2020年 · 第58卷第12期

open reduction and internal fixation (ORIF) is an effective surgical method for the treatment of complex acetabular fractures. Because acetabular fracture belongs to high energy injury, local anatomy is complicated, anatomical reduction is difficult, postoperative complications occur from time to time after ORIF^[1,2,3]。 It has been reported that nearly 8% of patients require total hip arthroplasty (THA) after surgery due to traumatic arthritis or femoral head necrosis^[4]。 THA with acetabular internal fixation is difficult and risky due to the problems of retention, safe exposure, acetabular defect and infection^[5,6]。 Robot-assisted surgery is a major progress in the field of surgery in recent years. At present, there are few clinical reports on the application of robot-assisted THA in patients with residual acetabular internal fixation. This study retrospectively analyzed the clinical data of patients who underwent THA in the Department of Orthopedics, First Medical Center, PLA General Hospital from May 2016 to May 2019, and evaluated the clinical effect of robot application in this type of patients, which is reported as follows.

congenital intrahepatic portosystemic shunts (CIPSS) are rare vascular malformations, and their abnormal shunts are often located between the portal vein branches and the hepatic veins in the liver^[1]Patent ductus venosus is one of the special types^[2]。 The incidence of congenital portosystemic shunt (including extrahepatic portal shunt and intrahepatic portosystemic shunt) is 1:30 000^[3,4]While the incidence of intrahepatic portosystemic shunt was lower than that of extrahepatic portosystemic shunt. CIPSS causes part of portal vein blood to bypass the liver and directly enter the vena cava system, causing hypergalactosemia and increased bile acids, postprandial blood sugar and blood ammonia, which can lead to hepatic encephalopathy in severe cases. Ultrasound examination is an important method to confirm the diagnosis of CIPSS. Some children find this disease in prenatal ultrasound examination^[5]。 Some CIPSS can spontaneously close within 2 years of age, but children with clinical symptoms (including hyperammonemia, jaundice, and liver injury) or large shunt volume (generally>30% of shunt clinically symptomatic) often require surgery or interventional treatment. At present, the choice of treatment options for CIPSS is still controversial. Due to the very low incidence of this disease, most studies on CIPSS are case reports. Therefore, we summarized the experience of surgical treatment of 5 children with CIPSS in our center through this study.

Caroli disease is a rare congenital disease, manifested by multiple segmental dilatation of intrahepatic bile duct, also known as congenital intrahepatic bile duct dilatation, congenital bile duct cyst type V, etc. Caroli's disease is called Caroli's syndrome when combined with portal hypertension. If recurrent symptoms of cholangitis, cholelithiasis and severe portal hypertension occur, the quality of life of patients will be seriously affected, and satisfactory results can often not be obtained through traditional drug treatment, local drainage or surgical resection, so liver transplantation is needed. In recent years, liver transplantation was performed in 8 patients with Caroli syndrome in our hospital, and the effect was good. The report is as follows.

In laparoscopic pancreatoduodenectomy (LPD), although laparoscopy can enlarge the surgical field, it cannot be fluoroscopic and accurately identify the internal anatomy of the organ. The surgeon needs to combine preoperative imaging data to imagine the relationship between the lesions and blood vessels in the surgical field^[1,2]This process relies heavily on the accumulation of surgical experience. In the previous research, the laparoscopic augmented reality navigation system independently developed by our team^[3]Application of real-time fusion navigation of non-rigid registered multimode images in three-dimensional laparoscopic hepatectomy with satisfactory results^[4,5]。 We intend to explore the clinical application value of three-dimensional laparoscopic augmented reality navigation system in LPD intraoperative navigation.

Male, 52 years old. He was admitted to hospital on July 7, 2016 due to "liver mass found for 10 days". The patient had a history of hypertension and hepatitis B virus carrier for more than 10 years. CT examination of upper abdomen was performed in an external hospital 10 days before admission, which showed that the left liver occupied space, and considered liver cancer combined with inferior vena cava tumor thrombus. Physical examination: The liver can be palpable 3 cm below the xiphoid process, which is hard in texture and has poor mobility. Laboratory tests: ALT 207 U/L, AST 169 U/L, lactate dehydrogenase 330 U/L; Tumor marker: alpha-fetoprotein 43.3 μ g/L, CA19-9 87.1 U/ml; Serum markers of hepatitis B virus infection: HBsAg (+), HBeAb (+), HBVpreS1Ab (+), HBVDNA 1.65×10^{6 U/L}； The 15 min retention rate of indocyanine green was 15.8%. CT examination (July 16, 2016) showed that there was a space-occupying lesion in the left lobe of the liver, with a size of about 88 mm ×79 mm. CT angiography showed that the left hepatic vein and the left branch of the portal vein were invaded. The filling defect changes in the proximal end of the inferior vena cava, and the formation of tumor thrombi is considered. Preliminary diagnosis: (1) Left liver cancer with inferior vena cava tumor thrombus (7th edition AJCC liver cancer stage: stage IIIB, Barcelona stage C); (2) Chronic hepatitis B (active phase) liver function Child-Pugh grade A; (3) Hypertension (Grade II, very high-risk group); (4) Hypertensive heart disease (slight regurgitation of tricuspid and pulmonary valves).

