury was determined to be 1.5cm above the front of the nipple under direct vision. Under the guidance of biliary tract investigators, the ruptured bowel was trimmed and repaired carefully with double-layer suture and omentum covering. No tension was detected. The repair was satisfactory and the opening of the common bile duct was not affected.

The common bile duct was rinsed, and no leakage was found at the repaired part. The T-tube was used for external drainage, and the repaired common bile duct was rinsed under pressure without leakage.

Gastric antrum resection was performed, followed by decompression by duodenostomy, and gastrojejunostomy was performed before the colon. The anastomosis length was 4.5cm along the peristalsis opening.

As mentioned above, all procedures were in accordance with Berne’s procedure except for non-transection of the gastric vagus nerve, turning the damaged part into a duodenal diverticulum to facilitate the successful repair.

The abdominal cavity was thoroughly washed again, and tubes were placed for drainage from the Venturi orifice and the pelvic floor, followed by a duodenal fistula and T-tube insertion to lead out of the abdomen.

The abdomen was closed according to the layers and the operation was completed. The operation was uneventful and there was no accidental bleeding or collateral damage during the operation.

Conclusion of the operation:

Retroperitoneal injury and extensive inflammatory edema in the descending part of duodenum. The operation was conducted 28 hours after the injury, and the patient was in a critical condition. However, thorough diverticularization treatment was performed at the repair part, and healing was expected.

Performer and Record: Mingjie Li, 1993/10/7

Note: No postoperative complications occurred and the patient recovered smoothly. The patient was hospitalized for 34 days and then discharged from hospital. The patient was followed up for two years after operation and he had lived and worked normally. No doctor visit was required after operation.

Case 4. Left lateral hepatectomy, intrahepatic lithotomy and hepatobiliary basin internal drainage

Single operation record of Wuhu Changhang Hospital for Surgery Case 4

Name: Shui XX
Gender: Male
Age: 46

Bed No.: 10
Hospitalization No.: 16502

Operation Date: 1991/4/18

Pre-operation Diagnosis: hepatobiliary stones

Post-operation Diagnosis: hepatobiliary stones

Surgery operated: resection of most of the left external lobe of the liver + hepatobiliary stones removal + residual cholecystectomy + liver tube jejunum pelvic internal drainage

Operation Time: started at 2pm, ended at 8:40pm

Blood transfusion volume: 1200ml

Surgeon: Mingle Li

Assistant 1: Yang, Zonghua
Assistant 2: Shi, Lianghui
Surgical nurse: Gao, Jieqing

Anesthesia: intravenous compound intubation general anesthesia
Anesthesiologist: Chen Qibin

Macroscopic examination of surgical specimens revealed left intrahepatic stones, common hepatic duct, common bile duct, and residual gallbladder stones Name of pathological specimen sent for examination: left extrahepatic lobe Procedure: If epidural anesthesia was not effective, intravenous combined with tracheal intubation general anesthesia was adopted. Supine position, chest and abdomen routine iodine tincture, alcohol disinfection, disinfection shop single three layers. An arc-shaped incision was made under the right upper abdominal costal image to dry the left side of the xiphoid process first, and then the tip of the right 11 rib reached the right anterior axillary line, 30cm in length. The original surgical scar was excised, subcutaneous hemostasis was performed, and a skin towel was used. The incision was made layer by layer into the abdomen, and there was extensive intra-abdominal adhesion. After separation, the peritoneal cutting edge was sutured to the skin towel to isolate the incision. Blunt and sharp adhesion was separated along the hepatic margin, revealing the common bile duct, and its expansion reached 2.5cm, touching multiple stones. The gallbladder remained from the original operation, which was 2.0cm in diameter and contained stones. Stones were palpated in the transverse portion of the left hepatic duct. The liver was normal in color and soft without space-occupying lesions or fibrous atrophy. Stomach intestine pancreas spleen normal. We decided to perform hepatobiliary incision and stone removal, partial resection of the left outer lobe of the liver, residual cholecystectomy, and hepatic duct plastic basin-type enterohepatic drainage. The common hepatic duct was cut at a high position for stone removal and exploration of the biliary tract therefrom. The common bile duct and grade I and II hepatic ducts in the liver were all filled with stones, and the left hepatic duct still had a narrow ring, so the deep stones were difficult to be taken out. Hence, they were shelved and left lateral lobectomy was performed instead. Cut off the ligament of liver garden, falciform ligament, left coronary ligament, left and right trigonal ligament, make the liver down loose. A needle was inserted through the suture 1.5cm left of the second hepatic gate to pre-ligate the left hepatic vein. In turn, the hepatic pedicle was blocked (25 minutes) and most of the left outer lobe was excised so as to expose the transitional part of the transverse part of the left hepatic duct. The vessels on their sections were clamped, ligated and stopped bleeding respectively, the hepatic pedicle tourniquet was released, and the transverse part of the left hepatic duct was opened. Three grams of pigment stone in the inner bladder was removed. After the hepatic portal Glisson’s sheath was cut, the first-grade branch of the hepatic duct was separated upward along the hepatic door panel, and 4–5 g of calculi were removed from the confluence area of the hepatic ducts, and the calculi in the liver were removed by realignment and washing at the cross-section of the left hepatic duct. Then the “small gallbladder” was excised to dredge the entire distal common bile duct. The cystic duct was sutured and repaired without leakage by using the Oddis probe No.9. The common hepatic duct together with the left and right primary hepatic ducts were all unfolded, and they were sutured and ligated while being towed to expose the openings of the secondary hepatic ducts in the liver under direct vision, to remove the stones therein and expand the stenosis, which was then rinsed with hydrogen peroxide. The basin edge of the hepatic duct was trimmed with a basin diameter of 4.5cm. The jejunum was cut off 15cm below the initial position, and the abdominal vascular arch of the intestinal system was cut so that the distal jejunum tube was lifted to the brim of the basin without tension. A layer of mucosa-to-mucosa whole-layer suture was made with the mouth of the basin at an interval of 3mm with a new suture circle. No leakage was found after examination and extrusion. The periphery of the anastomosis was further reinforced by covering with paddle membrane, and several needles were suspended from the intestinal end slightly distal to the anastomosis and the liver bed to reduce tension. The ascending bowel was routed through the anterior colon without causing compression. The cross-section of the liver was reexamined and compressed with hot saline gauze to stop bleeding. After there was no bleeding or bleeding, the liver was left open and uncovered, so that a small amount of postoperative bleeding could be absorbed into the peritoneum. A lateral end anastomosis was performed at the distal 40cm part of the enteric loop for gallbladder transportation with the proximal section of jejunum. The entire inner layer was intermittently sutured, and the external reinforcement suture was performed, together with synchronous suture for 5cm, to make it Y-shaped, so as to resist reflux. After the surgical field was completely removed and wiped, both anastomoses were found to be satisfactory without distortion or compression. Double cannulae were placed under the liver, and the wound from the right abdomen was poked out of the abdomen. One needle was fixed and sutured. The abdomen was routinely closed according to the layers, and the wound was covered with dressings after operation, which was smooth during the operation and satisfactory in anesthesia. The patient was sent back to the ward. Surgical conclusion: 1 The hepatolith was removed completely, and the residual gall bladder was excised. There was no stenosis in the distal common bile duct through No.9 probe. 2 Partial resection of the left outer lobe of the liver is performed to eliminate left hepatic duct stones and stenosis. Its section is perfect for hemostasis. 3 The common hepatic duct and the left and right primary hepatic ducts were trimmed together into a “basin”, with the diameter of 4.5cm. All the secondary hepatic ducts were expanded, and stones were removed for washing. 4 Hepato-intestinal-pelvic anastomosis, with a diameter of 4.0cm, resistant to reflux. 5 The two anastomoses were sutured orderly without leakage, tension, distortion or compression.

Operator, record Li Mingjie 1991, 4, 19

Note: No residual stone or recurrence was found after reexamination by B ultrasound and follow-up for 4 years.

四、芜湖长航医院手术记录单例4

手术后标本肉眼检查所见: 左肝内结石，肝总管、胆总管、残余胆囊结石

送出检查病理标本名称: 左肝外叶

手术经过:

硬脊膜外麻醉无效改行静脉复合气管插管全麻。仰卧位，胸腹部常规碘酊、酒精消毒，铺消毒单三层。择右上腹肋像下弧形切口，始干剑突左旁，终于右11肋尖抵右前腋线，长30cm，切除原手术疤痕，皮下止血，披皮巾，逐层进腹，腹内广泛粘连，分离后，将腹膜切缘缝于皮巾以隔离切口。

沿肝缘钝性、锐性分离粘连，显露胆总管，见其扩张达 2.5cm，扪及多处结石，原手术残余胆囊，直径2.0cm，内含结石。左肝管横部扪及结石。肝色泽正常，质软，无占位病变，无纤维萎缩。胃肠胰脾正常。决定行肝胆管切开取石，肝左外叶部分切除，残余胆囊切除，肝管整形盆式肝肠内引流术。

高位切开总肝管，取石并由此探查胆道，胆总管、肝内 I、Ⅱ级肝管均充斥结石，左肝管尚有狭窄环，其深部结石不易取出，乃就此搁置，转而作左外叶肝切除。

切断肝园韧带、镰状韧带，左冠状韧带，左右三角韧带，使肝下降松动。于肝二门之左1.5cm处贯穿缝扎一针以预扎肝左静脉。转而阻断肝蒂 (25分钟) 切除左外叶大部，以显露左肝管横部移行部为度，其断面脉管分别钳夹结扎止血，松开肝蒂止血带，开放左肝管横部，取出其内胆色素性结石3克。

切开肝门Glisson氏鞘，沿肝门板向上分离出肝管一级分支，在肝管汇合区取出结石4-5克，并于左肝管断面会师冲洗取净肝内结石。继而切除“小胆囊”，疏通远端胆总管全程，Oddis括约可通过9号探子，缝合修补胆囊管无漏。

将肝总管连同左右一级肝管全部展开，边缝扎边牵引，直视显露肝内诸二级肝管开口，清除其内结石并扩张狭窄，双氧水冲洗。

修整肝管盆缘，盆径4.5cm。

空肠起始下15cm切断，剪裁其肠系腹血管弓，使远断肠管上提至盆缘无张力，与盆口作一层粘膜对粘膜全层缝合，针距3mm，间新缝合一圈，检查、挤压无泄漏，吻合口周边再以桨膜复盖加固，复在吻合口稍远侧肠端与肝床悬吊数针以减张力。上提之肠管由结肠前途径，未致压迫。

复查肝断面，热盐水纱布敷压止血，待无出血渗血后，任其敞开未加复盖，以期术后少量渗液利于腹膜吸收。

输胆肠袢远侧40cm处与空肠近端断面作侧端吻合，内全层间断缝合，外加固缝合，并作同步缝合5cm，使其呈y形，以抗返流。

彻底清除手术野，拭净，检查两吻合口满意，无扭曲及压迫，肝下置双套管，右腹戳创引出腹外，并于固定缝合一针。

常规依层关腹，术毕敷料复盖伤口，术中平顺，麻醉满意，送返病房。

手术结论:

1 肝内胆石已取净，残余胆囊切除，胆总管远端通过9号探子无狭窄。

2 肝左外叶部分切除，消除左肝管结石及狭窄。其断面止血完善。

3 肝总管与左右一级肝管共修整成“盆”，盆径4.5cm，诸二级肝管均已扩张，取石冲洗。

4 肝管肠盆式吻合，口径达4.0cm，抗返流。

5 两吻合口缝合有序，无漏、无张力、无扭曲及压迫。

术者、记录李名杰
1991，4，19

注: 术后B超复查及随访4年无残石及复发。

Case 5. Focal clearance and drainage for acute pancreatitis

手术后标本肉眼所见: 胰腺弥漫性水肿出血、局灶性坏死、腹腔大量血性渗出液、广泛皂化斑、胆囊结石水肿充血。送出检查病理标本名称: 胰腺、网膜、胆囊。

手术经过:

硬脊膜外麻醉有效。取仰卧位，腹部常规碘酊洒精消毒，铺无菌单三层。择右腹直肌纵切口长20cm，上抵剑突，下达脐下3cm，皮下止血，披皮巾，逐层开腹。

腹腔大量血性混浊液体涌出，量约2000ml，吸引之。腹腔广泛水肿充血、出血及遍布皂化斑，大网膜炎性团块状，全胰腺高度水肿伴出血坏死，小网膜腔积液500ml，胆囊充血水肿，其内结石多枚，最大一枚3.5cm及众多不成形胆泥，胆总管及肝内未扪及结石。肝质地色泽正常，脾正常，阑尾正常。

作胰包膜上下缘切开减压引流，清除少量坏死胰灶，再行Kocher切开松动胰头。胆囊切除，胆总管切开，其内径
0.8cm，未见结石及蛔虫等，下端可通过8号探子，置T管外引流。团块网膜部分切除，敞开小网腹腔，以利引流。

反复彻底冲洗腹腔、拭净。盆底Douglas窝双套管、胰床后下及网膜孔各置单管引流，连同T管分别戳创引出腹外并予以固定。

术中血压波动较大，麻醉深浅不定，手术进行颇为艰难，但无意外损伤、出血，术中补液3000ml、全血400ml，5% S.B. 500ml。

清点纱布器械无误，按层关腹，术毕安返病房。

手术结论:

1 急性重症胰腺炎，病性重，死亡率高，预后莫测。

2 手术已充分松动胰床、减压引流，胆总管减压引流，对抑转病情有利; 然胰腺有继续坏死可能。

3 胆囊已切除，消除了并存胆囊病灶。

Single operation record of Wuhu Changhang Hospital for Surgery Case 5

Name: Tang XX

Gender: Male

Age: 60

Bed No.: 38

Hospitalization No.: 15539

Operation Date: 1989/11/20

Pre-operation Diagnosis: Acute Severe Pancreatitis, Peritonitis, and Gall Bladder Stones

Post-operation Diagnosis: Pancreas Focus Clearance, Pancreas Bed Drainage, Cholecystectomy, Choledochal
T-tube External Drainage, Abdominal Cavity Drainage

Operation Time: started at 9pm, ended at 21, 开始于9Pm，完毕于21，1.30/Am ??? 1.30/Am

Blood transfusion volume: 400ml

Surgeon: Mingle Li

Assistant 1: Huang, Hongcheng
Assistant 2: Shi, Lianghui
Surgical nurse: Gao, Qingsheng

Anesthesia: continuous epidural block
Anesthesiologist: Wang Yisen

Macroscopic findings of the specimen after surgery included diffuse edematous hemorrhage of the pancreas, focal necrosis, massive hemorrhagic exudate from the abdominal cavity, extensive saponifying plaques, and edematous and hyperemic cholecystolithiasis. Name of pathological specimen sent for examination: pancreas, omentum and gall bladder. Procedure: Epidural anesthesia is effective. In the supine position, the abdomen was routinely disinfected with iodine tincture and covered with three sterile sheets. A longitudinal incision with a length of 20cm was made in the right rectus abdominis muscle, reaching up to the xiphoid process and down to 3cm below the umbilicus. The incision was stopped by subcutaneous hemostasis, covered with a skin towel and laparotomized layer by layer. A large amount of bloody and turbid fluid gushed out from the abdominal cavity, measuring about 2000ml, and it was attracted. There were extensive edema, congestion, hemorrhage in the abdominal cavity and saponifying plaques, large omental inflammatory lumps, high-level edema of the whole pancreas with hemorrhage and necrosis, 500ml of fluid in the small omental cavity, and congestion and edema of the gallbladder. There were many stones therein, the largest one was 3.5cm and many unformed biliary muds, and there were no stones palpable in the common bile duct and liver. The liver is normal in color, the spleen is normal, and the appendix is normal. An incision was made at the upper and lower margins of the pancreatic capsule for decompression and drainage, to remove a small amount of necrotic pancreatic lesions. Then a Kocher incision was performed to loosen the pancreatic head. Cholecystectomy and common bile duct incision were performed. The inner diameter was
0.8cm, and no stones or ascaris lumbricoides was found. The lower end could be drained through a T-tube through a No.8 probe. Partial resection of the omentum of the mass was performed, and the small omental cavity was opened for drainage. Repeatedly and thoroughly wash the abdominal cavity and wipe it clean. Single drainage tubes were respectively placed in the double sleeves of Douglas fossa at the pelvic floor, the posterior lower part of the pancreatic bed, and the omental foramen, and then they were separately wound-poked and led out of the abdomen together with the T-tube and fixed. Blood pressure fluctuated greatly during the operation, and the degree of anesthesia was variable. The operation was quite difficult, but there was no accidental injury or bleeding. During the operation, 3000ml of fluid replacement, 400ml of whole blood, and 5% S.B. 500ml were administered. Count gauze equipment and correct, according to the layer of abdominal, BiAn return ward. Surgical conclusion: 1 Severe acute pancreatitis is characterized by severe illness, high mortality and unpredictable prognosis. 2 The operation has fully loosened the pancreatic bed, decompressed drainage and decompressed drainage of the common bile duct, which are beneficial to the disease inhibition and metastasis. However, there is a possibility of continue pancreatic necrosis. 3 The gallbladder has been excised, and the coexisting gallbladder lesions have been eliminated.

Operator, record: Mingjie Li, 1989/11/21

Note: stress ulcer bleeding and shock occurred 14 days after operation, and the patient was rescued without second operation. Recovered and discharged. Followed up for 6 years with no recurrence. Case 6. Radical surgery for rectal cancer

手术后标本肉眼检查所见: 菜花样癌块6cm，侵犯肠管一圈，累及肠壁全层。

送出检查病理标本名称: 直肠癌肿连同其上25cm、其下5cm肠管，肠系膜下动脉根部淋巴结。

手术经过:

仰卧，头向低15，臀部抬高体位。会阴消毒，预置导尿管开放于床边挂并内。

腹部常规消毒，铺单三层，择经左腹直肌纵切口长25cm，脐上二指至耻骨上缘，皮下止血，披皮巾，逐层开腹。切口全层予以隔离。

无腹水，腹膜无结节，肝正常，无转移灶，胃胰脾无异，肠系膜下动脉根部及主动脉旁无肿大之淋巴结，全结肠无病变，腹内无粘连，小肠系膜多发黄豆大淋巴结。腹膜反折上1cm直乙交界处肿块6cm侵及该段肠管一圈及全层，但未梗阻，结肠空虚。

决定作直肠前切除术，Dixon术式。阻断癌肿上、下肠腔，病灶部肠内注入 5-Fu 500mg。作肠系膜下动脉根部淋巴结活切。结扎切断左结肠动脉降支，保留其与升支边缘动脉网，病灶上10cm结肠血动良好。

左侧腹膜后解剖，直视左输尿管全程，离断乙状肠系膜，远离病灶外3cm切开腹膜反折，游离达肿块下7cm直肠。

盆腔内生殖器无病复，子宫略大 (经后期)，附件(一)，与癌肿无关联，术终时应求顺予扎管绝育 (各缝扎一针)。

切除病灶上25cm及下5cm之乙直肠，消毒后作对端吻合，两层间断缝合，无泄漏，血运良好，无张力。

分别以蒸馏水、0.1%新吉尔灭、5-Fu 500mg 及生理盐水浸泡、清洗腹、盆腔、仔细止血。

修复后腹膜及重建盆底、将吻合口置于腹膜外，其附近置双套管负压引流戳创引出。腹腔Douglas后窝烟卷引流。

清点纱布器械无误，分层关腹，术中失血少，经过平顺，术毕，安返房。

Single operation record of Wuhu Changhang Hospital for Surgery Case 6

Name: XXX
Gender: Female
Age: 44

Bed No.: 38
Hospitalization No.: 13533

Operation Date: 1987/4/2

Pre-operation Diagnosis: rectal adenocarcinoma

Post-operation Diagnosis: DukesB1 stage of rectal adenocarcinoma

Surgery operated: anterior rectal resection (Dixon’s technique)

Operation Time: started at 9am, ended at 1:30pm

Blood transfusion volume: 800ml

Surgeon: Mingle Li

Assistant 1: Cai, Yalun
Assistant 2: Shen, Yaping
Surgical nurse: Gao, Jieqing

Anesthesia: continuous epidural block
Anesthesiologist: Chen Qibin

Macroscopic examination of the specimen after surgery showed that the cauliflower-like carcinoma was 6cm in size and involved one circle of the intestinal canal and the entire intestinal wall. Name of pathological specimen sent for examination: rectal cancer swelling together with its upper 25cm and lower 5cm intestinal tubes, and lymph node at the root of inferior mesenteric artery. Procedure: Supine, head down 15, hip up position. Perineum disinfection, preset catheter open in the bed hanging and inside. The abdomen was routinely sterilized and spread in three layers. The longitudinal incision through the left rectus abdominis muscle, 25cm in length, and the two upper navel fingers to the upper margin of pubic bone were selected for subcutaneous hemostasis, and the abdomen was opened layer by layer with a skin towel. The entire lay of that incision is isolated. No ascites, no nodule in peritoneum, normal liver, no metastasis, no difference in stomach, pancreas and spleen, no enlarged lymph nodes at the root of inferior mesenteric artery and paraaortic, no lesion in the whole colon, no intra-abdominal adhesion, and multiple soybean and large lymph nodes in mesentery. The mass at the junction of straight B and 1cm in retroperitoneal fold invaded one circle and the whole layer of this segment of intestine by 6cm, but it was not obstructed and the colon was empty. It was decided to perform anterior resection of the rectum using the Dixon procedure. The upper and lower intestinal cavities of the cancer were blocked, and 5-Fu 500mg was injected into the intestine of the lesion. A lymph node biopsy of the root of the inferior mesenteric artery was performed. The descending branch of the left colonic artery was cut off by ligation, and its marginal arterial network with the ascending branch was preserved. The blood movement of the colon 10cm above the lesion was good. The left retroperitoneum was dissected, and the whole process of the left ureter was observed under direct vision. The B-shaped mesentery was separated, and the peritoneum was incised and reversely folded 3cm away from the outside of the lesion and free to the rectum 7cm below the mass. There was no recovery of pelvic internal genitalia, and the uterus was slightly larger (in the later stage), Appendix (1), which had no connection with cancer. Therefore, ligation and sterilization (one needle for each suture) should be performed smoothly at the end of the operation. The second rectum 25cm above and 5cm below the lesion was excised. After disinfection, it was anastomosed to the right end with two layers of intermittent suture without leakage, good blood supply and no tension. Rats were immersed in distilled water, 0.1% neomycin, 5-Fu 500mg and normal saline, respectively, for abdominal and pelvic cleaning and careful hemostasis. The retroperitoneum was repaired and the pelvic floor was reconstructed. The anastomosis was placed outside the peritoneum, and a double-tube negative pressure drainage puncture wound was placed nearby for extraction. Abdominal Douglas posterior fossa cigarette drainage. The gauze devices were counted without error, and the abdomen was closed in layers. The blood loss during the operation was small. After the operation was smooth and completed, the gauze was returned to the room.

Conclusion of the operation:

The adenocarcinoma of upper rectum has a good differentiation. Although it has invaded 肠管 and the whole layer of intestine one week, and the disease stage is fairly long, no extra-intestinal metastasis is found. The prognosis is estimated to be better following the standard Dixon radical resection.

There is no tension at the anastomosis, the blood supply is good, and the suture is satisfactory, so the complication risk of leakage should be small. The operation has been conducted in accordance with the principle of sterility and no tumor, hence iatrogenic implantation dissemination will be rare. Postoperative chemotherapy should be supplemented to enhance the curative effect.

Operator, record: Mingjie Li, 87/4/2

Note: Patient recovered well without any complications. She had been hospitalized for 26 days and discharged after recovery. The patient was followed up for 8 years without recurrence or symptoms, and her quality of life was normal. Digital rectal examination showed soft mucosa at anastomosis, with intestinal cavity free and wide.

Treatment of scapulohumeral periarthritis with acupuncture combined with warm moxibustion

Chinese Medicine Paper III

Treatment of scapulohumeral periarthritis with acupuncture combined with warm moxibustion

Scapulohumeral periarthritis is a degenerative, aseptic, chronic inflammation of the capsula articularis humeri and the soft tissue of periarthritis humeri. It is often seen in patients around the age of 50, so it is also called “fifty shoulders”. We explored the treatment of 152 cases of scapulohumeral periarthritis with acupuncture at Jianyu (LI 15) through Jiquan (EX-B2) combined with warm moxibustion and western medicine prednisolone blocking method. It shows that the acupuncture treatment has satisfactory efficacy. The results are summarized below.

Clinical Data

In the 152 cases of general data, there are 70 males and 82 females, with the minimum age of 42 years and the maximum of 67 years. The shortest course of disease was two months and the longest was 10 years.

Clinical manifestations:

Pain in the shoulder, involving the neck and the whole upper limb, numbness of the fingers, limited abduction, external rotation and internal rotation, different degrees of obstacle at the shoulder joint, and disuse atrophy of the muscles.

Treatment methods:

1. Acupuncture combined with warm moxibustion group (94 cases)

Acupoint selection: in sitting position, with elbow flexion, and arm abduction to a horizontal position, at the same height as the shoulder, in the center of the upper part of the deltoid muscle, a bright depression is observed as acupoint on the lower margin of the acromion.

Acupuncture depth: the needling is performed vertically and deeply for about four inches, to the extent that the tip could be touched in the axilla, without passing out of the skin.

Manipulation: the needles are first inserted by twirling, lifting and thrusting, followed by twirling and tonifying.

Needle sensation: the swelling and numbness in the shoulder can be radiated to the elbow, or even to the neck and fingers, and the local warm sensation can be diffused around. Retain the needle in place for 15–20 minutes.

Moxibustion therapy: the mild moxibustion was performed using suspended moxibustion with moxa stick or fixed with a moxa holder, which lasted about 20 minutes.

Moxibustion sensation: the local baking-like heat sensation is transmitted to the neck, transverse to the shoulder, or even to the finger, or after moxibustion the patient feels cold sensation outward, with the cool sensation flowing mixed with warm sensation, and finally replaced by heat sensation, whereupon the symptoms well improved or disappeared. Acupuncture is usually applied in the morning and moxibustion in the afternoon, with seven days as a course of treatment.

2. Local blocking with prednisolone group in contrast (58 cases)

Prednisolone 25MG plus 2% procaine 2-4ML was injected into the greater tuberosity of humerus, gluteus monodon and other common tender points. Generally, there is a rebound reaction with aggravating symptoms on the next day, and the symptoms gradually improved after that. The treatment was conducted once every seven days, and three to five times constituted a course of treatment.

Efficacy criteria

Recovery: Pain disappeared, affected limb abduction, adduction, anterior flexion and posterior extension activities freely.
Markedly effective: The pain basically disappeared, and the shoulder joint function was basically restored, but the affected shoulder was sour, swollen and uncomfortable.
Improved: The pain was obviously milder, and the shoulder joint function was improved as compared with that before treatment.
No effect: No change in symptoms after treatment.

Therapeutic effect

Acupuncture combined with warm moxibustion group (94 cases): 48 cases (51%) cured, 24 cases (25.5%) markedly improved, 19 cases (20.2%) improved, 3 cases (3.2%) ineffective, and the effective rate is 96.8%.
Prednisolone blocking group (58 cases): 116 cases (27.6%) cured, 24 cases (41.3%) improved, 18 cases (31.0%) ineffective, and the effective rate is 69% (P<0.01???).

A typical case:

Wang XX, a 59-year-old woman, had a history of right scapulohumeral periarthritis for ten years, with repeated episodes of severe winter and mild summer. In case of relapse due to coldness, local sealing with prednisolone, acupuncture, and Chinese medicine treatment could slightly relieve the pain. 疼痛、發涼、酸痛 and aching pain of shoulder joint were mild in day and severe at night, with limited activity. The affected limb was not easy to extend, and the right arm could not reach the left shoulder, nor could it reach the front of the iliac. The shoulder felt stiff, like in a bundle shape 如捆绑状. The patient accepted Gu Jiu-xiang纳谷久香, and her tongue coating was thin and white, and his pulse was deep and slippery. After deep needling of “Taiji Spring” at the lower part of Jianyu (LI 15) 給予深針肩髃穴下透極泉, the manipulation was performed as presented above, so that the warm sensation in the shoulder was felt to flow into the palm of the hand. After the needle, the pain was relieved by half and the activity was improved. In the afternoon, moxibustion was applied, and after 15 minutes, the patient felt cold air driven outward, followed by warm sensation in the whole shoulder and upper limb. The limbs after moxibustion felt comfortable and their function was improved. Four days after the treatment, no further chill occurred, and the shoulder muscles felt released. The right hand could touch the left shoulder, and backward extension could reach the twelve thoracic vertebrae. After two weeks of this routine treatment, all the symptoms disappeared and the shoulder joints moved freely. The 4-year follow-up showed no recurrence.

Experience and insights

Jianyu (LI 15) is an important acupoint for the treatment of persistent ailment of shoulder and arm. In classical works, there was a quotation that “Zhenquan acupuncture projects immediately from Jianyu (LI 15)”, revealing its great efficacy. Ancient physicians attached great importance to the treatment of this disease with local shoulder measurements at Jianyu (LI 15). In “Song of Jade Dragon” written by Guonao Wang from the Yuan Dynasty, he said, “the swelling and pain at the shoulder were unbearable, and that cold and dampness vied with qi and blood. If one applied nourishment and reduction to the shoulders and curls, one could benefit from moxibustion for peaceful health”. Yiding Wu in the late Qing Dynasty also wrote in his “On Magic Moxibustion“: “mortals’ shoulder arms often feel cold pain once encountering cold weather. Some suggested to massage with hot hands, and add comforters in the night to make do. Moxibustion with two acupoints at Jianyu (BL15) is required to treat this disease. “

The author’s own experiences are as follows.

1, The cases of red swelling and hot pain in scapulohumeral periarthritis are rare, and most of them are cold, wet and cold. It has been proved in practice that acupuncture and moxibustion at Jiquan (CV 4) through Jianyu (LI 15) have the effects of dredging channels and collaterals, dispelling wind and cold, activating blood and relieving pain. My teacher, Director Meisheng Zhou, believes that deep needling and good needling sensation are the key for effective treatment. The depth of acupuncture at this point must be limited to about 4 cun4寸, and the needling manipulation is preferably to such extent that the needle enables the local warm sensation diffusing to the perineum or limb end. The effect is due to moxibustion sensation from local baking-like heat, flowing hot air with outflow of cold air. There are also cases of cure due only to local warm sensation.

2. The key for the successful penetration of Jianyu Jiquan 肩髃透極泉?? Lies in the anatomical factors. The shoulder joint is the joint with the largest overall range of motion, belonging to the ball-and-socket joint屬球窝關節. Its glenoid is only 1/3–1/4 that of the humeral head其關節盂僅及肱骨頭的1/3～1/4. The glenoid fossa is extremely shallow, and the joint capsule is thin, loose and wide. In addition, due to the above special position during needle insertion, the penetration of Jianyu Jiquan is possible, and the humeral head cannot block it. It has been proved clinically that it is easy to succeed as long as the essentials are grasped.

3. Compared with the control group (locally blocked group) using western medicine, this method is not only free from the side effects of hormones and symptoms rebound from local irritation, as well as from the pains of having to accept multiple times of multi-point injections, it is also superior to the strong “correcting” therapy in preventing the aggravation of chronic strain.

By Yangzhen Li & Mingle Li

“Naturopathy” (quarterly), Vol. 15, no.3 (autumn), 1992

Treatment of acute soft tissue injury with moxibustion (draft)

Chinese Medicine Paper II

Treatment of acute soft tissue injury with moxibustion

Report of 113 cases

Since 1987, we have treated 187 cases of acute soft tissue injury with moxibustion using “Zhou’s All-power Moxibustion Pen” invented by the moxibustion expert Dr. Meisheng Zhou and using conventional local closed control in western medicine, proving that the curative effect of moxibustion is satisfactory for acute soft tissue injury. The results are summarized below.

Clinical data

本组共187例，其中男117例，女70例;年龄最小11岁，最大78岁，以20~50岁者为多见; 病程均在3天以内，以6小时内为多。肘部损伤12例，腕部损伤14例，腰部损伤76例，膝部损伤16例，踝部损伤69例，以腰、踝部损伤多见。本组病例全部选择闭合性损伤，并以软组织损伤为限，主要是急性肌肉扭伤，不包括急性韧带挫伤、韧带断裂和各类骨折、骨裂，并剔除急性椎间盘突出。主要临床表现为局部疼痛，放射至邻近部位，肿胀、乏力，功能减退或消失，活动受限，损伤之关节不能作全幅活动，被动拉伸。做最大静力收缩和重复损伤机转时，疼痛均显著加重，多可在一条或数条肌肉处查到固定压痛点，肌肉损伤能摸到紧张性痉挛。其中灸疗组113例，局封组74例。

There were 187 cases in this group, including 117 males and 70 females. The youngest was 11 years old and the oldest was 78 years old, and the patients aged from 20 to 50 years old were more common. The course of the disease was within three days, most of which was within six hours. There were 12 cases of elbow injury, 14 cases of wrist injury, 76 cases of waist injury, 16 cases of knee injury and 69 cases of ankle injury, among which the waist and ankle injuries were more common. All cases in this group chose closed injury, which was limited to soft tissue injury, mainly acute muscle sprain, excluding acute ligament contusion, ligament rupture, and all kinds of fractures and fractures, and excluding acute disc herniation. The main clinical manifestations include local pain, radiation to adjacent parts, swelling, weakness, hypofunction or disappearance, limited motion, inability to make full motion of the damaged joint, and passive stretching. When the maximum static contraction and repeated injury machine rotation are performed, the pain is significantly aggravated, and more fixed tenderness points can be found in one or more muscles, and tonic spasm can be felt due to muscle injury. There were 113 cases in the moxibustion group and 74 cases in the local sealing group.

