经脐单孔、常规腹腔镜与开腹先天性巨结肠根治术的对比研究

发布时间：2018-07-11 10:37

本文选题：先天性巨结肠症 + 腹腔镜　；参考：《河北医科大学》2012年硕士论文

【摘要】：目的：先天性巨结肠症（Hirschsprung’s Disease, HD）又称肠管无神经节细胞症，是以消化道远端肠壁粘膜下和肌间神经丛内神经节细胞缺如为特征的常见发育畸形。HD的治疗经历了Swenson、Duhamel、Soave等术式的演变，并且随着微创外科技术的发展，腹腔镜辅助的各种手术方式也已开展并取得良好效果。虽然单纯经肛门直肠内拖出术以简便、微创、美观而成为短段型和部分常见型HD的主要方法，但腹腔镜辅助巨结肠根治术的适应症更广泛、并可进行术中活检确定移行段，处理系膜血管更具有优势。本研究通过总结我科近年来常用的三种手术方法治疗HD的技术和结果，比较并评价腹腔镜微创技术特别是经脐单孔腹腔镜监视下巨结肠根治术治疗HD的可行性和安全性，探讨其手术相关并发症的发生情况及其相应处理措施，为避免术中意外的发生、减少手术后并发症及防治对策提出可行性建议。方法：回顾性分析2003～2011年在我科接受HD根治术治疗194例病儿的临床资料。男142例，女52例，男：女=2.73:1；年龄46天～14岁，平均28.4±34.8月。手术方法包括开腹Duhamel手术54例、Ikeda手术26例、改良Swenson或Soave手术30例和Boley手术2例，单纯经肛门拖出手术29例，常规腹腔镜辅助改良Swenson或Soave手术29例、单切口腹腔镜辅助Duhamel手术3例和经脐单孔腹腔镜监视下改良Soave手术21例。所有病儿根据典型临床表现、钡灌肠和24小时残留钡剂检查、肛管直肠测压和术中活检确定诊断。将具有可比性的开腹、常规腹腔镜辅助和经脐单孔腹腔镜辅助下改良Swenson或Soave手术80例病儿作为研究对象（开腹Swenson或Soave手术30例、常规腹腔镜辅助Swenson或Soave手术29例和经脐单孔腹腔镜Soave手术21例），记录手术时间、病变类型、术中和术后并发症、术后肠功能恢复时间以及随访排便控制情况。结果：80例改良Swenson或Soave手术中HD常见型58例和长段型22例。三种术式均顺利完成手术，腹腔镜组无中转开腹及术中并发症出现。男55例，女25例；年龄3个月～14岁，平均25.1±29.0月。各组在性别、年龄和病变类型构成比无差别。术前诊断与术后病理诊断符合78例，符合率为97.5%。开腹手术平均耗时185.2±55.9min，术中平均出血77.8±23.7ml，术后肠功能恢复时间3.4±1.1d，术后并发症包括切口感染3例、切口裂开1例、小肠结肠炎3例和粘连性肠梗阻2例。常规腹腔镜辅助手术平均耗时166.1±56.6min，术中平均出血23.2±7.9ml，术后肠功能恢复时间1.5±0.7d，术后并发症包括小肠结肠炎2例，回肠末端穿孔1例，不全肠梗阻1例。经脐单孔腹腔镜手术时间161.0±51.5min，术中平均出血23.3±8.2ml，术后肠功能恢复时间1.3±0.5d，术后出现并发症包括吻合口部分裂开1例，小肠结肠炎并腹腔残余感染1例。常规腹腔镜组和经脐单孔腹腔镜手术组较开腹手术组出血量少(P=0.005)、手术时间缩短（P=0.036）以及肠蠕动功能恢复快（P=0.001）；常规腹腔镜组和经脐单孔腹腔镜手术组比较在出血量、手术时间和肠蠕动功能恢复时间无差别。开腹手术切口感染率高、并发症多。62例获得随访3个月～10年，除开腹组1例远期污粪外，排便功能随着术后时间的延长逐渐恢复，各种术式在各时段排便功能均无明显差异；手术后3个月各组病儿肛门直肠功能基本恢复正常。无死亡病例发生。结论：通过典型临床症状、钡灌肠和24小时残留钡剂检查以及肛管直肠测压可初步诊断HD，手术中取活检可以更加精准地确定病变范围。腹腔镜辅助手术较开腹手术创伤小、并发症少、恢复快。经脐单孔腹腔镜监视下HD根治术与常规腹腔镜手术相比具有相似的手术效果和围手术期并发症的发生率，，同样安全可靠，可进一步减少腹壁创伤，脐部疤痕隐蔽使美容效果更佳。虽然腹腔镜HD根治手术已十分普遍，但依然存在需要注意的细节问题，在选择治疗HD腹腔镜手术方式时，需要同时考虑到病儿病情和医生能力两方面因素，个体化地选择熟练技术，以最小的创伤和痛苦，最彻底的去除病因为治疗原则。此外，HD根治术后需仔细护理，若发生术后并发症应早诊断和早治疗，从而达到最佳的治疗效果。
[Abstract]:Objective: congenital megacolon (Hirschsprung 's Disease, HD), also known as intestinal anaglioblastic disease, is a common developmental malformed.HD, characterized by the absence of ganglion cells in the distal intestinal wall of the digestive tract and intermuscular plexus, and has undergone the evolution of Swenson, Duhamel, Soave, and with the development of minimally invasive surgery. All kinds of laparoscopic assisted surgery have also been carried out and achieved good results. Although simple, minimally invasive, and beautiful, simple, minimally invasive, and beautiful, the main method of short segment and partial common HD is simple through anorectal dragging, but the indications of laparoscopic assisted megacolectomy are more extensive and can be identified by intraoperative biopsy. In this study, the techniques and results of the treatment of HD in our department in recent years were summarized, and the feasibility and safety of the laparoscopic minimally invasive technique, especially in the treatment of megacolon under the monitoring of megacolon under umbilical single hole laparoscopy, were compared and evaluated, and the incidence of the complications of the operation and the corresponding complications of the operation of the HD were evaluated. In order to avoid intraoperative accidents, reduce postoperative complications, and put forward feasible suggestions for prevention and treatment.
Methods: retrospective analysis of the clinical data of 194 cases of children treated with HD radical operation for 2003~2011 years. 142 men, 52 women, male: female =2.73:1; age 46 to 14 years old, with an average of 28.4 + 34.8 months, including 54 open abdominal Duhamel surgery, 26 cases of Ikeda operation, 30 cases of improved Swenson or Soave operation and 2 cases of Boley operation, simple via anus. 29 cases of open door surgery, 29 cases of conventional laparoscopic assisted modified Swenson or Soave surgery, 3 cases of single incision laparoscopic assisted Duhamel surgery and 21 cases of improved Soave operation under single umbilical laparoscopy were performed. All cases were diagnosed according to typical clinical manifestations, barium enema and 24 hour residual barium examination, anorectal manometry and intraoperative biopsy. With comparability, 80 cases of Swenson or Soave surgery were treated as subjects (30 cases of open Swenson or Soave, 29 cases of Swenson or Soave surgery and 21 cases of single hole laparoscope Soave hand operation). The operative time, type of operation and neutralization were recorded. Postoperative complications, postoperative bowel function recovery time and follow-up defecation control were observed.