Male, 46 years old, was admitted to hospital on June 13, 2019 for "28 years of ankylosing spondylitis, severe kyphosis with difficulty walking for 5 years". The patient was diagnosed with ankylosing spondylitis at the age of 18. He developed hunchback deformity 10 years ago. In the past 5 years, it has progressed rapidly, gradually appearing trunk folding, his head gradually approaching his right thigh, and his hip joints gradually stiffened, making him unable to walk. Because the lips are close to the front of the right thigh, it is difficult to eat, and food can only be stuffed into the mouth from the left corner of the mouth. I often feel abdominal distension, poor appetite and poor nutritional status. Physical examination: The wheelchair was pushed into the ward, and the whole trunk was in a deformity folded state of mandible close to sternum, sternum close to pubic bone, and face close to thigh: the thoracolumbar segment (T₁₂~ L₁) is the breaking point, the head and chest are folded towards the thighs and abdomen, and are deflected to the right. The face is close to the right thigh, the forehead is about 5 cm away from the right thigh, and the lips are about 2 cm away from the right thigh; The sternum is close to the pubic bone, and the skin of the chest and the abdomen form reverse folds and compress each other, resulting in multiple skin ulcers at the fold; The lower jaw is close to the sternum, forming a typical maxillothoracic deformity. Complete skeletal ankylosis of bilateral hip joints with complete loss of mobility (FIG. 1A）。 Both knee joints were enlarged with flexion contracture deformity, with a range of mobility of 90° ~100°. The sensation and muscle tone of both lower limbs were normal. The muscle strength of both lower limbs cannot be checked due to limited joint movement. The muscle strength of both feet is normal. Bilateral knee tendon and Achilles tendon reflexes were not drawn out, bilateral patellar and ankle clonus were negative, and bilateral Babinski sign was negative. Full-length lateral X-ray of the spine in standing position (FIG. 1B) showed complete bone ankylosis of the whole spine and bilateral hip joints, severe osteoporosis, and multiple vertebral compression fractures. CT images of the whole spine and bilateral hip joints showed deformities of the patient's mandible close to the sternum, sternum close to the pubic bone, and face close to the thigh (Figure 1C、Figure 1D）。 Due to restricted posture, spinal MRI was not completed, and the visible range of echocardiography was limited. The ejection fraction was measured to be 64%, and the pulmonary function test could not be completed. Diagnosis: (1) Kyphosis in extremely severe ankylosing spondylitis; (2) Bilateral hip ankylosis due to ankylosing spondylitis; (3) Osteoporosis.

A 2-year-old female was admitted to the hospital on January 3, 2020 because "the left palm was twisted by a motorcycle chain and the radial half was completely disconnected for more than 7 hours". Physical examination: The vital signs were stable, and the left palm disconnection plane was oblique from the radial side of the wrist to the distal wrist transverse stripe to the middle ring between the fingers and the webs, and the wounds were all at the joints. The severed body was dressed with gauze, and the peripheral ice pack was cold compressed. The severed limbs were still intact, and the skin was abrasive on the middle finger. There was no active hemorrhage in the proximal section of the dissection, severe contusion in the section, uneven skin margin, and a large amount of oil pollution was seen. The ring pinky finger has a rosy complexion and feels normal (FIG. 1A、FIG. 1B）。 Diagnosis: Type IV dissection of left palm. Immediate emergency "left palm palm replantation" under general anesthesia. During the operation, the deactivated tissue with severe contusion was trimmed, the oil stain in the cross section was removed, and the tissue was washed repeatedly. The flexor pollicis longus tendon, the flexor deep of the middle finger (the flexor superficial of the finger tendon was removed), the extensor pollicis longus tendon, the extensor pollicis brevis tendon and the abductor pollicis longus tendon, and the extensor of the middle finger tendon were identified and marked in turn. The 1st and 2nd carpometacarpal joints and the 3rd metacarpophalangeal joints were fixed longitudinally with three 1.2 mm diameter Kirschner wires. Fluoroscopy showed that the broken end was well aligned. The interosseous muscles, the 1st and 2nd carpometacarpal joint capsules and the 3rd metacarpophalangeal joint capsules were repaired with 4-0 non-invasive suture, the flexor tendons were sutured with modified Kessler method, and the rest tendons were repaired with "8" suture method. Three anastomotic arteries were found under the microscope, namely, the radial artery located at the snuff pit, the first metacarpal artery from the deep palmar arch, and the volar proper artery on the ulnar side of the middle finger (the first common artery from the superficial palmar arch was not found, and there may be variation or vascular withdrawal). Appropriate free artery, cut to normal position, use 10-0 non-injury line to anastomose the digital volar proper artery on the ulnar side of the middle finger, and 9-0 line to anastomose the first metacarpal artery and radial artery. When the tourniquet is loosened, the skin edge at the distal end of the disconnect is bleeding actively, and the skin color at the fingertips is gradually rosy. The inherent nerve on the palmar side of the thumb and middle finger and the dorsal branch of the radial nerve of the hand were sutured with 9-0 line. One concomitant vein of the palmar artery, the cephalic vein and three superficial veins of the dorsal hand were anastomosed. After half an hour of observation, the thumb showed that the blood supply of the middle finger was good, the skin was sutured, and the operation was completed (Figure 1C、Figure 1D）。 Postoperatively, plaster external fixation was used for anti-infection, vasodilator and anticoagulant therapy. Secretions were cultured at emergency admission and the first dressing change after surgery. The affected limb was warm ischemic for 11.5 h, and the blood supply was normal at 72 h after operation. The limb was slightly swollen, with a little exudation from the wound edge and no purulent secretion.