2022年 · 第60卷第06期

Looking back at the development of the surgical field in New China, whether it is the 1950s and 1960s when textbooks are scarce, or the present day when textbooks, books, videos, online live surgery and other learning resources are abundant, there are always a few surgical books that have a profound influence on our study, medical practice or teaching career. "Huang Jiasi Surgery" is such a heavy surgical masterpiece. It has written a magnificent chapter of the development of surgery in New China for more than half a century, engraved the footprints of the surgical ancestors of New China who have sought their lives for the surgical cause in China, nourished and nurtured tens of thousands of surgeons in New China, and witnessed their unremitting pursuit and struggle for new surgical technologies and ideas across the centuries.

Osteochondral injury of the talus is very common in patients with ankle pain. In severe cases, the patient is unable to walk with weight and often requires surgical intervention^［1］。 Multiple methods can be used to treat osteochondral injury of the talus, with bone marrow stimulation for areas less than 15 mm²The damage effect is better^［2］It is mostly used to treat early talus osteochondral injury. Park et al.^［3］The study found that most patients with poor results after bone marrow stimulation can undergo secondary osteochondral grafting to relieve symptoms. Autologous osteochondral grafting is widely used as the "gold standard" for the treatment of Hepple IV and V talus osteochondral injuries. However, in the case of Hepple type V cystic degeneration of talus combined with large-area bone marrow edema, the effect of autologous osteochondral transplantation is limited, and large-area autologous osteochondral transplantation will affect the function of the donor site. Therefore, the combination treatment options such as bone marrow stimulation, allogeneic osteochondral transplantation, pedicled iliac bone flap transplantation and platelet-enriched plasma are worth trying. Akpancar and Gül^［4］It is suggested that hyperplasia therapy and platelet enriched plasma technique can achieve the goal of treating talus osteochondral injury, but it is rarely carried out in China. Considering that this kind of treatment does not restore the complete osteochondral structure of the articular surface and it is difficult to achieve the physiological function of the original articular cartilage after operation, we attempted to apply peripheral pre-decompression autologous osteochondral grafting to treat patients with talus Hepple type V osteochondral injury while reducing the transplantation amount of autologous osteochondral column. The report is as follows.

laparoscopic cholecystectomy (LC) is the "gold standard" for the treatment of benign gallbladder diseases such as gallstones and gallbladder polyps^{［1, 2］}。 The classical three-hole method is the most widely used LC surgical method in clinical practice. In order to further reduce surgical trauma, transumbilical single-port LC has been used clinically by some laparoscopic surgeons^［3］。 However, in single-port laparoscopic surgery, there is inevitably a "chopstick effect" between the operating instruments^［4］It increases the difficulty of surgical operation and makes the surgeon's operation experience poor, resulting in single-hole LC not being widely carried out in clinical practice. magnetic anchor technique (MAT) can be used to assist in pulling exposure in laparoscopic surgery, replacing the function of secondary operating hole instruments, thereby achieving the purpose of reducing poking holes. In the early stage, we used MAT in LC, realized two-well LC, and achieved good clinical application results^{［5, 6］}。 The clinical application of MAT in transumbilical single-port LC is now reported below.

Acute mesenteric ischemia is a kind of rare life-threatening acute abdominal disease caused by mesenteric blood supply disorders caused by different etiologies, resulting in intestinal ischemia, inflammatory injury and even intestinal necrosis^{［1, 2］}。 The cause may be embolism, stenosis and thrombosis of the superior mesenteric artery, thrombosis of the superior mesenteric vein, or non-obstructive lesion^［3］。 Despite the abundance of modern diagnosis and treatment methods, the overall mortality rate of acute mesenteric ischemia is still 50% ~70%^［4］。 The main reason for the poor prognosis is that the early clinical manifestations of patients are often unspecific, resulting in untimely diagnosis and delayed treatment opportunity. The proportion of different degree of superior mesenteric artery stenosis in the elderly can reach 17.5%^［5］, with the advent of an aging society, the incidence of acute mesenteric ischemia may continue to increase^［6］。 With the progress of interventional technology and the improvement of operating room conditions, compound surgery has gradually developed and risen in recent years. The compound application of interventional technology and open surgery can complement each other and achieve twice the result with half the effort. Our hospital applied one-stop compound surgery to 2 patients with acute mesenteric ischemia with thrombosis secondary to superior mesenteric artery stenosis and intestinal necrosis, and the clinical results were satisfactory. The report is as follows.