Therapeutic method

1. 灸疗组取穴原则为在损伤部位上下、周围循经选穴，局部损伤部位，从背部寻找阳性压痛点。三者均是本病选穴的思路。肘部损伤取手三里、曲池、肘髎、尺泽。腕部损伤取阳溪、阳池、阳谷、外关、大陵、支沟、太渊。腰部损伤取肾俞、委中、昆仑、腰阳关、秩边、殷门、命门。膝部损伤取阳陵泉、阴陵泉、足三里、梁丘、血海、承山、委中、膝眼、犊鼻、曲泉、梁门。踝部损伤取昆仑、太溪、申脉、解溪、悬钟、丘墟、中封。同时加用局部损伤部位和背部阳性压痛点。将点灸笔点燃后，右手食指和拇指挟持药笔下1/3端，左手将备好的药纸平铺覆盖在穴位上，用点灸笔隔药纸对准所选穴位雀啄样点灼4~5下即可，避免将药纸燃穿，防止造成烫伤，灸后患者自觉局部不痛或仅有蚊咬样微痛，局部皮肤无改变，或微红润。灸量以轻重适中为佳，重则易烫伤皮肤起水泡，手法过轻则达不到治疗目的。灸后局部穴位可搽薄荷油，以防发疱。若不慎而烫伤发疱，可用绿药膏外搽或自制蟾皮油膏搽拭 (蟾皮 6g, 冰片 6g，麻油250g，将蟾皮、冰片研粉浸人麻油中，7天后可用)，每日数次，3~5日后可愈，不留疤痕。每日点灸2次，3日为1个疗程。

1, The principle of acupoint selection in the moxibustion group was to select acupoints above, below and around the injury site along the meridians, and to find positive tenderness points from the back of the local injury site. All these are the ideas of acupoint selection for this disease. For elbow injury, the acupoints of Zusanli (ST 36), Quchi (LI 11), Quliao (LI 14) and Chize (CV 12) were selected. The wrist injuries were recorded from Yangxi (GB 34), Yangchi (GB 34), Yanggu (GB 34), Waiguan (GB 26), Daling (GB 39), Zhigou (GB 34) and Taiyuan (GB 39). Shenshu (BL 23), Weizhong (BL 40), Kunlun (BL 60), Yaoyangguan (GB 34), Zhibian (GB 26), Yinmen (BL 21) and Mingmen (BL 21) were selected for the lumbar injury. For knee injury, Yanglingquan, Yinlingquan, Zusanli, Liang Qiu, Xuehai, Chengshan, Weizhong, Xiyan, Dubi, Ququan and Liangmen were selected. The ankle injuries were taken from Kunlun, Taixi, Shenmai, Jiexi, Xuanzhong, Qiuxu and Zhongfeng. Meanwhile, positive tenderness points at local injury site and back were added. After the moxibustion pen is ignited, the index finger and the thumb of the right hand grip the 1/3 end of the medicinal pen, the left hand flatly covers the prepared medicinal paper on the acupoints, and the medicinal paper partition of the moxibustion pen is used for aiming at the sparrow-pecking point burning at the selected acupoints for 4-5 times, so that the medicinal paper is prevented from being burnt through, and the scald is prevented; and after moxibustion, the patient feels no local pain or only slight pain like mosquito bites, and the local skin is unchanged or slightly ruddy. The optimal quantity of moxibustion is moderate in severity, which is apt to cause burns and blisters on the skin if it is severe, or therapeutic purpose can not be achieved if the manipulation is too mild. Peppermint oil can be applied to local acupoints after moxibustion to prevent blistering. For burns and blisters caused by carelessness, the green ointment could be applied externally or the self-made toad skin ointment could be applied for wiping (6g of toad skin, 6g of borneol and 250g of sesame oil; the toad skin and the borneol were ground into powder and immersed in the sesame oil for 7 days; the powder could be used); the ointment could be applied for several times a day and cured after 3–5 days without leaving scars. Moxibustion was performed twice a day, and 3 days constituted a course of treatment.

2. 局封组取1%利多卡因2~10ml加地塞米松5~10mg，据不同损伤部位及年龄大小酌量注射治疗。如腕部损伤一般注射2~4ml，而腰部损伤则可注射5~10ml。其要点是必须使药液注射到肌肉于骨骼附着点内，腰部则将其注人骶棘肌肌腹中，而不可仅注人皮下疏松组织中。

2. In the local sealing group, 2–10 mL of 1% lidocaine plus 5–10 mg of dexamethasone were injected, appropriately according to the injury site and age. For example, 2–4 mL can be injected for wrist injury and 5–10 mL for waist injury. The main point is that the liquid medicine must be injected into the muscles at the attachment points of bones, and into the muscular belly of human sacrospinous muscle at the waist, instead of only into the subcutaneous loose tissues.

治疗结果

两组疗效比较，统计学处理 x平方 = 16.68，P < 0.01, 点灸组疗效明显优于局部封闭组。

Treatment results

The curative effects were compared between the two groups. The statistical treatment showed that the x-square was 16.68, P < 0.01. The curative effect of the moxibustion group was significantly better than that of the local sealing group.

体会

急性软组织损伤是临床多发病，尤以腰踝部损伤多见，西医较优良方法常是局部封闭疗法，以促进瘀血吸收，肿胀消退，并阻断局部恶性刺激的反射弧，增进无菌性炎症的消退以达到止痛和恢复功能。实践证明，点灸疗法在对穴位进行温热刺激后，能使损伤之肌肉组织在发生节律性强烈收缩后转为松弛，能改善患处的微循环，提高新陈代谢，使气机通畅，血脉调和，经络通达，加速渗出物的吸收，从而使本疗法具有解痉消炎，消肿止痛，尽快恢复受伤部位功能的作用。

Experiences and insights

Acute soft tissue injury is a frequently-occurring disease in clinic, especially in the waist and ankle. The local blocking therapy is often adopted by the better western medicine to promote the absorption of blood stasis and the regression of swelling, block the reflex arc of local malignant stimulation, and promote the regression of aseptic inflammation to achieve the purpose of pain relief and recovery. It has been proved in practice that after warm stimulation, the damaged muscle tissues can be converted into relaxation after rhythmic and strong contraction, thereby improving the microcirculation and metabolism of the affected part, enabling the qi movement to be smooth, the blood vessels to be harmonious, the meridians to be accessible, and the absorption of exudate to be accelerated. As a result, the moxibustion therapy has the effects of relieving spasm and inflammation, relieving swelling and pain, and recovering the function of the injured part as soon as possible.

Date of Receipt: June 09, 1998

Author’s affiliation: 241000 Wuhu, Second Affiliated Hospital of Southern Anhui Medical College (Zhen, Li Yang); Wuhu Changhang Hospital (Li Mingjie) Original edition of Shanghai Journal of Acupuncture and Moxibustion (Vol. 18, No.1, 1999) (clinical report)

收稿日期 1998-06-09 齐丽珍发稿

作者单位: 241000 芜湖，皖南医学院附属第二医院(李杨缜); 芜湖长航医院 (李名杰)

原载《上海针灸杂志》1999年2月第18卷第1期（临床报道）

Non-operative treatment of senile cholelithiasis with integrated traditional chinese medicine

Chinese Medicine Paper I

Non-operative treatment of senile cholelithiasis with integrated traditional chinese medicine

Cholelithiasis is a common disease in digestive system of the elderly. In recent years, we have adopted non-operative therapy of integrating Chinese traditional medicine and Western medicine to treat 26 cases of cholelithiasis in the elderly and have obtained some experience. The report is as follows.

1 Clinical data

1.1 General information

There were 7 males and 19 females in this group, including 17 cases aged 60–70 years old, 6 cases aged 70–80 years old, and 3 cases over 80 years old. All cases were confirmed as cholelithiasis by B-scan ultrasound. There were 8 cases of gallbladder stones, 9 cases of common bile duct stones, 5 cases of gallbladder bile duct stones, and 4 cases of intrahepatic bile duct stones. There were 5 cases with the diameter of stone <5mm, 6 cases with the diameter of 6–10mm, 11 cases with the diameter of 11–15mm, 2 cases with the diameter of 16–20mm and 2 cases with the diameter of 21–30mm. There were 17 cases of multiple calculi and 9 cases of single calculi in this group.

1.2 Dialectical classification

Dialectical classification mainly involves liver-qi stagnation type, liver and gallbladder damp-heat type, and liver stagnation and spleen deficiency type.

Their common symptoms include distending pain in the right hypochondrium to varying degrees, even reaching to the shoulders and back, nausea, vomiting, aversion to oil, and less belching and anorexia嗳气纳少.

For the liver-qi stagnation type, the symptoms also include shifting pain points, distension and pain in the right hypochondrium, which vary in severity following the emotional changes, bitter mouth and dry throat, pale tongue with white coating and tight pulse. They are mostly seen in the early stage of the disease and sometimes accompanied by biliary colic.

For the damp-heat type of liver and gallbladder, the interaction between cold and heat is noticed, together with paroxysmal biliary colic, and mild and moderate yellow staining of sclera or skin. Urine looks like cypress juice, having red tongue with yellow and greasy coating, and wiry or slippery pulse 脉弦或滑数 is more common in patients with concomitant biliary tract infection.

For liver stagnation and spleen deficiency syndrome, the symptoms include dull pain in the right hypochondrium, anorexia, white tongue coating, and wiry and thin pulse, which are more common in patients with chronic cholecystitis.

2 Treatment methods

2.1 Indications for non-operative therapy of integrating traditional Chinese medicine with modern western medicine

All cases in this group were treated with non-operative therapy of integrated Chinese and Western medicine. The subjects of this therapy were those who met the following conditions: (i) those with gallstones < 5mm and good gallbladder function; (ii) Gallstones > 5mm with cardiopulmonary dysfunction; (iii) choledocholithiasis < 20mm in diameter or mild cholangitis; (iv) those with intrahepatic bile duct stones but cannot be operated on.

2.2 Treatment methods

2.2.1 TCM treatment: the basic prescription of TCM is for oral intake, including 20g of Herba Lysimachiae, 10g of Radix Bupleuri, 12g of Radix Scutellariae, 12g of Radix Curcumae, 12g of Radix Aucklandiae, 12g of Fructus Aurantii Immaturus, 12g of Semen Arecae, and 10g of Radix Glycyrrhizae. The prescription should be decocted with water for oral administration. The drug is taken one dose per day, and the treatment is conducted continuously for 1 to 2 months. Configurations depending on types: for patients with exuberant stagnation of liver-qi, flavoring paste and dried tangerine peel can be added; for patients with exuberant damp-heat, add Jun Chen and Shan Zhi. For patients with exuberant spleen deficiency, Rhizoma Atractylodis Macrocephalae, Poria, and Radix Codonopsis are added. For patients with exuberant Yin deficiency, remove Radix Bupleuri plus Radix Glehniae, and add Radix Paeoniae Alba and Radix Rehmanniae. For patients with extravasated blood, 淤血者加赤芍、丹参 add Radix Paeoniae Rubra and Radix Salviae Miltiorrhizae. For patients with difficult stool and dry constitution, 加大黄、元明粉Dahuang and anhydrous sodium sulfate are added. For severe abdominal pain, add Rhizoma Corydalis 15 and Fructus Citri Sarcodactylis. Patients accompanied with coronary heart disease, hypertension, chronic bronchitis, diabetes, etc., had better follow the therapy principle of integrated traditional Chinese medicine with conventional western medicine for treatment.

2.2.2 Acupuncture therapy: acupoints of Ganshu (BL 18), Danshu (BL 23), Yanglingquan (GB 34) and Dannang (BL 20) are pinpointed for acupuncture once or twice a day, with the needle retained for 30 minutes. Therapy for 10 days forms a treatment course and leave two days at the interval between the treatment courses. The acupuncture therapy continues to dredge meridians and collaterals, promote gallbladder function and remove stones in coordination with Chinese traditional medicine.

2.2.3 With western medicine drugs and fluid replacement, correct the imbalance of water and electrolyte. For antipyretic and antibiotics, choose ampicillin, 4g a day to add to 250-500 ml of sugar salt water in the static drops 静滴. Prescribe metronidazole 0.4g each time, 3 times a day, 10–20 days as a course of treatment. If clinical symptoms such as fever do not improve, perform blood culture and drug sensitivity teststo help select antibiotics. For patients with emesis, metoclopramide 5mg should be alternately injected at Zusanli (ST 36). 呕吐者用胃复安5mg足三里交替注射

3 Treatment results

3.1 Efficacy criteria: efficacy is assessed based on clinical symptoms, signs and auxiliary examination results.

3.1.1 Cure: the symptoms and signs disappear completely. The body temperature and hemogram are back to normal. B-scan ultrasonography is used to re-examine cases to ensure that there are no stones remaining in the gallbladder or hepatobiliary ducts.

3.1.2 Markedly effective: symptoms have disappeared, with normal body temperature and hemogram, B-scan ultrasound re-examination indicating significant reduction of gallstones or hepatobiliary calculi.

3.1.3 Improved: the symptoms are basically under control, with normal body temperature and hemogram. No significant reduction of the gallstones or hepatobiliary calculi under B-scan ultrasonography.

3.1.4 No effect: symptoms and physical signs stay unchanged after treatment, and the stones have not been discharged upon B-scan ultrasound examination. The patient needs to be treated by other methods.

3.2 Treatment results: out of the 26 cases, 8 cases cured, accounting for 13%; 12 cases (46%) markedly improved, and 4 cases (15%) improved, 2 cases (7%) ineffective. The overall effective rate is 93%.

4 Example Case

Zhang XX, female, 67 years old, retired worker. Her first diagnosis was made on July 10, 1993. The patient had a history of cholelithiasis in the past. The pain in her right upper abdomen occurred three times in the preceding month. As the symptoms became milder, suddenly, after lunch that day, she had right upper abdominal colic radiating to her right shoulder and back, with continuous moaning, aversion to cold, fever, nausea and vomiting of stomach contents, anorexia, asthenia, and loose stool纳呆乏力，溲赤便约. Also observed were red tongue with yellow and greasy coating and wiry and rapid pulse. Physical examination: T 38.7C degrees, blood pressure 18/12Kpa. Acute pain, mild yellow staining of skin and sclera, cardiopulmonary (1) 心肺(一), abdominal muscle tension, liver, spleen and subcostal untouched. Mofei’s sign is positive. 墨非氏征阳性。

B-scan ultrasonography revealed: (i) Multiple gallstones, the largest of which was 20×25 mm. (ii) Left intrahepatic bile duct stone. Blood white matter count, WBC 8.2×10/L N 0.83 L 0.17. Liver function, jaundice index 29mmol/L, GPT74 units, HBSAg negative. 血白分计数，WBC 8.2×10/L N 0.83 L 0.17。肝功能，黄疸指数 29mmol/L，GPT74单位，HBSAg阴性。

Lipid analysis:

Cholesterol 4.5mmol/L, triglycerides 1.18 mmol/L. In traditional Chinese medicine (TCM), acupuncture at Yanglingquan (GB 34), Ganshu (BL 18) and Danshu (BL 23) is the first choice for relieving pains due to the syndrome of damp-heat in liver and heat accumulation due to qi stagnation. Anti-inflammatory fluid replacement with western medicine has the effects of regulating the balance of water and electrolyte and reducing the fever of acute patients caused by frequent nausea, vomiting, anorexia, or diarrhea triggered by diarrhea drugs. Moreover, the body fluid was quickly replenished, thus avoiding bile concentration, beneficial to the dissolution of gallstones.

Most of the 26 patients had gallbladder and biliary tract inflammation in the past, and the total white blood cells and neutrality were often high. Some patients had jaundice and liver damage to different degrees. Acupuncture, anti-inflammation and fluid replacement, as well as the traditional Chinese medicines of soothing liver, cholagogue and clearing heat, and resolving stasis 中药疏肝利胆清热、化淤诸法 were all conducive to improving the symptoms and controlling inflammation. Practice has proved that acupuncture and the combination of Chinese and western medicine complement each other and can bring out the best effects.

By Mingjie Li & Yangzhen Li, 05/11/1991

Proceedings of First International Conference on Naturopathy in China (37)

Prevention and treatment of trichomonas vaginalis and mold infection (draft)

Appendix II: by Pan, Yaogui

Prevention and treatment of trichomonas vaginalis and mold infection

Physiology mechanism 生理 of vaginal channel:

The vaginal mucosa epithelial cells of adult healthy women contain animal starch, and the vagina contains gram-negative bacilli, the so-called vaginal bacillus (Doderlein’s bacilli), which can decompose starch into lactic acid to maintain a certain acidity (PH=4.5) in the vagina, to prevent pathogenic bacteria from multiplying in the vagina, thereby maintaining biological characteristics and self-defense function in the vagina.

为阴道毛滴虫，属鞭虫种系，呈梨形，较中性白血球稍大，其顶端有四条鞭毛，体部有波动膜，尾部有轴柱，活动为直轴转动和向前波动。

当PH5.5-6.0时最适宜生长:当PH<4.5>7.5时就不易生长。

当温度在35℃-37℃最适宜生长，但在一10℃和38-40℃亦能活7-9小时。而25-27℃可活120-150小时(一般浴水约30℃);普通井水可活5天，在肥皂水中可活9小时在干燥环境中可活12-20小时。。

1 Trichomonas vaginitis

1.1. Etiology

Trichomonas vaginalis, a whipworm strain, is pear-shaped and slightly larger than neutrophils; it has four flagella at the top, a fluctuating membrane at the body, and an axial column at the tail, with the activities rotating along a straight axis and fluctuating forwards.

Optimum PH5.5-6.0 for growth: PH<4.5>7.5 for poor growth. The optimum growth temperature is 35 C-37 C, but it can survive 7-9 hours at a temperature of 10 C and 38-40 C. While from 25 to 27. degree. C. to 120 to 150 hour (generally about 30. degree. C. in bath water); Normal well water can live for 5 days, 9 hours in soapy water and 12-20 hours in a dry environment. Apparently, it can widely exist in nature and is easy to get spreaded.

1.2 Method of dissemination:

1.2.1 Direct transmission: sexual transmission is dominant.

1.2.2 Indirect infection: via bath, bath utensils, underwear and personal feces, urine infection, toilet, medical equipment, etc.

1.3 Pathogenesis

Although there are different theories, it is mostly believed that trichomonas is not pathogenic. It mainly consumes glycogen in vagina and hinders the formation of lactic acid, thus reducing the acidity in vagina and destroying the defense function of vagina. Pathogenic bacteria are then easy to propagate and cause inflammatory reaction. Trichomonas does not invade tissues to cause pathological changes.

1.4 Incidence rate:

In China, the incidence of minor illnesses is about 20% (20–25%) 小发病牵国国内统计为20%左右 in the United States and 10%-25% in the Soviet Union) and 16.7%-32.36% in factories. It is higher among married women than among unmarried women; the rate is higher for pregnant women than other women.

1.5 Symptoms and Signs:

Symptoms usually begin one week after infection.

1.5.1 Vaginal vulva is itchy and has the sensation of insect crawling, but does not affect sleep and activity, only triggered by secretion stimulation. A few cases evolve to dermatitis.

1.5.2 Vaginal secretions increased, a yellowish foam (due to decomposition of carbon water compounds and discharge gas), thin, with a bad smell or hemorrhagic, purulent, stimulate the pudendal skin and cause discomfort and pain.

2.阴道分泌物增多，呈灰黄色泡沫状(因分解炭水化合物而排出气体)、稀薄、有臭味或血性、脓性，刺激阴部皮肤而致不适及疼痛。

1.5.3 Infertility: trichomonas can devour sperm, vaginitis can affect sperm survival so as to interfere with pregnancy.

1.5.4 Urinary system symptoms: urethritis symptoms such as frequent micturition, urgency urination, and urinary pain.

1.5.5 Examination of vaginal speculum: red granules are observed on the vaginal wall, in the shape of waxberry fruit.

1.6 Diagnosis:

According to medical history, pruritus and foamy leucorrhea can be diagnosed. The diagnosis requires suspension for the detection of active trichomonas, as well as smear and culture methods.

1.7 Treatment:

1.7.1 General treatment: pay attention to personal health, avoid sex life, reduce local stimulation, keep local dry.

1.7.2 Local treatment:

①阴道酸化，恢复其生物特性和自净作用。常用0.5%醋酸液或1%乳酸液冲洗，每天一次，10天为一疗程，注意孕妇只能擦洗，未婚者用导尿管冲洗。大蒜头煎汤熏洗亦有效。

②驱虫治疗:灭滴灵、滴维净、卡巴肿等，每晚塞阴道内1片，10天为一疗程。曲古霉素10万单位，每晚一片塞阴道，14天为一疗程。

Vaginal acidification to restore its biological characteristics and self purification. Commonly used 0.5% acetic acid solution or 1% lactic acid solution washing, once a day, 10 days as a course of treatment, pay attention to the pregnant women can only be swabbed, unmarried with catheter washing. Decocting garlic in soup and fumigating and washing are also effective.
deworming treatment: one tablet was stuffed into the vagina every night for metronidazole, diweijing, and carboprost, with 10 days as a course of treatment. The quantity of tricitabine was 100,000 units. One tablet was used to plug the vagina every night, and 14 days constituted a course of treatment.

1.7.3 Systemic treatment:

Oral anthelmintic; (for ordinary couples), metronidazole 0258/ day, 10 days as a course of treatment. Or 2 g (0.25×8), the cure rate is 95% and the side effects are not more than 10 days therapy. (1-HI)
Treatment of comorbidity: the treatment of genital inflammation can restore the biological characteristics of the vagina, which is not conducive to the growth of trichomonas.
Complications of treatment: for example, symptomatic treatment of urinary tract infection, antibiotic treatment of vaginitis (chloramphenicol 0.25 for vagina), and repeated treatment if there were still symptoms after one course of treatment.

3.全身治疗:

①口服驱虫药;(一般夫妻同时服)灭滴灵0258/日，10天为一疗程。或2克(0.25×8)顿服，其治愈率达95%，副作用并不比10日疗法多。(1-HI)

②治疗并存病:治疗生殖系炎症可恢复阴道生物特性，从而不利滴虫生长。

③治疗并发症:如:尿路感染对症治疗，阴道炎抗菌素治疗(氯霉素0.25塞阴道)，如果经治疗一疗程仍有症状可重复治疗。

1.8 Prevention:

Strengthen health education, do a good job in personal health, ban pool bath, transform public toilets from sitting to squatting, bath isolation (with individual towels and basins), medical equipment disinfection, treatment and strict management of the patients carrying worms.

六、诊断:

根据病史，骚痒症状及白带呈泡沫状等即可诊断。确诊需悬液检见活动的毛滴虫，还可用涂片及培养方法。

2 Mycotic vaginitis (candidal vaginitis)

Mycotic vaginitis is vaginal inflammation caused by Candidaalbicans. Its incidence rate is second only to trichomonas vaginitis, and it is more common in pregnant women, patients with diabetes and those who have long-term application of antibiotics. And is often complicated with other inflammation. Candida can be parasitic in the vagina at ordinary times, and whenever glycogen in the vagina increases: when the acidity increases, it can rapidly proliferate and cause symptoms. First, the mode of infection: mainly indirect.

2 霉菌性阴道炎(念珠菌阴道炎)

霉菌性阴道炎是由白色念珠菌(Candidaalbicans)所致的阴道炎症。其发病率仅次于滴虫性阴道炎，多见于孕妇、糖尿病患者及长期应用抗菌素者。并常与其他炎症并发。

念珠菌平时可寄生于阴道，每当阴道内糖元增多:酸性增强时即可迅速繁殖而引起症状。

一、传染方式：以间接为主。

二、临床表现及特征：

1.外阴奇痒:由小阴唇内侧开始后蔓延至外部症状十分显著。

2.阴道分泌物:急性期常减少，呈凝乳块或豆渣样白带。

3.窥阴器检查;外阴、阴道粘膜常被一层白膜复盖，揭除后显示粘膜轻度红肿。

4.分泌物涂片及悬液检见病原菌，亦可作培养。

三、治疗:

1冲洗阴道:常用2-4%苏打水或龙胆草液(4两煎成500cc水)3/日，10天一疗程。

集育

2.制霉菌素，50万单位每晚一次，塞阴道，10天一疗程。

3.曲古霉素膏外用(溃疡面)或0.5%龙胆紫涂外阴及阴道壁。

4.内服治带净片8片，8/日。

四、预防:

1.加强卫生宣传教育，说明此病传染方式。

2.治疗原发病，如糖尿病。避免滥用抗菌素。

3.杜绝传染源:改良浴具、浴池、厕所等，医疗器械严密消毒，以杜绝交叉感染。

II. Clinical manifestations and characteristics:

Abnormal vulva itching: The symptoms that begin on the inner side of the labia minora and spread to the outside are very significant.
Vaginal discharge: it is often reduced in the acute phase, with a white discharge like curds or bean dregs.
Examination of vaginal speculum; Vulva and vaginal mucosa were often covered with a layer of white membrane, and the uncovered mucosa showed mild swelling.
Excreta smears and suspensions may be cultured if pathogenic bacteria are detected. III. Therapies: 1 Vaginal irrigation: 2-4% soda water or Radix Gentianae liquid (decocted into 500cc water in 4 pairs) was usually used for 3/ day, and a course of treatment lasted for 10 days. Set education 2. Nystatin, 500,000 units once every night, vaginal plug, 10 days of treatment. 3. Qugu mycin ointment is applied externally (on the ulcer surface) or 0.5% gentian violet is applied to the vulva and vaginal wall. 4. Take 8 Zhidai Jing tablets orally, 8/ day. IV. Prevention: 1 to strengthen health publicity and education, that the disease transmission. 2. treating primary diseases such as diabetes. Avoid abuse of antibiotics. 3. Eliminate the source of infection: improve the bath, bath, toilet, etc., and closely disinfect the medical devices to eliminate cross infection. Comparison of trichomonas vaginitis and mycotic vaginitis

滴虫性阴道炎和霉菌性阴道炎比较表

病名	滴虫性阴道炎	霜菌性阴道炎
病原体	毛滴虫，正常健康阴道内无。	白色念球菌，正常阴道内也存在。
传染方式	以直接为主: 性交等方式	以间接为主; 通过浴具、浴池等。
临床特征	阻止阴道内正常乳酸形成，阴道内酸度减低，破坏正常防御机能，有利于病菌生长、繁殖而致阴道炎，本身无致病性。	在正常阴道内霉菌虽存在，但不致病，而每当阴道酸度增强时(如糖尿痼患者或孕妇及常用抗菌素者)则霉菌即可迅速繁殖，而引起阴道发炎。
发病机理	1. 外阴，阴道痒，不影响工作和睡眠。 2. 白带多、灰黄色、或伴有血性及脓性，呈泡沫状 3，阴道壁有红色颗粒，呈杨梅果样。 4. 或有尿道炎症状并存。 5. 悬液检查见活毛滴虫。	1. 外阴奇痒，重者可影响睡眠及工作。 2. 白带多少不一，呈乳凝块或豆渣样。 3. 阴道粘膜被一层由膜覆盖，揭除后可见粘膜红肿。 4. 无泌尿系炎症情况。 5. 悬液检查可见白色念球菌。
治疗	1. 常用酸性液冲洗阴道，如0.5%醋酸或1%乳酸、大蒜头液熏洗。 2. 驱虫治疗: 灭滴灵、滴维净、卡巴肿、曲古霉素等塞人阴道内或口服灭滴灵。 3、抗菌素同时合并应用(青链、氯等)。 4. 治疗并发病，泌尿系炎症 (呋喃坦啶)。 5. 治疗、管理带虫者。	1. 常用碱性液冲洗阴道，如2-4%苏打水。 2. 制霉菌素，曲古霉素，阴道内用药。 3. 一般不用抗菌素。 4. 病因治疗: 如糖尿病的治疗等。 5. 不需要治疗带菌者(因为正常阴道内有霉菌存在)。

By Yaogui Pan, Gynaecology and Obstetrics Department

Nanling Medicine, 1979; 1:45-47

Rivanol induction of labour by amnion cavity injection (draft)

Obstetrics and gynecology paper II

Rivanol induction of labour by amnion cavity injection

Clinical Analysis of 120 Cases

妊娠全程中，因某种原因随时需要终止妊娠，本是妇产科工作内容之一。在大力推行计划生育工作中，仍以此作为避孕、绝育的补救措施，更有增加趋势。除早孕以吸宫、刮宫一次处理完毕作为定型手术而获得较为满意的效果外，孕周在13周以后的中、晚期妊娠，则需要人工引产。虽方法众多，但均因各有利弊而不尽完善。近年来同道们正力图不断更新方法，以期求得安全、有效、少痛苦、缩短时间。我院在进行过程中，天花粉、芜花、羊水、高渗糖及羊水、高渗盐水交换等引产法之后，吸取国内外先进经验，于1980年4月-10月又集中开展了一批利凡诺羊膜腔注入引产法。通过临床实践，感到效果良好，现就资料完整120例予以总结，并略加分析、讨论。

Pregnancy termination is required at any time during the whole pregnancy process for some reason, which is one of the tasks in obstetrics and gynecology department. In the vigorous implementation of family planning work, it is still used as a remedial measure for contraception and sterilization, and there is a growing trend. In addition to treating early pregnancy with one-off aspiration and curettage to obtain a satisfactory effect as a finalize the design operation, artificial induction of labor is required for the middle and late pregnancies with gestational weeks beyond 13 weeks. Although there are many methods, they are not perfect due to their respective advantages and disadvantages. In recent years, our colleagues are trying to constantly update the method, in order to obtain safe, effective, less pain, shorten the time. In the process of induction of labor in our hospital, after the induction of labor with trichosanthin, Wuhua, amniotic fluid, hypertonic glucose and amniotic fluid, hypertonic saline exchange, and drawing on the advanced experience in China and abroad, another batch of induction of labor with rivanol amnion implantation was carried out intensively from April to October 1980. Through clinical practice, we feel the effect is good. 120 cases with complete data are summarized, and slightly analyzed and discussed.

适应症与禁忌症

1、18孕周以上，直至临产床前，因主动要求或因病被迫需妥终止妊娠，而又无禁忌症者。但妊娠34周以上，胎儿有可能成活。如因母子原因需提早分娩而又希望胎儿成活者除外。

2、生殖器炎症，若经阴道途径引产易致宫内感染者适于此法。

3、体质衰弱，心、肾、肝、肺功能不全。急性传染病等需积极治疗待改善后方可慎行。

4、急慢性泌尿系感染，需先行控制。否则易因上行感染而加重病情。

5、妊娠晚期若并有产道机械障碍或胎位不正。胎儿畸形，需在引流中适时给以助产或碎胎或放弃引产改行手术产。

Indications and contraindications

1, more than 18 weeks of gestation, until before the delivery bed, due to active request or due to illness was forced to properly terminate the pregnancy, and no contraindications. However, after 34 weeks of gestation, the fetus may survive. Except in cases where early delivery is required due to mother-child reasons and the fetus is expected to survive.

2, genital inflammation, if induced labor by vaginal route easily cause intrauterine infection is suitable for this method.

3, weak constitution, heart, kidney, liver, lung dysfunction. Acute infectious diseases need active treatment and can be treated cautiously only after improvement.

4, acute and chronic urinary infection, need to control. Otherwise, the disease is easily aggravated by ascending infection.

5. If there is any mechanical disorder of the birth canal or abnormal fetal position during the third trimester of pregnancy. Fetal malformations, need to give timely midwifery or fetal fragmentation in drainage or give up induced labor to surgery.

临庆资料

全组120例。年龄最小15岁，最大为48岁，初孕妇22人，经孕妇98人。孕期在18-38周。一次功成119例，成功率99.11%。作产时间: 初孕妇平均为40.3小时。经产妇为58.5小时，平均49.4小时。一次排出88例，胎盘残留者24例，有宫缩乏力行钳刮7例。失败一例，改用水囊引产而获成功。本组无二次注药。平均住院5天，住温66例正常，54例低热，最高为38℃，待胎儿排出后均自行下降正常。平均出血量约50毫升，全组无死亡。但有一例在钳刮中并发羊水栓塞经抢救成功。

Clinical materials

There were 120 cases in this group. The youngest was 15 years old and the oldest was 48 years old. There were 22 primiparous women and 98 menstruating women. Pregnancy is between 18 and 38 weeks. One-off success was achieved in 119 cases, with the success rate of 99.11%. Labor time: the average duration of first trimester pregnancy was 40.3 hours. 58.5 hours, with an average of 49.4 hours. There were 88 cases of one-time discharge, 24 cases of retained placenta, and 7 cases of curettage with forceps due to uterine inertia. In the case of failure, the abortion was succeeded by using water bladder instead. There was no second drug injection in this group. The average hospitalization time was five days. Among the 66 cases with normal dwell temperature and 54 cases with low grade fever, the highest was 38℃, and all of them spontaneously declined to normal after the fetus was discharged. The average amount of bleeding was about 50 ml, and there was no death in the whole group. However, one case of complicated amniotic fluid embolism during curettage was successfully rescued.

induction of labor effect:

Among 119 cases of successful induction of labor, 112 cases of fetus were discharged by oneself, and all of them were stillborn. The remaining seven cases were 18–24 weeks pregnant. If the orifice of the uterus was opened due to uterine inertia or abnormal fetal position, curettage was performed with satisfactory results (Table 1)

Table 1 relationship between drainage time and gestational week and cases The drainage time mostly disappeared between 25 hours and 72 hours, reaching 88%, and the duration of labor was shorter as the gestational month became larger. There are many opportunities for natural childbirth, which shows that the uterus is relatively sensitive.

