21世紀外科開展方向移植外科微創外科修復外科腫瘤的分子生物學治療偉大思想的提出-----公元前460-377提出借助某種手段窺視和檢查直腸病變Hippocrates1795年德國PhilipBozzini開創了診斷與治療的新天地現代腹腔鏡的起源1901年，德國的外科醫師Georgkelling在狗的腹腔內插入一根膀胱鏡,并用空氣制造氣腹進行檢查，這為腹腔鏡的起源。Georgkelling1910年瑞典斯德歌爾摩的jacobaeus首次在臨床使用腹腔鏡和胸腔鏡檢查，并將其定義為Laparoscopy。Hepublishedhisreportin?MünchenerMedizinischeWochenschrift.?HansChristianJacobaeus(1879–1937)1911年美國johnshopkins醫院的外科醫師bernhein經腹壁的切口把直腸鏡插入腹腔，用發射光做光源。1924年美國堪薩斯的內科醫師stone用鼻咽鏡插入狗的腹腔，并推薦用一種橡膠墊圈幫助封閉穿刺套管防止操作中漏氣。1938年匈牙利的外科醫師veress介紹了一種注氣針，可以平安地做成氣胸；在做氣腹時，可以防止針尖損傷針下的內臟。這種平安穿刺針制作氣腹的主張被普遍接受，并沿用至今。揭開了微創外科開展的新紀元

BettercosmeticresultsLesspain,lessanalgesicsrequiredShorterin-hospitalstayLesscomplications(outcome?)Betterpulmonaryfunction(inparticularinobesepatients)Fastrecovery,bettercomfortCholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicCholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicOpenportion50%CholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicOpenportion33%CholecystectomiesinaHospital19901991199219931994199519961997200120020306090120150180210240OpenLaparoscopicOpenportion13%SurgeonUrologistGynecologistDiagnosticIntestinalHerniotomyLiverSpleenFundioplicationCholecystectomyEsophagusAxillarlymphonodesGastricbandingAdrenalectomyParathyreoidectomyDiagnosticNephrectomyKidneycystsProstatectomyVaricoceleLymphadenectomyTesticulardescensusDiagnosticTubarligationAdnexectomyOvarectomyLymphadenectomyEndometriosisMyomectomyAxillarlymphonodes三、對麻醉的要求與挑戰氣腹1.氣腫2.氣胸3.氣體栓塞4.對通氣的改變5.高碳酸血癥6.對血流動力學的反響7.局部血流動力學的影響8.心率失常9.反流誤吸10.肩部酸痛對肺功能影響OrganSystemPhysiologicEffectPotentialOutcomePulmonary?peakairwaypressure?pulmcomplianceSuperiordisplacementofdiaphragm?end-tidalCO2Barotrauma?pCO2or?pO2?pCO2or?pO2Acidosis對心血管功能影響OrganSystemPhysiologicEffectPotentialOutcomeCirculatoryDirecteffects-?CVP,CWP,SVR(afterload),MAPIndirecteffects–arteriolardilationandmyocardialdepressionIndirecteffects–sympathetics,renin-angiotensin?cardiacwork?bloodpressure?Bloodpressureandcardiacoutput?Urineoutput?體位

頭低位:↑CVPandcardiacoutputAffectpatientswithcoronaryarterydiseaseElevationintraocularvenouspressure

(worsenacuteglaucoma)IncreaseriskofgasembolismAtelectasisDecreasedFRC,totallungvolume