Patient 1, a 26-year-old male, was seen in Beijing Chuiyangliu Hospital affiliated to Tsinghua University on October 16, 2006 due to "severe horseshoe varus deformity of left foot with skin ulcer in weight-bearing area for 10 years". The patient suffered from bipedal deformity secondary to lumbosacral spondylosis, and his defecation and defecation could be partially controlled. When he was young, he underwent lumbar meningocele cyst resection and meningoplasty. Mild hindfoot varus on the right foot, severe horseshoe varus deformity on the left foot combined with dorsal sensory disorder, walking with weight on the anterolateral dorsal side of the foot, and the skin ulcer in the weight-bearing area has not healed for more than 10 years. I have been seen in many hospitals, and all of them recommended the installation of prosthetic limbs after amputation, but the patient refused and went to our hospital for further treatment. Physical examination: The left foot showed severe horseshoe varus deformity, contracture of Achilles tendon, posterior tibial tendon and metatarsal fascia, fixed varus adduction deformity of foot bones and joints, muscle strength of triceps of calf grade III, muscle strength of anterior tibia, posterior tibia, peroneal longus and brevis muscle, flexor toe and extensor toe extensor muscle grade 0, lack of skin sensation on the dorsum of the foot and the lateral part of the foot, and crater-like ulcers with a size of 5 cm ×3 cm and marginal keratinization in the anterior lateral weight-bearing area of the dorsum of the foot. The tissues of the ulcer area were taken and sent to pathological examination, and the results were reported as inflammatory changes. X-ray examination revealed the absence of the fifth metatarsal bone (resected during debridement with osteomyelitis) (Figure 1). Following Qin Sihe's orthopedic philosophy (orthopedic natural reconstruction concept + minimally invasive, simple and effective surgical operation principle), orthopedic surgery of left foot (ulcer debridement, extension of Achilles tendon, posterior tibial tendon, flexor longus hallucinus tendon, triple joint osteotomy, Ilizarov foot and ankle deformity distraction) was performed under general anesthesia on October 21, 2006. During the operation, pneumatic tourniquet was used for the affected limb, and the foot ulcer was first removed, and the granulation tissue on the bone surface was curetted. On the bone surface of the ulcer, wedge osteotomy of the talocalcaneal joint, talocaphoid joint and calcaneocubular joint was performed with an osteotome, and most of the skeletal deformities were corrected during the operation. Then, the Ilizarov ring external fixator was installed with a needle to maintain the appropriate orthopedic position of the foot and ankle (Figure 2), and the incision was partially sutured. The remaining edge of the wound skin was nailed to the bone surface with a thin steel needle to prevent retraction, and the sterile dressing was dressed.

The 55-year-old male patient was admitted to our department on June 29, 2021 for further treatment due to "primary malignant tumor of the liver was found for 4 months and treated with transcatheter arterial chemoembolization (TACE) for 4 weeks". The patient developed abdominal pain and abdominal distension 5 months ago, which gradually worsened. On February 28, 2021, a CT examination of the upper abdomen was performed in the local hospital, and the results showed intrahepatic mass, which was considered to be liver cancer. MRI of upper abdomen was performed in this hospital on March 1, 2021, which showed intrahepatic mass and liver cancer. He was admitted to the interventional department of our hospital. Based on the patient's condition, if he underwent right hemihepatectomy, the remaining liver volume after resection was insufficient, and the risk of liver failure was high, which met the treatment indications of TACE combined with lenvatinib. He received TACE treatment in the interventional department of our hospital on March 11, 2021, April 22, 2021, and May 31, 2021, respectively, during which he was given oral lenvatinib. The patient had a history of hepatitis B and liver cirrhosis in the past and was not treated regularly. No long-term smoking or drinking history. The patient's father had a history of liver cancer. Laboratory test for this admission: hemoglobin 119 g/L, white blood cell count 4.4×10⁹/L, platelet count 212×10⁹/L; Alpha-fetoprotein 498.30 μ g/L, carcinoembryonic antigen 1.64 μ g/L, CA19-9 80.31 U/ml; ALT 10 U/L, AST 29 U/L, total bilirubin 8.8 μ mol/L, direct bilirubin 8.4 μ mol/L. CT examination showed that the lesion occupied the 5th, 6th, 7th and 8th segments of the liver, and although the size increased from 11 cm ×10 cm without relevant treatment to 13 cm ×11 cm, there was obvious necrosis inside the tumor, and the lipiodol deposition was sufficient, and gas appeared in the tumor (Figure 1). The Child-Pugh classification of preoperative liver function was A, and the 15-min retention rate of indocyanine green was 5.9%; Right hemihepatectomy is proposed, and the proportion of remaining liver is expected to be 38%.