(一) 引产效果:

引产成功的119例中，自行排出胎儿112例，全部死胎。余7例均为妊娠18-24周，因宫缩乏力或胎位不正，而宫口已开，则行钳刮术而获效满意(如表1)

表1 引流时间与孕周关系及例数

孕周	例数	24小时内	25-48小时	49-72小时	> 73 小时	平均作产时间
18-21	38	2	15	18	5	56.1
22-25	35	0	11	21	3	48
26-29	22	1	8	12	1	45.3
30-34	16	7	3	6	0	44
> 35	8	3	3	2	0	42
合计	119	13 10.9%	40 33.0%	59 50%	7 5.9%	47.1

引流时间大多数在25小时至72消失之间，达88%，而孕约月愈大作产时问愈短。自然娩出机会多，显示子宫较为敏感。

References

Special summary of induced labor in second trimester pregnancy: materials from National Family Planning Experience Exchange Meeting
Department of Obstetrics and Gynecology, Bengbu Third Hospital, 1978: summary of 216 cases of induced labor in second and third trimester pregnancy by amnion cavity injection from Rever Woer. Family planning data compilation 1978
Liu Yong et al., amniotic fluid (review). Foreign Medical References, Gynaecology and Obstetrics fascicle 2:41 1975
Zhou Lijuan et al. Effect of rivanol on immune uterus. Data compilation of rivanol induced labor in second trimester
Wu Hanjing: 525 cases were treated with rivanol amnion injection. Analysis of the Effect of Induced Labor in Middle and Late Pregnancy (Internal Data) 1980
First Medical University: Gynaecology and Obstetrics. P: 61-541 people’s health press, 1978 September 1980 exchange of materials at the first academic conference on obstetrics and gynecology of anhui province by li mingjie, pan yaogui, nanling county hospital

参考资料

[1] 中期妊娠引产专题小结: 全国计划生育经验交流会资料 1978年[2] 蚌埠三院妇产科: 雷佛妇尔羊膜腔注射中、晚期妊娠引产216例小结。计划生育资料汇编 1978年[3] 刘庸等：羊水 (综述)。国外医学参考资料、妇产科分册 2:41 1975年[4] 周丽娟等: 利凡诺对免子宫作用的探讨。利凡诺中期妊娠引产资料汇编[5] 吴涵静：525例利凡诺羊膜腔注射。中晚期妊娠引产效果分析 (内部资料) 1980年[6] 上一医等: 妇产科学。P: 61-541 人民卫生出版社 1978年

一九八〇年九月南陵县医院李名杰潘耀桂安徽省首届妇产科学术会议交流资料

Extraperitoneal cesarean section (draft)

Appendix I: by Pan, Yaogui

Extraperitoneal cesarean section

Clinical Summary of 8 Cases

为结束妊娠必须娩出胎儿及其附属物，以恢复孕妇原先的生理状态。若因产道障碍无法由阴道分娩，或胎儿窘迫不及等待自然分娩，就需另寻分娩途径。

It is necessary to deliver the fetus and its appendages in order to end the pregnancy and restore the original physiological state of the pregnant woman. If vaginal delivery is not possible due to birth canal obstruction, or if the fetus is embarrassed and cannot wait for natural delivery, alternative routes of delivery may be necessary.

有史可查，早在500年前即有“帝王切开”古典式剖腹产，近代发展到子宫下段剖腹产，而此两术式均属腹膜内剖腹产术，可导致羊水、胎粪、血液等污染腹腔，引起肠麻痹、腹胀、腹痛等症状，甚至招致肠粘连、腹膜炎等严重並发症，带来不良预后，尤其是宫内感染者，更形不利。

According to available history, as early as 500 years ago, there was a classical cesarean section called “imperial incision”. In modern times, it has developed to the cesarean section at the lower part of the uterus. Both of these operations are intraperitoneal cesarean sections, which can cause amniotic fluid, meconium and blood to contaminate the abdominal cavity, causing symptoms such as enteroparalysis, abdominal distension and abdominal pain, and even causing serious complications such as intestinal adhesion and peritonitis, with a poor prognosis. Particularly, people infected in the uterus are even more disadvantageous.

1909年拉氏Latzk首创了腹膜外剖腹产。国内60年代逐渐开展(1)，直到近来才开始普及，并作了改进。80年10月份我省妇产科年会上省立医院报告了该院同年元月份起施行的30例临床小结(3)。会议以后，我院由11月份起开展了此项手术，两月来共施行8例。现将初步体会报告如下。

The extraperitoneal caesarean section was first performed by laplace Latzk in 1909. It was gradually carried out in the 1960s in China (1) until recently it began to be popularized and improved. The clinical summary of 30 cases implemented in the provincial hospital since January of the same year was reported at the annual meeting of obstetrics and gynecology department of our province in October of 80 years (3). Since the meeting, we have performed this procedure since November. A total of eight cases have been performed in the past two months. The preliminary experience is reported as follows.

临床资料

1980年我科剖腹产共45例 (小型剖腹产除外），分别为古典式12例, 子宫下段25例，腹膜外8例，其中11月份以后10例剖腹产中8例施行了腹膜外术式，全部病例均已痊愈出院。

现将8例腹膜外剖腹产的有关临床情况，列表与其它术式比较 (取其平均值):

* 该术式11月份新开展，故与全年其它术式例数无比较意义。

clinical data

In 1980, 45 caesarean sections were performed in our department, including 12 cases of classical cesarean section, 25 cases of lower uterine segment, and 8 cases of extraperitoneal. Among the 10 caesarean sections performed after November, 8 cases underwent extraperitoneal surgery, and all the cases were discharged after recovery. The clinical conditions of 8 cases of extraperitoneal cesarean section were listed and compared with other operations (the average value was taken): * This procedure was newly performed in November, so it had no significant comparison with other procedures throughout the year.

上表显示腹膜外剖腹产术式最大特点为肠排气时间短，平均术14分12秒, 而另两术式均需2~3天，因而可以进食早，输液少，节省费用，增进机体恢复。

The above table shows that the greatest feature of the extraperitoneal cesarean section is the short time of intestinal flatus, with an average of 14 minutes and 12 seconds, while the other two procedures require two to three days, thus leading to early intake of food, less infusion, cost saving, and improved body recovery.

(一) 手术指征:

凡剖腹产术的手术指征，皆适於此术，若有宫内感染，指征则更为强烈。本组手术对象为： 1 产道障碍 (头盆不称) 3例；2 宫内窘迫 (早期破水) 4例；3 头盆不称並发先兆子宫破裂 (死胎) 一例。

1, Surgical indications: All indications for cesarean section are suitable for this operation, and the indication is more intense if intrauterine infection exists. The surgical objects in this group were as follows: 1) 3 cases with birth canal disorder (cephalopelvic disproportion); 2 intrauterine distress (early water breakthrough) 4 cases; One case of threatened uterine rupture (stillbirth) complicated with cephalopelvic disproportion.

2, Anesthesia: Total epidural anesthesia. Good muscle relaxation facilitates blunt dissection and the patient is quiet during surgery.

(二) 麻醉:

全部硬膜外麻醉。良好的肌肉松弛，便於钝性剥离，术中病人安静。

(三) 手术方法:

我们全部采用诺通式 (Noton) 法。取脐耻间正中纵型切口10 –12厘米，逐层切开腹壁，仅留腹膜不切开，常在左侧腹壁连同腹横筋膜深入钝性分离膀胱侧壁筋膜寻找黄色脂肪垫，推去此脂肪块后即见腹膜反折与膀胱侧壁及闭锁的腹下A形成的“三角区”，以此为基点向右、向前、然后向后，作钝、锐性分离。若剥破腹膜即予缝合。待子宫下段显露足够时开宫。胎儿及其附属物的娩出、宫壁缝合等均同子宫下段术式。膀胱及腹膜反折自然复位，不需缝合。但需仔细止血，清理创野以减少术后渗血及吸收热。常规分层缝合腹壁各层，可不予引流(4)。

3, Surgical methods: We all adopt the Noton method. A longitudinal incision 10–12 cm was made in the middle of the area between navel and disgrace. The abdominal wall was incised layer by layer, leaving only the peritoneum without incision. The fascia on the lateral wall of bladder was often deeply and bluntly separated from the fascia on the left abdominal wall together with the transverse abdominal fascia to find the yellow fat pad. After the fat mass was pushed out, the “triangle area” formed by retroperitoneum, the lateral wall of bladder and the atretic infraabdomen A was seen, and the blunt and sharp separation was performed rightward, forward, and then backward based on this. If the peritoneum is peeled off, it is sutured immediately. Open the uterus when the lower part of the uterus is exposed enough. The delivery of the fetus and its appendages, and the suture of the uterine wall were all the same as those for the lower uterine segment. The bladder and peritoneum were reversely folded and naturally restored without suture. However, careful hemostasis and clearing of the wound field are needed to reduce postoperative bleeding and heat absorption. The layers of the abdominal wall were sutured conventionally in layers without drainage [4].

充盈膀胱，对初术者似有必要，便于认清解剖关系。我们在第一、二例中，术前曾用美兰液充盈膀胱，第三例用无菌生理盐水灌注膀胱。后即免除此一手续，同样可以辩认榜胱境界。

Filling the bladder may be necessary for the primary operator to understand the anatomical relationship clearly. In the first and second cases, the bladder was filled with methylene blue before surgery, and in the third case, the bladder was filled with sterile normal saline. Later that is exempt from this procedure, also can identify countries.

(四) 並发症:

全组手术无膀胱损伤，仅两例术后24小时内有轻微血尿，后自止转清，但有三例术中剥破腹膜，均於开宫前缝合，术后排气时间並未延长。

4, Complications:

There was no bladder injury during the operation of the whole group. Only two cases had slight hematuria within 24 hours after operation and recovered from scratch. However, in three cases, the peritoneum was torn during the operation, and all of them were sutured before opening the uterus. The postoperative exhaust time was not prolonged.

讨论

腹膜外剖腹产的最大特点是不经腹，无腹腔搔扰、污染之弊，术后病人恢复顺利，若剥离得当、创野清理得仔细、止血彻底，感染极少，一般无需引流，吸收热亦不高，本组平均4.4天，体温降到正常，无一例感染。

Discussion

Extraperitoneal cesarean section is the biggest characteristic of the abdominal, no abdominal itching, the disadvantages of pollution, postoperative patients recover smoothly, if peeling properly, carefully clean up the field, hemostasis thoroughly, very few infection, generally no drainage, heat absorption is not high also, the average of 4.4 days, the body temperature fell to normal, no infection.

此术操作难点在於腹膜外的钝性剥离，一边是菲薄透亮的腹膜，一边是膀胱壁，两者均顾忌损伤，而致初术者左右为难，也因此长期阻碍着此术式的普及和推广(1)。但近年来大量实践证明，並非如此困难，其实子宫下段剖腹产也就是腹膜外术式操作的一部分，只不过经腹打开膀胱腹膜反折而已。如果复习一下妊娠期该处局部解剖上改变，就能发现由於子宫的增大，子宫下段与膀胱及其腹膜反折的关系都相应发生变化，使膀胱旁窝升出盆腔，因此手术易於将腹膜反折经由腹膜外将其从膀胱顶部和子宫前壁推开，再者膀胱肌层在钝性剥离下並不易损伤全层。即使剥破腹膜，由于在开宫前即可缝合，仍然杜绝了腹腔污染的可能，同样不会减弱“腹膜外”手术意义。而若能够掌握要领，即在左侧 (右侧亦可，但习惯於左侧，除顺手方便之外，产时子宫多向右旋转，此处易於显露) 找到“脂肪垫”和“三角区”以便直入膀胱子宫间隙，获得一个恰当的“层”，在此处开始扩大剥离腹膜反折，亦较方便。但需注意，腹膜不能承受过大张力，尤其着力不均，易致撕破，可在直视下锐性分离来回避这一可能。这样进宫时间较其它术式並不显著延长。国内近年来各院报告，术始到胎儿娩最短为14分至25分。本组最快一例亦为14分钟。关键在于熟练和得法，在此基础上手术指征可以放宽，凡需要剖腹产者，一般皆能适应。即使胎儿窘迫，产前出血和紧急情况，熟练术者亦不作禁忌之列。本组胎儿窘迫4例，子宫先兆破袭1例，均施此手术，除一例死胎外，余者均母子平安。如同时有剖腹探查指征者，我们的看法，亦可在腹膜外剖腹产操作完成並清理创野之后，隔离下切开腹膜探查。如並行输卵管结扎者，亦可在宫腔操作之后，腹膜打一小洞而行之。故此类病创亦绝非此术的禁忌症，同样可以保持宫腔内容物不污染腹控的优越性。

The difficulty in this operation lies in the blunt dissection outside the peritoneum. One side is the thin and translucent peritoneum, and the other side is the bladder wall. Both of them are not afraid of injury, which causes the dilemma for the initial operator and hinders the popularization and promotion of this operation for a long time (1). However, a large number of practices in recent years have proved that it is not so difficult. In fact, the cesarean section in the lower part of the uterus is part of the extraperitoneal operation, which is just to open the bladder peritoneum and fold it backwards through the abdomen. If we review that anatomic change at this site during pregnancy, we will find that due to the enlargement of uterus, the relationship between the low part of uterus and bladder and its peritoneum reflex will change accordingly, causing the paravesical fossa to rise out of the pelvis. therefore, the operation is easy to push the peritoneum reflex away from the top of bladder and the anterior wall of uterus through extraperitoneum. moreover, the bladder muscular layer is not easy to damage the whole lay under the blunt dissection. Even if the peritoneum is peeled and broken, the possibility of abdominal cavity pollution is still eliminated because the suture can be performed before the uterus is opened, and the significance of “extraperitoneal” surgery is not weakened. If we can grasp the essentials, we should find the “fat pad” and “trigone” on the left side (the right side is also acceptable, but we are used to the left side. In addition to being convenient, the uterus is often rotated to the right during labor, and it is easy to expose here) to directly enter the bladder-uterine space and obtain an appropriate “layer”, where we can begin to expand the stripping peritoneum and reflex, which is also more convenient. However, it should be noted that the peritoneum cannot bear excessive tension, especially due to uneven application of force, which is prone to tear. The possibility can be avoided by sharp separation under direct vision. The time to enter the uterus in this way was not significantly longer than that in other operations. In recent years, various hospitals in China have reported that the shortest score from the start of surgery to the delivery of the fetus is 14 points to 25 points. The fastest case in this group was also 14 minutes. The key lies in proficiency and good method. On this basis, the surgical indications can be relaxed, and patients who need cesarean section can generally adapt to it. Skilled artisans are not contraindicated even in the setting of fetal distress, antepartum hemorrhage, and emergencies. Four cases of fetal distress and one case of threatened uterine rupture were treated. Except for one dead fetus, the mother and child were all safe. In our opinion, laparotomy can also be performed under isolation after the extraperitoneal cesarean section has been completed and the wound field has been cleared. For tubal ligation, a small hole in the peritoneum can be made after uterine cavity manipulation. Therefore, such lesion is not a contraindication for this operation, and it can also maintain the superiority of abdominal control without polluting the intrauterine contents.

最后关于此术式命名问题，我们赞成南京工人医院妇产科意见 (2)。因为此术並不剖腹而仅剖宫，故称之为“腹膜外剖宫取胎术”较之“腹膜外剖腹取胎术”这一含混矛盾的命名为妥。

Finally, regarding the nomenclature of this procedure, we agree with the opinion of the Department of Obstetrics and Gynecology of Nanjing Workers’ Hospital [2]. Because this operation does not involve laparotomy but only dissection of the uterus, it is better to call it “extra-peritoneal dissection of the uterus and fetuses” than the vague and contradictory name of “extra-peritoneal laparotomy and fetuses taking”.

小结

本文报导我院80年11月份以来开展的腹膜剖腹产8例，並与同年其它术式作一临床比较。结合复习文献，通过操作体会，认为此术式术后恢复快，手术技术亦易掌握，在熟练的基础上，基本上可以取代其它术式。

我们仅在开展初期，体会十分肤浅，犹待积累更正。

Summery

In this paper, we report 8 cases of C-section of peritoneum performed in our hospital since November 80 and make a clinical comparison with other procedures in the same year. Based on literature review and operating experience, it is considered that this operation has a rapid postoperative recovery and easy mastering of surgical techniques. On the basis of proficiency, it can basically replace other operations. We are only in the early stage of development. Our experience is very superficial and we still need to accumulate and correct it.

References

Clinical application of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology 1965 November (4) P315
Nanjing Workers’ Hospital: Clinical application value of extraperitoneal cesarean section. Chinese Journal of Obstetrics and Gynecology 1965 November (4) P29
Anhui Provincial Hospital: Clinical summary of extraperitoneal cesarean section. Provincial Annual Meeting of Gynaecology and Obstetrics in 80 Years (Internal Data)
Su Yingkuan et al. Gynaecology and Obstetrics Surgery (P440) People’s Health Publishing House, 1973 January 5, 1981 nan ling county hospital obstetrics and gynecology pan yaogui This paper is an academic exchange paper of provincial society of obstetrics and gynecology

参考资料

[1] 腹膜外剖腹产手术的临床应用。中华妇产科杂志 1965年11月(4) P315[2] 南京工人医院: 腹膜外剖腹产临床应用价值探讨。中华妇产科杂志 1965年11月(4) P29[3] 安徽省立医院: 腹膜外剖腹产临床小结。80年省妇产科年会 (内部资料)[4] 苏应宽等: 妇产科手术学（P440）人民卫生出放社，1973年

一九八一年元月五日南陵县医院妇产科潘耀桂

本文为省妇产科学会学术交流论文

Intrauterine abortion combined with tubal pregnancy rupture (draft)

obstetrics and gynecology paper I

Intrauterine abortion combined with tubal pregnancy rupture

A Case Report

子宫内、外同时妊娠並均中止，临床上极为罕见。我们出诊遇到一例，现报告如下。

It is extremely rare to have both intra-uterine and extra-uterine pregnancies terminated simultaneously in clinic. We encountered a case of house call, which is now reported as follows.

患者23岁，结婚两年未曾生育，平素月经尚属正常。停经52天，伴有恶心、偏食、嗜睡等早孕反应。79年4月22日突然阴道流血伴下腹痛，继而排出胚胎组织，经检查证实为完全流产。俟后阴道流血停止及腹痛消失，一般情况尚好。尔后于第九天夜间，患者诉开始行房，当即感到右下腹疼痛伴头昏出汗等，急诊於当地医院被认为流产后感染或肠寄生虫症，给予四环素及止痛片，患者回家。翌晨再次剧烈腹痛並伴休克，於5月2日上午7时住入公社医院，检查血压60/30毫米汞柱，脈率112/分，面色苍白，大汗、烦燥，全腹压痛，右下腹肌紧张，扪之饱满感，有移动性浊音，诊断性腹穿，容易抽出不凝之暗红色血液，诊断为異位妊娠破裂。给以快速补液并输血400毫升，局麻下手术，腹腔积血和血块约2000毫升, 发现右侧输卵管壶腹部增粗如鸭蛋大。破裂出血，见3厘米长男性成形胎儿游离于腹腔。行右侧输卵管切除，其内见胎盘组织。对侧输卵管、卵巢均正常。子宫软而略增大，无粘连。收集腹腔积血350毫升回输无反应。术后10天痊愈出院。

A 23-year-old woman had not given birth after two years of marriage and her menstruation was normally normal. She stopped menstruating for 52 days, accompanied by nausea, partial eclipse, drowsiness and other early pregnancy reactions. On 22 April 79, sudden vaginal bleeding with lower abdominal pain and subsequent discharge of embryonic tissue were confirmed as complete abortion. After vaginal bleeding stopped and abdominal pain disappeared, the general situation was good. Later, on the night of the ninth day, the patient complained that he started to have sex, and immediately felt right lower quadrant pain with dizziness and sweating. In the emergency department, the patient was considered to have post-abortion infection or intestinal parasitic disease in the local hospital. He was given tetracycline and pain-killer tablets, and he went home. Rosty Yi again severe abdominal pain and shock, at 7 a.m. on May 2 in commune hospital, check the blood pressure of 60/30 mm Hg, pulse rate of 112/ minute, pale face, sweat, irritation, abdominal tenderness, right lower abdominal muscle tension, the feeling of fullness of ammon, mobile voice, diagnostic abdominal wear, easy to draw out the dark red blood coagulation, diagnosed as ectopic pregnancy rupture. After rapid fluid replacement and blood transfusion of 400 ml, the operation was performed under local anesthesia, and about 2000 ml of blood and clots were accumulated in the abdominal cavity. The ampulla of the right fallopian tube was found to be thickened as large as a duck’s egg. The rupture was bleeding, and a 3-cm-long male fetoprotein was found free in the abdominal cavity. A right salpingectomy was performed, which revealed placental tissue. The contralateral fallopian tube and ovary were normal. The uterus was soft and slightly enlarged without adhesion. There was no reaction after 350 ml of blood collected from abdominal cavity was transfused. He recovered and was discharged 10 days after surgery.

By Yaogui Pan & Mingjie Li, Nanling County Hospital, 05/14/1979

Nanling Medicine, 1979; 1:21

obstetrics and gynecology paper II

Rivanol induction of labour by amnion cavity injection

Clinical Analysis of 120 Cases

适应症与禁忌症

2、生殖器炎症，若经阴道途径引产易致宫内感染者适于此法。

3、体质衰弱，心、肾、肝、肺功能不全。急性传染病等需积极治疗待改善后方可慎行。

4、急慢性泌尿系感染，需先行控制。否则易因上行感染而加重病情。

5、妊娠晚期若并有产道机械障碍或胎位不正。胎儿畸形，需在引流中适时给以助产或碎胎或放弃引产改行手术产。

Indications and contraindications

2, genital inflammation, if induced labor by vaginal route easily cause intrauterine infection is suitable for this method.

3, weak constitution, heart, kidney, liver, lung dysfunction. Acute infectious diseases need active treatment and can be treated cautiously only after improvement.

4, acute and chronic urinary infection, need to control. Otherwise, the disease is easily aggravated by ascending infection.

临庆资料

Clinical materials

induction of labor effect:

(一) 引产效果:

引产成功的119例中，自行排出胎儿112例，全部死胎。余7例均为妊娠18-24周，因宫缩乏力或胎位不正，而宫口已开，则行钳刮术而获效满意(如表1)

表1 引流时间与孕周关系及例数

孕周	例数	24小时内	25-48小时	49-72小时	> 73 小时	平均作产时间
18-21	38	2	15	18	5	56.1
22-25	35	0	11	21	3	48
26-29	22	1	8	12	1	45.3
30-34	16	7	3	6	0	44
> 35	8	3	3	2	0	42
合计	119	13 10.9%	40 33.0%	59 50%	7 5.9%	47.1

引流时间大多数在25小时至72消失之间，达88%，而孕约月愈大作产时问愈短。自然娩出机会多，显示子宫较为敏感。

References

Special summary of induced labor in second trimester pregnancy: materials from National Family Planning Experience Exchange Meeting
Department of Obstetrics and Gynecology, Bengbu Third Hospital, 1978: summary of 216 cases of induced labor in second and third trimester pregnancy by amnion cavity injection from Rever Woer. Family planning data compilation 1978
Liu Yong et al., amniotic fluid (review). Foreign Medical References, Gynaecology and Obstetrics fascicle 2:41 1975
Zhou Lijuan et al. Effect of rivanol on immune uterus. Data compilation of rivanol induced labor in second trimester
Wu Hanjing: 525 cases were treated with rivanol amnion injection. Analysis of the Effect of Induced Labor in Middle and Late Pregnancy (Internal Data) 1980
First Medical University: Gynaecology and Obstetrics. P: 61-541 people’s health press, 1978 September 1980 exchange of materials at the first academic conference on obstetrics and gynecology of anhui province by li mingjie, pan yaogui, nanling county hospital

参考资料

一九八〇年九月南陵县医院李名杰潘耀桂安徽省首届妇产科学术会议交流资料

In commemoration of the 50th anniversary of Dr. Xu Jingbin’ s medical career (draft)

Appendix

In commemoration of the 50th anniversary of Dr. Xu Jingbin’ s medical career

【立委按】中国骨科的泰斗级许老医生竟斌先生是老爸的骨科导师。许老先生生前，老爸协同其他许老弟子，举办了“许竟斌从医五十周年纪念活动”，出了专辑，《皖南医学》增刊。相关资料摘要汇编如下，纪念这位德高望重的专家长者。

皖南医学院学报1994年第 13 卷增刊

1973 骨训班师生合影（后两排“九大金刚”，中排最右是李名杰）
前排三位老师，左是地区医院袁思忠（班主任），许老居中，其右是弋矶山医院张戡主任

[Editor’s Comment] China orthopedic heavyweight Xu old doctor unexpectedly Mr Bin is dad’s orthopedic mentor. Before Mr. Xu’s death, his father, in collaboration with other disciples of Mr. Xu, held a “commemoration of the 50th anniversary of Xu Jingbin’s medical career” and published an album entitled “Southern Anhui Medicine” supplement. A summary of relevant information is compiled below in memory of this highly respected expert elder.

Journal of Southern Anhui Medical College Vol. 13 Supplement in 1994

1973 bone training class group photo of teachers and students (after two rows of “nine donkey kong”, the right is Li Mingjie) three teachers in the front row, the left is the regional hospital Yuan Sizhong (teacher in charge), Xu old center, the right is the director of the YiJiShan hospital Zhang Jian

A model in white: congratulations to professor Xu jingbin, a famous orthopedist in China, on his 50th anniversary as a medical practitioner

老骥伏枥白衣楷模
——祝贺我国著名的骨科专家许竞斌教授从医五十周年

为适应当前改革开放的大好形势，促进学术交流，加强本区域与全国各地骨科同道的友好交往，中华医学会芜湖分会主持召开了这次学术研讨会。大会针对目前骨科临床中普遍存在较为突出的问题，如创伤与骨折; 内固定与骨不连; 股骨颈骨折; 显微外科; 椎管病变; 颈椎病等，有重点地进行专题研讨并将一些具有临床先进性、实用性的论文选登在本期皖南医学院学报增刊。

In order to adapt to the excellent situation of the current reform and opening up, promote academic exchanges, and strengthen the friendly exchanges between our region and fellow orthopedic surgeons all over the country, the Wuhu Branch of the Chinese Medical Association hosted the academic seminar. The General Assembly focused on the prominent problems commonly existing in orthopedic clinic at present, such as trauma and fracture; Internal fixation and bone nonunion; Femoral neck fracture; Microsurgery; Spinal canal lesions; Cervical spondylosis, etc ., have focused on thematic discussion and some with clinical advanced, practical papers selected in this issue of the journal of southern anhui medical college supplement.

在这春风吹绿江南岸，骨科同道聚皖南的美好时光，也正值我国骨科前辈著名骨科专家许竞斌教授从医五十周年。他数十年如一日，勤勤恳恳，用精湛的技术诊治很多患者，并解除其痛苦，他为党和人民培养造就一大批临床骨科的技术人才，借此机会举行一次别开生面的学术性庆祝活动是颇有意义的。

The wonderful time for Jiang Nanan, where the spring breeze blows green, and for fellow orthopedists to gather in the south of Anhui also coincides with the 50th anniversary of Professor Xu Jingbin, a famous orthopedist of our country’s senior orthopedist. He has been working diligently for decades, treating many patients and relieving their sufferings with exquisite skills. He has trained a large number of clinical orthopedics technicians for the Party and the people. It is quite significant for him to take this opportunity to hold a special academic celebration.

许竞斌一九一九年生于江西九江。1944年毕业于湖南国立湘雅医学院。1948年任前中央医院骨料、外科主治医师; 1951年任志愿军抗美援朝手术队长: 1953年至今任解放军南京81医院骨科主任。五十年代初期在军区和江苏省首先开展腰椎间盘脱出摘除术，骨与关节结核的病灶清除术; 六十年代采用大量自来水对严重的开放性创口进行压液冲洗，使创口的感染率下降到千分之四。首先于国内文献报告了人工股骨头的置换术，枕骨颈椎融合术。八十年代创制骨不连治疗仪，治疗骨不连患者数百例，目前这种不需要手术治疗骨不连的方法已被全国各地医院广为应用，1986年应邀赴美国哥伦比亚大学，纽约骨科中心，新泽西洲电生物研究所讲学，为祖国赢得荣誉。

Xu Jingbin was born in Jiujiang, Jiangxi Province in 1919. Graduated from Hunan National Xiangya Medical College in 1944. Before 1948, he was appointed as Aggregate and attending surgeon of Central Hospital. He was the captain of the volunteer army’s operation to resist U.S. aggression and aid Korea in 1951: since 1953, he has been the director of orthopedics department of Nanjing 81 hospital of the PLA. In the early 1950s, lumbar disc herniation extraction and focus removal of bone and joint tuberculosis were first performed in military regions and Jiangsu Province. In the 1960s, a large amount of tap water was used to compress and rinse the severe open wounds, which reduced the infection rate of the wounds to four per thousand. First, the replacement of artificial femoral head and occipital cervical fusion were reported in the domestic literature. The therapeutic apparatus for bone nonunion was invented in the 1980s to treat hundreds of patients with bone nonunion. At present, this method of treating bone nonunion without surgery has been widely used in hospitals all over the country. In 1986, he was invited to give lectures at Columbia University in the United States, new york Orthopedics Center, and Institute of Electrobiology in New Jersey, winning honor for his motherland.

近年来他通过临床实践，对很多手术器械，内固定材料进行了革新设计，如治疗股骨颈骨折的加压母子钉，骨外穿钉骨外固定支架，使这类患者能早期下床恢复功能，避免由于长期卧床而出现的各种并发症。

In recent years, through his clinical practice, he has made innovative designs for many surgical instruments and internal fixation materials, such as compression mother-child nails for the treatment of femoral neck fractures and bone external fixation brackets with screws threaded through the bones, so that these patients can get out of bed early to recover from their functions and avoid various complications arising from long-term bed rest.

五十年来他从军内到地方，从城市到农村，从军营到厂矿，在手术台旁，无影灯下，用锐利的手术刀冲向病魔，杀向死神，单腰椎间盘脱出摘除手术就成功地完成了三千多例。他的高尚医德，精湛的技术，无私的幸献，值得我们敬佩和学习。

他教学严谨，诲人不倦，除完成临床的正常带教外，培养出有骨科专业造诣出类拔萃的……

In the past 50 years, he has been in various places from cities to rural areas, from military camps to factories and mines. Under the shadowless lamp beside the operating table, he used a sharp scalpel to rush toward the disease and kill death. The operation to remove the prolapse of lumbar intervertebral disc has successfully completed more than 3,000 cases. His noble medical ethics, exquisite technology, and selfless dedication are worthy of our admiration and learning. He is rigorous in teaching and tireless in teaching. in addition to completing the normal clinical teaching, he has cultivated outstanding orthopedic professional attainments.

Excerpts from commemorative supplement papers: …………

纪念增刊论文片段节选：

…………

疗效评定: 优 —— 骨折愈合，骨折部位的关节功能恢复正常，无晚期并发症; 良 —— 骨折愈合骨折部位的关节功能范围减少在20度以内，无晚期并发症，或虽有晚期并发症，但以补救处理后达到优良标准; 差 —— 骨折愈合，骨折部位的关节功能减少在20度以上，或并发伤造成终身残疾。本组110例多发骨折的治疗结果是优80例(72.7%); 良7例(6.4%); 差11例10(10%); 死亡 12例 (10.9%)。

Evaluation of therapeutic effect:

excellent—fracture healing, joint function at the fracture site restored to normal, and no late complications; Good—The reduction in the joint function range of the fracture site for fracture healing is within 20 degrees, and there is no late complication, or the excellent standard is achieved after remedial treatment despite of the late complication; Poor–Fracture healing, joint function at the fracture site is reduced by more than 20 degrees, or the concurrent injury causes permanent disability. The therapeutic result of 110 cases of multiple fractures in this group was excellent in 80 cases (72.7%); Good in 7 cases (6.4%); 11 cases (10%) were poor; There were 12 deaths (10.9%).

体会

1 快速、全面的检查，早日作出准确的诊断及正确的处理是多发性骨折合并创伤性休克治疗成功的关键; 而休克抢救的成功率与入院前有无正确的处理及来诊时间成正比。有效的抢救应该从受伤现场开始，伤后数分钟~数小时是抢救成功与否的关键，本组抢救成活者多数系入院前处理较好，或来就诊较早，死亡病例中除5例脑干损伤及3例脾破裂外，其余4例均因就诊晚而延误了抢救时机。如一例伤后低血压未处理，至伤后48小时转来本院时血压已测不到，并呈进行性呼吸困难，于次日死于呼吸窘迫综合症，说明现场急救的重要性，尤其基层医护人员技术素质、转运设备及城镇的应急能力都是急救工作的重要组成部分。

Experience

1 Rapid and comprehensive examination, early and accurate diagnosis and correct treatment are the keys to successful treatment of multiple fractures combined with traumatic shock; The success rate of shock rescue is directly proportional to the correct treatment and visiting time before hospitalization. Effective rescue should start from the scene of injury. Minutes to hours after injury is the key to successful rescue. Most of the survivors in this group received good treatment before hospital admission or came to hospital early. In the dead cases, except for five cases of brain stem injury and three cases of splenic rupture, the other four cases were delayed in rescue due to late doctor visit. For example, a case of post-injury hypotension was untreated, and the blood pressure was undetectable by the time of transfer to our hospital 48 hours after the injury and the patient presented with progressive dyspnea and died of respiratory distress syndrome on the next day. This demonstrates the importance of on-site first aid. In particular, the technical quality of grassroots medical staff, transfer equipment and the emergency response ability in cities and towns are all important components of first aid work.

