截屏自“百度百科”。在这个介绍中，“微创手术无须开刀，只需在病人身上开1–3个0.5–1厘米个小孔，病人不留疤痕、无疼痛感、只需3–5天便可完成检查、治疗、康复全过程。”“住院时间短， ……， 3–5天出院，一周后基本恢复，费用相对降低。”的潜台词是安全、有效、舒适、便捷、便宜。再归纳一下，就是切口小，效果好，风险低。这就是“微创手术”在非医学人群中的理解。这些理解有没有问题？时至今日，“微创手术”广泛开展，其外延不断拓展。现在开展的“微创手术”有：1，大体腔腔镜（腹腔镜、胸腔镜）；2，经皮穿刺进入器官腔腔镜（如经皮肾镜、经皮膀胱镜、关节镜、心包镜、阴囊镜、脑室镜、鼻窦镜）；3，（经皮扩张建立）筋膜间腔隙腔镜（如泌尿外科后腹腔镜，纵膈镜、椎间盘镜、甲状腺甲状旁腺镜、乳腺镜）；4，经人体自然通道进入器官腔的腔内镜（尿道膀胱镜、输尿管肾盂镜、输精管精囊镜、阴道镜、宫腔镜、胃镜、小肠镜、肠镜、咽喉镜、气管和支气管镜）；5，一些组合形式的腔镜（NOTES、taTME）；6，血管镜、经血管介入、经皮介入；7，以及可能会归入“微创手术”的非接触治疗。广泛的临床实践，使医务人员在充分挖掘使用“微创手术”的优势的同时，也更全面地认识了“微创手术”的局限性。“微创手术”的实施有两个基本前提：1，需要建立、维持、清洁相应的手术空间。2，要获取直接的观察和操作角度。病灶不大、层面清晰的标准病例是”微创手术“的良好适应证。最典型的病种是小的肾上腺瘤。肾上腺位置深在，开放手术需要一个较大的切口才能到达并显露病灶，但病灶的处理步骤不多、手术范围不广，属于“大切口、小手术”。对这些“大切口、小手术”病例实施“微创手术”，就有机会避免大的切口，又能取得与传统开放手术相当甚至更好的手术效果，总体创伤也会下降，疼痛减轻，恢复也会更快。一些深在器官，比如前列腺，也因为腹腔镜能提供更好的视角，反而比开放手术视野更清晰。达芬奇又额外提供了3D视野和更多的操作维度，使深在术野的操作也更加方便。为了维护手术空间，腔镜手术则需要建立一定压力的气腔（胸腔镜因为有胸廓支撑及肺的天然塌陷，不需要通过机器维持气腔）。维持在一定压力的气腔（成人12–15mmHg，小儿8–10mmHg）很少给患者带来风险。但是，腔镜手术时术者双手隔着体壁利用器械在气腔内操作，当有出血等紧急情况时，处理的及时性、有效性、持续性、可靠性不好传统开放手术，从而增加出血风险。当病灶或靶器官与血管或邻近脏器粘连严重，出血或邻近脏器受伤的风险也会增加。对于需要缝合打结等操作时，在学习曲线期内，操作质量也不能预见和重复。经皮穿刺或经自然通道进入器官腔的腔内镜手术也需要通过灌注一定压力的灌注液进入器官腔来维持器官腔空间以实施腔内镜手术。进入对于泌尿系的腔内镜手术，当存在泌尿系感染时，灌注液的压力可能促进细菌和毒素入血，从而增加菌血症、毒血症、败血症、脓毒血症，以及进一步继发多器官功能障碍和DIC的风险。腔内镜手术同样有继发出血需要介入栓塞或开放手术止血的风险。可见，“微创手术”并不是“微创伤手术”，更不是“低风险手术”。当病灶巨大时，外科医生很难获取足够的手术空间和理想的操作角度。对这类患者勉强实施“微创手术”，尽管体壁切口创伤减少，因为空间太小、显露困难和操作角度不佳，术区可能出现更大的甚至不可控的出血、损伤和肿瘤破裂，从而增加手术的总体创伤（对这部分病例，开放手术的总体创伤可能更少）。所以，我们并没有必要“把'微创手术’进行到底”，而是要认识到：开放手术和“微创手术”都是治疗方式的一种，它们本身不是目标，而是实现目标的路径，两者各有其最佳适应证。用恰当的方式治疗恰当的疾病，方是恰当的决策方式。一定要做“微创手术”，或认为“微创手术”较开放手术更为高等，都可能提示我们需要去见过、处理过更多、更复杂的病例，以及在处理这些病例中获得更多的经验和教训。见得越多，碰到的问题越多，自然就会更冷静、更客观、更全面、更虚心，重回以解决问题为目标的初心。在英语语境，“MIS (Minimally Invasive Surgery)”，以下简称MIS，是对应开放手术产生。开放手术的操作、步骤、器械更早被系统化。通过一个足够长的切口，利用拉钩协助，再通过无影灯照明，可以获得足够的显露和组织辨识。但是，长的切口会带来术后更明显的术后疼痛，从而影响患者的术后感受和术后恢复。在开放手术逐步完善的同时，利用器械观察深在器官，明确诊断也是医生的追求。在这个过程中，镜体的设计、光源和光的传导、气腹的建立和维持设备的逐步完善，医生已经可以观察腹腔、胸腔、膀胱、阴道、咽喉、以及直肠。当时腹腔镜检查的场景是：建立二氧化碳气腹，经腹壁上的trocar置入已连接好外置光源光纤的腔镜，医生弓着腰，通过接目镜观察腹腔，可以另外再加一个trocar，置入操作钳进行一些简单的活检、摘除、甚至取卵的操作。20多年前我刚入行做膀胱镜的状态就与40年前的腹腔镜医生类似。我的老师区来发主任带着我象虾米一样在两腿之间弓着腰，区主任一只眼睛凑在膀胱镜的接目镜上，看到输尿管口后，就自己扶着镜，把头移开，让我凑上眼去看一下输尿管口。但其实区主任一移身，在大多数时候镜子已经移位，我并没有看到输尿管口。区主任对我很好，为免得区主任长时间为我扶镜，我很认真地看了一会，不管有没有看到，我都说区主任我看到了，区主任就很高兴。这就是当时的状态，如果膀胱过满，灌注液和尿液的混合物就会喷到眼睛、脸上和嘴上。这样学了半年后，我才真正能找到输尿管口。1982年，医疗工业制造行业发明了内窥镜的摄像显示系统。将摄像头接到内窥镜接目镜上，并将接物镜看到的图像信号传输到主机，主机处理后再传输到显示屏上。这是一个革命性的变化，它意味着，腹腔镜外科医生“从此站起来了”。因为有了助手扶镜，腹腔镜外科医生不需要再象虾米一样趴在镜子上，而是直起腰看屏幕，双手也被解放，可以用来做出复杂、精细、精确的操作。这与百万年前猿猴进化到双脚直立行走从而变成人时具有同样的意义。摄像显示系统的使用也使主刀、助手、学员及手术室内的工作人员都能看到同样的图像，这与开放手术时代绝然不同。