外科總論緒論感染法文

鄭民華上海市微創(chuàng)外科臨床醫(yī)學(xué)中心上海瑞金醫(yī)院胃腸外科Introductiondelachirurgie外科緒論

鄭民華上海市微創(chuàng)外科臨床醫(yī)學(xué)中心上海瑞金醫(yī)院胃腸外科IntroductionofSurgery外科緒論IntroductiondelachirugiecommentdevenirunchirurgienHistoireetFuturecommentedudierLachirurgie

estunensembled'opérationsmanuellesetinstrumentalesréaliséessuretdansuncorpsvivantàdesfinsthérapeutiques.C'estl'undesplusanciensartsmédicaux.

Sonefficacitéaététrèslongtempslimitéeparquatrefacteurs:l'ignorancede

l'anatomie

etdelaphysiologie

l'hémorragieladouleurl'infectionSommaire1L'époquepréhistorique2L'Antiquité3LeMoyen?ge4LaRenaissance5LeXVIIeetleXVIIIe

siècles6LaRévolutionetl'Empire7leXIXe

siècle8LeXXe

siècle9LeXXIe

siècleSommaire

SurgeryinitshistoricalperspectiveTheBirth:

Hippocrates400yearsB.C.:KhirourgeaKhir=hand;ourgea=actionCHIRURGIE theartoftreatinghealthdisordersbyactionofthehandsofamedicaldoctor

J.PERISSAT“cheir”“ergon”ChirurgiesurgeonGreco-RomancivilazationEarlyciviliztion外科發(fā)展起步期始期沒落期復(fù)恢期發(fā)展期廿世紀(jì)Ⅴ世紀(jì)ⅩⅤ世紀(jì)5thC.AD.DevelopmentofSurgeryMiddleAgesDarkAgesRenaissanceAdvance15thC.AD.20thC.AD.起2250B.CHammurabiCode

History

àBabylones'appliquaitlaloidutalionissueducoded'Hammurabi,celaimpliquait,parexempleencasdedécèsd'unpatientpendantouaprèsl'acteopératoire,unesanctionquiétaitdecouperlesmainsdel'opérateur

EdwinSmithPapyrus(Egyptien)

48casesoftraumafromheadtofootTheworldearlierclinicreport1600B.C

History

J.PERISSATJ.PERISSAT

SurgeryinitshistoricalperspectiveThemodestbeginning:

From400yearsB.C.to400A.C.

TheArtofSurgeryAminorbranchofMedicineModestpartofpracticeofeachMedicalDoctorsThemosthandycalled

“Surgeons”J.PERISSATSurgeryinitshistoricalperspectiveTheanticages:From400B.Cto400A.C.Thelimitsofsurgery:CrossingthelineofperitoneumorpleurawassynonymousofdeathJ.PERISSAT460-370B.CHippocrates

FatherofModernMedicine72books&59treatisesSeparatedsciencefromreligionHippocrates’oath

History

Surgeryinitshistoricalperspective

Thewreck

From400to1100A.C.SurgerydeniedaspartofMedicalArtSurgicalpracticedevotedto“Barbers”J.PERISSATSurgeryinitshistoricalperspective

Therenaissance:From1100to1840A.C.From“Barbers”to“Barbers-Surgeons”to“Surgeons”SurgeryfullrecognitionaspartofMedicalArtJ.PERISSAT

Therenaissance

ThemajorLandmarks

1126Averroes1360GuydeChauliac1477Firstprintedmedicalbook

1490TheaterofPadovaforCadaverDissection1543Vesale.BasicbookofanatomyJ.PERISSATTherenaissance

ThemajorLandmarks

1545A.Paré.FirstbookonArtofSurgery1628W.Harvey1743AcadémieroyaledeChirurgie1760J.Hunter1801-1815D.LarreyJ.PERISSATVesalius?Fabricia?in1543Renaissance

History

Surgeryinitshistoricalperspective1545-1850FromParétoLarreyAchievementofAnatomyknowledgeDescriptionofnewsurgicalprocedures(Oncadaver)Pain,InfectionandShockTheblockingfactorsforSurgeons'handssuccessfulclinicalresultsJ.PERISSATAmbroiseparé(1510~1590)RenaissanceArmysurgeonin1537ClearmindKeenobservationOwnconclusions

History

Ilestconsidérécommeétantlepèredelachirurgiemoderne.?

Jelepansai,Dieuleguérit.