2 多发性骨折合并创伤性休克，病情往往严重而复杂，诊断、治疗都有其特殊性，在伤情允许时，要准确收集病史，进行重点、全面的检查，特别要注意发现那些足以危及生命的隐蔽伤，不能只靠血压来确定有无休克，要根据伤情、病人的全身情况而考虑。对生命监护记录做必要而快速的化验检查血气分析，及时迅速的输液、输血、给氧，尽快缩短休克期。对危及生命的严重并发伤要果断处理，不能观察等待。本组有30例是在纠正休克的同时处理骨折，25例伴有一般并发症或开放伤口者在血压基本平稳时施行了手术，40处骨折进行了固定。对10例危及生命的并发伤，当收缩压在8. 0kpa时就做了手术处理，其中7例挽救了生命。

2 Multiple fracture combined with traumatic shock, the condition is often serious and complex, diagnosis and treatment have their own particularity, when the injury condition allows, to accurately collect history, focus, comprehensive examination, pay special attention to find those who are enough to endanger the life of the hidden injury, can’t only rely on blood pressure to determine whether there is shock, according to the injury, the patient’s whole body condition and consider. Necessary and rapid laboratory tests shall be performed on life monitoring records for blood gas analysis, timely and rapid infusion, transfusion and oxygen supply, so as to shorten the shock period. For life-threatening serious concurrent injury to decisive treatment, can’t wait. In our group, 30 cases were treated with fracture while correcting shock, 25 cases with general complications or open wound underwent surgery when the blood pressure was almost stable, and 40 fractures were fixed. Ten life-threatening complications were treated surgically when the systolic blood pressure was 8. 0kpa, seven of which were life-saving.

3 迅速及时的补充血容量，缩短休克期，是抢救性失血性休克成功与否的关键。由于失血过多，低血压时间长，若不及时补充血容量，组织细胞长时间灌注不足，可发展转化为弥漫性血管内凝血 (DIC)，本组就有9例经积极治原发伤，足量输血，特别是输大量新鲜血，既补充了血容量，又补充了大量凝血因子。再适量给予肝素、低分子石旋糖酐，并注意及时调整水电解质平衡，均挽救了生命。

3 Prompt and prompt replenishment of blood volume and shortening of the shock stage are the key to the success of rescue hemorrhagic shock. Because of excessive blood loss and long hypotension time, if the blood volume is not replenished in time, the tissue cells will be insufficient for a long time and will develop into disseminated intravascular coagulation (DIC). Nine cases in this group have received adequate blood transfusion after active treatment for primary injury. In particular, a large amount of new blood is infused, which not only replenishes the blood volume, but also replenishes a large amount of coagulation factors. Life was saved by proper administration of heparin and low-molecular-weight chrysotile anhydride, as well as timely adjustment of water and electrolyte balance.

4 多发性骨折合并创伤性休克的骨折处理，以避免或减少死亡率为准则，应把骨折的早期处理作为抗休克的重要手段之一。对长管状骨骨折可做坚强的内固定，对部分开放性骨折，只要条件允许，可在彻底清创的基础上，一期手术内固定。这样把复杂变成简单骨折、变开放骨折为闭合骨折、有利于抢救，也有利于关节早期活动及全身财政部的恢复。

4 Multiple fractures with traumatic shock fracture treatment, in order to avoid or reduce mortality as the criterion, should be the early treatment of fractures as one of the important means of anti-shock. Strong internal fixation can be performed for long tubular bone fractures, and partial open fractures can be internally fixed by one-stage operation on the basis of thorough debridement as long as conditions allow. In this way, the complexity can be changed into simple fractures and open fractures into closed fractures, which is beneficial to rescue, early joint movement and the recovery of the whole body finance department.

[related]

“I and 127 hospital” Xu Guangming-dedicated to Mr Xu jingbin, his lifelong admirer

【相关】

《我与127医院》

徐光明 – 含英咀华献给终生仰慕的恩师许竞斌先生

Intervertebral disc excision in community health centers (draft)

Orthopedic paper VII

Intervertebral disc excision in community health centers

OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER

ABSTRACT

This is clinical review of 104 cases of protrusion of the lumbarintervertebral disc treated with surgery from 1974 to 1980 in a healthcenter of a people’s commune.

After the operation, all the cases were followed up for 2-8 yearswith an average of 5 years. The results of the 104 operated cases: excellent 68 (65.4%), good 22 (21.2%), fair 10 (9.6%), failure in 4(3.8%). The method and the result of the operative treatment arepresented and the experiences are described in detail

ABSTRACT

This is clinical review of 104 cases of protrusion of the lumbar intervertebral disc treated with surgery from 1974 to 1980 in a health center of a people’s commune. After the operation, all the cases were followed up for 2-8 years with an average of 5 years. The results of the 104 operated cases: excellent 68 (65.4%), good 22 (21.2%), fair 10 (9.6%), failure in 4 (3.8%). The method and the result of the operative treatment are presented and the experiences are described in detail.

椎间盘摘除术治疗腰间盘突出引起的腰腿痛，是一种公认的病因疗法。现在，在县以上的医院这种手术已相当普及，但在基层公社卫生院仍开展较少。于1974~1980年间，我们在许竞斌教授的直接指导下，在公社卫生院共做腰椎间盘摘除手术104例; 术后经2~8年的随访，绝大多数都取得了满意效果。现就在条件较差的基层卫生院如何提高手术效果问题，点滴体会如下:

Discectomy is an acknowledged etiological therapy for lumbocrural pain caused by lumbar disc herniation. At present, this kind of surgery has been quite popular in the hospitals above the county level, but it is still less carried out in the grass-roots commune hospitals. From 1974 to 1980, under the direct guidance of professor xu jingbin, 104 cases of lumbar disc extraction were performed in the commune hospital. After two to eight years of follow-up, the vast majority of patients have achieved satisfactory results. On the issue of how to improve the surgical effect in the grassroots hospitals with poor conditions, we have the following experiences to report.

一般资料

104例中，男85例，女19例，发病最大的年岁56岁，最小23岁; 腰 4、5 间突出49例，腰 5 骶 1 间突出31例，双突出22例，腰 3、4 间2例。其中椎间盘突出髓核破入椎管内2例，同时伴有骨赘形成12例。

根据马植尧等疗效评定标准 [2] 统计如下表:

手术效果

疗效	优	良	中	差	合计
例数	68	22	10	4	104
%	65.4	21.2	9.6	3.8	100%

General information

There were 85 males and 19 females in the 104 cases, and the oldest patient was 56 years old and the youngest was 23 years old. There were 49 cases with protrusion between the 4th and 5th lumbar vertebra, 31 cases with protrusion between the 1st lumbar vertebra and 5th sacral vertebra, 22 cases with double protrusion, and 2 cases with protrusion between the 3rd and 4th lumbar vertebra. There were two cases in which the herniated nucleus pulposus broke into the spinal canal, and 12 cases with osteophyte formation. According to Ma Zhiyao’s efficacy evaluation criteria [2], the statistics are shown in the following table:

Surgical effects

Experience

体会

一、显露问题: 本组除8例半椎板切除外，其余全部采用“开窗”显露，包括12例铲除骨赘在内。通过手术实践的体会和观察，我们认为“开窗”与半椎板切除二种方法在显露效果上无明显差别，所以在显露问题上，除非真正特别需要外，如髓核破入椎管内，一般均可采用“开窗”法。这样一般不影响小关节突，损伤小，便于患者术后早期起床活动，减少神经根粘连的可能。本组“开窗”病例，都是术后3~5天开始起床活动，未发现异常。

1, Exposure problem: In this group, except for 8 cases with hemilaminectomy, all the others were exposed by “fenestration”, including the removal of osteophyte in 12 cases. Through the experience and observation of surgical practice, we believe that there is no significant difference in exposure effects between the two methods of “fenestration” and hemilaminectomy. Therefore, in the exposure problem, unless really necessary, such as nucleus pulposus breaking into the spinal canal, the “fenestration” method can be generally used. This generally does not affect the small articular process, small injury, easy for patients to get up early after surgery activities, reduce the possibility of nerve root adhesion. In the fenestration cases in our group, the patients started to get up 3–5 days after operation, and no abnormality was found.

二、减压问题: 手术治疗腰椎间盘突出症不满意的原因，1951年 Armstrong 氏指出，一是由于诊断错误，二为椎间盘突出病变实际存在，而手术未能完全解除其病因。随着医疗技术不断发展和提高，对于椎间盘突出症的误诊和手术遗漏的机会是越来越少，所以在手术中真正做到“完全减压”的问题，显得较为重要。我们在显露突出的椎间盘，保护好神经根后，用小尖刀沿突出椎间盘的外径环切一周，再用垂体钳取出突出的椎间盘及椎间隙内的退化组织，然后用刮匙刮取一些破碎的组织，基本上做到“掏空”; 而不是单纯摘取髓核部分。遇有骨赘病例, 在铲除骨赘后, 也同样做到“掏空”。我们体会这样对神经根彻底减压，不但疗效好，而且有利防止复发。

II. Decompression:

The cause of dissatisfaction with surgical treatment of LDH. Armstrong pointed out in 1951 that the first reason was due to incorrect diagnosis, and the second reason was the actual existence of LDH lesion, and surgery failed to completely remove the cause. With that continuous development and improvement of medical technology, the opportunity for misdiagnosis and surgical omission of disc herniation are becoming less and less, so the problem of truly achieve “complete decompression” in surgery appears to be relatively important. After revealing the herniated intervertebral disc and protecting the nerve root, we used a small sharp knife to make a circumferential cut along the outer diameter of the herniated intervertebral disc for one week, and then took out the herniated intervertebral disc and the degenerative tissues in the intervertebral space with a pituitary forceps. Then we used a curette to scrape out some broken tissues, and basically “hollowing out”. Rath than simply harvesting that nucleus pulposus portion. In case of osteophyte, “tunneling” is also performed after the osteophyte is removed. We realized that complete decompression of nerve root in this way not only had good curative effect, but was also beneficial to prevent recurrence.

三、防止感染问题: 感染是椎间盘术后严重的并发症之一，尤其是椎间隙感染，给病人带来很大的痛苦，恢复时间也较长。在条件设备尚不完好的基层卫生院，对这个问题更应该引起高度重视。为了防止感染，我们除严格执行各项无菌操作外，还对每个手术病人在术前用肥皂水反复刷洗腰背部皮肤，在切除椎间盘后，常规改用 1:1000 洗必太液加压冲洗被掏空的椎间隙，继后用洗必太湿纱布堵住创口，让整个创口在洗必太液里浸泡3分钟左右，再除去纱布。因为洗必太具有广谱高效，无耐药性的特点，对神经等组织无不良反应和刺激。这样反复冲洗和浸泡，使细菌和碎屑组织都不复存在的机会; 再结合抗生素的应用、引流等综合措施，对防止感染起着积极作用。

III. Prevention of infection:

Infection is one of the serious complications after intervertebral disc surgery, especially intervertebral space infection, which brings great pain to patients and requires a long recovery time. This problem should be paid more attention to in the basic level health centers with imperfect equipments. In order to prevent infection, in addition to strictly carrying out various aseptic operations, we also repeatedly washed the skin on the lower back of each patient undergoing surgery with soapy water before surgery. After the intervertebral disc was removed, we routinely switched to 1:1000 chlorhexidine solution to pressurize and wash the hollowed intervertebral space. Afterwards, the wound was blocked with chlorhexidine gauze, and the whole wound was immersed in the chlorhexidine solution for about 3 minutes, followed by gauze removal. Because chlorhexidine hydrochloride has the characteristics of broad spectrum and high efficiency, and no drug resistance, it has no adverse reaction or stimulation to nerves and other tissues. Such repeated washing and soaking, make bacteria and debris tissue no longer exist; Combined with the application of antibiotics, drainage and other comprehensive measures, to prevent infection plays a positive role.

四、防止椎管内继发血肿问题: 因为椎管内是不应存留任何异物的，所以对于椎管内出血既不宜用丝线结札，也不好用游离肌肉作填塞物，止血方法，一般来说只是压迫。因此术后椎管内少量出血是难免的。由于出血形成血肿，继发压迫神经根，甚至血肿机化、纤维化，造成神经根的粘连，从而影响了手术效果。对于这个问题，我们认为首先应该是术者操作熟炼、动作轻柔，在切除之前，要在突出椎间盘的上下方各填塞一个带线的棉球，待把突出椎间盘清楚暴露以后，在良好光线下直视切除。切勿盲目下刀和钳挟。由于暴露清楚，遇有小血管可以避开，做到尽可能不损伤小血管，这样椎管内出血机会就大为减少。尽管这是无菌手术，但是，我们是常规放置橡皮引流条，腰背筋膜这一层不缝合，术后患者仰卧位，以利引流。在冲洗创口时，我们有意让少量的洗必太液存留在创口内，即使创口内有少量出血，也被稀释，更易引流。我们从术后48小时拔除引流条时观察到，每患者引出的血水达40~250亳升左右 (以浸湿纱布的方法计算)。由此可见，恰当的引流是有裨益的。

IV. Prevention of secondary hematoma in the spinal canal: Because no foreign body should be left in the spinal canal, it is not advisable to use silk thread for internal hemorrhage in the spinal canal or use free muscle as stuffing to stop bleeding. Generally speaking, it is only compression. Therefore, a small amount of intraspinal hemorrhage after surgery is unavoidable. Hematoma is formed due to hemorrhage, which will lead to secondary compression of nerve root, and even organization and fibrosis of hematoma, resulting in adhesion of nerve root, thus affecting the operation effect. To solve this problem, we believe that the operator should first practice manipulation and perform gentle movements. Before resection, a cotton ball with a line should be inserted into the upper and lower parts of the herniated intervertebral disc. After the herniated intervertebral disc is clearly exposed, the disc should be excised under direct vision in a good light. Do not blindly under the knife and clamp. As the exposure is clear, it can be avoided in case of small blood vessels, so as not to damage the small blood vessels as much as possible, and thus the chance of intraspinal hemorrhage is greatly reduced. Although this was a sterile procedure, we routinely placed a rubber drainage strip without suturing this layer of the lumbar dorsal fascia, and the patient was in the supine position postoperatively to facilitate drainage. When washing the wound, we intentionally left a small amount of chlorhexidine hydrochloride in the wound, so that even if there was a small amount of bleeding in the wound, it would be diluted and easier to drain. We observed that about 40 to 250 ml (calculated by soaking gauze) of blood was drained from each patient when the drain was removed 48 hours after surgery. Thus, proper drainage is beneficial.

references

Xu Jingbin. Analysis of the efficacy of LDH, Chinese Journal of Surgery 4421, 1956
Ma Zhiyao et al. Effects of surgical treatment of LDH, Chinese Medical Journal 5:51, 1965
Lu Yupu et al. Surgical treatment of LDH, Chinese Journal of Orthopedics 2:77, 1981
OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER Ding Ming-xiu
Nanling Health School, Anhui

By Mingxiu Ding, Jingbin Xu & Mingle Li, 09/01/1983

Proceedings of third orthopedic academic conference of Anhui

参考文献

[1] 许竞斌: 腰椎间盘突出症的疗效分析，中华外科杂志4421，1956[2] 马植尧等: 手术治疗腰间盘突出症的效果，中华医学杂志 5:51，1965[3] 陆裕朴等: 腰椎间盘突出症的手术治疗，中华骨科杂志2:77，1981

Sept 1， 1983

安徽省第三届骨科学术会议交流资料

南陵县卫生进修学校丁明秀指导者:许竞斌李名杰

Fifth metatarsal fracture caused by varus sprain (draft)

orthopedic paper VI

Fifth metatarsal fracture caused by varus sprain

Report of 30 cases

收集我院83年以来足部扭伤经X线片确诊的第5跖骨基底部撕脱骨折30例，予以分析报导。

Thirty cases of avulsion fracture of the base of the fifth metatarsal bone diagnosed by X-ray of foot sprain in our hospital since 83 years are collected and analyzed.

临床资料男性22例，女性8例，年龄在23至54岁，40岁以下24例，可见多发生在活动量大的中青年，致伤原因全部为行走不慎患足内翻扭伤, 单纯骨折错位不显著28 例，2 例呈粉碎型,经一般治疗或不予治疗，1~2月均可基本恢复功能。

Clinical data include 22 males and 8 females, age ranging from 23 to 54 years old, with 24 cases under 40 years old. It could be seen that most of them occurred in the young and middle-aged with high activity. All the injuries were caused by accidental walking with varus sprain. There were 28 cases with simple fracture dislocation but no significant ones. The two cases were of comminuted type. After general treatment or no treatment, the patients could basically recover to their functions within 1–2 months.

讨论
除直接暴力和开放性外伤外，对日常生活中, 自身行走不慎发生足内翻位扭伤可致骨折，往往为医患双方所忽略，常延迟数日因软组织肿胀消退而症状不减，才拍片确诊。其骨折机理为足部急促过度内翻，腓骨短肌强力收缩牵拉，使该肌附丽点第5跖骨基底部撕脱骨折, 骨折线常呈斜形、不整、分离状态，临床上局部压痛明显,可出现皮下淤血, 较长时间的肿胀, 妨碍行走和正常活动，X线拍片即可避免漏诊。除移位和分离明显者需外翻位石膏托固定三周外，一般可不予特殊处理。适当休息2至3周, 症状消失, 即可负重行走操练, 而不必等待X线片上骨性愈合。本组30例，历经1至8年观察, 无一例遗有功能障碍, 这是因为单纯扭伤, 其外力不足以造成足部横弓及外侧纵弓的解剖学的严重紊乱或破坏。

Discussion

In addition to direct violence and open trauma, fractures caused by pronation and sprain of your foot due to careless walking in daily life are often ignored by both doctors and patients. The diagnosis is usually confirmed through radiography after a delay of several days because the symptoms do not decrease due to the disappearance of soft tissue swelling. The fracture mechanism was rapid and excessive varus of foot, and strong contraction and traction of peroneal brevis, which caused avulsion fracture of the base of the fifth metatarsal bone at the point of attachment of this muscle. The fracture lines were often in an oblique, irregular and separated state. In clinic, local tenderness was obvious, and subcutaneous congestion could occur. The swelling for a long time prevented walking and normal activities. The missed diagnosis could be avoided by X-ray radiography. In addition to the obvious shift and separation of the need to evert the cast fixed for three weeks, generally can not special treatment. After an appropriate rest for two to three weeks, the symptoms disappear and the patient can walk with load without waiting for bony healing on the X-ray film. After one to eight years of observation, none of the 30 cases in this group has been left with dysfunction, which is due to the severe disorder or destruction of the anatomy of the transverse and lateral longitudinal arches of the foot due to the simple sprain with insufficient external force.

By Mingjie Li, Wuhu Changhang Hospital

Journal of Southern Anhui Medical College 1994 Vol 13 Supplement

Treatment of femoral neck fracture with closed nailing (draft)

orthopedic paper V

Treatment of femoral neck fracture with closed nailing

Report of 45 cases

摘要: 45例外伤性股骨颈骨折行闭合复位小切口三棱钉内固定治疗，随访1-3年，骨折延迟愈合1例，迟发性股骨头坏死2例，余均在3-6个月弃拐步行。本疗法具有创伤小、恢复快、安全、适应证宽，以及手术简便和不破坏解剖等特点，易为病人所接受。文中详述手术方法及操作要点，并介绍器具革新。

关键词: 闭合复位股骨颈骨折三棱钉

ABSTRACT

Early manual reduction and closed internal fixation by triangular nail were applied to eight cases of femoral neck fracture from October 1981 to December 1982. Following up six to twenty months, the operators found that the functions of the hip were getting satisfactory in all of them. The indications were discussed and details of operative procedures were presented. This operation, which is emphatically recommended by the authors, is simple and safe, with little injury, fast recovery, and no destruction to anatomy.

Abstract

Forty-five cases of traumatic femoral neck fracture were treated with closed reduction and small incision internal fixation with triangular nail. The patients were followed up for 1 to 3 years. There were one case of delayed fracture healing and two cases of delayed femoral head necrosis. The rest patients abandoned crutch and walked within 3 to 6 months. This therapy has the characteristics of small trauma, rapid recovery, safety, wide indications, and simple operation without destroying the anatomy, which is easily accepted by patients. In this paper, the surgical method and operation points are described in detail, and the appliance innovation is introduced.

Keywords: closed reduction femoral neck fracture triangular nail

股骨颈骨折，尤其在老年人，临床上常见。至今仍无规范的治疗方法，探索安全有效而又易于普及的疗法，是骨科界多年努力的目标。1931年Smith-Petersen氏创用三棱钉内固定以来，在缩短疗程，降低卧床并发症及病残率，提高连接率等方面，成绩显著。但其开放打钉法，则有损伤大，再次破坏骨膜和血供及招致感染等缺点; 而其闭合复位经皮穿钉 (包括近年来发展的加压螺钉或母子钉)，随着放射设备的日臻完善，加之技术改进，器具创新和经验积累，使之大为简化和可行。现就我们近年来开展此项手术并将随访的 45例予以报导。

Femoral neck fractures, especially in the elderly, are clinically common. There is still no standardized treatment so far. To explore safe, effective and easy-to-popularize therapies has been the goal of the orthopedic community for many years. Since Smith-Petersen’s invention of internal fixation with triangular nails in 1931, significant achievements have been made in shortening the course of treatment, reducing the rate of complications and disability in bed, and improving the connection rate. However, open nailing has the disadvantages of large injury, secondary destruction of periosteum and blood supply, and infection. However, its closed reduction percutaneous nailing (including compression screws or parent-child screws developed in recent years) is greatly simplified and feasible with the gradual improvement of radiation equipment, coupled with technical improvement, instrument innovation and experience accumulation. Here we report 45 cases in which we performed this procedure in recent years and we will follow up.

1 临床资料

45例都为新鲜骨折。男30例，女15例。年龄40-81岁，平均62岁。左侧32例，右侧13例。外展型6例，余均为内收型。囊内34例 (头下7、颈中27)，囊外11例 (颈基底部)。伤后即入院者14例。皆予早期手术，余均在一周内手术，穿钉成绩佳者术后可不予限制，即可有协助下床上翻动和坐起; 否则，予以下肢牵引2-3周，或穿防旋木板鞋，尔后即可扶双拐下地，全部病例无手术感染。

1 Clinical data

All 45 cases were fresh fractures. There were 30 males and 15 females. Age ranged from 40 to 81 years, with an average of 62 years. There were 32 cases on the left side and 13 cases on the right side. There were six cases of abduction type, and the others were of adduction type. There were 34 cases within the capsule (7 under the head and 27 in the neck), and 11 cases outside the capsule (basal part of the neck). 14 cases were admitted to hospital immediately after injury. Early operation was performed for all patients, while for others, the operation was performed within one week. Patients with good nailing performance could turn over on the bed and sit up with the help of the unrestricted operation after operation. Otherwise, lower limbs will be towed for 2–3 weeks, or anti-rotation wooden board shoes will be worn, and then both crutches can be lifted to the ground. All cases have no surgical infection.

随访结果: 全部病例随访1-3年，术后 3月骨性愈合，患髋无痛，无跛形并可持拐步行者占 90% (40/45)。头下型骨折者2例，术后半年X线片显示股骨头内侧局限性囊性变、头塌陷，但可步行，一年后略有修复。1例复位欠佳，遗有轻度跛行，另1例术中嵌插不足，术后一年拔钉者25例。

Follow-up results

All cases were followed up for 1–3 years. Bone healing occurred 3 months after operation, and 90% (40/45) of the patients had painless hip, no lame shape and walking with crutch. There were two cases of infrahead fracture. The X-ray film six months after the operation showed localized cystic changes in the medial aspect of the femoral head and head collapse, but the fractures could be walked, and the fractures were slightly repaired one year later. One case had suboptimal reduction with mild claudication, the other one had insufficient insertion during the operation, and 25 cases had their nails removed one year after operation.

2 手术指征

除无移位嵌插骨折无需特殊治疗，粉碎骨折预计穿钉无效外，无论何种骨折均可施此手术。

2 Surgical indications This procedure can be performed for any type of fracture, except for non-displaced impaction fractures, which do not require special treatment, and comminuted fractures, for which nailing is not expected to be effective.

3 手术方法

骨折24小时内入院者，全身和局部无特殊手术禁忌症，不预作牵引，尽早给予手术，因此时组织反应不重，肌肉弹性可逆，容易复位; 否则，要预作骨牵引48-72小时，旨在克服骨折移位。根据骨折线方位和变位等病理情况，以估计其剪力，头血供及肌力作用，以确定拟议中的复位方案.

3 Surgical methods Patients admitted within 24 hours of fracture, the whole body and local no special contraindications to surgery, not for traction, to surgery as soon as possible, so the tissue reaction is not heavy, muscle elasticity reversible, easy to reset; Otherwise, bone traction is foreseen for 48 to 72 hours in order to overcome the fracture shift. The shearing force, blood supply to the head and muscular force can be estimated according to the pathological conditions such as the position and displacement of fracture line to determine the proposed reduction plan.

通常用硬膜外阻滞麻醉，可获肌肉松弛、复位方便及手术无痛；或者，局麻亦可完成。

Epidural anesthesia is usually used for obtaining muscle relaxation, convenient reduction and painless operation. Or, local anesthesia can also be completed.

病人仰卧X线诊断台上，行Whitman氏手法复位。注意按“先离后合”原则，先稍外旋、内收下肢，使骨折面松开，有利牵引下移，待纠正缩短移位，两下等长后再改外展内旋，荧光下检视确定恢复解剖对位并尽力使骨折线靠拢扣紧，使患肢维持内旋15°，以抵消生理前倾角，便于穿针时水平进针。在股骨头中央皮表投影的腹股沟韧带与股动脉交会点上以铅字予以际记。

The patient was supine on the X-ray table and reduction by Whitman’s maneuver was performed. Pay attention to according to the principle of “separation before closing”, first slightly external rotation and adduction of lower limbs, to loosen the fracture surface, which is beneficial to traction down. After the shortening and shifting are corrected, the external rotation and internal rotation are changed after two times of equal length. The anatomy and alignment are confirmed through fluorescence examination and we will try our best to make the fracture line close and fasten, so that the affected limb maintains internal rotation by 15, to offset the physiological anteversion angle, and it is convenient for horizontal needle insertion during needle insertion. The intersection point of the inguinal ligament and the femoral artery projected from the central skin surface of the femoral head was marked with type.

常规按无菌要求在大粗隆下 3cm 处皮外穿入引针，抵达骨质时需试探其最近点，即股骨外缘切线点上，防止滑前和清后。对准标靶，大致按130°方向水平穿入，直达股骨头缘进针深度可以进针点与标靶间距作为比较，以减少手术人员接触X线量；否则，亦可在荧光下确定。按此规程，熟练术者，几乎均可一次成功。为监测其穿针准确程度，可拍患髋正侧位片，若满意，则另在较上部位横行插入克氏针通过股骨头至髋臼，防止头旋转。注意: 此针勿与导针交扰，并使其间保持三棱钉宽度距离。

According to the aseptic requirements, the introducer needle was routinely inserted through the skin 3cm below the greater trochanter. When the introducer needle reached the bone mass, the closest point, i.e., the tangent point of the outer edge of the femur, should be explored to prevent anterior slip and posterior clear. Aim at that target, and horizontally penetrate the target along the direction of approximately 130 degrees, wherein the penetrate depth reaching to the femoral head margin can be compared with the distance between the penetrating point and the target, so as to reduce the x-ray contact amount of operator; Otherwise, it can also be determined under fluorescence. According to this procedure, skilled operators can almost succeed at one time. To monitor the accuracy of needle insertion, a frontal and lateral radiograph of the affected hip could be taken. If satisfactory, a K-wire was transversely inserted into the upper part of the hip through the femoral head to the acetabulum to prevent the head from rotating. Note: The needle should not be interfered with the guide needle, and the width distance of the triangular nail should be kept there between.

在导针进皮处作软组织切开2cm许直达骨质，用自制的皮质开口器 (三棱钉作成齿状递进阶梯) 套钉击穿皮质预作隧道，旋即拔出，检视导针无移动后，根据其刻度，选用适宜三棱钉，再套钉对槽，徐徐打入，防止偏位、卡壳和穿出头缘，拔除引针和壳氏针，用自制小园钢筒予以嵌插使骨折面加紧，创口一层缝合，加压包扎，术毕。

A soft tissue incision was made for 2cm at the site where the guide needle entered the skin so as to reach the bone mass. The self-made cortical opener (the triangular nail was made into a toothed progressive step) was used to set the nail to puncture the cortical prefabricated tunnel and it was pulled out immediately. After checking that the guide needle did not move, the appropriate triangular nail was selected according to its scale, and the nail was set into the groove and then it was driven in slowly to prevent misalignment, shell sticking and threading edge. The guide needle and the Shell needle were pulled out, and the fracture surface was tightened by embedding with the self-made small round steel cylinder. The layer of the wound was sutured, pressure-wrapped, and the surgery was completed.

4 讨论

髋关节周围肌肉丰富，肌力强大，加之干颈头不在一个轴线上，股骨颈骨折后剪式应力极易造成缩短变位; 还由于这是一个杵臼关节头，失去干的连续和控制，在臼内易于旋转，造成畸形连接，而影响日后该关节某个方位的运动幅度; 再者，一个硕大的下肢要去长期维持对合一个极易转动的头，也是十分不易的。这些解剖和病理的因素，决定了很多保守疗法的不良后果。为此，及时复位，有效的内固定，对维待良好的对位和及早解脱卧床，以及提高治愈率，十分必要。

4 discussion

The muscles around the hip joint are rich and the muscle strength is strong. In addition, the head of the dry neck is not on a single axis, so the shearing stress after the femoral neck fracture is very easy to cause shortening and displacement. Also because this is a pestle mortar joint head, loss of dry continuous and control, easy to rotate in the mortar, cause deformity connection, and affect the joint movement amplitude of a certain position in the future; Furthermore, it is not easy to maintain a large lower limb with a very easy-to-rotate head for a long time. These anatomic and pathological factors determine the adverse consequences of many conservative therapies. Therefore, timely reduction and effective internal fixation are necessary for good alignment and early bed rest removal as well as improving the cure rate.

股骨颈骨折的闭式穿钉治疗，临床资料证明，它具有创伤小，手术简便，固定有效，恢复快，花费少，有利骨折愈合，适应症宽等优点。它不但使患者尽早离床，消除全身并发症的威胁，而且为病人保留一个自身股骨头，不破坏髋关节解剖，并大多恢复伤前功能。本组功能恢复达90% (40/45)。

The closed nailing treatment for femoral neck fracture has been proved by clinical data, which has the advantages of less trauma, simple operation, effective fixation, rapid recovery, less cost, favorable fracture healing, and wide indications. It not only enables the patient to leave the bed as soon as possible and eliminates the threat of systemic complications, but also preserves one’s own femoral head for the patient without damaging the hip joint anatomy, and mostly recovers the pre-injury function. The functional recovery in this group was 90% (40/45).

放射设备和技术细节是该术式实施的两个要素，在有放射电视和双球管设备的条件下则更为方便。技术要领是恢复生理干颈角、前倾角及股骨颈的解剖长度，防止髋内、外翻。穿针正确和骨折面紧扣是技术关键。基此，术后即可床上活动，有利机体恢复。

Radiological equipment and technical details are two elements of the operation, which are more convenient in the presence of radiotelevision and double-balloon equipment. The technical essentials are to restore the physiological dry neck angle, anterior inclination angle and the anatomical length of the femoral neck, and prevent hip varus and varus. The key technology is to correctly thread the needle and fasten the fracture surface. On this basis, you can move on the bed after surgery, which is beneficial to the body recovery.

鉴于髋关节的解剖生理及力学关系的复杂，欲在闭合的情况下复位满意，并使针准确地穿在头颈部中央轴上并有效地抗剪力，就要求术者在熟悉有关基础理论和掌握骨折病理的基础上，具有一个立体概念而不致顾此失彼。改革器具，改良牵引及固定体位的方法，可使该手术更臻完善。近年来我们改用加压螺钉获得更佳成绩，它可使骨折面更形嵌插 (2); 足蹬会阴部牵引架可保证有效牵引和术中体位稳定; 皮质开口器使之准确凿开骨皮质而防止坚质骨医源性劈裂; 小钢筒嵌插器有利于小切口的术末嵌插等等，是近年来的新进展，大大简化了手术程序，提高了医疗效果。

In view of the complexity of anatomical, physiological and mechanical relations of the hip joint, to restore satisfaction under the condition of closure, and to make the needle accurately penetrate on the central axis of head and neck and effectively resist shearing force, the operator is required to have a stereoscopic concept on the basis of being familiar with relevant basic theories and mastering fracture pathology without paying attention to either one. The operation can be further perfected by reforming the apparatus and improving the methods of traction and fixation of body position. In recent years, we have obtained better results by using compression screws, which can make the fracture surface more shape insertion [2]; Pedal perineum traction frame can ensure effective traction and stable position during the operation. The cortical ostium was used to accurately cut the bone cortex to prevent iatrogenic splitting of the hard bone. The small steel cylinder impactor is beneficial to the intraoperation insertion of a small incision and the like, and is a new progress in recent years, greatly simplifies the operation procedure and improves the medical effect.