因为大家看着同一幅图像，术中讨论和学习也变得容易，图像还可以录制、储存、播放、复制、剪辑，成为全社会都能触及的知识财富，外科从此进入了一个新的时代。开放手术时深在部位的解剖和操作不仅助手不可见，术者也不可见，很多时候依赖的是术者的触觉判断和手指操作，因而是个触觉手术。时到今日，开放手术的教学、资料获得和存留都还是一个没有很好解决的问题。新的时代需要一个新的名字与传统进行切割，这样就诞生了“MIS，Minimally Invasive Surgery”这个词。这个词传入中国，被译成了“微创手术”，我自己也在这个词的影响下成长。以我当时的理解，“微创手术”就是腹腔镜手术，就是“微创伤手术”。那么，对英语语境里“MIS”的意象与对汉语语境里“微创手术”的意象是否相同？所谓“意象”，是指某个词汇在人们脑海中产生的形象和/或感受。比如“金色”这个词汇，在人的脑海中会展现一种颜色，还会在脑海中产生“高贵、豪华、奢华”的一系列联想。苹果iphone的早期在白色和黑色配色基础上加上的第一个颜色就是金色。我没有查到“MIS, Minimally Invasive Surgery”第一次在文章的出处，但在互联网上找到以下一部分资料：资料1：https://en./wiki/Minimally_invasive_procedureMinimally invasive procedures encompass surgical techniques that limit the size of incisions needed and so lessen wound healing time, associated pain and risk of infection. Surgery by definition is invasive and many operations requiring incisions of some size are referred to as open surgery, in which incisions made can sometimes leave large wounds that are painful and take a long time to heal. ……Diagnostic techniques that do not involve the puncturing of the skin or incision, or the introduction into the body of foreign objects or materials, are known as non-invasive procedures. There are also several treatment procedures that are classed as non-invasive. A major example of a non-invasive alternative treatment to surgery is radiation therapy, also called radiotherapy.Minimally invasive procedures were pioneered by interventional radiologists who had first introduced angioplasty and the catheter-delivered stent. Many other minimally invasive procedures have followed where images of all parts of the body can be obtained and used to direct interventional instruments by way of catheters (needles and fine tubes), so that many conditions once requiring open surgery can now be treated non-surgically. A minimally invasive procedure typically involves the use of arthroscopic (for joints and the spine) or laparoscopic devices and remote-control manipulation of instruments with indirect observation of the surgical field through an endoscope or large scale display panel, and is carried out through the skin or through a body cavity or anatomical opening. Interventional radiology now offers many techniques that avoid the need for surgery.Many medical procedures are called minimally invasive; those that involve small incisions through which an endoscope is inserted, end in the suffix -oscopy, such as endoscopy, laparoscopy, arthroscopy. Other examples of minimally invasive procedures include the use of hypodermic