The patient, a 38-year-old female, was admitted to the emergency department on 01-Apr-2021 due to "sudden upper abdominal pain for 1 d". The patient self-complained of sudden upper abdominal pain without obvious trigger 1 day ago, which was paroxysmal, without abdominal distension, diarrhea, nausea, vomiting, fever, chills, and normal defecation. No previous special medical history. Admission physical examination: blood pressure 201/113 mmHg (1 mmHg =0.133 kPa), acute painful face, no obvious yellowing of skin and sclera, flat and soft abdomen, tenderness under xiphoid process, no rebound pain, negative Murphy sign, no palpable mass, abdominal percussion drum sound, and normal intestinal sound. Laboratory tests: free methoxyepinephrine 101.0 ng/L (normal reference value: 0-62 ng/L), free methoxynorepinephrine 5 030.0 ng/L (normal reference value: 0-145 ng/L), tumor marker CA19-9 55.69 U/ml (normal reference value: 0-37 U/ml), serum glucose 19.06 mmol/L, glycated hemoglobin 11.1%, urine glucose (4+), urine ketone body (3+), Epstein-Barr virus coat antigen IgG antibody>750 U/ml (normal reference value: 0-20 U/ml), Epstein-Barr virus nuclear antigen IgG antibody>600 U/ml (normal reference value: 0-12.5 U/ml), Epstein-Barr virus coat antigen IgM antibody 35.20 U/ml (normal reference value: 0-30 U/ml), IL-6 13.27 ng/L (normal reference value: 0-7 ng/L). There were no abnormalities in aldosterone in upright position, angiotensin in upright position, cortisol and adrenocorticotropic hormone at each time point, blood routine, liver and kidney function and blood coagulation. Imaging examination: The results of CT plain scan + enhanced examination of the upper abdomen showed that an oval soft tissue mass shadow could be seen next to the retroperitoneal vena cava. The enhanced scan showed obvious uneven enhancement in the arterial phase, and a fissured low-density shadow could be seen inside, with a slight withdrawal in the venous phase and the equilibrium phase. The mass was closely related to the first segment of the liver, about 6.1 cm ×2.9 cm in size, and the adjacent liver was mildly compressed (Figure 1); The results of MRI plain scan + enhanced examination of liver, gallbladder, pancreas and spleen showed that mass shadows were seen retroperitoneally during plain scan, T1WI showed low signal, T2WI showed high signal, and small nodular T2WI high signal shadows were seen inside. Diffusion-weighted imaging showed uneven high signal, about 6.0 cm ×3.0 cm in size. In the enhanced stage, retroperitoneal lesions showed persistent progressive obvious uneven enhancement, and stripe-shaped areas without enhancement were seen inside (Figure 2). Preoperative diagnosis: (1) Ectopic pheochromocytoma; (2) Secondary hypertension; (3) Abnormal blood sugar: secondary hyperglycemia? Type 2 diabetes?

The patient was a 33-year-old female with 27 menopause⁺¹Zhou, was admitted to the hospital at 17:51 on February 12, 2021 for "knife stab wounds to the abdomen, left chest, neck for 7 h". Seven hours before admission, the patient was stabbed in the abdomen, left chest and neck with a sharp knife. After the injury, he felt pain in the abdomen and wounds, without coma, chest tightness and shortness of breath, hematuria, bloody stool and vaginal bleeding. He was immediately sent to a local hospital and given magnesium sulfate to protect the fetal cranial nerves. For further treatment, he was transferred to the emergency department of our hospital. The ultrasound results showed that the intrauterine single live fetus was late pregnant, and the fetal size was equivalent to 28⁺Weeks, placental thickness 19 mm. Consult with obstetrician and give dexamethasone 6 mg intramuscular injection to promote fetal lung maturation. He was admitted to the hospital with "abdominal trauma". Past history: On December 4, 2016, she underwent "left sacroiliac joint lesion excision + bone graft fusion" due to "left sacroiliac joint osteoblastoma", without history of abdominal surgery, pregnancy 5 and delivery 2, and last menstruation on August 6, 2020. Admission physical examination: body temperature 37.6 ℃, heart rate 92 beats/min, breathing 22 beats/min, blood pressure 111/65 mmHg (1 mmHg =0.133 kPa). His mind was clear, his expression painful. A wound about 2 cm long was visible on the left side of the neck without obvious swelling around it. A wound about 2 cm long was seen on the left anterior and lower chest wall (Figure 1). The breathing sounds of both lungs were clear, and no rales were heard. The lower abdomen is raised, the fundus of the uterus is high and the two horizontal fingers above the umbilicus, and irregular contractions can be palpable. A wound about 2 cm long was seen at the axillary midline of the left lower abdominal wall, with an unknown depth, and no prolapse of abdominal contents such as omentum was seen (Figure 1). Obvious tenderness and rebound pain in the whole abdomen, no moving void sound during percussion, and weak intestinal sound, 1 time/min. Please consult the obstetrician again, vaginal examination: the uterine mouth is not opened, the cervical canal is not disappeared, the presentation is undetermined, there is no vaginal bleeding, fluid, and fetal heart sound 135 times/min. Blood routine after admission: white blood cell count 15.88×10⁹/L, neutrophil percentage 91.4%, hemoglobin 84 g/L. Blood biochemistry: carbon dioxide binding capacity 18.8 mmol/L (normal range: 22-31 mmol/L), blood glucose 6.66 mmol/L (normal range: 3.9-6.1 mmol/L), no obvious abnormality. Admission diagnosis: (1) stab wounds to abdomen, left chest and neck; (2) Acute diffuse peritonitis; (3) Abdominal cavity organ injury to be discharged; (4) Pregnancy 27⁺¹Zhou, S.; (5) Anemia. After consultation and discussion with obstetricians and anesthesiologists, laparoscopic exploration, small intestine rupture repair, abdominal cleaning and drainage combined with debridement and suture of abdominal, left chest and neck wounds were performed under general anesthesia at 21: 45 on the same day.