关于骨不连接和头坏死，一般为15% -25%，据吴祖尧氏观察: 头坏死的发生早在骨折时即已决定，只不过晚后才出现征象。Meyes氏资料中股骨头坏死出现在伤后一年至一年半，早期却无可靠征象。它的发生与错位程度、骨折部位、复位时间和方法对位情况、穿针成绩以及患肢支重时间等因素有关。尤其要防止医源性再损伤，这就说明了开放复位内固定的弊端，Steinberg 通过组织学观察，伤后几周股骨头坏死率达 65%~85%但其中不少病例后来又有血管再生，说明头坏死有可逆变化及修复过程，对此，应予耐心追踪观察，不必急于再处理。

Regarding bone nonunion and head necrosis, the average figure is 15% to 25%. According to Wu Zuyao’s observation, the occurrence of head necrosis was decided as early as the time of fracture, and it only appeared after late. In Meyes’s data, femoral head necrosis occurred one to one and a half years after the injury, but there were no reliable signs in the early stage. Its occurrence is related to such factors as the degree of dislocation, fracture site, reduction time and method, para-position, needle insertion result, and the time for the affected limb to become heavy. In particular, iatrogenic re-injury should be prevented, which illustrates the disadvantages of open reduction and internal fixation. According to Steinberg’s histological observation, the femoral head necrosis rate reached 65%–85% in the weeks after injury. However, in many cases, vascular regeneration occurred later, indicating that there were reversible changes in head necrosis and the process of repair. Therefore, Steinberg should be patient in follow-up observation and it is unnecessary to rush to further treatment.

本疗法即使失败，如复位不良、穿针错误，术中卡壳、骨质劈裂以及坏死、骨不连等，还可以截骨术或人工股骨头位置换等办法予以补救。

Even if the therapy fails, such as poor reduction, wrong needle insertion, intraoperative shell sticking, bone splitting, necrosis, and bone nonunion, it can also be remedied by osteotomy or replacement of the artificial femoral head position.

References

Liu Shijie Chinese journal of surgery 1980 18: 125
Ouyang first-class Chinese journal of surgery 1978 16: 123
Wu Zuyao Chinese journal of surgery 1959 7: 135
Wang Yongchang Chinese journal of surgery 1982 20:289

参考资料

[1] 刘世杰中华外科杂志 1980 18:125[2] 欧阳甲等中华外科杂志 1978 16:123[3] 吴祖尧中华外科杂志 1959 7:135[4] 王永畅中华外科杂志 1982 20:289

Application of Closed Inserting with Triangular Nail in the Treatment of Femoral Neck Fracture

By Ming-jie Li, Jian-min Zhang, Jianzhong Xu, Nanling Hospital, Anhui

Sept. 1， 1988

李名杰 (芜潮长航医院)

原载《皖南医学院学报》1994年第13卷增刊，1994；37-38

Lipoma under soft spinal membrane complicated with high paraplegia (draft)

orthopedic paper IV

Lipoma under soft spinal membrane complicated with high paraplegia

椎管内肿瘤，虽85%为髓外肿瘤，然软脊膜下脂肪瘤实属罕见。因其位置紧贴脊髓，所造成的病理改变及临床症状易与髓内肿瘤相混。但因其为良性病变，手术处理及其预后均迥然不同。我院收治一例，术后随访半年，现已恢复。兹报告如下:

AAlthough 85% of intraspinal tumors are extramedullary tumors, infraspinal lipoma is rare. Because its location is close to the spinal cord, the resulting pathological changes and clinical symptoms are easy to be mixed with intramedullary tumors. However, due to its benign nature, surgical management and prognosis are quite different. One case was treated in our hospital and has been followed up for half a year after the operation. It has now recovered. This is reported as follows.

患者男性，39岁，本县农民，已婚，病案号1340，于1979年3月28日入院。

两下肢麻木、无力伴右胸带状刺痛半年，大小便困难，不能行走、站立2月，麻痹平面上升至乳头水平伴呼吸不畅2周。

A 39-year-old farmer from our county, married with medical record No.1340, was admitted to our hospital on March 28, 1979.

Numbness and weakness of both lower limbs with band-like stabbing pain in the right chest for half a year, difficulty in urination and defecation, inability to walk and stand for two months, and elevation of the plane of paralysis to the level of nipples with poor breathing for two weeks.

体检: 第二肋间以下浅感觉基本消失，以右侧为重，左侧遗有部分刺痛区。腹壁、提睾反射不能引出，两下肢肌力 8-4 级，无踝阵挛。上胸段脊柱棘突叩击痛，但无畸形。脊柱胸段X线片阴性。奎肯氏试验示蛛网膜下腔完全梗阻，脑脊液化验: 潘氏试验(+)，细胞数10个/立方毫米，呈弗洛因氏征(Froin)。截瘫指数2-4 (感觉2，运动1，括约肌1)。

Physical examination

The superficial sensation under the second intercostal space almost disappeared, with the focus on the right side, and some stabbing pain areas were left. Abdominal wall and cremaster reflex could not be extracted, and the muscle strength of both lower limbs was grade 8–4, with no ankle clonus. The spinous process of the upper thoracic spine was impacted with pain, but there was no deformity. X-rays of the thoracic spine were negative. A Kuiken’s test showed complete obstruction of the subarachnoid space, and cerebrospinal fluid tests: Pan Shi test (+), with 10 cells/mm3 and Froin. Paraplegia index was 2–4 (sensation 2, movement 1, sphincter 1).

手术前诊断: 颈胸段椎管内肿瘤并截瘫，髓外型。

4月4日在局麻下行椎管内探查。后正中入路，胸7-12全椎板切除，切开颈6-胸5椎管。硬膜外脂肪分布匀均，无局部吸收现象，亦未见局部隆起、增粗，扪之未发现硬变区。但术中胸4穿刺奎肯氐试验仍示梗阻，乃切开硬脊膜，见胸1:2脊髓背侧略偏右有35x20x12厘米脂肪样黄色柔软赘生物致使脊髓被压1/2，为蛛网膜下腔阻塞因素。在软脊膜下试行剥离切除，因其相邻紧密，为避免脊髓损伤仅切除赘生物80%，送检病理，银夹标记，冲洗手术野。此时可见脊髓恢复较弱搏动，硬膜未缝，任其敞开减压，常规缝合软组织，未引流。

Pre-operative diagnosis: tumor in cervical and thoracic spinal canal with paraplegia, extramedullary.

On April 4, the spinal canal was explored under local anesthesia. Through posterior midline approach, complete laminectomy was performed for thoracic region 7–12, and cervical region 6–thoracic region 5 spinal canal was cut open. Epidural fat was uniformly distributed and there was no local absorption, nor was there any local bulge or thickening, and no hard degeneration area was found in palpation. However, during the operation, the QUAKENBI test of thoracic 4-puncture still showed obstruction, and the dura mater was incised. It was shown that thoracic 1:2 spinal cord was slightly to the right at the dorsal side, and there were 35x20x12 cm fat-like yellow soft vegetation, which caused the spinal cord to be compressed by 1/2, which was the factor of subarachnoid space obstruction. Stripping resection was performed under the soft spinal membrane. Due to the close proximity, only 80% of the vegetation was removed to avoid spinal cord injury. The pathology was sent for examination, marked with silver clips, and the operation field was rinsed. At this time, the spinal cord recovered to weak pulsation, and the dura mater was not sutured, which was allowed to open for decompression. The soft tissues were routinely sutured, and no drainage was performed.

手术后48小时，两下肢即有烧灼感，尔后运动、感觉渐形恢复。术后19天撤除导尿管自行排尿，此时亦可自行翻身。住院36天，无并发症出院休养。

The burning sensation developed in both lower limbs 48 hours after the operation, and the movement and sensation gradually recovered. The urinary catheter was removed 19 days after surgery to urinate on his own, and he could also turn over on his own at this time. She was hospitalized for 36 days and discharged for rest without complications.

病理报告: 赘性生物为“脂肪组织”，病理号4724。

术后半年，患者可以扶拐下地行走，感觉全部恢复，大便正常，小便射程同正常，食纳佳，营养良好，可做编织类手工劳动。

Pathological report: The neoplastic organism was “adipose tissue”, pathological No.4724.

Half a year after the operation, the patient could walk under the crutch, and all of his feelings recovered. His stool was normal, and his range of urination was the same as normal. He had good food and nutrition, and could do manual work like weaving.

讨论

软脊膜下肿瘤为加盖在脊髓上的赘生物，造成占位性压迫导致椎管梗阻，而不同于髓内肿瘤直接破坏脊髓结构，除可致占位性病理改变外，还可损害脊髓功能，前者以良性病变居多，后者则恶性为主。但两者均因与脊髓关系密切，可早期出现截瘫，并且病情进展快。此例“脂肪瘤”，当属良性病变，仅半年病程，亦造成椎管完全梗阻的严重情况。

Discussion

Submucosal tumors of spinal cord are vegetations covered on the spinal cord, which cause space-occupying compression and spinal canal obstruction. Unlike intramedullary tumors that directly destroy the spinal cord structure, they can not only cause space-occupying pathological changes, but also damage spinal cord function. The former are mostly benign lesions, while the latter are mainly malignant. However, both of them are closely related to the spinal cord, so the paraplegia can occur early and the disease progresses quickly. The “lipoma” in this case was a benign lesion with a course of only half a year, which also caused a severe case of complete spinal canal obstruction.

髓内恶性肿瘤，如胶质细胞瘤，截瘫出现早而完全。紧邻脊髓的良性病变，往往因赘生物偏于某一侧面出现临床上同侧瘫痪较严重现象，即所谓布朗–色夸(Brown-sequard)氏征。该例两侧瘫痪程度不等，且早期出现右侧“肋间神经痛”，这与术中见赘生物偏于右侧相符合。同时，膀胱、直肠机能障碍亦不完全。

Intramedullary malignancies, such as gliomas, and paraplegia occur early and completely. Benign lesions adjacent to the spinal cord often present with clinically severe ipsilateral paralysis due to the deviation of the neoplasm to one side, the so-called Brown-sequard syndrome. In this case, the degree of bilateral paralysis was different, and the right “intercostal neuralgia” appeared in the early stage, which was consistent with the vegetation leaning to the right during the operation. At the same time, bladder and rectum dysfunction is not complete.

临床上进行性截瘫出现，奎氏试验示梗阻，即表示有机械受压因素，以早期手术探查病损并及时减压为宜。因为即使良性病变，压迫过久亦可造成脊髓之不可逆损害。有谓弛缓性瘫痪，即使数周也难以复元。我们此例，及时予以手术减压，效果良好。

In the clinical practice of progressive paraplegia, the Kwechsler test showed obstruction, which meant that there was mechanical compression factor. It was advisable to carry out early surgical exploration of the lesion and timely decompress. Because even benign lesions, prolonged compression can cause irreversible damage to the spinal cord. It’s called flaccid paralysis, and you can’t recover from it for weeks. In our case, surgical decompression was performed in time with good results.

根据临床上麻痹平面以及奎氏试验、脊髓造影常可了解椎管梗阻情况和指示定位。术中视脊髓恢复搏动情况来判断减压效果。在不能彻底清除赘生物的情况下，硬膜敞开的减压措施是十分必要的。

According to the plane of clinical paralysis and the Quirrell test and myelography, we can often understand the situation of spinal canal obstruction and indicate the location. The decompression effect was judged according to the recovery of spinal cord pulsation during the operation. In cases where the neoplasm cannot be completely removed, decompression with an open dura is necessary.

软脊膜下脂肪瘤，组织柔软，又系良性，在硬膜上不造成脂肪被吸收，又无局部隆起及发硬区，故不能在硬膜外被察出; 当切开硬脊膜，透过软膜，可以清楚地被识出: 一块黄色赘生物盖在脊髓上，血管增多，分布异常，脊髓受压变扁。

The lipoma under the soft spinal membrane has soft tissue and is benign. It does not cause fat absorption on the dura mater, and there is no local uplift and hard area, so it cannot be detected outside the dura mater. When the dura mater was incised and the soft membrane was penetrated, it was clearly recognized that a yellow vegetation covered the spinal cord, with an increase in blood vessels, an abnormal distribution, and the compressed and flattened spinal cord.

小结

本文报告了一例软脊膜下脂肪瘤并截瘫的少见病例及其治疗经过和恢复情况，从病理和临床角度分析了其与髓内肿瘤的鉴别，提出了诊断和治疗意见。指出: 手术宜尽早施行，但不须冒险“彻底”切除肿瘤，而脊髓减压措施十分必要。

Summary

In this paper, we report a rare case of infraspinal lipoma with paraplegia, as well as its treatment and recovery. The differential diagnosis from intramedullary tumor was analyzed from the pathological and clinical aspects, and the diagnosis and treatment were proposed. It was pointed out that the operation should be performed as soon as possible without risking “complete” resection of the tumor, and spinal cord decompression was necessary.

By Mingjie Li, Nanling Hospital Surgery Department

原载

Surgical analysis of surgical paraplegia (draft)

orthopedic paper III

Surgical analysis of surgical paraplegia

Report of 14 cases

Abstract This paper reviews the surgical treatment and long-term follow-up of 14 cases of paraplegia due to surgical causes encountered by the author in the past 13 years. The results are obtained in 10 cases for full recovery, 3 cases for improvement, and 1 death. The etiology, pathology, and the surgical approach are presented and discussed in details.

ABSTRACT

14 cases of paralysis due to the trauma or compression of spinal cord in the last 13 years have been reviewed. The operative procedures and long-term follow-up reveal the results: excellent 10, survivals 3 and death 1. The etiology, pathology and operation are discussed in detail.

According to etiologic survey, they are classified thus: spinal columa fractures and co-existing dislocations in 7 cases, tuberculosis in 5 and tumor in 2.

Fracture-dislocations of spinal column can easily cause bad injury in spinal cord, especially when the injury lies in cervical and last-dorsal vertebrae. However, except for the carvical damage which susceptibly causes death, as a rule, the patients may still live rather long. So a fit prescription should be given.

The thoracic vertebrae tuberculosis, as abscess cannot be far drained away, is likely to cause pressure which brings about paralegia as a result. However, surgical treatment can lead to excellent result. The author specially recommends the practice of via-thorax one-time operation.

Most of the tumors within vortebral canal are benign, and they are usually located in the outside-cord. Excision is also good for the outcome.

按病因分类为:脊柱骨折7例，脊柱结核5例，椎管内肿瘤2例。

脊柱骨折，尤其是“横断全骨折” (指椎体、椎弓及椎间诸韧带一并损伤)，易致脱位；若在颈胸段，每易挫损或压迫脊髓而发生截瘫。其中脊髓毁损4例, 术中见脊髓实质呈粉糊样漂流，无论何种术式皆不能使截瘫抑转，但除1例颈髓高位损伤致呼吸困难、肺部感染而于伤后一月死亡外，一般皆可带残延年，甚至可行手工劳动、自食其力，故仍应重视其合理处理。脊柱骨折使脊髓受压而截瘫的3例，在排除脊髓体克后极早地施行骨折复位和减压术，能使截瘫迅速恢复，并且预期康复。此类病人，术中应仔细探查脊髓受损、受压的病理情况，以估计预后；要有效减压，力争复位，并力戒医源性重复损伤; 还需坚强的内固定，以恢复脊柱的稳定性和支持力，有利于早期活动和恢复劳动能力，减少并发症的产生。

According to etiological classification, there were 7 cases of spinal fracture, 5 cases of spinal tuberculosis and 2 cases of intraspinal tumor.

Spinal fracture, especially “transverse total fracture” (refers to the simultaneous injury of vertebral body, vertebral arch and various intervertebral ligaments), is easy to cause dislocation. If it is in the cervical and thoracic segments, each one is liable to lose or compress the spinal cord, and paraplegia occurs. In four cases of spinal cord injury, the pasty rafting of spinal cord parenchyma was observed during the operation. No matter what operation method is adopted, the paraplegia cannot be inhibited and turned. However, except for one case who died one month after injury due to dyspnea and pulmonary infection caused by high level injury of cervical spinal cord, the patients can generally live with disability and prolong life, and even can work manually and earn their own living, so they should still pay attention to their reasonable treatment. In the 3 cases of paraplegia caused by spinal cord compression due to spinal fracture, reduction and decompression of the fracture were performed very early after removal of the spinal cord mass, which can lead to a rapid recovery of paraplegia and is expected to recover. In such patients, the pathological conditions of spinal cord injury and compression should be carefully explored during operation to estimate the prognosis. Effective decompression should be carried out to strive for reduction, and iatrogenic repeated injury should be strictly avoided. Rigid internal fixation is also needed to restore spinal stability and support, facilitate early mobility and restore labor capacity, and reduce complications.

脊柱结核，若在胸段，因其脓肿无法远处流注，加之此处椎管相对狭窄，易于造成椎管梗阻，压迫脊髓而致截瘫。文中收集的5例，均在下胸段，椎体结核4例，椎弓结核1例，经手术清除病灶，全部痊愈。文中着重推荐在有适应症的病例施行经胸一次病灶清除并前路椎间植骨术式，不但提高了疗效，也大大缩短了疗程，显示了优越性。对于少见的椎弓结核，应予重视和寻找，祛除病灶，易于收效。

For spinal tuberculosis located in the thoracic segment, the abscess cannot flow far away, and in addition, the spinal canal here is relatively narrow, which is likely to cause spinal canal obstruction and compression of the spinal cord, resulting in paraplegia. Five cases, all in the lower thoracic region, 4 cases of vertebral tuberculosis and 1 case of vertebral arch tuberculosis were collected in this paper. All of them were cured after the lesions were cleared by surgery. In this paper, we emphatically recommend the transthoracic radical debridement and anterior intervertebral bone grafting in cases with indications, which not only improves the curative effect, but also greatly shortens the course of treatment and shows the superiority. For the rare vertebral arch tuberculosis, we should pay attention to and search for it, remove the focus and it is easy to achieve results.

椎管内肿瘤，多为良性，位于髓外，手术摘除或并减压措施，收效良好。本组2例均为髓外良性肿瘤，一例完全摘除，一例大部分摘除并硬脊膜敞开减压，均获痊愈。不过，对于恶性肿瘤，手术宜十分慎重，以免误伤和发生难以控制的出血。

Intraspinal tumors, most of which are benign and located extramedullary, have been surgically removed or decompressed with good results. Two cases were extramedullary benign tumors in this group. One case was completely removed, and the other case was mostly removed and the dura mater was opened for decompression. All of them were cured. However, for malignant tumors, surgery should be very careful to avoid accidental injury and uncontrolled bleeding.

概述

脊髓因损伤而功能丧失，或因受压而功能不全，临床上出现程度不等之截瘫表现，给病人带来严重后果; 若处理得当，可挽回大多数病例。作者自一九六八年至一九八一年的13年间，共遇此类病人14例，均经手术，明确诊断，并作了相应的处理，获得10例痊愈，8例好转和1例死亡的结果。兹就本组病例的病因、病理、手术及预后作一介绍与分析。

Overview

Paraplegia of varying degrees occurs clinically because of loss of function due to injury to the spinal cord, or dysfunction due to compression, bringing serious consequences to patients; If properly managed, most cases can be saved. During the 13 years from 1968 to 1981, the authors encountered 14 such patients. All of them were confirmed by surgery and treated accordingly. The results were as follows: 10 cases were cured, 8 cases were improved and 1 case died. We present and analyze the etiology, pathology, surgery and prognosis of this group of patients.

一、病因分类

脊柱骨折	脊柱结核	椎管内肿瘤
脊髓损伤｜脊髓受压	椎体结核｜椎弓结核	硬膜内神经纤维瘤｜软膜下脂肪瘤
4 ｜ 3	4 ｜ 1	1 ｜ 1

二、截瘫程度

截瘫指数	1	2	3	4	5	6
例数	0	0	2	4	3	5

三、麻醉选择及手术入路

麻		醉	手术		入路
局麻	硬麻	全麻	椎板后入路	侧前方入路	经胸前入路
2	4	8	11	1	2

四、手术方法

探查+牵引	探查+复位+固定	减压+复位+固定	病灶清除+减压	病灶祛除
1	3	3	5	2

五、病理改变与预后

脊髓损伤	(4例)	脊髓受压 (10例)
无改变	死亡	痊愈 (恢复)
3	1	10

I. Etiological classification

II. Degree of paraplegia

III. Anesthesia selection and surgical approach

IV. Surgical methods

V. Pathological changes and prognosis

关于脊柱骨折合并截瘫

脊柱骨折，由于外力作用点的不同，可以出现在脊柱各段。但因脊髓园锥终止于第一腰椎下缘，其下即为马尾，而马尾系神经纤维，其损伤一般是不完全的; 脊髓却十分脆嫩，易于毁损。所以颈胸段脊柱骨折并发截瘫率高，而且预后多系不良。此类病人的治疗目的是: 1. 探查脊髓，查清病理改变，力谋解除压迫或并加减压措施，以恢复椎管通畅，并对预后作一估计。2. 在手术直视下使骨折复位，力戒重复损伤，加以坚强的内固定，以恢复脊柱的稳定性和支持力。基于以上目的，虽然涉及到骨科和神经外科两科工作，但必须兼顾而不得偏废，因为恢复脊髓功能，关系到生命安危; 而脊柱稳定性的恢复，却关系到恢复劳动力。临床上常一并处理之。·

About spinal fracture combined with paraplegia

Spinal fractures can occur in various segments of the spine due to different points of external force. However, the injury is generally incomplete because the spinal cord cone terminates at the lower margin of the first lumbar vertebra, below which is the cauda equina, and the cauda equina nerve fibers. Spinal cord is very fragile, easy to damage. Therefore, cervical and thoracic spinal fractures complicated with paraplegia have a high rate and poor prognosis. The therapeutic purposes of these patients are as follows: 1. Probe the spinal cord, identify the pathological changes, and strive to relieve the compression or add decompression measures to restore the patency of the spinal canal, and make an estimation on the prognosis. 2. The fractures should be reduced under the direct vision of surgery. Repeated injuries should be strictly avoided and strong internal fixation should be performed to restore the stability and supporting force of spine. Based on the above purpose, although the work of two departments of Orthopedics and Neurosurgery will be involved, both must be taken into consideration and must not be discarded, because the restoration of spinal cord function is related to the safety of life; However, the restoration of spinal stability is related to the restoration of labor force. It is often treated together clinically. ·

一、病例摘要

二、典型病例介绍

例①: 男性，36岁，脊柱胸9横断性全骨折并脱位。手木探查: 脊髓受压、无毁损。直视下行骨折复位、解压，脊柱钢板内固定。术后14天自行排尿，下肢肌力III级，感觉恢复。术后一月出院，三个月扶拐下地，以后逐渐行动自如，并恢复劳力。一年后拆除钢板，痊愈。

例②: 颈椎4.5.粉碎骨折并高位截瘫，手术探查证实脊髓毁损，仅予颅骨牵引，终因呼吸功能不全、肺部感染及褥疮而於手术后一个月死于全身衰竭。

Case Summary

II. Introduction of typical cases

Case ①: A 36-year-old man presented with complete transverse fracture and dislocation of thoracic spine 9. Wood exploration by hand: The spinal cord was compressed and there was no damage. Reduction and decompression of the fracture and internal fixation with spinal plate were performed under direct vision. He urinated on his own 14 days after surgery, and his lower limb muscle strength was grade III, and his feelings were restored. He was discharged one month after the operation and was helped to walk by crutches three months later. He gradually moved freely and recovered his strength. One year later, the steel plate was removed and the patient was cured.

例③: 男，42岁，胸8脊柱全骨折并截瘫，手术见脊髓呈粉糊样漂流，给以脊柱钢板内固定，截瘫末恢复，下肢肌内萎缩，上肢发达，全依扶杖移动，反射性膀胱，但可进行编织劳动，5年后死于糖尿病。

Case 2: cervical vertebra 4.5. comminuted fracture with high paraplegia, spinal cord damage confirmed by surgical exploration, only given skull traction, and finally died of systemic failure due to respiratory insufficiency, pulmonary infection and bedsore one month after surgery.

Case ③: A 42-year-old man with complete thoraco-8 spinal fracture and paraplegia presented with pasty spinal cord rafting during surgery, who was given internal fixation with spinal steel plate, recovered from paraplegia, with intramuscular atrophy of lower limbs, developed upper limbs, all moving in accordance with a crutch, reflective bladder, but able to perform weaving work, and died of diabetes five years later.

三、讨论

脊柱骨折并发截瘫，除脊髓休克可按期恢复外，少数因椎体压缩楔变，其后缘向椎营内退让移位，压迫脊髓前方，加上血肿压迫及脊髓反应性水肿所致; 多数的情况是椎体及其附件乃至椎间诸韧带均在一个平面上的损伤或移位，即“脊柱横断全骨折”，使脊柱的正常解剖遭受破坏。于是坚硬的骨质或骨折碎片极易挫毁，切割脆嫩的脊髓实质，而使其功能丧失; 且难以恢复。对前者，Osterholm①氏认为脊髓一旦机械受压，局部儿茶酚胺含量就不断增加，使该处血管强力收缩而致血供障碍，导致该段脊髓变性、软化，加速截瘫的发展，或使截瘫变得不可回逆。基于此理，则力劝人们甚至予以急症手术复位或解压，以免贻误治疗时机。不过，临床上亦有延迟手术使截瘫获得恢复的报告。至于后者，即脊髓已被毁损，却仅仅为了探查和避免尚未损伤的部分重复遭受医源性再损伤，而保留可能存在的一部分脊髓功能。 Allem氏曾指出①: “脊髓在严重损伤后24~48小时内全部溶解，这与髓内固有的自体破坏过程有关”。因此，对脊髓有部分实质性损害患者，最好在24小时内手术。除椎板减压、脊膜切开，还得考虑作脊髓背侧切开，以改变神经传递物质与出血性坏死的损伤反应，以阻断续发性脊髓损害。根据本组病例的手术检视和长期随访观察，病人的预后主要取决于脊髓损伤的病理改变程度。凡脊髓毁损者，恢复极少，例2、3、4 属此，例7也可能恢复无望; 而脊髓受压者，只要有效减压则可望痊愈，例1、5、6 属此。国内外资料表明②: 胸12以上脊柱移位程度大于1厘米伴全瘫者，常表示脊髓严重受损，恢复希望极少; 移位小于1厘米之全瘫，表示脊髓轻度受伤，恢复希望较大。但需注意脊柱骨折移位常有自动弹回的情况，故X线片示移位程度常小于实际受伤瞬间的错位幅度。一般统计，手术组较保守治疗组恢复率高50%左右。对于压缩椎体后上角突出于椎管压迫脊髓前方者，公认为侧前方减压效果较好，后侧椎板减压常无效果，但本组例1虽属此，而仅行后侧半椎板减压，亦获疗效。

Iii.

discussion

Spinal fracture complicated with paraplegia, in addition to spinal cord shock can be recovered on schedule, a few due to vertebral compression wedge change, its posterior margin to vertebral camp concession shift, compression of the spinal cord in front, plus hematoma compression and spinal cord reactive edema caused by; In most cases, the vertebral bodies and their attachments as well as the intervertebral ligaments are damaged or displaced in a single plane, that is, “complete transverse fracture of spine”, causing damages to the normal anatomy of the spine. As a result, the hard bone or fracture fragments are easily damaged and the crisp and tender spinal cord essence is cut to make it lose its function. And difficult to recover. For the former, Osterholm① (1) believes that once the spinal cord is mechanically compressed, the local catecholamine content will continuously increase, making the blood vessels here contract strongly, resulting in blood supply disorder, degeneration and softening of the spinal cord in this section, accelerating the development of paraplegia, or making paraplegia irreversible. Based on this reason, people are urged to even perform emergency surgical reduction or decompression to avoid delaying the timing of treatment. However, there are also clinical reports of delayed surgery for recovery of paraplegia. As for the latter, the spinal cord has been damaged, but only in order to explore and avoid the part that has not yet been damaged from repeated iatrogenic re-injury, and to retain a part of the spinal cord function that may exist. Allem once pointed out that ①: “The spinal cord is completely dissolved within 24–48 hours after severe injury, which is related to the inherent process of autologous destruction in the marrow”. Therefore, surgery within 24 hours is preferred in patients with partial substantial damage to the spinal cord. In addition to laminectomy and spinal meningotomy, a dorsal incision of the spinal cord must be considered to alter the injury response of neurotransmitters and hemorrhagic necrosis to block the secondary spinal cord damage. According to the surgical examination and long-term follow-up observation of our cases, the prognosis of our patients depends mainly on the degree of pathological changes of spinal cord injury. Recovery is minimal in all cases with spinal cord injury, as in cases 2, 3, and 4, and hopeless in case 7. For patients with spinal cord compression, recovery is expected as long as effective decompression is performed, as in Cases 1, 5 and 6. The data both in China and abroad showed that ② The patients whose spinal column shift above thoracic vertebra 12 was more than 1cm with total paralysis often presented with severe spinal cord injury and little hope of recovery; Total paralysis with the displacement less than 1cm indicates mild spinal cord injury, and recovery is hopeful. However, it should be noted that automatic rebound is often found in the displacement of spinal fractures, so the degree of displacement shown in X-ray films is often less than the displacement amplitude at the moment of actual injury. According to general statistics, the recovery rate in the operation group was about 50% higher than that in the conservative treatment group. For the patients whose posterior superior horn of compressed vertebral body protrudes beyond the spinal canal to compress the anterior aspect of spinal cord, it is recognized that the anterolateral decompression is effective, while the posterior laminectomy is often ineffective. However, in case 1 of the present group, only the posterior hemilaminectomy was performed and the efficacy was also achieved.

四、小结

说明外伤性截瘫，除高位截瘫因严重并发症而近期死亡外，若压迫所致，一旦解压多能恢复; 而脊髓挫伤则难于希望恢复，但通过手术复位内固定，稳定脊柱，仍可以较长时间生存。需注意: “压迫和挫伤”之间并非绝对分界，且常可交迭存在，况且肉眼所见难以十分准确，故“挫伤”者，尚寄希望于维护残存的部分脊髓功能; “压迫”者，亦可因水肿、局部贫血而续发脊髓变性，使截瘫加重。因此，对疑有脊髓实质损害者，亦宜按“受压”来处理，以作最大的挽救。

IV. Summary

It indicated that traumatic paraplegia, except high paraplegia which recently died due to severe complications, could be recovered once decompressed if it was caused by compression. Spinal cord contusion is hard to recover, but it can still survive for a long time through surgical reduction and internal fixation to stabilize the spine. It should be noted that the boundary between “compression and contusion” is not absolute, and they can often overlap, and the macroscopic view is difficult to be very accurate. Hence, for “contusion”, the hope is still placed on the maintenance of the residual spinal cord function. “Compression” person, also because of edema, local anemia and secondary spinal cord degeneration, make paraplegia aggravating. Therefore, patients with suspected spinal cord parenchymal damage should also be treated as “stressed” for maximal salvage.

关于脊柱结核并发截瘫

脊柱结核，以椎体结核为多见，脊椎附件结核却甚为少见，约占1%，若因结核性物质充填椎管造成梗阻，可发生截瘫，常在胸段，因此处椎管相对狭窄。

胸椎结核并发截瘫机会甚多，保守治疗，不但卧床时间漫长，而且治愈机会极少。而截瘫并发症又咄咄逼人，刻不容缓，适当准备后力争尽早手术，已成为现代定型观点。在抗痨治疗的保护下，给以彻底病灶清除，使椎管通畅; 若再加上植骨融合，稳定病灶部位脊柱，能收到较好的效果，且能防止复发。本组5例经手术全部治愈。

On spinal tuberculosis complicated with paraplegia

Spinal tuberculosis is more common than vertebral tuberculosis, while the tuberculosis of spinal attachment is rare, accounting for 1%. Paraplegia may occur due to obstruction caused by filling spinal canal with tuberculous substance. The spinal canal is often located in the thoracic region, so the spinal canal is relatively narrow.

Thoracic vertebra tuberculosis complicated with paraplegia has many opportunities. Conservative treatment not only requires a long time to stay in bed, but also has few chances of cure. The complications of paraplegia are very aggressive and urgent. We should strive to operate as soon as possible after proper preparation, which has become a modern stereotypes. Under the protection of anti-tuberculosis treatment, the lesions were removed completely to make the spinal canal unobstructed. If bone grafting and fusion are used to stabilize the spine at the focus, good results can be achieved and recurrence can be prevented. All the 5 cases in this group were cured after surgery.

一、脊柱结核病例摘要

二、典型病例介绍

1. 例1, 男，35岁，胸椎8.9.结核并截瘫。经过三周抗痨准备，按照分次、分侧手术计划，先予硬麻下行后入路清除右侧病灶, 清出多量脓汁、死骨及结核肉芽，术后显示截瘫有恢复，但末能撤除导尿管。一月后拟再次手术清除对侧病灶并行融合术，但全麻后高热 (41℃) 惊厥，被迫停止手术。尔后病家不愿再手术，乃出院休养。返家20天导尿管脱出而自行排尿，三月后扶拐下地，半年后轻劳动，手术后一年患者竟将其病母抬送40里来院看病，使术者感到惊讶!

I. Summary of spinal tuberculosis cases

II. Introduction of typical cases

Case 1, male, 35 years old, thoracic 8.9. Tuberculosis with paraplegia. After three weeks of antituberculosis preparation, according to the plan of divided and lateral operations, the right lesion was cleared through the posterior approach under rigid anesthesia first, and a large amount of pus, dead bone and tuberculosis granulation were cleared. The postoperative paraplegia was shown to be recovering, but the urinary catheter could not be removed. After one month, another operation was planned to remove the contralateral lesion and fusion was performed, but after general anesthesia, with high fever (41℃) convulsion, the operation was forced to stop. Later, the patient did not want to have another operation but was discharged to recuperate. After returning home for 20 days, the catheter came out and urinated on his own. After three months, he helped the patient to the ground and half a year later he worked lightly. One year after the operation, the patient unexpectedly sent his sick mother to the hospital for 40 miles to see a doctor, which surprised the operator.

