2016年 · 第54卷第05期

With the continuous progress of population aging and the increasing incidence of cardiovascular diseases, the prevention, treatment and treatment of thromboembolic diseases have gradually attracted the attention and attention of various disciplines. venous thromboembolism (VTE) includes pulmonary thromboembolism (PE) and deep vein thrombosis (DVT). PE and DVT are two clinical manifestations at different stages of the same disease development and at different sites. Both are collectively referred to as VTE.

Bladder cancer is one of the most common malignant tumors in the world, with 429 800 newly diagnosed patients and 165 100 deaths in 2012^[1]。 In China, bladder cancer is currently the most common malignant tumor of urinary system, and its incidence is increasing year by year^[2]。 Bladder urothelial carcinoma is the most common pathological type of bladder cancer, of which 70% ~80% are non-muscle invasive tumors. Most of them have good prognosis, but the recurrence rate is high, 50% ~70%, of which 20% ~30% will progress to muscle invasive tumors. Cystoscopy is the most important method in the diagnosis, treatment and postoperative monitoring of bladder tumors. However, for some flat lesions and small papillary lesions, cystoscopy may miss or misdiagnose the tumors^[3]。 Therefore, how to improve the traditional white light cystoscope, increase the detection rate of bladder tumor lesions, improve the thoroughness of surgical resection and reduce the postoperative recurrence rate has become one of the difficulties that trouble urologists at present.

With the development of robot technology and the promotion of minimally invasive surgery concept, medical surgical robots have been maturely applied to various fields of surgery. With the support of the National 863 Project, Naval General Hospital and Beijing University of Aeronautics and Astronautics have completed the research and development of five generations of robots and successfully completed a large number of frameless stereotactic surgery^[1]。 In recent years, with the great emphasis and strong support of the country on the research and development of robot technology and digital surgical equipment, on the basis of the successful application of the original five generations of robots, from December 2014 to May 2015, the sixth generation robot system (Remebot frameless brain stereotactic surgery system, referred to as Remebot) with clinical application automation successfully performed 30 operations, and achieved satisfactory results.

When the instability of the craniocervical junction leads to neurological dysfunction, surgical treatment is required clinically. Traditionally speaking, for reducable atlantoaxial joint dislocation, the posterior approach internal fixation technique can be used to fix it; For non-reducible patients, the ligament around the odontoid process can be released through the anterior approach to transform it into a reducible atlantoaxial joint, and then internal fixation by oral approach or posterior approach can be used^[1,2]。 However, the oral approach is a bacterial approach, which has a long preoperative preparation time, small surgical space, difficult operation and high surgical risk, so it is not popular in clinical practice. Treatment of atlantoaxial joint dislocation with posterior approach and internal fixation can avoid the disadvantages of transoral approach; Moreover, with the maturity of internal fixation technology and the improvement of internal fixation materials through posterior approach, better treatment results can be obtained for dislocations that were considered difficult or even irreversible in the past^[3,4]。 Based on the anatomical study of the craniocervical junction, we treated such patients with posterior median cervical approach, occipital-axial screw and titanium rod (plate) internal fixation, with satisfactory results, which are reported below.

A 41-year-old female was admitted to the hospital on 15 January 2014 for "progressive painless cutaneous scleral yellowing for 1 month". One month ago, the patient had no obvious inducement to develop skin sclera yellowing, no fever, abdominal pain, dark yellow urine, and clay-colored stool. Previous history of hepatic cyst. Admission physical examination: vital signs were stable, the skin and sclera of the whole body were severe yellowing, the abdomen was flat, the abdomen was soft, there was no tenderness and rebound pain, the liver and spleen were not palpable under the costs, and there was no percussion pain in the liver area. Laboratory tests: total bilirubin 407.9 μ mol/L, direct bilirubin 299.5 μ mol/L, indirect bilirubin 112.6 μ mol/L, ALT 172 U/L, AST 124 U/L, alkaline phosphatase 560 U/L, R-glutamyltransferase 550 U/L, urinary bilirubin (+ +). Blood routine, blood amylase, coagulation function, alpha-fetoprotein, carcinoembryonic antigen, CA125 and CA19-9 were all normal. Ultrasonography: cystic space-occupying lesion of the left lobe of the liver, 5.0 cm ×5.3 cm in size, with clear boundaries and intracapsular separation; The volume of the gallbladder increases, and the gallbladder mud accumulates; The intrahepatic and extrahepatic bile ducts were dilated, and the left hepatic duct was distinctly dilated. CT findings of liver, gallbladder, spleen and pancreas: the left lobe of liver occupied cystic space, with clear and smooth boundary, uniform internal density, and CT value of 5 HU; The intrahepatic and extrahepatic bile ducts were mildly dilated, and the left hepatic duct and common bile duct were obviously dilated; Multiple cysts in both kidneys. MRI + magnetic resonance cholangiopancreatography findings: increased gallbladder volume; Liver and kidney cysts may be, intrahepatic and extrahepatic bile duct dilatation, lower common bile duct truncation, and signs of biliary obstruction (Figure 1)。 Initial diagnosis: bile duct tumor, choledocholithiasis, liver cyst compressing the common liver duct.

The patient was a 50-year-old male. He went to our department for "repeated painful urination and frequent urination for 2 years". Cystoscopy: scattered congestion can be seen in the bladder under ordinary white light (Figure A,Figure C), suspicious lesions of bladder mucosa were found under narrow band light (Figure B,Figure D), and randomized biopsy was performed. Routine pathological report: cell atypia, individual suspected mitotic images, combined with UroVysion^®Fluorescence in situ hybridization was finally determined to be bladder carcinoma in situ.

Question 1Please talk about your understanding of the new robotic surgery.

Question 9Recently, more and more patients ask whether minimally invasive surgery can be performed when seeing a doctor. Is the era of "colorectal gold standard" coming? Are we ready on the supply side? How to accelerate the improvement of the concept, technology and level of the supply side?