injection, and air-pressure injection, subdermal implants, refractive surgery, percutaneous surgery, cryosurgery, microsurgery, keyhole surgery, endovascular surgery using interventional radiology (such as angioplasty), coronary catheterization, permanent placement of spinal and brain electrodes, stereotactic surgery, the Nuss procedure, radioactivity-based medical imaging methods, such as gamma camera, positron emission tomography and SPECT (single photon emission tomography). Related procedures are image-guided surgery, and robot-assisted surgery.Sometimes the use of non-invasive methods is not an option, so that the next level of minimally invasive techniques are looked to. These include the use of hypodermic injection (using the syringe), an endoscope, percutaneous surgery which involves needle puncture of the skin, laparoscopic surgery commonly called keyhole surgery, a coronary catheter, angioplasty and stereotactic surgery.“Open surgery” is any surgical procedure where the incision made is enough to allow the surgery to take place. With tissues and structures exposed to the air, the procedure can be performed either with the unaided vision of the surgeon or with the use of loupes or microscopes. 资料2：https://www./our-services/surgical-services/treatments/minimally-invasive-surgery/what-is-minimally-invasive-surgery/Minimally invasive surgery refers to any surgical procedure that is performed through tiny incisions instead of a large opening. Because your surgeon will make smaller incisions, you will likely have a quicker recovery time and less pain than traditional open surgery but with the same benefits as traditional surgery.During minimally invasive surgery, your MedStar Surgeon will make several small incisions in your skin, typically a few millimeters long. Your surgeon will then insert an endoscope (a long, thin tube fixed with a camera and light) into one of the incisions. Images from the endoscope are sent to monitors in the operating room so that your surgeon can view clear, magnified pictures of the area needing surgery. Your surgeon will then insert surgical instruments through the other incisions, allowing your surgeon to perform the surgery on whatever’s wrong inside your body.