2. 例3, 男，36岁，胸7椎弓结核并截瘫。全椎板减压后4个月下地，一年后亦恢复劳动。此例行脊髓造影，因蛛网膜粘连出现假性定位; 术中找到病灶，切除后经病理证实。

Case 3, a 36-year-old male, presented with 7-thoracic pedicle tuberculosis with paraplegia. She went down four months after total laminectomy and resumed her work one year later. In this routine myelography, pseudolocalization occurred due to arachnoid adhesion; The lesion was found during surgery and confirmed pathologically after resection.

3. 例5, 女性，29岁，工人, 胸椎8.9.结核，椎体塌陷出现驼峰，同时有肺部增殖性结核灶, 右髋结核并脱位, 痊愈型。体质弱, 体重42公斤。住院作术前准备期间，截瘫进行性加重，毒血症状未能控制。气管内乙醚全麻下经右胸一次直视下清除病灶，切除病椎2.5个，椎管前减压，潜行刮出10厘米椎管内结核物质，可见到硬脊膜恢复搏动，椎体间嵌入肋骨条 2根，冲洗手术野，转移胸膜办修补手术区的胸膜缺损，常规关胸。术后无并发症，截瘫迅速解除，机体恢复亦顺利，卧床4个月下地，一年后重返纺织工作。拍片复查植骨片融合，椎旁脓肿影消失，肋角稍钝。

Case 5, female, 29 years old, worker, thoracic vertebra 8.9. Tuberculosis, vertebral collapse hump, at the same time there are pulmonary proliferative tuberculosis, right hip tuberculosis and dislocation, cured type. Weak constitution, weight 42 kg. During hospitalization for preoperative preparation, the paraplegia progressed and the toxic blood symptoms could not be controlled. Under general anesthesia with intratracheal ether, the lesions were removed under direct vision through the right chest at one time, 2.5 diseased vertebrae were excised, anterior spinal canal decompression was performed, and 10 cm of intraspinal tuberculous substance was scraped out stealthily, so that the dura mater could be seen to resume beating. Two rib strips were embedded between vertebral bodies, and the operation field was rinsed. The pleura was transferred to repair the pleural defect in the operation area, and the chest was closed conventionally. There were no postoperative complications. The paraplegia was quickly resolved and the body recovered smoothly. He stayed in bed for four months and went back to work in textile after one year. After reexamination of radiography and bone graft fusion, the paraspinal abscess disappeared and the costal angle was slightly blunt.

三、讨论

脊柱结核系一特异感染，结核肉芽、干酪样物质、脓液充斥于椎管内外、脊髓周围，尤其在胸椎管狭窄，脓液又无法远处流注，加上死骨或坏死椎间盘组织，使椎管梗阻、脊髓受压而出现截瘫。此时结核的毒血症状侵扰机体各个器官，较之机械压迫因素造成的截瘫，病情大为复杂和难处理。

Iii. discussion

Spinal tuberculosis is a specific infection. Tuberculosis granulation, cheese-like substances and pus fill the inside and outside of the spinal canal and around the spinal cord, especially in thoracic spinal stenosis. The pus cannot flow far away. In addition, dead bone or necrotic intervertebral disc tissue causes spinal canal obstruction and spinal cord compression, resulting in paraplegia. At this time, the poisonous blood symptom of tuberculosis invades all organs of the body. Compared with the paraplegia caused by mechanical compression factors, the condition of the disease is much more complicated and difficult to handle.

后入路分次分侧病灶清除，是习用至今的定型手术。它除能清除病灶和打破“结核屏障”，有利病灶的痊愈外，还能同时进行椎板减压，对并发截瘫的恢复，亦甚有效，甚至仅作一侧病灶清除亦显示了疗效，如例1。不过带有较大的盲目性，因为手术是在视野不清的深部操作，只能凭借经验进行和做到“相对彻底”，更还有误伤血管、脊髓或内脏的危险。据国内方先之氏报导47例手术效果为61.6%④。而经胸前入路，不但能在直视下安全有效地进行彻底病灶清除，更可清除椎管内结核性破坏物质，解除脊髓的压迫因素，加之椎管前方可靠的减压，更有利于截瘫恢复⑤。同时行前路椎间植骨, 促成加压融合, 利于恢复脊柱的稳定性。这不但避免了多次手术的痛苦和经济负担，而主要是大大提高了治愈率和缩短了疗程⑥。我们近年来已有改行经胸手术的倾向，如例4、例5，在经胸一次手术之后完成了清除病灶、椎管减压、椎体间植骨三个目的，使截瘫迅速恢复，均一年内恢复了劳动能力，是值得推荐的一种好的治疗途径。

The posterior approach for removing the foci in multiple stages and by different sides has been a conventional and standardized operation up to now. In addition to clearing the lesions and breaking the “tuberculosis barrier”, which is beneficial to the recovery of the lesions, it can also simultaneously carry out laminectomy and is very effective for the recovery of complicated paraplegia. Even the clearing of only one side of the lesion also shows the efficacy, as in Example 1. However, it is blinded because the operation is performed in a deep part with an unclear field of view. It can only be performed and “relatively thorough” based on experience, and there is a risk of accidental injury to blood vessels, spinal cord or internal organs. According to Fang Xianzhi’s report in China, the surgical results of 47 cases were 61.6%④. The transthoracic approach can not only safely and effectively remove the lesions completely under direct vision, but also remove the tuberculous destructive substances in the spinal canal and relieve the compression factors of the spinal cord. In addition, the reliable decompression in front of the spinal canal is conducive to the recovery of paraplegia ⑤. At the same time, anterior intervertebral bone grafting was performed to facilitate compression fusion, which is conducive to the restoration of spinal stability. This not only avoids the pain and economic burden of multiple surgeries, but mainly greatly improves the cure rate and shortens the treatment course ⑥. In recent years, we have tended to switch to transthoracic surgery, for example, cases 4 and 5. After a transthoracic surgery, we completed the removal of lesions, spinal canal decompression and bone grafting between vertebral bodies, so that the paraplegia recovered rapidly and the labor ability was restored within one year. This is a good treatment approach that is worthy of recommendation.

脊柱附件结核，发病率低，周围肌肉多，血液循环好，病灶易被吸收，一般予后良好。但在胸段亦能并发截瘫。给以椎板减压，祛除病灶、若不破坏小关节突，则无碍脊柱的稳定，治疗尚称方便，如文中例3。

Spinal attachment tuberculosis, with low incidence, many surrounding muscles, good blood circulation and easily absorbed lesions, is generally good after giving it. However, paraplegia can also occur in the thoracic region. The vertebral plate was decompressed to remove the lesions, but the stability of the spine would not be hindered if the facet joints were not damaged. The treatment was convenient, as in Case 3.

关于椎管内肿瘤并发截瘫

椎管内肿瘤以髓外硬膜内的神经纤准瘤为常见，髓内多为胶质瘤和室管膜瘤，而软脊膜下脂肪瘤较为罕见。肿瘤对脊髓构成占位性压迫，可逐渐产生部分瘫并随着肿瘤的生长、增大，截瘫程度也进行性加重，非手术切除或推管减压所不能逆转，应予重视⑦。但需区别内科截雍 — 横断性脊髓炎、蛛网膜下腔出血等，以免误行手术，增加病情。

一、病例摘要

例次	年份	节段	奎氏试验	病理诊断	手术所见	手术方法	预后
1	1969	T10	部分梗阻	神经纤维瘤	T10右旁硬膜内髓外1.5×1.0×1.0Cn	完全摘除肿瘤	痊愈（2个月恢复）
2	1979	C7 T1	完全梗阻	软膜下脂肪瘤	C7 T1软脊膜下脂肪块压扁脊髓50%达3cm	摘除肿瘤约70%，硬脊膜敞开减压	痊愈（6个月恢复）

On intraspinal tumor complicated with paraplegia

Intraspinal tumors are common as neurofibroblastomas in the extramedullary dura, mostly as gliomas and ependymomas in the medulla, and suboccipital lipomas are rare. Tumor constitutes space-occupying compression to spinal cord, which can gradually produce partial paralysis. With the growth and enlargement of tumor, the degree of paraplegia also gradually aggravates. It cannot be reversed without surgical resection or push tube decompression. It should be paid attention to ⑦. However, internal medicine interception–transverse myelitis, subarachnoid hemorrhage and others should be distinguished so as to avoid misoperation and increase the disease condition.

Case Summary Ii.

二、讨论

上述两例均由临床神经定位诊断的，术中证实无误。对其具体病理请况和最后的定性诊断，术前难以确定，但手术切除或减压，肯定能改善病情。例1神经纤维瘤在髓外，完全摘除痊愈; 例2肿瘤在软膜下与脊髓紧贴，已系颈陶段高位，故未敢彻底切除，给予敞开硬脊膜减压，术后病理报告为良性脂肪瘤，故亦痊愈，是解除了有脊髓压迫之故。

Discussion

The above two cases were both diagnosed by clinical neurolocalization, and they were confirmed to be correct during the operation. The specific pathological conditions and the final qualitative diagnosis are difficult to determine preoperatively, but surgical resection or decompression can certainly improve the condition. Case 1 The neurofibroma was extramedullary and completely removed and cured. In Case 2, the tumor was in close contact with the spinal cord under the soft membrane, and it had been tied to the high part of the cervical pottery segment. Therefore, the tumor did not dare to be completely removed, and open dura mater decompression was given. The postoperative pathology report showed that the tumor was a benign lipoma, and the tumor was cured, which explains why the spinal cord compression was relieved.

椎管内肿瘤所造成截瘫的原因，除恶性肿瘤对脊髓实质破坏外，归根到底是椎管内占位性压迫因素。它所构成的椎管内梗阻，可以由脑脊液动力学试验和脑脊液化学检查来确定。至于压在何处，临床上定位神经损害颇能提示，而脊髓造影，理论上是可靠的定位方法，然而需排除操作的误差及蛛网膜下腔的粘连、血管异常等病理因素的干扰，提高放射线学诊断水平才不致被可能出现的假象所迷惑，俾增进术前的正确判新。

The cause of paraplegia caused by intraspinal tumors is, in the final analysis, a space-occupying compression factor in the spinal canal, in addition to the destruction of the spinal cord parenchyma by malignant tumors. The intraspinal obstruction it constitutes can be determined by cerebrospinal fluid kinetics and cerebrospinal fluid chemistry. As for the location of the compression, clinical localization of nerve damage can be quite suggestive, and myelography is theoretically a reliable localization method. However, it is necessary to rule out the operation error and the interference of pathological factors such as subarachnoid adhesions and vascular abnormalities, so as to improve the radiological diagnosis level and avoid being confused by the possible false appearances, thus improving the correct diagnosis before surgery.

术前还需尽力明确肿瘤在髓内抑或髓外、是良性抑或恶性，它对手术的难度和予后估计皆具意义。脊柱各个方位的X线片，可剔除椎管的骨质损伤或破坏。改进脊髓造影技术，注意临床症状和体征，正确施行奎肯氏试验等，加以综合分析，有可能提高诊断水平。不过，对于确实无法明确诊断者，亦不能因循延误，以尽早手术探查为好。因为: 其一，椎管内肿瘤以良性肿瘤居多，手术摘除易于收效。其二，即便系恶性肿瘤, 起码可以减压而缓解病情。(但需慎重，因手术可能发生意外出血和损伤。) 其三，通过手术检视和病理检查，可以明确诊断，而给予适当处理和估计予后。

Preoperative efforts should also be made to determine whether the tumor is intramedullary or extramedullary, benign or malignant, which is significant for both the difficulty of surgery and the prognosis. X-ray films of various orientations of the spine can be used to eliminate bone damage or destruction of the spinal canal. Improvement of myelography, attention to clinical symptoms and signs, correct implementation of the Kuiken’s test, and comprehensive analysis may improve the diagnostic level. However, for patients who cannot be diagnosed definitively, early operative exploration is better than follow-up delay. Because: First, spinal canal tumors are mostly benign tumors, and surgical removal is easy to achieve results. Second, even if it is a malignant tumor, it can at least relieve stress and alleviate the disease. (However, caution is required, as accidental bleeding and injury may occur during the operation. Thirdly, through surgical examination and pathological examination, a definite diagnosis can be made and appropriate treatment and estimation can be made later. summary Through reviewing the long-term observation of 14 patients with paraplegia caused by surgical reasons in our hospital in the past 13 years, Muwen introduced the treatment process and outcome of typical patients, evaluated various treatment methods, analyzed the individual situations of paraplegia caused by trauma, tuberculosis and tumor, and put forward some suggestions. There was no operative mortality in 14 cases. 10 cases recovered completely; 1 case died recently after operation of high paraplegia due to cervical trauma; 1 chest

总结

木文通过回顾本院近13年来因外科原因所致的截瘫14例手术后病人的长期观察，介绍了典型各例病人的处理过程和转归，评价了各种治疗方法，分析了外伤、结核和肿瘤所引起的截瘫的各别情况，提出了推荐意见。

全组14例，无手术死亡率。完全恢复痊愈10例; 1例颈段外伤高位截瘫术后近期死亡; 1例胸段外伤性截瘫于撰写本文时术后才一个月余，犹待继续追访; 另两例胸椎骨折伴脊髓毁损，术后截瘫未恢复，但术后生存了5年及3年分别死于其他并发症 — 糖尿病和肠梗阻，这种死因与截瘫有无因果关系尚难定论。

结核和脊髓良性肿瘤手术，显示100%疗效。对胸椎结核并发截瘫的治疗，已进展到经胸一次手术，疗程大为缩短，而且可以予期收效，改变了过去对“截雍”望而生畏的态度，从而展望了新的前景。至于外伤性截瘫的预后，关键是由脊髓受伤情况决定的。

Summary

Through reviewing the long-term observation of 14 patients with paraplegia caused by surgical reasons in our hospital in the past 13 years, Muwen introduced the treatment process and outcome of typical patients, evaluated various treatment methods, analyzed the individual situations of paraplegia caused by trauma, tuberculosis and tumor, and put forward some suggestions.

There was no operative mortality in 14 cases. 10 cases recovered completely; 1 case died recently after operation of high paraplegia due to cervical trauma; One case of thoracic traumatic paraplegia was still awaiting follow-up more than one month after surgery at the time of writing this article. The other two cases of thoracic vertebra fracture with spinal cord damage did not recover from paraplegia after operation, but survived for 5 years and 3 years after operation and died from other complications—diabetes mellitus and intestinal obstruction, respectively. Whether there is a causal relationship between these causes of death and paraplegia is still uncertain.

Tuberculosis and spinal cord benign tumor surgery, showing 100% efficacy. The treatment of thoracic spinal tuberculosis complicated with paraplegia has progressed to one-off transthoracic surgery, with greatly shortened course of treatment and predictable outcomes. This has changed the daunting attitude of the past towards “stagnation”, and thus prospected new prospects. As for the prognosis of traumatic paraplegia, the key is determined by the condition of spinal cord injury.

参考资料:

郭世绂等: 脊髓损伤后病理改变及应用不同疗法的初步观察 (动物实验)，骨料附刊: 4∶176， 1979
胥少汀: 地震脊柱骨折并脊髓损伤的早期处理。骨科附刊: 4:146， 1980
郭巨灵等: 震伤截瘫治疗初步总结。骨科附刊: 1:28， 1978
方先之等: 骨关节结核病灶清除疗法。P: 58 (人民卫生出版社) 1957
范秉哲: 开胸施行胸椎结核病灶清除术。中华外科杂志: 7∶20， 1959
王志先: 经胸腔施行椎结核病灶清除术。中华外科杂志: 7:271， 1959
曾广义等: 脊髓肿瘤。中华外科杂志: 10:(6)374， 1962
吴英恺等译: 苏联卫国战争医学经验，外科部分摘译。第十一卷人民卫生出版社: 1956

References:

Guo shihe et al. preliminary observation on pathological changes after spinal cord injury and application of different therapies (animal experiment ), aggregate supplement: 4: 176, 1979
Xu shaoting: early treatment of spinal fracture and spinal cord injury after earthquake. Orthopedics Supplement: 4:146, 1980
Guo Juling et al. Preliminary summary of treatment for paraplegia caused by earthquake. Orthopedics Supplement: 1:28, 1978
Fang xianzhi et al. focus removal therapy for osteoarticular tuberculosis. P: 58 (people’s health press) 1957
Fan Bingzhe: Thoracotomy is performed to remove the focus of thoracic vertebra tuberculosis. Chinese journal of surgery: 7: 20, 1959
Wang Zhixian: The focus removal of vertebral tuberculosis was performed through the thoracic cavity. Chinese journal of surgery: 7:271, 1959
Zeng Guangyi et al. spinal cord tumor. Chinese journal of surgery: 10 (6) 374, 1962
Wu Yingkai et al. Translation: Medical Experience in the Great Patriotic War of the Soviet Union, Excerpts from the Surgical Section. Vol. 11 People’s Health Publishing House: 1956 First draft of January 1981 by Li Mingjie, Nanling County Hospital, Anhui Province; Amended september 1981 Exchange of data at the second academic conference of orthopedics in anhui province

安徽省南陵县医院李名杰一九八一年一月初稿; 一九八一年九月修正

安徽省第二届骨科学术会议交流资料

AN ANALYSIS ON OPERATION OF 14 CASES OF PARAPLEGIAFOR SURGICAL CAUSES

Li MingjieNanling People’s Hospital, Anhui

Oct1 1981.

注: 本文承芜湖地区医院骨科袁思忠医师审阅，特此致谢。

原载《安徽省第二届骨科学术会议交流资料》

Transpedicular tuberculosis complicated with paraplegia (draft)

orthopedic paper II

Transpedicular tuberculosis complicated with paraplegia

A Case Report

脊椎附件结核仅占脊柱结核的1%，在胸段易发生截瘫，容易误诊 [1]。我院曾遇一例，术前误诊为脊髓肿瘤，手术后病理证实为椎弓结核。随访三年，现已痊愈。国内此类报告甚少，现报告如下:

Spinal attachment tuberculosis accounts for only 1% of spinal tuberculosis, and paraplegia is easy to occur in the thoracic region and it is easy to be misdiagnosed [1]. In one case reported in our hospital, spinal cord tumor was misdiagnosed preoperatively, and transpedicular tuberculosis was confirmed pathologically after surgery. He was followed up for three years and has recovered. There are few such reports in the country and they are now reported as follows.

患者伍xx，男性，36岁，农民，已婚，南陵人。病案号:1928。

腰背痛三年，行走不稳一年，截瘫三个月，大小便障碍。于1976年4月27日人院。检查: 两下肢呈伸直痉挛性瘫痪，肌肉萎缩，肌力0级，感觉麻痹在胸10水平，膝反射亢进，踝阵挛。截瘫指数5 (感觉2、运动2、括约肌1)。胸椎无后突畸形，胸椎4-10均有叩痛，奎肯氏试验证明部分梗阻。脑脊液色黄，蛋白量增高 (潘氏试验+)。5月3日脊髓造影示胸11右侧不规则充盈缺损，少量造影剂通过狭窄处上升。胸腰段脊柱X线片未提示特殊阳性征象。临床印象: 脊髓肿瘤髓外型。胸10左右。于76年5月5日在气管内乙醚全麻下行脊髓探查。后中线进路，胸7-12全椎板切除，未累及小关节突。术中奎氏试验仍示梗阻，乃切开硬脊膜探查脊髓，未查到病变，复在胸椎7的右侧椎板附近小关节处有“肉芽”压迫脊髓，乃刮除之。再用细导尿管探查蛛网膜下腔，证实通畅无碍。此时脊髓恢复搏动。术中见蛛网膜部份粘连，椎弓未见明确的骨质破坏。病理报告为“结核”。病理号: 2476 (解放军127医院)。手术后48小时，两下肢有自主活动，肌力三级，踝阵挛消失，感觉部分恢复，以后逐渐改善，切口按期愈合，术后20天大小便可以自解，于5月28日出院休养，继续抗痨治疗，住院31天。

Patient Wu xx, male, 36 years old, a farmer, was married from Nanling. Medical record no. 1928.

Low back pain for three years, walking instability for one year, paraplegia for three months, urination and defecation disorders. The hospital on april 27, 1976. Examination: both lower limbs showed unbend spastic paralysis, muscle atrophy, muscle strength of grade 0, sensory paralysis at chest level 10, knee hyperreflexia, ankle clonus. Paraplegia index 5 (sensation 2, movement 2, sphincter 1). There was no kyphoscoliosis in the thoracic vertebrae and knocking pain was observed in all thoracic vertebrae 4–10, with partial obstruction demonstrated by the Kuiken’s test. Cerebrospinal fluid yellow with increased protein content (Pan Shi test+). Myelography on 3 May showed an irregular filling defect on the right side of chest 11, with a small amount of contrast rising through the stenosis. X-ray of the thoracic and lumbar spine did not show any special positive signs. Clinical impression: extramedullary spinal cord tumor. Chest 10 or so. Spinal cord exploration was performed on May 5, 76 under general anesthesia with endotracheal ether. Posterior midline approach, total laminectomy of thorax 7-12, without involvement of facet joints. During the operation, Quirrell’s test still showed obstruction, in which the spinal cord was explored by incision of the dura mater, but no lesion was found. Additionally, there was “granulation” compressing the spinal cord at the small joint near the right vertebral plate of thoracic vertebra 7, which was shaved off. Then the subarachnoid space was explored with a thin urinary catheter, and the patency was confirmed. At this point the spinal cord resumes beating. Partial adhesion of arachnoid membrane was observed during the operation, and no definite bone destruction was observed in the vertebral arch. The pathological report was “tuberculosis”. Pathological number: 2476 (People’s Liberation Army Hospital No.127). At 48 hours after the operation, both lower limbs had spontaneous activity, muscle strength was grade III, and ankle clonus disappeared. The sensation was partially restored and it gradually improved later. The incision healed on schedule. The patient could urinate 20 days after the operation and was discharged for rest on May 28. Anti-tuberculosis treatment was continued and the patient was hospitalized for 31 days.

随访情况: 术后四个月带拐起床，又五个月弃拐步行，再一年参加劳动，现做9分工，可行20-30里路，一般情况正常。检查: 手术段脊柱有部分强直，故弯腰、挑抬略差。79年8月14日复查X线片示骨质无破坏和其他变异，留有下胸段棘突和椎板缺如，并残留造影剂。

Follow-up results: patients who took crutches and got up four months after surgery, and then abandoned crutches and walked five months later. After another year of labor, they now work in 9 divisions, with a possibility of 20 to 30 miles. The general conditions are normal. Examination: The spine at the operation section was partially rigid, so the bending and lifting were slightly poor. A reexamination X-ray on 14 August 79 showed no destruction and other variations of the bone, leaving acanthosis of the lower thoracic segment and absence of the vertebral plate, and a residual contrast agent.

讨论:

(1) 对于痉挛性截瘫的病例，临床外科自然想到脊髓的占位性压迫。奎氏试验、脑脊液检查、脊髓造影可以证实蛛网膜下腔梗阻情况和提示定位。唯椎弓结核少见，临床资料也少，若无局部体征如脓肿或瘘管等，X线片上又因椎体和大量软组织重叠，难以显示病损，诊断较为困难。天津骨科医院统计该病20中，误诊率达40%。文中此例术前就误诊为脊髓肿瘤。因此，在手术探查时未发现脊髓肿瘤和其他病损，除注重恢复蛛网膜下腔通畅外，要仔细寻找硬膜的压迫因素，刮除此处肉芽组织切片检查，往往可获正确诊断，从而获得合理治疗。

Discussion:

In the case of spastic paraplegia, space-occupying compression of the spinal cord naturally occurs to clinical surgeons. Quetiapine test, cerebrospinal fluid examination, and myelography can confirm the presence of subarachnoid obstruction and suggest localization. Only vertebral arch tuberculosis is rare, with few clinical data. Without local signs such as abscess or fistula, and because of the overlap of vertebral body and a large number of soft tissues on X-ray film, it is difficult to show the lesion and the diagnosis is relatively difficult. According to the statistics of 20 cases in Tianjin Orthopedics Hospital, the misdiagnosis rate reached 40%. This case was misdiagnosed as spinal cord tumor before operation. Therefore, spinal cord tumor and other lesions were not found during surgical exploration. In addition to paying attention to the recovery of subarachnoid patency, we should carefully look for the compression factors of the dura mater and scrape off the granulation tissue for sectioning, which often leads to the correct diagnosis and reasonable treatment.

(2) 椎弓较之椎体血运丰富，周围肌肉多，其结核病灶，一般可保守治疗;若并有截瘫，必予手木。其一进行探查和解除压迫; 其二可以清除病灶或打破“结核屏障”，术后残余结核灶也易于被抗痨药所治愈。文中此例为“孤立性”病灶，仅切除椎板，刮除“肉芽”，预后也甚良好。

Pedicle is more abundant in blood supply and surrounding muscles than vertebral body, and the focus of tuberculosis can generally be treated conservatively. If you also have paraplegia, you will have to use artificial limbs. One is to explore and relieve the compression; Second, the lesions can be removed or the “tuberculosis barrier” broken, and the postoperative residual tuberculosis lesions can be easily cured by antituberculosis drugs. In this case, it was described as a “solitary” lesion with only the laminectomy and “granulation” curettage, and the prognosis was also very good.

(3) 椎管探查、全椎板切除若不破坏关节突，根据脊柱三点应力的原理，其稳定性毋庸顾虑。作者此例切除包括棘突、两侧椎板共6节，长约15cm，脊柱的支持力良好。

According to the principle of three-point stress in spine, there is no need to worry about its stability if the zygapophyseal is not damaged during spinal canal exploration and total laminectomy. In our case, the resection included 6 segments of spinous process and bilateral laminae, with a length of about 15cm, and good spinal support.

(4) 碘剂脊髓造影常因蛛网膜下腔的粘连、血管异常、脊髓水肿等因素而出现假象 [3], 造成诊断和定位的错误。本例造影示胸11即有充盈缺损，术中见为蛛网膜下腔粘连所致，而压迫、梗阻却在胸7。另外，本例虽在造影后两天手术清除造影剂，而术后三年X线片的复查却示造影剂残留。幸此例尚无神经痛，估计已纤维包裹，因此对脊髓造影要有选择的慎用为宜。

Iodine myelography often shows false appearance due to subarachnoid adhesion, vascular abnormalities, spinal cord edema and other factors [3], resulting in wrong diagnosis and positioning. The angiography in this case showed that there was immediately a filling defect in chest 11. During the operation, it was seen that the defect was caused by adhesion of subarachnoid space, while the compression and obstruction were in chest 7. In addition, although the contrast was surgically removed two days after contrast in our case, reexamination of the X-ray three years after surgery revealed residual contrast. Fortunately, there was no neuralgia in this case, and it was estimated that the nerve fibers were wrapped, so it was advisable to use myelography selectively and cautiously.

(5) 该病与椎管内结核，有时实难鉴别，它们均能造成蛛网膜下腔梗阻而出现截瘫。而且脊柱X线征象往往阴性，脊髓造影同样可见造影剂停滞和充盈缺损。但后者发病急，全身毒血症状重，往往并有他处结核灶 (如肺结核、胸膜炎等); 局部病理改变显著，结核肉芽可从四周包绕脊髓，使截瘫发展迅速。据杨氏等报告5例，截瘫皆在三个月内出现 [4]，而预后也较严重，故仍有别于本病。

It is sometimes difficult to distinguish the disease from intraspinal tuberculosis, which can both cause subarachnoid obstruction and induce paraplegia. Moreover, spine X-rays tend to be negative, and myelography also reveals contrast stagnation and filling defects. However, the latter is acute and has severe symptoms of systemic toxic blood, and often has tuberculosis foci elsewhere (such as tuberculosis and pleurisy). Local pathological changes were significant, and tuberculosis granulation tissue could surround the spinal cord from all sides, making the paraplegia develop rapidly. Yang et al. reported five cases of paraplegia, all of which developed within three months [4], and the prognosis was also quite severe, so the disease was still different from paraplegia.

总结:

本文报告了一例胸椎椎弓结核合并截瘫的临床诊断、治疗和预后，结合复习文献，提出：(1) 椎弓结核发病率低、误诊率高，(2) 位于胸段者并发截瘫率高，(3) 手术治疗效果良好，以及 (4) 对脊髓造影、广泛全椎板切除的脊柱的稳定性等问题进行了探讨。

Summary

This paper reports the clinical diagnosis, treatment and prognosis of a case of thoracic vertebral pedicle tuberculosis complicated with paraplegia. Combined with literature review, the following issues were raised: (1) The incidence of vertebral pedicle tuberculosis is low, and the rate of misdiagnosis is high; (2) Patients located in thoracic segment are complicated with paraplegia is high; (3) The surgical treatment is effective, and (4) The spinal stability during myelography and extensive total laminectomy is discussed.

参考文献

[1] 天津骨科医院临床骨科学结核分册, P253 人民卫生出版社 1974[2] 王桂生等脊椎结核并发截瘫的手术治疗, 中华外科杂志 10:365 1962[3] 曾广义等脊髓肿瘤中华外科杂志, 10: (6)374 1962[4] 杨维明等椎管内结核中华外科杂志 14: (3)165 1966

References

Clinical Bone Science Tuberculosis Branch of Tianjin Orthopedic Hospital, P253 People’s Health Publishing House, 1974
Surgical treatment of spinal tuberculosis complicated with paraplegia such as Wang Guisheng, Chinese Journal of Surgery 10: 365, 1962
Zeng Guangyi and other spinal cord tumor Chinese Journal of Surgery, 10: (6) 374, 1962
Yang Weiming and other Chinese Journal of Surgery for intraspinal tuberculosis 14: (3) 165, 1966 Li Mingjie, surgeon of Nanling County Hospital, was born in Wuhu Medicine after the exchange of Provincial Orthopedics Annual Meeting. 1980. thirteen to eight

南陵县医院外科李名杰原载省骨科年会交流后《芜湖医药》1980；7:47

A surgical treatment of spinal tuberculosis (draft)

orthopedic paper I

A surgical treatment of spinal tuberculosis

Report of Three Cases

脊椎结核占全身骨关节结核的首位，为47.28%（1），临床上常见。保守治疗，虽在抗痨药物问世的今天，亦迁延多年，难以治愈。手术治疗，虽大为改观，但往往需要2-3次的大手术，费时、费钱、增加痛苦; 而一次手术治愈，实为多快好省。兹就我院75、76年间有病历资料的计划一次手术治疗的颈、胸、腰椎结核各一病例报告如下。

Spinal tuberculosis accounts for the first place of osteoarticular tuberculosis in the whole body, accounting for 47.28%(1), which is common in clinical practice. Conservative treatment, although in the anti tuberculosis drugs come out today, also delayed for many years, it is difficult to cure. Surgical treatment, although greatly improved, but often need two to three major surgery, time-consuming, expensive and increase the pain; And an operation cure, it is really how fast good province. We hereby report the following cases of tuberculosis of the cervical, thoracic and lumbar vertebrae that were planned to be treated by one operation with medical records available in our hospital during the period of 75 and 76 years.

例一: 男性，18岁，农民，繁昌县人。病案号: 12179。

颈痛一年。活动受限半年。发烧，颈部肿块，吞咽困难二周。不能进食、进水，不能言语，且有呼吸困难4天。X市医院已穿刺减压为白色稀薄脓汁，并摄片确诊为颈椎3、4结核并巨大咽后脓肿，气管、食道受压。于75年10月26日急诊入我院。检查: 颈部无活动，颌下饱满、膨出、波动。张口呼吸、不语、大汗、脱水，但无紫绀。其他无特殊。快速补液1000cc，入院后两小时局麻下急诊手术，颈左前外侧进路，吸出脓液600cc，刮除脓腔壁，中线切开颈椎骨膜，直视下取出颈椎3下缘脓栓，窥见0.5×0.6cm骨洞，乃咬开外口，小心刮除结核肉芽、干酪样物及砂粒样碎骨，冲洗脓腔，因病椎间隙已消失并自行融合，故未植骨，置入青、链霉素，橡皮片引流，分层缝合，手术顺利。术毕呼吸平稳、正常，并能进食，也能发音说话。术后颈部制动，抗痨，6天拆线，切口愈合，10天出院。注射链霉素60克，服雷米封半年，术后2个月恢复了轻劳动，一年后为整劳力，随访三年半一切正常，颈部活动无碍，79年8月14日摄片复查示3-4颈椎骨性融合，无死骨、脓肿及骨质破坏。(X片号2090)

Case 1: A man, 18 years old, a farmer from Fanchang County. Medical record number: 12179.

