Laparoscopic surgery in hepatobiliary,splenic and pancreatic diseases is being widely used.However,the incidence of postoperative complications is relatively higher due to the complexity of the operative procedures.Surgeons are expected to have familiarity with normal and variant anatomy,as well as a good command of prevention and management of bleeding.Different separation techniques should be used based on the different characteristics of tissues.Moreover,digestive tract reconstruction is the technical bottleneck in laparoscopic hepatobiliary,splenic and pancreatic surgeries,and depending on the team work.Different anastomotic methods should be applied according to patients' condition.Three-dimensional laparoscopy and Da Vinci robot surgical system have greatly promoted the development of complex laparoscopic surgery in hepatobiliary,splenic and pancreatic surgeries.Comprehensive perioperative management and enhanced recovery after surgery are the guarantee of safe and quick postoperative recovery,which also fully embody the advantages of minimally invasive surgery.

Objective To determine the effect of laparoscopic abdominal wall components separation procedure on a porcine model of intra-abdominal hypertension (IAH). Methods IAH to 25 nun Hg was created by insufllating carbon dioxide into abdominal cavity of eight anesthetized pigs. Bilateral subcutaneous tunnels above the plane of the abdominal musculature were developed. Dissection of the external oblique insertion and development of the plane between external and internal oblique muscles was performed using ultrasonic scalpel monitored by laparoscopy. Changes in intra-abdominal pressure (IAP), waistline (WL), mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP) were recorded. Results Following intra-abdominal hypertension, WL, MAP, HR and CVP changed significantly. After laparoscopic abdominal wall components separation, there was a significant decrease in IAP from 25 mm Hg to ( 16. 0 ± 1.5 ) mm Hg ( P < 0. 01 ). Also, this procedure increased WL by (5.6 ± 2. 0) cm [ from (65.3 ± 2. 5 ) cm to (88 ± 14) cm; P < 0. 01 ]. Due to abdominal depression, the MAP was significantly increased from to (88 ± 14) mm Hg to ( 100 ± 12) mm Hg ( P <0. 01 ). Moreover, there were significant improvements in circulation status including HR from (115 ± 9) beat per minute (bpm) to (97 ± 7) bpm (P<0.01), CVP from (10.8±2.2) cm H2O to (7.3 ± 1.8) cm H2O (P<0.01), etc. Conclusions IAH results in changes of hemedynnmies. Laparoscopic abdominal wall components separation significantly decreases IAH improving porcine hemodynamics.

ObjectiveTo evaluate the feasibility of endoscopic thyroid adenoma excision. Methods Dogs were used to practice endoscopic thyroid surgery under anesthesia. On the basis of animal experiment, endoscopic technique was introduced into dissection of follicular nodule of the thyroid lobe. One male and 11 females, aging between 23～52, underwent endoscopic enucleation of thyroid tumors from March 2002 to October 2002. Results The procedure was successful in 11 cases with 1 case converted to open surgery. The average time of operation was 70*!min, and intraoperative blood loss was 5～20*!ml. The patients had minimal pain. The cosmetic result was excellent. The incisions were completely hidden even with open necked skirt. Conclusions The cosmetic result of endoscopic thyroidectomy is satisfactory.

Objective To evaluate the feasibility and effect of the treatment of hematopathy by laparoscopy plus small incision splenectomy. Methods Dissection and separation of the ligaments of the spleen with laparoscopy first. And then made a small abdominal incision to ligate and divid the pedicle of spleen to finish splenectomy. Sixteen cases of idiopathic thrombocytopenic purpura(ITP) and 4 cases of heriditary spherocytosis(HS), who were treated by medication but no effect or recurrence, were treated by this procedure. Results All the patients recovered smoothly without infection of the wound ,without fluid collection in the spleen fossa,and without great intraoperative blood loss.The operating time was 1.5～2.5h(average 2.2h), intraoperative blood loss was 30～85ml(average 65ml).Hospital stay was 4～7d( average 6d). No recurrence was found during the follow-up for 0.5 to 2.5 years in this series. Conclusions Laparoscopy plus small incision splenectomy in the treatment of some hematopathy has many advantages,such as less trauma, safety, effective and quick recovery.

Objective To study the outcome of lost gallstones in peritoneal cavity. Methods Gallstones and bile collected from 51 patients undergoing laparoscopic cholecystectomy were analysed and cultured.One to three gallstones from each patient were placed into the peritoneal cavity of a corresponding Wistar rat on sterile condition. Results 8 rats died of peritoneal infection, intestinal fistula and ileus within one month. Abdominal wall abscess occured to one rat. All survival rats were sacrificed three months later. Pathologic results showed that the nidus of abscess appeared in tissue around the stone. Conclusions Lost gallstone is harmful to body. We should avoid gallstone lost in peritoneal cavity.