资料3：https:///patients/diseases-and-conditions/a-z/minimally-invasive-surgeryIn traditional open abdominal surgeries, surgeons typically make an incision 6 to 12 inches in length, large enough to offer adequate visibility, provide access to the abdominal organs and allow the use of hand-held surgical instruments. Minimally invasive surgical approaches have been developed to perform operations through smaller incisions, reducing the discomfort and healing complications associated with long incisions. Minimally invasive surgery can be used to effectively treat a variety of common benign and malignant colon and rectal conditions.资料4：https:///advantages-and-disadvantages-of-minimally-invasive-surgery/Minimally invasive surgery refers to techniques that involve small operation sites. As opposed to large incisions, you will only experience small cuts with MIS. This means that there is minimal trauma to surrounding tissues, muscles, and nerves, as well as your organs. Smaller incisions also mean less bleeding during a procedure and less post-operative scarring. Another benefit of MIS is a reduced need for narcotics due to little or no pain during or after the procedure. Moreover, your hospital stay will be cut by more than half. Finally, minimally invasive surgery is less taxing on your immune system. 资料5：https://www./news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/minimally-invasive-surgery/ Surgery is termed “minimally invasive” if it uses small or no incisions (cuts). Surgeons see your body’s organs with the help of small telescopes and cameras. Surgical repairs are made with very small instruments. Most problems can be treated at the time of diagnosis as one procedure.Technology has propelled surgery into an age of minimally invasive (or “minimal access”) operations. 资料6：https://www./environment/encyclopedias-almanacs-transcripts-and-maps/minimal-access-surgery minimal access surgery Operations that do not involve cutting open the body in the traditional way. Minimal access (keyhole) procedures are performed either by means of an endoscope, or by passing miniature instruments through a fine catheter into a large blood vessel. The surgical laser is also used.在讨论这些英文资料前，我们先讨论汉语语境下的“微创手术”。https://www./yuexie/shuojie/20200801281383.html 创：《创》字义，《创》字的字形演变，说文解字《创》“创”是指事字。金文像一个人形，手上脚上的小竖表示受了创伤；或象个刀形，刀刃有两处伤痕或两滴血液。小篆的写法基本上同于金文。隶变后楷书写作“創”。汉字简化后写作“创”。“创”的本义应为“割”。引申“伤”。如《后汉书·华佗传》：“四五日创愈。”所以“创”的原义是“伤口”。在指代伤口的基础上，“创”再引申为指代伤口相关的各种不适如疼痛出血等伤痛，即“创伤”。随着人们对于“创伤”理解的增加，“创伤”的含义也进一步扩大，比如也指称心理创伤、社会创伤、环境创伤等。所以，在汉语语境下，“创”有三个层次的含义，原义指伤口本身，引申义指损伤及伤口相关的不适，拓展义为各种“创伤”。随着社会发展和需要表达的内容增多，与古代汉语中单字词常见不同，现代汉语由早期的综合语发展为现在的分析语，更多地采用两字以上的合成词来命名某一事物、现象或感觉。所以，“创”的原义伤口不再叫作“创”，而是用“伤口、切口”等来称呼，渐渐没有了“创”字。当我们再看到“创”字时，我们接触和熟悉的是它的引申义“创伤”，即指称各种心理、生理、社会、环境的具体的或抽象的“创伤”。