Neck pain for a year. Limited activities for half a year. Fever, neck mass, dysphagia for two weeks. Can’t eat, water, can’t speak, and have difficulty breathing for 4 days. X City Hospital has punctured and decompressed the thin white pus, and the diagnosis was confirmed as cervical vertebra 3 and 4 tuberculosis and huge retropharyngeal abscess with pressure on trachea and esophagus by radiography. She was admitted to our hospital for emergency treatment on October 26, 75. Examination: The neck is immobile, and the mandible is full, swollen and fluctuating. Mouth breathing, silence, profuse sweating, dehydration but no cyanosis. Nothing special. After rapid fluid infusion of 1000cc, emergency operation was performed under local anesthesia two hours after admission. 600cc of pus was sucked out from the left anterolateral approach of the neck, and the pus cavity wall was scraped off. The cervical periosteum was cut by the midline, and the pus plug at the lower margin of cervical vertebra 3 was taken out under direct vision. After the 0.5×0.6cm bone hole was detected, the patient bit the external opening. The tuberculosis granulation, cheese-like substance and sand-like bone fragments were carefully scraped out, and the pus cavity was rinsed. Due to the fact that the intervertebral space had disappeared and self-fused, bone grafting was not performed, followed by placement of penicillin and streptomycin, rubber sheet drainage, and layered suture. The operation was He breathed steadily and normally after surgery and was able to eat and speak with pronunciation. Postoperative cervical immobilization and antituberculosis occurred, and the suture was removed 6 days later, with incision healing, and the patient was discharged 10 days later. After 60 grams of streptomycin injection and half a year’s administration of remifentanil, the mild labor was resumed two months after the operation and the labor was completed one year later. After a follow-up of three and a half years, everything was normal and there was no obstruction to the neck movement. The reexamination taken on August 14, 79 showed that the 3–4 cervical vertebrae were osseous fused and there were no dead bones, abscesses and bone destruction. (x-piece no.2090)

例二: 男性，23岁，南陵人，农民，病案号: 2875。

因胸椎9、10结核并椎旁脓肿于76年5月31日入院，经术前准备，检查无手术禁忌症，于76年6月19日在气管内乙醚全麻下, 经右胸第9肋骨床进胸, 切开纵膈膜胸进人脓腔达椎体，吸净脓汁，在处理两根肋间动、静脉后，扩大内暴露，直视对侧病灶至肋骨横突头节处，刮除结核肉芽、干酪样物、坏死椎间盘以及死骨并冲洗之。将病椎间上下凿成骨槽，同时植入肋骨片四条，并使其嵌紧，置入抗菌素，严密缝合之。彻底冲洗胸腔，关胸并闭锁引流。术后恢复顺利，26小时拨除胸管，72小时胸透肋膈角已锐。术后第五天体温正常，于76年6月29日出院，住院29天。嘱卧床四个月，抗痨治疗9个月。随访: 术后一个月下地活动，并逐渐恢复轻工作，但出现驼背。一年以后正常劳动。三年后X线摄片复查椎旁无脓肿阴影、无死骨，胸椎9、10已融合，但植骨片被吸收，胸10椎体塌陷，出现驼峰。 (X线片号2104)

Case 2: A 23-year-old man from Nanling County, farmer, medical record No.2875. He was admitted to our hospital on May 31, 76 because of thoracic vertebra 9,10 tuberculosis and paravertebral abscess. After preoperative preparation and examination, he had no contraindication to surgery. On June 19, 76, under general anesthesia with diethyl ether in trachea, he entered the chest through the 9th costal bed on the right chest, cut the mediastinum chest, and entered into the abscess cavity to reach the vertebral body. He sucked out the pus. After handling the two intercostal arteries and veins, he enlarged the internal exposure, looked the contralateral lesion into the cephalic segment of costal transverse process, and shaved off the tuberculosis granulation, cheese-like objects, necrotic intervertebral discs and dead bones, and rinsed them. Osteogenic slots were cut up and down from the diseased intervertebral space, and four rib pieces were implanted at the same time to make them tightly embedded. Antimicrobial was inserted and tightly sutured. The thoracic cavity was thoroughly rinsed, closed, and closed for drainage. The postoperative recovery was smooth. The chest tube was removed in 26 hours, and the costophrenic angle of the chest X-ray was sharp in 72 hours. Her body temperature was normal on the fifth postoperative day, and she was discharged on 29 June 76 and hospitalized for 29 days. Ask to stay in bed for four months and anti-tuberculosis treatment for nine months. Follow-up: he was active one month after surgery and gradually returned to light work with hunchback. Normal labor after a year. Three years later, there was no shadow of an abscess near the vertebra and no dead bone in the X-ray reexamination. The thoracic vertebrae 9 and 10 were fused, but the bone graft was absorbed, and the thoracic vertebra 10 collapsed with hump. (x-ray no. 2104)

例三:男性，50岁，已婚，农民，南陵人。病案号:1462。

腰椎2、3结核并发腰大肌脓肿，已注链霉素20克，于76年8月8日入院。76年8月9日在硬麻下左侧剖腰切口进路，行病灶清除加前路植骨术。切除12肋备用，腹膜外分离，切开腰大肌进入脓腔，继而安全处理椎旁腰横血管2根（2），扩大内暴露并由此途径清理对侧腰大肌脓肿，全面刮除脓腔壁的肉芽，瞬即以大热盐水纱布填塞压迫5分钟以减少大面积渗血，再扩大椎体上骨洞，彻底清除死骨、坏死椎间盘等大量结核组织。清洗后检查认为满意，在病椎间凿成骨槽，嵌入取下之12肋，一次完成清除病灶和前路植骨。术后恢复顺利，切口一期愈合，于78年3月24日出院，住院21天。术后卧床四个月，半年恢复劳动，现在已做9分工，能行50里，无不适，精神和体质均好。术后三年，于79年8月15日检查，两侧腰大肌均未扪及肿块，脊柱无叩痛，活动良好。胸透: 右上肺结核吸收好转期，腰椎X线片示腰椎1-4骨性融合，无死骨、脓肿。(X线片号2101)

Case 3: Male, 50 years old, married, peasant, from Nanling. Medical recordno.: 1462. Tuberculosis of lumbar vertebra 2 and 3 complicated with psoas major abscess, with streptomycin 20g injected, was admitted on August 8, 76. On 9 August 76, lesion removal with anterior bone grafting was performed using the left lumbar incision approach under rigid anesthesia. The 12 ribs were excised for standby, followed by extraperitoneal separation, and the psoas major muscle was cut into the abscess cavity. The two (2) paravertebral transverse lumbar vessels were then safely treated to enlarge internal exposure and clear the abscess of contralateral psoas major muscle through this pathway. The granulation tissue on the wall of the abscess cavity was comprehensively scraped off, and immediately large amount of tuberculous tissue such as dead bone and necrotic intervertebral disc was removed by filling and pressing with hot saline gauze for 5 minutes to reduce massive bleeding, and then the bony cavity on the vertebral body was enlarged. After washing, the examination was considered satisfactory, and an osteogenic groove was cut in the intervertebral space of the diseased vertebra and the removed 12 ribs were embedded. The lesion removal and anterior bone grafting were completed at one time. His postoperative recovery was uneventful, with primary healing of the incision. He was discharged on 24 March 78 and hospitalized for 21 days. After the operation, he stayed in bed for four months and resumed his work for half a year. Now he has divided his work into nine parts, which can cover 50 miles without any discomfort. His spirit and constitution are both good. Three years after surgery, on examination on 15 August 79, no mass was palpable in both psoas muscles, and there was no knocking pain in the spine, with good activity. Chest X-ray: the upper right pulmonary tuberculosis was in an absorption and recovery stage, and the lumbar vertebra X-ray showed lumbar vertebra 1–4 osseous fusion, without dead bone and abscess. (x-ray no. 2101)

讨论:

(1) 脊柱结核的治疗，经历了漫长的演变过程。从长期卧床、全身抗痨到姑息性脓肿切开，脓肿刮除、瘘管缩短术; 根治性的分侧病灶清除加融合术，以至发展到近年来人们寻求一次手术解决问题。但因脊柱的解剖关系复杂，暴露困难，手术风险大，阻碍着“清除彻底”，所以一次手术治愈此类疾病至今尚未普及。通过改进外、内暴露，使清除彻底有了可能，我们经历了上述三例，均在半年内获得痊愈，较其他治疗方案显示了优越性。

Discussion

1、 The treatment of spinal tuberculosis has experienced a long evolution process. From long-term bed rest and systemic antituberculosis to palliative abscess incision, abscess curettage and fistula shortening; In recent years, people have been searching for a surgical solution to the problem due to the development of radical bilateral nidus clearance plus fusion. However, due to the complex anatomical relationship of the spine, difficult exposure and high surgical risk, which hinders the “thorough removal”, a cure for this disease by one operation has not yet been popularized. Thorough removal was made possible by improving the external and internal exposure. We experienced the above three cases and all recovered within six months, showing superiority over other treatment options.

(2) 手术治疗脊椎结核，除了清除脓肿和椎体病灶外，也同时打破了“结核屏障”，使抗痨药能够达到病灶部，较之单纯保守治疗大大提高了治愈率（3）。我院同期另有五例包括其中的二例胸椎结核并发截瘫者，因故只接受了一侧病灶清除或单纯融合术，也都获得了痊愈，不过时间皆在一年左右;而文中病例由于清除较为彻底，所以痊愈时间更为缩短。

2、 Surgical treatment of spinal tuberculosis not only eliminates abscesses and vertebral lesions, but also breaks the “tuberculosis barrier” so that antituberculosis drugs can reach the lesion, which greatly improves the cure rate as compared with simple conservative treatment (3). In the same period in our hospital, there were five other cases, including two cases of thoracic tuberculosis complicated with paraplegia, who, for some reason, only received unilateral lesion clearance or simple fusion surgery, and all of them were cured, but the time was about one year. In this case, the recovery time was shortened due to the thorough removal.

(3) 脊柱结核的治疗，既要求病变痊愈，又要求恢复脊柱的支持力和稳定度，故植骨融合术遂成为治疗中重要的一环。后路植骨要承受张力，不利于植骨的生长; 前路植骨却受到压力，有利于植骨的生长，又可在病灶清除的同时施行，以外暴露切下之自体助骨为材料，其方法以支持嵌入较之上盖、充填为好，使之能起到临时支持和融合后的永久支持的双重作用，故较为合理。但必须以病灶清除彻底和没有混合感染为先决条件，否则植骨片易被吸收或坏死（3）。本文例二、例三均无混合感染，清除亦“满意”，故同时施以前路植骨。

椎体间植骨，受到压力影响，容易移位而被吸收，故必须保证卧床3个月以上。而农村病例常不愿长期住院，在家若擅自过早活动，易使植骨失败。文中例二术后1个月即下床，导致植骨片移位、吸收、椎休塌陷而出现驼背。例三则遵医嘱获得预期效果，实为一经验教训。

3、 The treatment of spinal tuberculosis requires the recovery of the lesion as well as the restoration of spinal support and stability, so bone graft fusion has become an important part of the treatment. The posterior bone graft should bear the tension, which is not conducive to the growth of the bone graft; The anterior bone graft is under pressure, which is beneficial to the growth of the bone graft. It can also be performed simultaneously with the removal of the lesion. The external exposure of the cut autologous bone graft is made of material. The method is better than embedding the support in the upper cap and filling, so that it can play a dual role of temporary support and permanent support after fusion, which is reasonable. However, complete removal of the lesion and the absence of mixed infection must be a prerequisite, otherwise the graft may be easily absorbed or necrotic (3). In both cases, there was no mixed infection and the removal was also “satisfactory”. Therefore, anterior bone grafting was performed simultaneously.

The bone graft between vertebral bodies is easily displaced and absorbed under the influence of pressure, so the patient must stay in bed for more than three months. However, cases in rural areas were often reluctant to be hospitalized for a long time, and if they moved too early at home without authorization, bone grafting would easily fail. In the second case, the patient got out of the bed one month after surgery, which led to the displacement and absorption of the bone graft and the collapse of the intervertebral disc, leading to the hunchback. In the third case, the doctor’s advice was followed to obtain the expected effect, which is actually a lesson learned.

(4) 颈椎结核并咽后脓肿形成占位性压迫，致使吞咽、发音甚至呼吸困难，构成急诊。因其进路方便，局麻即可，失血及损伤均少，手术堪称方便。又因脓肿撑开周围组织，病椎前方显露宽敞，只要遵循“中线切开”（1）的原则推开骨模，椎体病灶可在直视下进行彻底清除，加之颈部血运丰富，病灶吸收快，修复能力强，易于获得好的疗效，本文例1术后疗效极为满意。关于植骨、牵引、固定与否要根据病椎的稳定情况来定。但需严防颈髄震损，以避免高位截瘫的严重事故发生。(①不用骨凿，②清除时不越过后纵韧带。)

4、 Cervical tuberculosis and retropharyngeal abscess form space-occupying compression, resulting in swallowing, pronunciation and even dyspnea, constituting an emergency department. Because of its convenient access, local anesthesia is enough, and less blood loss and injury, the operation can be rated as convenient. Moreover, because the abscess spread the surrounding tissue, the front of the diseased vertebra showed spacious. As long as the bone model was pushed open according to the principle of “midline incision” [1], the vertebral lesions could be completely removed under direct vision. In addition, due to rich blood supply to the neck, rapid absorption of lesions, strong repair ability, and easy access to good curative effect, the curative effect of case 1 in this paper was extremely satisfactory. Bone grafting, traction and fixation should be performed according to the stability of the diseased vertebra. However, earthquake damage of neck and thigh should be strictly prevented to avoid serious accidents of high paraplegia. (1) no osteotome, 2) not over the posterior longitudinal ligament when clear. )

(5) 胸椎结核，位于3-10者，若条件许可，经胸途径，可一次完成两侧病灶清除及前路植骨（2-7），为病人所欢迎，亦节约床位。虽有开胸之骚扰和感染之虞，在现代麻醉、无菌、抗菌素等条件下，尚称安全。文中例2术后10天出院休养。

5、 For thoracic tuberculosis located in the range of 3–10, bilateral lesion clearance and anterior bone graft (2–7) can be completed in one step by transthoracic approach if the conditions permit. This therapy is popular with patients and saves bed space. It is safe under modern anesthesia, sterility, and antibiotic conditions, despite the possibility of thoracotomy disturbance and infection. Case 2 was discharged for rest 10 days after operation.

(6) 腰椎深在，周围重要组织多，显露困难，手术创伤大，且清除病灶不易彻底，常规需2-3次手术。但在病人体质条件许可下，通过腰血管的特殊处理（1），遵循骨膜下分离，可以安全而宽敞地显露病椎，便于清除病灶彻底。

6、 The lumbar vertebra is deep, and there are many important surrounding tissues, which makes the exposure difficult. Besides, the surgical trauma is large, and the removal of the lesion is not easy to complete. Thus, two to three operations are required conventionally. However, under the permission of the patient’s physical condition, the diseased vertebra can be safely and capably exposed through the special treatment of the lumbar vessels [1], following the subperiosteal separation, to facilitate the thorough removal of the lesion.

For the clearance of abscess in contralateral psoas major muscle, the source of pus was directly looked through by squeezing the contralateral waist, and then the expanded internal exposure was used to scrape out the abscess through the bypass extension with tuberculosis curette of various bends. If necessary, under the guidance of a curette, an incision could be made at the diameter of the safety part on the opposite side for “stationed” removal. It should be noted that all important organs are located outside the psoas major, so it is still safe to follow the scratch of “intramuscular” abscess, but we should still guard against accidental injury of blood vessels and nerves [9]. On this basis, anterior bone grafting at the same time can also be expected to recover, greatly shortening the course of treatment, as in Example 3.

关于对侧腰大肌脓肿清除问题: 通过挤压对侧腰部，直视脓液来源，再由扩大的内暴露，用各种弯度之结核刮匙，绕道伸入刮除; 必要时也可在刮匙指引下，于对侧安全处径作切开，“会师”清除。需要说明: 一切重要器官均位于腰大肌之外，故遵循“肌内”脓肿搔刮，尚为安全，但仍应提防血管、神经误伤（9）。在此基础上同时行前路植骨，也可以预期痊愈，大大缩短了疗程，如例3。

Summary: Through that author’ s clinical practice of three case, the clinical course and follow-up results of 3-4 year of one-operation cure for cervical, thoracic and lumbar tuberculosis are described. The first case was an emergency, the second and third cases were treated with anterior bone grafting at the same time. It was pointed out that the key was good exposure and thorough removal. Combined with review of the literature, some technical measures were proposed and the treatment of spinal tuberculosis was briefly discussed.

小结:

通过作者三例临床实践，叙述了颈、胸、腰椎结核一次手术治愈的临床经过和3-4年的随访结果。其中例一为急诊，例二、例三均同时前路植骨，指出关键为好的显露和清除彻底，结合复习文献，提出了一些技术措施，并对脊椎结核的治疗作了粗浅的讨论。

参考文献:

①天津病院骨科临床骨科学结核分册P183人民卫生出版社1974

②方先之: 骨关节结核病灶清除疗法人民卫生出版社 1960

③郭巨灵: 前路植骨在脊柱结核治疗中作用和问题中华外科杂志11:12: 1963

④刘忠: 胸椎结核经胸腔病灶清除术中华外科杂志8:531: 1960

⑤范秉哲: 开胸施行胸椎结核病灶清除术中华外科杂志7:20: 1959

⑥王志先: 经胸胸施行胸结病灶清除术中华外科杂志:271: 1959

⑦罗先正: 经胸廓胸膜外脊椎结核病灶清除术的初步报告中华外科杂志12: 1144: 1964

⑧田成瑞: 病灶清除疗法治疗脊柱结核的几点体会天津医药骨科附刊 2:76:1678

⑨于培礼等: 腰椎结核病灶搔爬术中髂外动脉误伤(临床病例讨论) 中华外科杂志 11:936:1963

References:

Clinical Tuberculosis of Orthopedics and Osteology Branch of Tianjin Hospital P183 People’s Health Press, 1974
Fang Xianzhi: People’s Health Publishing House of China 1960 on focal debridement for osteoarticular tuberculosis
Guo Juling: role and problem of anterior bone graft in that treatment of spinal tuberculosis Chinese journal of surgery 11:12: 1963
Liu Zhong: Chinese Journal of Surgery 8:531: 1960
Fan Bingzhe: Chinese Journal of Surgery 7:20: 1959: Thoracotomy to Remove Focus of Thoracic Spinal Tuberculosis
Wang Zhixian: Chinese Journal of Surgery: 271: 1959
Luo Xianzheng: Preliminary report on debridement of thoracic extrapleural spinal tuberculosis lesions Chinese Journal of Surgery 12: 1144: 1964
Tian chengrui: some experiences on treatment of spinal tuberculosis with focus removal therapy; attached journal of tianjin medical orthopedics 2:76:1678
Yu Peili et al., Accidental injury of external iliac artery during lesion curettage of lumbar tuberculosis (discussion of clinical cases) Chinese Journal of Surgery 11:936:1963 Li Mingjie, Orthopedic Officer, Nanling County Hospital, Anhui Province, China 1979

南陵县医院骨科李名杰原载安徽省首届骨科学会交流论文 1979

Clinical observation of a new minimally invasive circumcision (draft)

Surgical paper XX

Clinical observation of a new minimally invasive circumcision

包皮过长的经典治疗方法为包皮坏切手术，至今无突破性进展。2003年10至2005年2月，我院采用微创手术坏治疗包皮过长52例，现报告如下。

The classical treatment of redundant prepuce is circumcision, and no breakthrough has been made. From October 2003 to February 2005, 52 cases of redundant prepuce were treated with minimally invasive surgery in our hospital. The report is as follows.

材料与方法

一、临床资料

本组52例，年龄最小17岁，最大56岁，平均38岁，术前阴茎静态下最短 2.5cm，最长10cm，其中已婚 40 例，未婚12例。

Materials and methods

I Clinical Data Among the 52 cases in this group, the youngest was 17 years old and the oldest was 56 years old, with an average age of 38. The shortest penis size under preoperative static state was 2.5cm and the longest was 10cm. There were 40 married cases and 12 unmarried cases.

二、手术方法

1、取材: 手术采用中国管理科学院特约研究员商建忠先生发明的微创手术环(专利号2003.ZL02 2 37969.X）。此手术环选取聚丙烯工程塑料模压面成，器械分内坏与外环部分，二环合拢以螺丝连接卡压。产品分不同型号，为无菌包装一次件使用。(附图)

II. Surgical methods

1 Sampling: The minimally invasive surgical ring invented by Mr. Shang Jianzhong, a special researcher at the Chinese Academy of Management (PatentNo. 2003.ZL02 2 37969.X) was used for the surgery. The surgical ring was made of polypropylene engineering plastic molded surface. The instrument was divided into inner ring and outer ring. The two rings were closed and clamped with screw connection. Products are divided into different models, for sterile packaging a use. (attached) Fig. 1 Integrated micro-invasive circumcision device with inner ring and outer ring (see inset)

附图1 微创包皮环切器内环 微创包皮环切器外环 微创包皮环切器整体（见插图）

2、手术方法: 消毒，铺洞巾，暴露阴茎: 在阴茎根部以橡皮筋止血带环绕阴茎根部，阻断静脉回流，作怒张的静脉穿刺，抽吸积血，注入用2%利多卡因2ml，待5分钟，麻醉十分满意、完全。选用适当型号包皮手术环，先将内环套上阴茎。外翻包皮至内环上，如系包茎需在背侧切开少许，充分暴露龟头，内板保留至冠状沟以远0.5Cm，系带部略长约1.0cm，套上外环，旋紧螺丝，切平压环外多余包皮，用无菌纱布条覆盖创面，龟头外露，解除止血带，术毕。6天后去环，约15-20天痊愈。附图2 微创包皮手术愈合后微创包皮手术完成微创包皮手术前（见上插图）。

2 Surgical method: disinfection, laying of a towel, and exposure of the penis: at the root of the penis, a rubber band tourniquet was used to surround the root of the penis to block the venous return, and an irate venipuncture was performed. The accumulated blood was aspirated and 2ml 2% lidocaine was injected. After 5 minutes, the anesthesia was completely and completely satisfactory. The foreskin operation re of an appropriate model is selected, and that inn ring is sleeved on the penis first. Eversion of the foreskin to the inner ring, such as phimosis need to cut a little on the back side, fully expose the glans penis, the inner plate retained to the crown groove to 0.5Cm, frenum slightly about 1.0cm long, put on the outer ring, tighten the screw, cut out the extra foreskin outside the pressure ring, with sterile gauze cover wound, glans penis exposed, remove the tourniquet, after surgery. After 6 days, the ring was removed and the patient recovered in about 15 to 20 days. Fig. 2 Minimally invasive foreskin operation after healing and before completing the minimally invasive foreskin operation (see the above illustration).

结果

52例中，术后伤口一期愈合50例，2例因未遵医嘱，提前性生活而感染，愈合期延迟。无远期后遗症，愈后无疤痕。

Results

Among the 52 cases, 50 cases had primary wound healing after surgery, and two cases were infected due to noncompliance with doctor’s advice and early sexual life, with the healing stage delayed. There was no long-term sequelae and no scar after recovery.

讨论

包皮过长，因冠状沟不能外露造成长期分泌物过多不能及时消除而引起包皮炎，长时间的炎性刺激还可诱发阴茎癌。包茎可使阴茎发育不良，并影响性生活，包皮过长是困扰男性患者的一种常见病。微创包皮环切术适用于男性包皮过长及包茎者、传统治疗方法，即包皮环切，需要切除、止血、缝合，愈合后尚留有疤痕; 激光手术又有热力伤等弊端。

Discussion

Foreskin is too long, because the coronal groove cannot be exposed to cause long-term discharge too much cannot be eliminated in time and cause dermatitis, long-term inflammatory stimulation can also induce penile cancer. Phimosis can make the penis dysplasia, and affect the sex life, foreskin is too long is a common disease bothering men. Minimally invasive circumcision is suitable for male foreskin is too long and phimosis, traditional treatment, that is, circumcision, need to resection, hemostasis, suture, after healing there are still scars; Laser surgery has the disadvantages of thermal injury, etc.

本疗法突破传统思维模式，无需手术切割与缝合，环压后使远端局部组织缺血、坏死而脱落，而完成包皮环切。一般6天左右下环，15-20左右痊愈，愈合后无疤痕，手术时间仅2-5分钟。不另需任何医疗器械，避免了繁琐的止血步骤。且感染发生率低，无需服用雌激素，术后可自由活动，生活无不便，可洗澡，不影响排尿，无并发症

新型方法与传统方法比较

	新型方法	传统方法(环切、激光)
1、手术方式	微创、简便痛苦小，无疤痕	有创，繁琐痛苦大，有疤痕
2、人力配备	施术者一般只需1人	施术者最少2人
3、材料消耗	无需手术器械，成本小	需在手术室，必备手术器械
4、创口出血	无出血，无需止血	止血烦琐
5、手术时间	小于5分钟	大于 30 分钟
6、费用	花费少	需一定经费

This therapy breaks through the traditional thinking mode, and does not require surgical cutting and suture. After cyclic compression, the distal local tissue falls off due to ischemia and necrosis, and circumcision is completed. It usually takes about 6 days to lower the ring, and it recovers about 15 to 20 years old. There is no scar after healing, and the operation time is only 2 to 5 minutes. No other medical device is needed, and the fussy hemostasis step is avoided. And has no complication Comparison between new method and traditional method As the shackles of foreskin were lifted, some of the 52 cases treated with this therapy experienced different degrees of penis growth and thickening as well as enhanced sexual function.

由于解除了包皮的束缚，本疗法52例中，术后部分患者阴茎不同程度增长、增粗，同时性功能增强。

结论: 这种全新型微创式手术方法优于传统方法，疗效肯定，值得推广。

Conclusion: This new type of minimally invasive surgery is superior to the traditional method, and has a positive effect, which is worthy of promotion.

By Yangzhen Li, Mingjie Li, Jianzhong Shang, Tong Wang

本文原载…….

Clinical study of a novel circumcision with minimal invasion for phimosis

INTRODUCTION:

Conventional circumcision remains a traditional and the most common surgical option for phimosis and paraphimosis. There has not been a breakthrough in technology so far. In this report. we presented a novel operative technique, invented by Dr. Shang to remove the prepuce with minima invasion, and reported a study from 52 patients diagnosed of phimosis or paraphimosis and treated with this technique, from October 2003 to February 2005 in the 2nd Affiliated Hospital of Wannan Medical College.

MATERIALS AND METHODS:

Clinical data:

Fifty-two patients with phimosis or paraphimosis were included, 40 of them were married and 12 were unmarried, from the age of 17 years to 56 years with a mean age of 38 years. The length of resting penises ranged from 2.5 to 10 cm.

Surgical Procedure:

Material: the unique tool, called Noninvasive Operation Loops (patent number, 2003.ZL02237969.X), used for the operation, was invented by Dr. Jianzhong Shang, a special scientist of Chinese National Management Institute. These noninvasive operation loops cast in polypropylene engineering plastic consisting of an inner loop and an outer loop. These two loops can be held together through compression by screws. These noninvasive operation loops are composed of various sizes. packaged in sterile and disposable. (See figures in Figure1 (Legend: Inner loop, Outer loop, Combined loops).

Surgical Procedure: sterilize. unfold surgical towel, and expose the penis; block venous blood return with rubber cuff placed at the root of penis, extract venous blood from extended veins by a needle puncture, and slowly inject 2 ml of 2% lidocaine, wait for 5 minutes until anesthesia is completed and satisfactory; select a proper size of operation loop, first put the inner loop around penis, turn the foreskin outwardly to cap the inner loop, fully expose the glans, for phimosis, cut open the foreskin ventrally, place the inner loop 0.5 cm above the corona, and around 1.0 cm above penile ligament, cap the outer loop, and tie up screws. excise the extra foreskin along the outer loop. Expose the glans while covering wounds with sterile gauzes, and release cuff. Six days after surgery, remove loops, and the wound would fully heal within 15-20 days. (Figure 2: Prior surgery, operation completion, and after surgery)

RESULTS:After the operation, 50 out of 52 patients had primary wound healing. The remaining two individuals showed delayed wound healing secondary to wound infection caused by premature sexual intercourse in the ignorance of medical instructions. There was no scaring and no sequelae.

DISCUSSION:

Phimosis is a condition in which the foreskin cannot be retracted behind the glans penis. It may produce urinary obstruction with ballooning the foreskin and may lead to penile undergrowth and maidevelopment? in boys, recurrent meatitis and balanitis (i.e.. inflammation of the glans), and even penile carcinoma. It might affect patients’ sex life. Phimosis is not uncommon. Our new approach is indicated to patients with phimosis and paraphimosis. Conventional circumcision has traditionally been regarded as the treatment of choice for phimosis and paraphimosis. It requires multiple procedures such as incise. stanch, and suture. It is going to have a scar after healing. The laser operation procedure has its own disadvantages such as a thermal burn.

Our approach offers a breakthrough from traditional modes of thinking. The procedures in this revolutionary approach no longer require incision and suture. By compression of the operation loops, consequently, the distal part of the foreskin becomes ischemic, necrotic, and thus shed. The surgical procedures only take 2-5 minutes to complete. The operation loops are usually removed in 6 days after surgery. The wound heals in 15-20 days without scarring. No complex surgical tools are needed. Miscellaneous procedures such as stanching are avoided, therefore, the incidence of postoperative infection and other complications is significantly low. It is not necessary to take any medications such as estrogen or to limit daily activities such as taking a shower. It does not affect urination and has no complications.

Comparison between our novel approach and traditional circumcision:

Novel Circumcision Traditional Circumcision

Surgical procedures:near noninvasive, simple, less painful, and noscarringinvasive, complex, more painful, and scarring

Personnel requirement:usually only one surgeonat least two surgeons

Material consumption:no conventional surgical tools requiredboth conventional surgical tools and an operation room required

Wound bleeding:no bleeding, no stanchingstanching

Operation time:less than 5 minutesmore than 30 minutes

Cost:less costlymore costly

Because of the removal of the un-retractable foreskin, in a portion of our 52 patients with phimosis, the postoperative penis becomes longer and sturdy and improves its sexual function in variable degrees.

CONCLUSION:Our new method of circumcision with minimal invasion is superior to the traditional one with convincing curative effects. It deserves as a treatment of choice or at least as a viable alternative for phimosis.

Several improvement measures of circumcision (draft)

Surgical paper XIX

Several improvement measures of circumcision

1. 包皮局部静脉麻醉

阴茎根部橡皮筋环扎阻断静脉回流，使阴茎浅静脉怒张，细针向远侧穿刺阴茎皮下静脉，抽吸郁血并注入2%利多卡因2ml。优点是，麻醉完全、避免局部麻醉致包皮水肿而使切除线不准。

Local venous anesthesia of foreskin:

A rubber band around the root of the penis was used to block the venous return, causing the superficial vein of the penis to flare. The subcutaneous vein of the penis was punctured distally with a thin needle, and 2ml of 2% lidocaine was injected after aspirating the stagnant blood. The advantages are complete anesthesia and avoidance of foreskin edema caused by local anesthesia, resulting in inaccurate resection line.

2. 血运阻断无血手术

紧缩根部橡皮筋，阻断阴茎背动脉，使手术野无血、清晰，便于切准、切齐包皮，
先结扎可见之血管断端，再松开止血带，止血完全，利于手术进行。

Bloodless surgery by blood supply blocking:

The rubber band at the root part is tightened to block the dorsal artery of the penis, so that the operation field is bloodless and clear, and the foreskin is convenient to cut accurately and completely. First, the visible broken end of the blood vessel is ligated, and then the tourniquet is released to completely stop bleeding, which is beneficial to the operation.

3. 采用人发缝合

剪取女性长发若干根，经消毒液浸泡5分钟，盐水冲洗后用作缝线。可任意缝合包皮内外板，使之对合严密、准确，而不必拘泥于传统的8针，减少污染，利于愈合。术后无需拆线，7~10天发线自然脆裂脱落。

笔者施术30例，无创口裂开及感染，均获I级愈合。

Using human hair for suture:

A number of long tresses of female were cut, immersed in disinfectant for 5 minutes and then used as sutures after being rinsed with saline. The inner plate and the outer plate of the foreskin can be randomly sutured, so that the anastomosis is tight and accurate, the traditional 8-needle suture method is not limited, the pollution is reduced, and the healing is facilitated. Stitches were not needed to be taken out postoperatively, and the hair fell off with natural embrittlement 7–10 days later. Thirty cases were treated without wound dehiscence and infection, and they all obtained grade I healing.

By Mingjie Li, Wuhu Changhang Hospital

Traffic Medicine 90; 4（3）：66

安徽芜湖长航医院李名杰（论文刊于《交通医学》90;4（3）：66）

Subcutaneous heterotopic pancreas of abdominal wall (draft)

Surgical paper XIIX

Subcutaneous heterotopic pancreas of abdominal wall

A Case Report

异位胰腺，书上记载仅见于腹内脏器，尤其是消化道粘膜下。但临床上少见。而位于腹壁皮下者，迄今未见报导。本院收治一例，手术切除后为病理所证实，现报告如下。

Ectopic pancreas, the book records only in internal organs, especially the digestive tract submucosa. But it is rare clinically. However, those located under the abdominal wall have not been reported so far. A case was treated in our hospital, which was confirmed by pathology after surgical resection. The report is presented below.

患者男性，41岁，教师，1979年3月24日入院，病案号794。

一年前因左下腹包块在x医院手术切除，病理报告为“硬纤维瘤”。术后10个月复发指顶大肿块，无症状; 近一周突然增大至鸡蛋大，且伴有触痛，检查: 一般情况正常，表浅淋巴结不肿大，左下腹有一5厘米斜行手术疤痕，此下有一5x4x3厘米之包块，呈结节状，软，移动度不大，有轻度触痛，无红、热。白血球5600/立方毫米，中性58%，淋巴42%。入院后即于局麻下手术，肿块位于皮下、肌膜上，边界不清，无包膜，结节分叶
状，呈黄色。锐性分离切除包块，皮下引流24小时，切口一期愈合，住院9天出院。病理报告“腹壁纤维组织胰腺异位” (病理号4686)。

A 41-year-old teacher, a male patient, was admitted on 24 March 1979 with medical record number 794.