?Pathologyandexperimentale18thcentury?Pathologie-étiologie?GiovanniMorgagni1761

History

Surgeryinitshistoricalperspective

TheBreakthrough:From1850to1900Anaesthesia(WELLS1844)AntisepsisandAsepsisScienceinMedicineJ.PERISSATAnesthesiaJamesSimpson:Cloroform

1842

Grawford

Long:Ether1847

History

Thecontrolofinfection

50yearsofstruggle

1847Semmelweiss FirstReportoninfectionprevention1856Pasteur.Alcoholfermentation1862Lister.Antisepsis(sprayofPhenic–Acid)

1878Pasteur.Asepsis(bacteriology)1889Halsted.Useofgloves1896FirstoperatingroomgermproofJ.PERISSATJ.PERISSATJosephLister

(1827~1912)AntisepsisProfessoratGlasgow●

madeastrikingdropinmortalityrateafteramputations(45%)bysprayingthewound&theroomwithcarbolicacid●“Listerism”

History

J.PERISSAT

SirListerinsurgeryLouisPasteur(1822~1895)AntisepsisFounderofmodernmicrobiologyfermentation&yeastlacticacidbacillus&otherstreatmentofrabies“Pasteurisation”ofthemilk

History

J.PERISSATOperatingroom1896

ProfessorTerrierParisClaudeBernard1813-1878MedicalDoctorProfessorofPhysiologyParisHisMasterpieceBook:“Introductionofexperimentalresearchinmedicine”1868J.PERISSATSurgeryinitshistoricalperspective

TheTremendousExpansion:From1900to1950SurgicalSpecialtiesAntibioticsIntensivetherapyJ.PERISSAT20thCentury

TwoWorldWarsBirthandimprovementofVascularsurgeryThoracicsurgeryNeurosurgeryPlasticsurgeryResuscitation(Intensivecareunits)J.PERISSAT

ModernCardiacSurgery Extracorporealcirculation

1956OrganTransplant 1956Merrill

Kidney 1968BarnardHeart

StarlzLiver

Derom

Lung1973Cyclosporinnewstart1970Microsurgery

TrainingLangenbeck(1810~1887)FirstmedicalschoolWilliamHalstedThefounderoftheresidenttrainingprogram(1852~1922)

History

GANTSEINWilliamHalsted

ThefirstprofessorofsurgeryinJohnsHopkinsFatherofScientificSurgeryintheUSIntroducedLister’sprincipleofantisepticsurgery,experimentalsurgery&theresidenttrainingprogramTheodorBillroth(1829~1894)

aGermanprofessoratViennaintroducedantisepsisintotheORopenedthefieldofabdominalsurgery20thcentury

History

TheodorKocher(1841~1917)professoratBerne●representedanewbreedofsurgeons●hisworkonthethyroidearnedhimtheNoblePrizeforasurgeon20thcenturyHistoryAlexisCarrel(1873~1944)Transplantation1912NobelPrize20thcenturyHistoryCharlesHugginsHormonalsurgery1966NobelPrize20thcenturyHistorySurgeryinitshistoricalperspective

TheDilemma:

Howtomakeharmlesstheaccessofthesurgeon’shandsinsidethepatient’sbodyJ.PERISSATSurgeryinitshistoricalperspective

ThespectacularAchievement:From1950tonowadaysEndoftheDilemma:Harmlessaccessofthesurgeon’shandsinsideeverycornersofthepatient’sbody

ThepricetopaythedrawbacksoflargeopeningsJ.PERISSATSurgeryinitshistoricalperspective20thCentury1990TheTurningPointUnnecessarypresenceofSurgeons'handsinsideHumanBodyJ.PERISSATJ.PERISSATLaparoscopymilestoneofsurgeryLaparoscopicSurgerytheturningpointintheHistoryofSurgeryEndoscopyinitshistoricalperspective:Endoscopy(tolookinsideancientGreek)Fromantiquityto1900endoluminalexplorationSince1901Laparoscopy(exploration)InterventionalEndolaparoscopySince1970J.PERISSATLaparoscopiccholecystectomy

EmblematicoperationFirstlandmarksofthelaparoscopicrevolution

Precursor:EMühe1985

Pioneers:Ph.Mouret1987F.Dubois-J.Perissat

1988B.McHerman1988E.J.Reddick1988微創(chuàng)外科理念

在得到相同或甚至更好療效的前提下減少手術(shù)對病人心理及生理的創(chuàng)傷巨創(chuàng)微創(chuàng)無創(chuàng)內(nèi)鏡外科的需求與微創(chuàng)外科的到來1987Mouret1987

世界首例腹腔鏡膽囊切除術(shù)1987-MouretMuchPerrisat腹腔鏡膽囊切除術(shù)-

開創(chuàng)了外科的新時(shí)代J.PERISSATProfessorofGynaecologyKiehl

Pr.KurtSemmLaparoscopicSurgery

NewSpaces

PleuralcavityThoracicSurgery

RetroperitonealSpacesOrthopaedicSurgeryUrologyEndocrineSurgeryVascularSurgery

InterfasciasSpacesHeadandNeckSurgeryPlasticSurgeryJ.PERISSAT復(fù)雜手術(shù)挑戰(zhàn)極限佝僂病ClinicalCase