Pancreatic cancer is a highly malignancy of the digestive system, with low early diagnosis rate and poor prognosis. Cancer cachexia, muscle and adipose tissue wasting are important factors affecting surgical complications and long-term prognosis of patients with pancreatic cancer. On one hand, the occurrence and development of pancreatic cancer cachexia are associated with the decrease of food intake. On the other hand, the characteristic of tumor hypermetabolism, many inflammatory factors, fat and protein regulatory factors and many neuroendocrine pathways are also involved in pancreatic cancer cachexia. At present, the understanding of cancer cachexia and tissue wasting is not comprehensive, and the diagnostic methods are not unified. The main screening method is based on body mass index, but it is not applicable to obese patients. The detection of serum cytokines and determination of intramuscular fat content based on the abdominal computed tomography scan also play pivotal roles in the diagnosis of pancreatic cancer cachexia. Perioperative inhibition of tissue wasting can not only reduce surgical complications, but also improve the prognosis of pancreatic cancer patients. However, there is no effective method to completely reverse cancer cachexia. Multidisciplinary treatment is the routine therapy. Surgical treatment to remove the tumor is the fundamental measure to impede the development of cachexia. In addition, strengthening nutritional support, reducing inflammation and stress reaction, reducing the muscle wasting are also important in the treatment of cachexia during the perioperative period. Combined with self experience, the authors comprehensively analyze research advances, summarize the etiology, molecular mechanism, diagnosis and treatment of tissue wasting, in order to investigate tissue wasting and perioperative treatment strategies of pancreatic cancer patients.

Objective To explore the clinical value of laparoscopy in the treatment of pancreatic diseases.Methods Twelve patients with pancreatic diseases received laparoscopic surgery.Among which 9 patients with cystic diseases,4 cases underwent laparoscopic spleen-preserving distal pancreatectomy,2 cases received distal pancreatectomy and splenectomy,and 3 cases underwent pancreatic cystectomy.Laparoscopic insulinoma enucleation was performed for 2 patients who suffered from insulinoma.Besides,a patient suffered from pancreatic carcinoma recurrence received left thoracoscopic splanchnicectomy.Results All the operations were accomplished successfully,including 8 total laparoscopic surgery and 4 laparoscopic assisted surgery.The average operative time was 225 min(range 100-420 min),and the average volume of blood loss was 80 ml(range 2-150 ml).Pancreatic fistula was observed in 1 patient which was cured by conservative therapy.The postoperative average hospital stay was 7.2 d(range 5-13 d).The patient with recurrent pancreatic carcinoma survived for 6 months after operation and the pain-killing effect was satisfactory.With a follow-up of 10-36 months for other patients,the surgical effects were ideal and no recurrence occurred.Conclusion With the advantages of less trauma,less pain,fast recovery,and low morbidity rate,laparoscopic surgery is an effective and safe method for the treatment of pancreatic diseases,and thus may be widely used in the clinical settings in the future.

Objective:To study the expression of tenascin in hepatocellular carcinoma(HCC)and to investigate the roles of tenascin expression in microvessel angiogenesis,invasion,metastasis and prognosis of HCC.Methods:Formalin fixed,paraffin wax embedded specimens from 63 HCC patients were stained with an anti-tenascin monoclonal antibody,and the measurements were also done for paracancerous specimens from the same patients and specimens from 15 patients with liver cirrhosis and 10 normal liver.The correlation was analyzed between expression of tenascin and clinicopathological features as well as microvessel angiogenesis.Results:Tenascin immunoreactivity was observed in 65.1% samples of HCC,69.8% of paracarcinoma,20.0% of liver cirrhosis and negative of normal liver samples.Positivity and intensity of tenascin expressions in samples of HCC and paracarcinoma were higher than those in samples of cirrhotic and normal liver.Tenascin expression was correlated with Edmondson-Steiner grades,tumour numbers,capsule invasion,tumour metastasis and microvessel angiogenesis.Conclusion:The up-regulation of tenascin expression may play an important role in invasion and metastasis of HCC.

Objective: To evaluate the clinical value of 18F-FDG PET/CT in diagnosing the recurrence or metastasis of the postoperative patients with gastrointestinal malignant tumor. Methods: Sixty-eight postoperative patients with gastrointestinal malignant tumor were studied with 18F-FDG PET/CT, and serum CEA and CA19-9 were assayed. Results: Thirty-seven patients were found to be recurrent or metastatic. The sensitivity and specificity of PET/CT detection were 97.3% and 96.8%,and the positive rates of PET/CT combined with CEA and CA19-9 were 100% and 97.8%.Conclusion: PET/CT has a higher sensitivity and specificity than tumor marker detection in assessment of recurrence and metastasis.

Objective To investigate the effect and the mechanism of intragastric administration of gentamicin and lactulose on stress ulcer in rats with obstructive jaundice.Methods Forty male Wistar rats were divided into 4 groups: Jaundice(Ligation of the bile duct) and intragastric administration of gentamicin and lactulose(group A),jaundice with intragastric glucose(group B),sham operation with intragastris gentamicin and lactulose(group C);and sham operation with intragastric glucose(group D).Two weeks after the operation,the respective intragastric administration was given for 7 days,and then the water immersion and restraint stress induction procedures were performed in the 4 groups.Endotoxemia levels in portal vein were measured by the Limulus test and the ulcer index was calculated.Results Group A showed significantly lower ulcer index and lower level of endotoxemia compared to group B,while the levels of endotoxemia and ulcer index in group B were increased,and group C and D also showed lower ulcer index and lower level of endotoxemia.Conclusions Endotoxemia is an important aggravating factor for stress ulcer in obstructive jaundice.Intragastric administration of lactulose and gentamicin can decrease the level of endotoxemia which is beneficial to reduce the incidence of stress ulcer in rats with obstructive jaundice.