The left lower abdominal mass was surgically removed one year ago in Hospital X and was pathologically reported as “desmoid tumor”. Recurrence of large apical mass 10 months after surgery without symptoms; Nearly a week suddenly increased to egg big, and accompanied by tenderness, examination: general normal, superficial lymph node is not swollen, left lower abdomen has a 5 cm oblique operation scar, under this there is a 5x4x3 cm mass, nodular, soft, mobility is not big, there is a mild tenderness, no red, hot. White blood cells 5600/ mm3, neutral 58%, lymph 42%. The operation was performed under local anesthesia immediately after admission. The mass was located under the skin and on the sarcolemma, with an unclear boundary, no capsule, and the nodule was lobulated and yellow. The mass was excised with sharp dissection and subcutaneous drainage was performed for 24 hours, with primary healing of the incision, and the patient was hospitalized for 9 days and discharged. The pathological report was “heterotopic pancreas with abdominal wall fibrous tissue” (Pathology No.4686).

出院后一周皮下隆起、胀痛、波动，但不红、无发热，公社医院给抗菌素治疗，渐形消失，未抽吸化验，一月后恢复正常。

A week after discharge subcutaneous uplift, pain, fluctuation, but not red, no fever, commune hospital to antibiotic treatment, gradually disappear, no suction test, after a month back to normal.

By Mingjie Li & Jinxian He (Trainee in our Hospital)

“Nanling Medicine” 1979; 1:70

Abdominal trauma (draft)

Surgical paper XIIIX

Abdominal trauma

Literature Review

Abdominal trauma, including abdominal wall injury and abdominal visceral injury, is more common. The prognosis depends on early diagnosis and reasonable treatment, except depending on the severity of the trauma. However, the following errors are often prone to occur:

Medical history is unknown: (i) the wounded coma, we lost a valuable history. (ii) The history of mild trauma is ignored or forgotten.
Lack of positive signs in the early stage after injury. Such as intestinal small perforation is blocked and spillover is not much; Or the patients with mild damage to solid organs, less bleeding or self-stopping, may lack the symptoms of peritoneal stimulation.
Delayed visceral rupture occurs often without symptoms in the interstitial phase. Such as splenic subcapsular hematoma re-rupture.
Other severe injuries are combined, which diversifies the attention from the diagnosis of abdominal injury. Such as cerebral trauma, thoracic trauma, etc.
Lower thoracic spine and chest injury may result in abdominal signs, which may be mistaken as abdominal trauma. (because the abdominal wall is distributed by six pairs of spinal nerves of the lower thoracic vertebra. )
For the wounded with concealed symptoms, the abdominal wall is intact, and the doctor or the affected family holds an excessively palliative attitude in the hope of avoiding missed diagnosis due to laparotomy, resulting in missed opportunity.

腹部创伤，包括腹壁伤和腹内脏伤，较为常见。其予后如何，除视创伤严重程度外，遂有赖于早期诊断和合理治疗。然而，却常常容易发生下列错误:

一、病史不详:

1、伤员昏迷，使我们丧失了有价值的病史。
2、轻微外伤史被忽略或遗忘。

二、伤后早期缺乏阳性体征。如肠道小的穿孔被堵塞而外溢不多; 或实质性脏器损伤轻，出血量少或又自止者，可缺乏腹膜刺激症状。

三、迟发性内脏破裂，间隙期往往无症状。如脾包膜下血肿再破裂。

四、合并其他严重损伤，牵制了对腹部伤诊断的注意力。如脑外伤、胸部外伤等。

五、下胸段脊柱及胸部损伤，可出现腹部体征，误认为腹部外伤。(因腹壁为下胸6对脊神经所分布。)

六、对症状隐蔽之伤员，腹壁又完好，医生或患家持有过于姑息的态度，希望避免剖腹探查而漏诊，造成坐失良机。

Pathogenesis

Abdominal trauma refers to abdominal wall injury or visceral injury caused by external force, or both. Mechanical principles for injury:

Direct violence, and abdominal blow.
Indirect violence: such as falling from a high place, causing earthquake impact and injury.
Non-penetrating injury after extrusion: vehicle accident.
Penetration injury: such as knife, gun and explosion injury.

发病机理

腹部创伤是指外力所造成的腹壁伤或内脏伤或二者兼而有之。受伤的机械原理为: 1. 直接暴力，腹部受击。2. 间接暴力: 如从高处趺下，震冲受伤。3. 挤压后的非穿透性损伤: 车祸。4. 穿透性损伤: 如刀、枪、爆炸伤。

腹腔内脏大致分为三类:

一、实质性器官: 肝、脾、肾、胰等。

二、空腔 (有腔、中空) 器官: 胃、肠、膀胱、胆囊等。

三、支架结构: 肠系膜、腹膜、神经、血管等。

Abdominal viscera is roughly divided into three categories: (i) Substantive organs: liver, spleen, kidney, pancreas, etc. (ii) Cavernous (both luminal and hollow) organs: stomach, intestine, bladder, gall bladder, etc. (iii) Stent structure: mesentery, peritoneum, nerves, blood vessels, etc.

Trauma of solid organs and stent structures, with the main risk of hemorrhage. The main risk of cavity organ trauma is the infection caused by the contents overflowing into the abdominal cavity to form peritonitis. In fact, any visceral trauma can have a fatal hemorrhage, and liver and spleen damage appear long-term, stubborn, with repeated bleeding because the blood vessel wall of these organs is thinner. The organ itself is very fragile, lacking elasticity, so the blood vessel retreat and blood scab closed?? cannot effectively form. Moreover, when the bleeding stops, because these organs are rich in blood supply, once the blood pressure picks up, the hemostatic scab can be washed away and bleeding recurs. The chance of hollow organ injury was related to the amount of contents (the person with full stomach is liable to be injured). It is related to the degree of fixation (the distal and proximal ends of the small intestine, and the liver and spleen beats of the colon are vulnerable). It is related to the pre-existing illness (the ones with pre-existing illness are vulnerable).

实质性器官和支架结构的创伤，主要危险为出血; 空腔脏器创伤主要危险则为内容物溢入腹腔而致感染形成腹膜炎。

实际上任何内脏的创伤都可有致命的大出血，而肝、脾损伤则出现长期的、顽固的、反复的出血，是因为这些器官的血管壁较薄，器官本身又很脆弱，缺乏弹力，故血管退缩和血痂封闭不能有效的形成; 而且当出血停止后，因为这些器官血运丰富，一旦血压回升，又可将止血的血痂冲走而再复发出血。

空腔脏器受伤机会与其所含的内容物的多寡有关 (饱胀者易伤); 与固定度有关 (小肠的远、近端，结肠的肝、脾曲易受伤); 与原已有病与否有关 (先期有病的易受伤)。

The nature of the substances that stimulate the peritoneum determines its pathological changes and abdominal signs:

gastrointestinal bacteria increase from top to bottom, such as colonic damage of fecal peritonitis, infection is very strong??.
the chemical irritation of the gastrointestinal tract decrease from top to bottom, such as gastric, duodenal perforation caused by chemical peritonitis, ferocity.
bile, urine, bacteria may or may not, but for chemical mixture, can cause peritonitis, only a little later.
no bacteria in the blood, the peritoneal stimulation is small, so the hemorrhagic peritonitis reaction is slight. Five, gas stimulation of the peritoneum can also produce symptoms.

Regardless of the nature of the material spilling into the abdominal cavity, it often follows its natural drainage route of the produced peritoneal exudate to the paracolonic trough and pelvic floor, resulting in enteroparalysis and abdominal distension.

刺激腹膜的物质的性质决定其病理变化和腹部体征:

一、胃肠的病菌由上而下的增加，如结肠损伤的粪性腹膜炎，感染性很强。

二、胃肠道的化学刺激性由上而下的减少，如胃、十二指肠穿孔所致的化学性腹膜炎，病势凶猛。

三、胆汁、尿液，细菌可有可无，但为化学混合物，可致腹膜炎，唯时间稍迟。

四、血液无细菌，对腹膜刺激小，故血性腹膜炎反应轻微。

五、气体刺激腹膜，亦可产生症状。

不论溢入腹腔之物质的性质如何，它常能随其所产生的腹膜渗出液依其自然引流路线至结肠旁槽和盆腔底，以致产生肠麻痹和腹胀。

Symptoms and signs

Syncope or shock:

abdominal wall contusion is rare, abdominal visceral injury often. Substantial organ rupture bleeding, ferocious; Large vessel injury is more immediately fatal than rescue; Cavity organ perforation peritonitis, toxic shock.
Abdominal pain: Abdominal wall contusion is relatively limited and mild; Visceral injuries were extensive and persistent.
Abdominal distension: Progressive aggravation occurs as a symptom of internal hemorrhage and peritonitis, with abdominal respiratory depression. However, attention should be paid to the inhibition of intestinal peristalsis caused by the stimulation of intraperitoneal nerve plexus by the retroperitoneal injury and hematoma.
Abdominal tenderness: It refers to the sentinel muscle guard, tenderness and retraction tenderness, which can often indicate the injured site in the early stage. In the late stage, the disease is extensive and is often evidence for visceral injury.
Nausea and vomiting: reflex in the early stage and reflux in the late stage.
Cirrhosis of liver: abdominal distension can reduce it, and the free qi layer can eliminate it. Hematoma after liver rupture with enlargement of voiced boundary.
Mobile voiced sound: It is often an important basis for intra-abdominal blood or fluid accumulation.
Intestinal peristalsis; Early reflection decreases, and later “quiet abdomen” caused by inflammation.

症状和体征

昏厥或休克:

一、腹壁挫伤少见，腹内脏伤常有。实质性脏器破裂大出血，来势凶猛; 大血管损伤更可立即致命而不及抢救; 空腔脏器穿孔腹膜炎，则为中毒性休克。

二、腹痛: 腹壁挫伤较局限而轻微; 内脏伤则广泛且持续。

三、腹胀: 进行性加剧为内出血及腹膜炎的征兆，腹式呼吸抑制。但须注意腹膜后损伤、血肿刺激腹腔神经丛所致的肠蠕动抑制。

四、腹部压痛: 定点肌卫、压痛及回缩压痛，早期常能指示损伤的部位。晚期则泛发，常为内脏伤的佐证。

五、恶心呕吐: 早期为反射性，晚期则为回溢性的。

六、肝浊音界: 腹部气胀时则可以使之缩小，有游离气层就可使其消失。肝破裂后血肿，浊音界扩大。

七、移动性浊音: 常为腹内积血或积液的重要依据。

八、肠蠕动;早期反射性减弱，晚期则为炎症所致的“安静腹”。

Diagnosis

The central issues in the diagnosis of abdominal trauma are to be clear:

is it a simple abdominal wall injury or is it accompanied by visceral injury?
Which organ injury is single or multiple?
The amount and speed of internal bleeding, now check or bleeding?

Ask the medical history in detail, including the size and direction of violence and the injured posture, reaction after injury, whether there is any sudden sharp pain, syncope and vomiting, check the abdominal muscle guard, tenderness range, voiced boundary, tympanic area and its changes, measure the body temperature, pulse, respiration, blood pressure, blood test, urine and stool, X-ray and ultrasonic. Morphine and other anesthetics are prohibited during observation, except for the cases with a definite diagnosis and the operation has been decided. Laparotomy when necessary, even if no, is better than delaying the timing.

详细询问病史，包括暴力的大小、方向和受伤的姿势，伤后的反应，有无突然尖痛、昏厥、呕吐，检查腹部肌卫、压痛范围，浊音界、鼓音区及其变化，测量体温，脉搏、呼吸、血压、化验血、大小便，X线、超声波。在观察中忌用吗啡等麻醉剂，但明确诊断并已决定手术者除外。必要时剖腹探查，即使无获，也比贻误时机为好

1. Hematology: White blood cells increase, and the early stage is the physiological reaction of trauma. Some people think that intra-abdominal hemorrhage can produce a large amount of erythropoietin, which can be absorbed by the peritoneum and lead to leukocytosis (5). The peritonitis is naturally leukocytosis and left shift in neutrality. Internal bleeding is anemia.

2. hematuria as a powerful basis for urinary injury; It is also an effective indication for observing the outcome of injuries.

3. X-ray: Free air layer under diaphragm. It is generally believed that the positive rate is only 50%, which should be noticed. The height and movement of the septal muscle should be observed bilaterally in contrast, which may be helpful for the diagnosis of liver and spleen injuries.

4. Abdominal puncture: It is very valuable because the nature and condition of the extract can often be clearly diagnosed. Because the positive result can only be obtained with more than 200 ml of liquid in the abdominal cavity, someone used abdominal lavage to improve the positive rate. The puncture points were left and right Markov points, and the direction was generally pointed to the iliac fossa. In case of no capture, the puncture was performed after changing the direction and depth of the needle or at intervals. In addition to macroscopic observation, the puncture fluid can also be used for amylase quantification and smear examination. If various bacteria are found without pus cells, or parasitic eggs are seen, it is evidence of straying into the intestinal cavity.

5. Rectal digital examination and puncture of the posterior vault of the vagina of married women can be classified as routine examinations and can help make an early diagnosis.

1、血象: 白血球升高，早期为创伤的生理反应。有人认为腹内出血可产生大量激血球增加素，此种激索被腹膜吸收后，可出现白血球升高（5）。腹膜炎理所当然的是白血球升高和中性左移。内出血则呈现贫血。

2、血尿为泌尿系损伤之有力依据; 也为观察损伤转归之有效指征。

3、X线: 膈下的游离气层，一般人认为阳性率只有50%，宜注意及之。隔肌的高度、运动要两侧对比观察，对肝、脾的损伤的诊断或有助益。

4、腹穿: 很有价值，由其抽出液的性、状常能明确诊断，因为腹腔内要有200毫升以上的液体方可获阳性结果，故有人用腹腔灌洗法，可提高阳性率。穿刺点为左、右麦氏点，方向一般指向髂窝，无获时，改变针头方向和深度或间隔时间再行穿刺。穿刺液除肉眼观察外，还可做淀粉酶定量和涂片检查，若发现多种细菌而无脓细胞，更或见到寄生虫卵，为误入肠腔之佐证。

5、直肠指诊和已婚女性阴道后穹窿穿刺，可列为常规检查，能帮助早期诊断。

Management and treatment

When in shock, the two lower limbs are elevated slightly in the inclined decubitus position (favorable for breathing and venous blood return). Warmth, fluids, blood transfusions, oxygen, antibiotics. In view of the extremely strong anti-infection ability of peritoneum, far fewer people die from infection than from shock and bleeding. Therefore, the most important thing to do is to open the vein and rapidly restore the effective blood volume. Intra-abdominal injuries require surgery as soon as possible, preferably within six hours. If anti-shock fails, forced surgery should be performed to relieve the source of the disease as one of the rescue measures. Surgical incision is determined by the estimated injury site, and the principle is nearby and convenient. It is generally a midline longitudinal incision, which is fast to enter and convenient to extend. Before closing the abdomen, the abdominal cavity should be cleaned and sucked out; for patients with bile, pancreas, feces and urine pollution, drainage is required.

处理及治疗

休克时略斜坡卧位，抬高两下肢 (有利呼吸和静脉血回流）。保暖、补液、输血、给氧、抗菌素。鉴于腹膜抗感染能力极强，故因感染而致命者远比休克、流血致命者要少。故开放静脉，急速恢复有效血容量，最为追切。

腹内伤要尽早手术，以6小时内为好。若抗休克不见成效，亦应强迫手术，解除病源，作为抢救措施之一。

手术切口，由估计之损伤部位来定，原则是就近、方便。一般为中线纵切口，进入快，便于延伸。关腹前要洗净、吸清腹腔，胆、胰、粪、尿污染者，要引流。

I. Spleen rupture: The conventional method is resection. Recently, it has been advocated that even mild injuries can be repaired while preserving spleen function. In determining whether there is no combined injury, spontaneous blood transfusion is carried out without anticoagulation, which is economical, can solve blood source difficulty and avoid citric acid poisoning.

II. Small intestine rupture: repair, resection and anastomosis is performed. Use as little as possible when the intestine is external.

III. Liver injury: It is mostly caused by dehiscence of liver tissue, most of which is retained due to the relatively tough vessels. No further injury is recommended except for necessary debridement and ligation of the vessels and bile ducts on the section individually during treatment. It is usually sutured with full-layer mattress and covered with omentum. Sometimes omentum and muscle stuffing can also be used. Yarn filling should be avoided as much as possible. Local hepatectomy is recommended for localized contusion and laceration. If bleeding is very strong during the operation, porta hepatis occlusion can temporarily control bleeding (occlusion is allowed for 15 minutes at a time under normal temperature). For patients whose bleeding cannot be stopped, hepatic artery ligation can often produce immediate results. Adequate subhepatic drainage is required, with additional controlled detailed common bile duct expectoration decompression. Small injury, bleeding has stopped, can also be under close observation of conservative treatment, if found during the operation of such damage, as long as the blood stopped will not be sutured. I once encountered a case of traumatic liver injury in a 10-year-old child. Abdominal puncture was confirmed, but the patient’s family member refused to undergo surgery and the patient recovered. This was very enlightening. Liver suture, catgut and silk thread can be used. I think silk thread No.4 is appropriate. Ligation should not be too tight, to pressure the bleeding, to avoid complicated liver necrosis and liquefaction, delayed bleeding or biliary fistula. The author once encountered a case of massive hemobilia complicated by 21 days after liver repair. After repeated bleeding and blood transfusion for one week, the patient finally underwent reoperation and got better by ligating the inherent hepatic artery. The blood, mixed with bile, arguably can’t back. However, we encountered a case in the countryside where 1500 ml of infusion solution was given back to the patient due to blood source difficulty, and no adverse reaction was found, which can be used for reference. (it is generally considered that no extrahepatic biliary tract injury, the blood transfusion is safe. )

IV, colon injury, early repair; Late external, then elective resection and anastomosis. The abdominal cavity should be rinsed clean and drained.

V. Mesenteric rupture: repair and hemostasis. Pay attention to the blood supply to the intestine. If there is any disorder, intestinal resection is required.

VI. Pancreas injury: the small fissure was sutured to stop bleeding. The pancreatic duct injury was ligated. The pancreatic body and tail could be removed. If the head of the pancreas was injured, it must be replanted to establish a new pancreatic and intestinal channel with small omentum drainage.

VII. Gastroduodenal injury: repair. Pay attention to the discovery and repair of retroperitoneal duodenal injury.

VIII. Extrahepatic biliary tract injury: repair, fistulization, and external drainage.

IX. Kidney injury: it is more frequent, second only to spleen rupture. The treatment is conservative, and it is closely observed that since the kidney has a strong capacity to repair, it can often heal itself as long as the blood in the urine stops. Surgery is also based on repair, hemostasis, drainage, had to be removed.

X. Extrarenal urinary tract injury: ureteral injury is rare. Bladder injury is often complicated by pelvic fractures and is more common. But also repair, fistulization and drainage.

XI. Diaphragmatic muscle injury: it is common to find diaphragmatic hernia and hemorrhage (thoracic-abdominal pressure difference) on the left side, with high mortality. The chest repair, to very early treatment.

XII. Post-abdominal large vessel injury: It is usually repaired unless the situation is not satisfactory for the rescuer. The ligation can be cut off for the injury of inferior vena cava below the level of renal vein. Some people also advocate ligation for the injury of inferior vena cava above renal vein level if it cannot be repaired. However, if the right kidney is to be excised, the left kidney can rely on collateral circulation (adrenal vein). No problem is expected, but insufficient blood return may occur.

一、脾破裂: 常规的办法是切除。晚近有人提倡轻度损伤也可修补而保留脾脏功能。在确定无合并损伤时，自血回输，无需抗凝，既节约，又可解决血源困难和避免枸椽酸中毒。

二、小肠破裂: 予以修补或切除吻合。肠外置要尽量少用。

三、肝脏损伤: 多为肝组织裂开，因脉管较韧而大部分存留，处理时除必要的清创、个别结扎断面上的血管、胆管外，不宜再予损伤。一般用全层褥式缝合，网膜复盖。有时也可用网膜、肌肉填塞。纱条填塞要尽量避免。局限挫裂伤，宜局部肝切除。术中若出血很涌，肝门阻断可临时控制出血 (常温下一次允许阻断15分钟)。无法止血者，肝动脉结扎常可立即收效。肝下要充分引流，并附加控制性详细胆总管造痰减压。小的损伤，出血已止，也可在严密观察下保守治疗，术中若发现此类损伤，只要血止了就不予缝合。本人曾遇一例十岁儿童创伤性肝损伤，腹穿证实，但家属拒绝手术亦愈，很有启发。

肝脏缝合，肠线、丝线均可，本人认为4号丝线为宜。结扎不宜过紧，以压住出血即可，避免并发肝坏死而致液化、迟发性出血或胆瘘。作者曾遇一例肝修补术后21天，并发胆道大出血，经过反复出血、输血一周，终于再次手术，结扎肝固有动脉而愈。

此种血液，混有胆汁，按理不能回输。但我们出诊乡下曾遇一例，因血源困难，给于回输1500毫升，未发现不良反应，可供参考。(一般认为没有肝外胆道损伤者，自血回输尚称安全。)

四、结肠损伤，早期修补; 晚期外置，再择期切除吻合。腹腔要冲洗干净，并引流。

五、肠系膜破裂: 修补、止血。注意肠管血运，若有障碍，则加肠切除。

六、胰腺损伤: 小的裂口缝合止血，胰管损伤予以结扎，胰体、尾可以切除，胰头损伤，则须再植，建立新的胰肠通道，小网膜引流。

七、胃十二指肠损伤: 修补。注意腹膜后十二指肠损伤的发现与修补。

八、肝外胆道损伤: 修补、造瘘、外引流。

九、肾损伤: 比较多发，仅次于脾破裂。处理比较保守，严密观察，因肾的修复能力很强，只要尿血停止，常可自愈。手术亦以修补、止血、引流为主，不得已才予切除。

十、肾外尿路损伤: 输尿管损伤少见。膀胱损伤常为骨盆骨折所并发，较常见。也是修补、造瘘和引流。

十一、膈肌损伤: 左侧较常见，形成膈疝和出血 (胸腹腔压差)，死亡率高。经胸修补，要极早处理。

十二、腹后大血管损伤: 除不及抢救者外，一般予以修补。肾静脉水平以下的下腔静脉损伤可以切断结扎。肾静脉水平以上的下腔静脉损伤，若无法修补，有人也主张结扎，但要切除右肾，左肾可依赖侧支循环 (肾上腺静脉)，谅无问题，但可出现回心血量不足。

Discussion

Early diagnosis:

Abdominal wall contusion or abdominal visceral injury, which is related to whether to operate as early as possible and save life. Simple abdominal wall contusion can also stimulate peritoneum to produce abdominal pain, muscle guard and local tenderness due to abdominal muscle contusion and fissure and hemorrhage, and even accompanied by nausea and vomiting. In the early stage of visceral injury, it is easy to be confused because of little bleeding and leakage and dilution by abdominal fluid, with only slight signs.

Generally speaking, abdominal wall contusion, mild abdominal pain, limited muscle guard, or subcutaneous congestion, soft tissue swelling, small systemic disturbance, and no shock appeared.

讨论

早期诊断: 腹壁挫伤抑或腹内脏伤，这关系到是否要及早手术、抢救生命的大问题。单纯腹壁挫伤也可因腹肌挫裂、出血而刺激腹膜发生腹痛、肌卫、局部压痛，甚至伴恶心、呕吐; 而内脏伤早期，由于出血和泄漏量少，又被腹腔液所稀释，只出现轻微的体征，故易于混淆。

一般说腹壁挫伤，腹痛轻微，肌卫较局限，或出现皮下淤血，软组织肿胀，全身扰乱小，无休克。

Solid organ rupture:

Except for liver and gallbladder, the peritoneal irritation is generally milder than cavity organ injury. Total abdominal pain, but centered on the site of the damaged organ. The following points can aid in the diagnosis:

There are signs of internal bleeding after trauma to the upper abdomen of the lower chest, with increased pulse, decreased blood pressure, progressive anemia and disappearance of abdominal breathing.
Abdominal pain is mainly confined to the costa rica and radiated to the shoulder, back and waist.
Upper abdominal pain persists after injury, accompanied by local tenderness, muscle weakness, abdominal distension, and decreased borborygmus.
Enlargement of turbid and voiced boundary of liver or spleen: On X-ray, the shadow of liver or spleen was enlarged, the rising and movement of injured side diaphragm was weakened, and the shadow of psoas major muscle disappeared.
with fixed or mobile turbidity, abdominal wear with non coagulation of dark red blood (for the fibrin blood, and call related to the role of plasmin).

实质性脏器破裂: 除肝、胆外，其腹膜刺激症状，一般较空腔脏器损伤为轻。全腹痛，但以损伤器官所在的部位为著。以下几点可以有助诊断:

1、下胸部上腹部外伤后呈内出血征象，脉搏增快，血压下降，进行性贫血，腹式呼吸消失。

2、腹痛以季肋部为著，向肩、背、腰放射。

3、伤后上腹痛持续，伴有局部压痛、肌卫、腹胀、肠鸣音减低。

4、肝或脾浊浊音界扩大: X线见肝或脾阴影扩大，损伤侧膈肌上升和运动减弱，腰大肌阴影消失。

5、具有固定或移动性浊音，腹穿有不凝之暗红血 (为脱纤维蛋白血，又谓与纤维蛋白溶酶的作用有关）。

Hollow organ perforation:

The peritonitis occurs earlier, and the abdominal pain is more severe, which is easy for early detection. The following points are helpful for diagnosis.

Severe abdominal pain lasts for more than 4 hours after injury, accompanied by: (i) nausea and biliary vomiting. (ii) Pulse rate increase. (ii) Fixed tenderness. (iv) The scope of muscular guard is enlarged. (v) Increased white blood cells and left shift in classification. (vi) Abdominal respiration decreases or disappears.
The patient is not suffering from anemia, but his pulse is rapid and he is agitated.
The voiced boundary of the liver disappears, and the free gas layer under the septum is shown on X-ray.
Abdominal wear for turbid liquid, positive microscopic examination. For patients with compound injury, laparotomy should be performed as soon as possible as long as a reliable indication is grasped.

空腔脏器穿孔：发生腹膜炎较早，腹痛较剧，易于早期发现，以下几点有助诊断。

1、伤后剧烈腹痛4小时以上，伴有: ①恶心、胆汁性呕吐。②脉搏增速。③固定性压痛。④肌卫的范围扩大。⑤白血球增高、分类左移。⑥腹式呼吸减弱或消失。

2、贫血不著，但脉速、且烦燥不安。

3、肝浊音界消失，X线见隔下游离气层。

4、腹穿为混浊液，镜检阳性。

复合损伤者，只要抓住一项可靠指征，就要尽早剖腹探查。

Treatment problems

Conservative treatment is feasible under the following conditions: 1. The injury is limited to the abdominal wall. 2. Although there is hemoptysis in the abdominal cavity, there is no continuous hemorrhage, no manifestation of hollow organ perforation, and no fluctuation of body temperature, pulse and blood pressure. 3. One or two days after the injury, the general situation is good, intra-abdominal infection has been limited. 4 mild kidney injury, hematuria gradually reduce, pain relief.

治疗问题下列情况可行保守治疗: 1. 损伤仅限于腹壁者。2. 腹腔虽有积血但无继续出血，无空腔脏器穿孔的表现，体温、脉搏、血压无波动。3. 受伤一、二日，一般情况尚好，腹内感染已局限。4. 轻度肾损伤，血尿渐形减少，疼痛减轻者。

The hazards of abdominal injury are shock, hemorrhage and peritonitis. Except for the conservative treatment for kidney injury, early operation is recommended. For the suspected diagnostician, the changes of pulse, blood pressure and hemogram should be closely noticed and preoperative preparation should be made. In case of bad transformation, exploration is also recommended although the abdominal puncture is negative. For hemorrhagic shock, after rapid blood transfusion and other rescue does not get better, it suggests that bleeding speed, should be forced surgery, surgery to stop bleeding as one of the anti-shock measures. Patients with peritonitis, after correction of water and electrolyte disorders, anti-shock, also appropriate from early surgery, remove the source. Anesthesia: it is required to be complete, with loose abdominal muscles, so as to facilitate exploration and cleaning of the abdominal cavity. Hard hemp to hypotension, anemia patients, in theory should have concerns. However, it is still a commonly used anesthesia method due to its small physiological disturbance, good anesthesia effect and convenient operation. Continuous epidural anesthesia was used in the majority of our cases, which was safe and satisfactory, but required small and slow doses. It should be note that that amount of anesthetics require by such patients is much lower than that for general patients. Simple visceral injury with definite diagnosis and critical condition can also be performed under local anesthesia. Compound intravenous anesthesia is also suitable for some patients. Endotracheal ether general anesthesia is only considered for open-chest patients.

Exploration: pay attention to the existence of compound injury and avoid omission. Pay attention to the retroperitoneal fixed organs, such as the naked face of the duodenum, colon and liver. The greater omentum is often pointed to the lesion. Pay attention to the hint of abdominal fluid: dark red blood—spleen rupture; Bile-containing blood-liver rupture; Bile-containing fluid—high intestine; Green fluid—extrahepatic biliary tract; Feces-large intestine; Clear the liquid-urine extravasation. Suggested exploration sequence: spleen, liver, pancreas, diaphragm, gastric fundus, biliary tract, duodenum, mesentery, omentum, small intestine (from jejunum curvature to ileocecal part), large intestine (pay attention to liver and spleen curvature), retroperitoneum such as kidney and large blood vessels, and pelvic organs. Clear damage, should be dealt with first. Drainage: visual damage time, sensation

腹部损伤的危害，为休克、出血及腹膜炎，除肾损伤可先行保守治疗外，均宜及早手术。对疑似诊断者，要严密注意脉搏、血压、血象的变化，并作术前准备，若有坏的转化，虽腹穿阴性，亦宜探查。对于出血休克，经快速输血等抢救不见好转者，则提示出血速度快，应予强迫手术，视手术止血为抗休克措施之一。腹膜炎患者，在纠正水电解质紊乱、抗休克之后，也宜从早手术，除去病源。

Anesthesia: it is required to be complete, with loose abdominal muscles, so as to facilitate exploration and cleaning of the abdominal cavity. Hard hemp to hypotension, anemia patients, in theory should have concerns. However, it is still a commonly used anesthesia method due to its small physiological disturbance, good anesthesia effect and convenient operation. Continuous epidural anesthesia was used in the majority of our cases, which was safe and satisfactory, but required small and slow doses. It should be note that that amount of anesthetics require by such patients is much lower than that for general patients. Simple visceral injury with definite diagnosis and critical condition can also be performed under local anesthesia. Compound intravenous anesthesia is also suitable for some patients. Endotracheal ether general anesthesia is only considered for open-chest patients.

麻醉: 要求完全，腹肌松弛，便于探查和清洗腹腔。硬麻对低血压、贫血病人，在理论上应有顾虑。但因其生理扰乱小，麻醉效果好，操作又方便，故仍不失为常用的麻醉方法。我们的病例绝大多数采用连续硬麻，尚感安全和满意，但需小量、缓慢给药。须注意: 此类病人需要麻醉药量较一般病人大为减少。对于诊断明确的单纯某内脏伤，病情又危重，亦可在局麻下施行。静脉复合麻醉在某些病人亦较适用。气管内乙醚全麻只对开胸病人才考虑。

探查: 注意复合伤的存在，避免遗漏。注意腹膜后固定的脏器，如十二指肠、结肠、肝的裸面等。大网膜往往指向病变所在。注意腹腔液体的提示: 暗红色血 — 脾破裂; 含胆汁的血 — 肝破裂; 含胆汁的液体 — 高位小肠; 绿色液体 — 肝外胆道; 粪 — 大肠; 清彻的液体 — 尿外渗。

Suggested exploration sequence: spleen, liver, pancreas, diaphragm, gastric fundus, biliary tract, duodenum, mesentery, omentum, small intestine (from jejunum curvature to ileocecal part), large intestine (pay attention to liver and spleen curvature), retroperitoneum such as kidney and large blood vessels, and pelvic organs. Clear damage should be dealt with first.

建议探查次序: 脾，肝，胰，膈，胃底，胆道，十二指肠，肠系膜，大网膜，小肠 (由空肠曲至回盲部)，大肠 (注意肝、脾曲)，腹膜后如肾、大血管等，盆腔器官。

明确损伤者，应先行处理。

Drainage: It depends on the time of injury, the degree of infection, and the quantity and quality of intra-abdominal fluid. In the early stage of abdominal cavity pollution, thorough washing was mainly adopted, supplemented by drainage. Liver, gallbladder, pancreas, intestinal damage to drainage, late infection, adhesion into every other should not be washed, only appropriate suction net, drainage.

引流: 视损伤时间、感染程度、腹内液体的量和质而定。早期的腹腔污染，以彻底冲洗为主，引流为辅。肝、胆、胰、肠损伤要引流，晚期感染，粘连成隔不应冲洗，只宜吸净、引流。

Prognosis: The early death was severe combined injury, traumatic shock and massive hemorrhage. The late death was generalized peritonitis, toxic shock, and water and electrolyte disorders. The cure rate of surgical cases can reach about 90%.

预后: 早期死亡为严重复合损伤、创伤性休克和大出血。晚期死亡为泛发性腹膜炎，中毒性休克及水和电解质紊乱。手术病例治愈率可达90%左右。

参考资料

1. 黄家驷外科学人民卫生出版社 P: 497 1964

2. 高贤铭腹部创伤外科学报 6: 468 1951

3. 蒋克钩腹部创伤之诊断与处理外科学报 6: 376 1951

4. 黄文腹部挫伤98例临床分析中华外科杂志 4:370 1960

5. 龚松南腹部闭合伤 (附220例分析) 中华外科杂志 15: (2)96 1977

南陵县医院外科李名杰原载《南陵医学》1979；59-63

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