这也就是为什么当我们第一眼听到、看到、说到“微创手术”手术时，我们会将它理解为“微创伤手术”。现代汉语中的“创”字除了以上来源外，还有另外一个来源，即表示“突破”意义的“创造、创举、创意、开创”中的“创”，读作chuànɡ。资料7，https://baike.baidu.com/item/创/541864?forcehttps=1%3Ffr%3Dkg_hanyu《说文解字》认为“创造”之“创（chuàng）”本写作“刱”，其中“井”为意符，“刅”为声符。农业兴起以后，定居的生活方式及耕地选择的要求都呼唤着井的出现，正所谓“凿井而饮，耕田而食”。在古人心目中，井是一种非常典型的人类创造物（婴幼儿注意到自己最早的创造物是他自己的大小便，并因此引出佛罗伊德所描述的“肛欲期”，这也是一个非常有趣的话题），所以“刱”用“井”作意符。后来“刱”逐渐被弃置不用，为“创伤”之“创（chuāng）”所吞并。英语中也有很多类似的情况，比如非常熟悉的拼写“sound”，在字典里有一堆互不搭界的含义，其实这个字有三个不同的词源。“Sound”互不搭界的含义。这些互不搭界的含义中有以下三个来源。资料8，https://www./search?q=sound含义一：sound (n.1)，声音。“noise, what is heard, sensation produced through the ear,” late 13c., soun, from Old French son “sound, musical note, voice,” from Latin sonus “sound, a noise,” from PIE *swon-o-, from root *swen- “to sound.” 这个含义的词根派生出70后80后熟悉的两个品牌名“SONY”和“PANASONIC”。含义二：sound (adj.)，完好的，健康的。“free from special defect or injury,” c. 1200, from Old English gesund “sound, safe, having the organs and faculties complete and in perfect action,” from Proto-Germanic *sunda-, from Germanic root *swen-to- “healthy, strong” (source also of Old Saxon gisund, Old Frisian sund, Dutch gezond, Old High German gisunt, German gesund “healthy,” as in the post-sneezing interjection gesundheit; also Old English swið “strong,” Gothic swinþs “strong,” German geschwind “fast, quick”), with connections in Indo-Iranian and Balto-Slavic. Meaning “right, correct, free from error” is from mid-15c. Meaning “financially solid or safe” is attested from c. 1600; of sleep, “undisturbed,” from 1540s. Sense of “holding accepted opinions” is from 1520s.含义三：sound (v.2)，在泌尿外科熟悉的含义是“医用探条”。“fathom, probe, measure the depth of,” mid-14c. (implied in sounding), from Old French sonder, from sonde “sounding line,” perhaps from the same Germanic source that yielded Old English sund “water, sea” (see sound (n.2)). Barnhart dismisses the old theory that it is from Latin subundare. Figurative use from 1570s. sound (n.2) “narrow channel of water,” c. 1300, from Old Norse sund “a strait, swimming,” or from cognate Old English sund “act of swimming, stretch of water one can swim across, a strait of the sea,” both from Proto-Germanic *sundam-, from *swum-to-, suffixed form of Germanic root *swem- “to move, stir, swim” (see swim (v.)).讨论完汉语语境下“微创手术”的含义，我们接下来讨论一下英语语境下的“Minimally invasive surgery”的含义。资料9，https://fanyi.baidu.com/?aldtype=85#en/zh/invasiveInvasive的医学含义是“需要侵入人体的，开刀的，手术的”。