Totaloperativetimewas165minutes,andestimatedbloodlosswaslessthan50mlNopost-operativecomplicationsoccurredThepatientwasdischargedfromhospitalonthe 6thdayaftertheoperation單孔手術(shù)J.PERISSAT機(jī)器人手術(shù)進(jìn)入單孔時(shí)代3D電影如臨現(xiàn)場立體成像原理3D（立體）視覺能夠帶來對深度的準(zhǔn)確感知“黑客帝國”鐫刻歷史傳承文化廣慈醫(yī)院圣公會普育堂二醫(yī)老紅樓現(xiàn)行政樓解放以后五十年代百年瑞金解放時(shí)的情景六十年代80年代瑞金的臨床教學(xué)—我們的回憶上海第二醫(yī)學(xué)院首屆法文班充滿理想與激情的年代1986年在瑞金實(shí)習(xí)我的從醫(yī)路醫(yī)院科室同事我的第一個(gè)手術(shù)1989年在法國做腹腔鏡手術(shù)在法國指導(dǎo)大學(xué)生微創(chuàng)手術(shù)深入人心回顧歷史

展望未來開腹腔鏡NOTES單孔外科手術(shù)的演變我的從醫(yī)之路消毒與無菌麻醉與鎮(zhèn)痛百年傳統(tǒng)開放手術(shù)移植與環(huán)孢菌素腸內(nèi)腸外營養(yǎng)外科復(fù)蘇大外科與專科化“大醫(yī)生大切口”微創(chuàng)外科—前傳打好外科基礎(chǔ)的階段言傳身教熱點(diǎn)外科基本問題如何提高診斷水平愛組織、愛病人、愛器械手術(shù)如何更快不斷開發(fā)新手術(shù)、新術(shù)式開始嘗試分專業(yè)焦點(diǎn)如何預(yù)防和處理并發(fā)癥重視外科復(fù)蘇

微創(chuàng)外科-前傳腹腔鏡、胸腔鏡大外科到普外科良性病變的切除功能性疾病修復(fù)急腹癥探查診治攝像頭VCD水平膽道損傷傷腦筋初期不重視認(rèn)可微創(chuàng)外科—1.0觀望與漠視

要不要做？熱點(diǎn)要不要開展微創(chuàng)手術(shù)如何開展微創(chuàng)手術(shù)如何進(jìn)行微創(chuàng)培訓(xùn)不斷開發(fā)新手術(shù)、新術(shù)式腹腔鏡設(shè)備與器械焦點(diǎn)如何預(yù)防和處理膽囊手術(shù)并發(fā)癥如何開拓新領(lǐng)域超聲刀應(yīng)用

微創(chuàng)外科1.0對醫(yī)學(xué)職業(yè)的敬畏(如臨深淵,如履薄冰)對患者家人的關(guān)愛(人文修養(yǎng),仁心仁術(shù))對真理學(xué)術(shù)的追求(大醫(yī)精誠)做人民需要的外科醫(yī)師微創(chuàng)技術(shù)初步成熟進(jìn)入惡性腫瘤治療攝像頭達(dá)DVD水平能量系統(tǒng)得到推廣外科醫(yī)生迭代完成正從江湖走向廟堂外科培訓(xùn)紅紅火火微創(chuàng)技術(shù)走向?qū)？莆?chuàng)外科—2.0如火如荼

如何做？精準(zhǔn)外科膜解剖于外科間隙、層面微創(chuàng)外科未來發(fā)展方向整體化手術(shù)室多學(xué)科診治手術(shù)入路的創(chuàng)新與改良機(jī)器人手術(shù)創(chuàng)新與發(fā)展微創(chuàng)外科Plus微創(chuàng)外科—3.0高位平臺臺期

做什么？熱點(diǎn)精準(zhǔn)外科膜解剖于外科間隙、層面微創(chuàng)外科未來發(fā)展方向整體化手術(shù)室多學(xué)科診治手術(shù)入路的創(chuàng)新與改良成立各類微創(chuàng)外科學(xué)院成立各級學(xué)會及制定共識焦點(diǎn)機(jī)器人手術(shù)創(chuàng)新與發(fā)展微創(chuàng)外科Plus

微創(chuàng)外科3.0膽囊切除的變遷—微創(chuàng)理念的變化PostgruaduatetrainingLive

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Surgeryc.ContinuingMedicalEducation(CME)培訓(xùn)中國胃腸微創(chuàng)外科MINIMALLYINVASIVESURGERYOFGASTROINTESTINALINCHINAOPENCOURSE公開課培訓(xùn)與會議的顛覆？3DlapVRlivedemo2016-5-30成功實(shí)現(xiàn)2016-6-3首次發(fā)布1989年2007年似曾相識2014年2016年開放手術(shù)腹腔鏡機(jī)器人打好基礎(chǔ)全科知識

回顧歷史展望未來

找準(zhǔn)定位謀劃前途

學(xué)習(xí)很重要中國醫(yī)學(xué)生涯的自我評價(jià)

戰(zhàn)略

少則得

LESSISMORE

多則惑MOREISDIFFERENT

老子《道德經(jīng)》“曲則全，枉則直，洼則盈，

敝則新，少則得，多則惑”是以圣人抱一為天下式外科的“術(shù)”與“道”技術(shù)的更新?lián)Q代從仿制到創(chuàng)新

苦涯無邊別喊窮，因?yàn)闆]人給你錢別喊累，因?yàn)闆]人會幫你做別想哭，