Results: in 80 cases of improved Swenson or Soave, there were 58 cases of common HD and 22 cases of long segment. Three kinds of operation were all successfully completed. The laparoscopy group had no transfer to open the abdomen and the complications occurred. 55 men and 25 women; the age 3 months to 14 years, with an average of 25.1 + 29 months. The postoperative pathological diagnosis accords with 78 cases. The average time of 97.5%. laparotomy is 185.2 + 55.9min, the average bleeding in the operation is 77.8 + 23.7ml, and the recovery time of intestinal function is 3.4 + 1.1d. The postoperative complications include 3 cases of incision infection, 1 incision split, 3 cases of enterocolitis and 2 cases of adhesive ileus. The average time of routine laparoscopy assisted surgery is 166.1. The average bleeding was 23.2 + 7.9ml and the recovery time of intestinal function was 1.5 + 0.7d. The postoperative complications included 2 cases of enterocolitis, 1 cases of ileum perforation and 1 cases of incomplete ileus. The time of operation was 161 + 51.5min, the average bleeding was 23.3 + 8.2ml, the recovery time of intestinal function was 1.3 + 0.5d after operation, and postoperative complications occurred. There were 1 cases of anastomosis, 1 cases of enterocolitis and 1 cases of abdominal residual infection. There were less bleeding (P=0.005), shorter operation time (P=0.036) and rapid recovery of intestinal peristalsis (P=0.001) in the conventional laparoscopy group and the single laparoscope operation group, and the routine laparoscopy group and the umbilical single hole laparoscopic operation group were compared to the bleeding. There was no difference in the amount, the time of operation and the recovery time of the intestinal peristalsis. The infection rate of the incision in the open operation was high and the complications were followed up for 3 months to 10 years. Except for the 1 cases of the open faeces in the open group, the defecation function was gradually restored with the extension of the postoperative time. The anorectal function basically returned to normal. No deaths occurred.
Conclusion: barium enema, barium enema, 24 hour barium enema and anorectal manometry can be used to diagnose HD preliminarily, and the range of lesions can be accurately determined by biopsy in the operation. Laparoscopic assisted surgery is less traumatic, less complications and faster recovery. HD radical operation and conventional abdominal cavity under laparoscopy under laparoscopy are used. Endoscopic surgery is similar to the surgical effect and the incidence of perioperative complications. It is also safe and reliable. It can further reduce abdominal trauma and improve the beauty of the umbilical scar. Although laparoscopic HD radical surgery is very common, there is still a problem that needs attention. In the choice of the treatment of HD laparoscopic surgery, It is necessary to take into account the two factors of the illness and the ability of the doctor at the same time, individual choice of skilled technology, with minimal trauma and pain, the most thorough removal of the disease because of the principle of treatment. In addition, after HD radical mastectomy, careful nursing should be taken, and early diagnosis and early treatment should be taken to achieve the best treatment effect if the postoperative complications should be diagnosed and treated.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R726.5

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