“invasive”的词源：资料10，https://www./dictionary/invasive资料11，https://www./search?q=invasive重复粘贴资料1的部分：资料1：https://en./wiki/Minimally_invasive_procedureMinimally invasive procedures encompass surgical techniques that limit the size of incisions needed and so lessen wound healing time, associated pain and risk of infection. Surgery by definition is invasive and many operations requiring incisions of some size are referred to as open surgery, in which incisions made can sometimes leave large wounds that are painful and take a long time to heal. ……Diagnostic techniques that do not involve the puncturing of the skin or incision, or the introduction into the body of foreign objects or materials, are known as non-invasive procedures. There are also several treatment procedures that are classed as non-invasive. A major example of a non-invasive alternative treatment to surgery is radiation therapy, also called radiotherapy.很显然，invasion在英语中指的是切口，与现代英语中常用的“wound、incision”含义相同。在英语语境下，“Minimal Invasive Surgery”指的是“微切口手术”。在英语里，与汉字“创”概念发展历程相对的词语是“trauma”。资料12，https://www./search?q=trauma这个词的含义从1690年代的“躯体上的伤口”在1894年引申为“精神上的创伤”。资料13，https://fanyi.baidu.com/?aldtype=85#en/zh/trauma英文世界“Minimally Invasive Surgery”的另一个说法是“Minimal Access Surgery”，即“微侵入手术”，或“微切口手术”、“微入路手术”。这两个词中，Invasive是形容词，Access是名词。在下图中也可以看到两者同义。资料14：所以，在国际会议中，当以汉语母语的人和以英语母语的人同说一个词“Minimally Invasive Surgery”时，他们分别的脑海中的意象是不同的。我们说的是“微创伤手术”，而外国专家说的“微创口手术”。在外国专家的脑海中，他看到是“a small wound, or, a small incision”。 从英文的这个角度，就能容易地理解下一个词：“non-invasive surgery”。在英文语境，指的是“无切口手术”，比如经自然腔道的内镜手术，或接触或非接触的检查和治疗方式，如放射治疗，HIFUI治疗等。但是，如果按照“MIS”的现代汉译，将“non-invasive surgery”译作“无创手术”，在汉语语境中会理解为“无创伤手术”。我们在工作中都有体会，而且非常明白，英语的“无切口手术 non-invasive surgery”并非“无创伤手术”，比如经自然腔道的内镜手术，具体如输尿管软镜术，并非无创，它只是无切口，在一些极端情况下，它可以是一个严重创伤的手术，比如发展为败血症等。因此，把“non-invasive surgery”译作”无创手术“是否合适，可能是要打个问号的，甚至是可以直接否定的。当然，语言是不断发展的，发展的方向可以是向前，也可以是回归。如果我们接受现状，将“minimally invasive surgery”译作“微创手术”，将“non-invasive surgery”译作“无创手术”，则我们需要在脑海中修正我们的意象，即将“微创伤手术”和“无创伤手术”的意象修正为“微创口手术”和“无创口手术”，并在医学教育、学术交流、医学科普、医疗宣传中专门介绍这两个概念，将“创”的含义从现代汉语的“创伤”回归到古代汉语的“创口”。现在的医学科普和医疗宣传对“微创手术”的介绍，比如“将微创进行到底”，对于不了解医学的民众而言，很容易被赋上“切口小、恢复快、效果好，安全可靠”等意象。这个被牵强赋上的意象与实际并不相符。“微创口”不等于“微创伤”，“微切口”更不等于“微风险”。创口或切口、创伤、风险是三个不同维度的概念，不可混为一谈。彩蛋：1，翻译的要求是严复先生提出的“信、达、雅”(https://baike.baidu.com/item/信达雅/10899200?fr=kg_qa)。“信”指意义不悖原文，即是译文要准确，不偏离，不遗漏，也不要随意增减意思；“达”指不拘泥于原文形式，译文通顺明白；“雅”则指译文时选用的词语要得体，追求文章本身的古雅，简明优雅。“微创手术”，以及现在常提的“加速康复，enhanced recovery after surgery, ERAS”的汉译在实际应用中都令人费解，恐距“信、达、雅”中的“信”尚有距离。在以后的文章中再对这个问题进行讨论。2，“创伤”有几个层次：从器官、机体，再到术者、团队、环境，等。需要从这几个角度讨论“创伤”的含义。对“创伤”含义的拓展讨论将会引出“系统微创”、“洁净手术”和“舒适手术”的概念。3，对外科学和手术学的理解是手术治疗和患者恢复的关键，而非工具。一个乒乓菜鸟，不会因为用刘国梁获冠的球拍打球，就突然能打赢一位身手矫健的公园大叔。
