经自然腔道内镜外科技术在胸外科的实验研究及初步临床应用

发布时间：2018-05-12 22:25

本文选题：经自然腔道内镜手术 + 胸交感神经切断术　；参考：《福建医科大学》2013年博士论文

【摘要】：目的通过动物实验研究初步探讨分别经食道、阴道和脐实施胸交感神经切断术和心包开窗术的可行性和安全性。在积累动物实验经验的基础上，将经脐胸交感神经切断术初步应用于临床，探讨其可行性、安全性和有效性，为胸部NOTES手术的开展积累经验。方法动物实验部分以猪为实验动物，分别开展经食道、阴道-膈肌、脐-膈肌实施胸交感神经切断术和心包开窗术。每组各进行10例实验，其中急性实验3例，存活实验7例。急性实验术后立即处死尸检，存活实验4周后尸检。临床经脐胸交感神经切断术在全麻双腔气管插管下完成，记录术中情况，并对手术结果进行跟踪随访。结果共进行动物实验30例次，经食道组术中死亡2例，其余28例均成功完成目标手术。急性实验尸检发现经食道组发生胸主动脉损伤1例，左奇静脉损伤1例；经阴道组发生胸壁损伤2例，直肠损伤1例。各组胸交感神经切断准确彻底，心包开窗术完成良好。存活实验尸检发现食管造口愈合良好，食管外膜层和肺组织发生粘连3例；经阴道组阴道和膈肌切口均愈合良好，膈肌切口与肺组织粘连4例；经脐组膈肌切口与肺组织粘连3例。各组未见明显胸、腹腔感染迹象。临床共实施36例经脐胸交感神经切断术，均顺利完成。平均手术时间54min，均于术后第一天出院。术后随访6~12个月，手汗和腋汗的治愈率分别为100%和76%。共发生代偿性出汗13例（36.1%），所有患者手汗无复发，无膈疝、脐疝及霍纳氏综合征等严重并发症发生。结论 1、经食道入路虽然具有操作路径短的优势，但是该入路难度较大，就目前的技术而言在消毒、切口的选择和闭合上仍无法确保安全。 2、阴道入路的切开和缝合均可在直视下完成，，安全性高，但实施胸腔内手术路径太长，器械的可控性差。 3、经脐入路具有较高的可行性和安全性，就胸交感神经切断术治疗手汗症而言可以获得等同于胸腔镜手术的有效率，而且美容效果显著，但手术时间较长，其潜在的风险和优势有待于进一步评估。
[Abstract]:Purpose To explore the feasibility and safety of thoracic sympathetic neurotomy and pericardial fenestration through esophagus vagina and umbilical cord respectively. Based on the accumulation of animal experimental experience, we applied transumbilical thoracic sympathetic neurotomy to clinical practice, and discussed its feasibility, safety and effectiveness, and accumulated experience for the development of thoracic NOTES operation. Method In the animal experiment, pigs were used as experimental animals. Thoracic sympathetic neurotomy and pericardial fenestration were performed through esophagus, vagina, diaphragm and umbilical diaphragm respectively. There were 10 cases in each group, including 3 cases of acute experiment and 7 cases of survival test. Autopsy was performed immediately after acute experiment and 4 weeks after survival test. Clinical transumbilical thoracic sympathetic neurotomy was performed under general anesthesia with double lumen endotracheal intubation to record the intraoperative situation and follow up the results of the operation. Result 30 animal experiments were carried out, 2 cases died in the transesophageal group, and the other 28 cases successfully completed the target operation. Acute autopsy showed that thoracic aorta injury occurred in 1 case, left azygos vein injury in 1 case, thoracic wall injury in 2 cases and rectal injury in 1 case in transesophageal group. Thoracic sympathetic nerve transection in each group was accurate and complete, pericardial fenestration was completed well. In the survival experiment, the esophagostomy healed well, the esophagus outer layer and lung tissue were conglutinated in 3 cases, the vagina and diaphragm incision healed well in the transvaginal group, and 4 cases were conglutinated between the diaphragm incision and the lung tissue. Adhesion between diaphragm incision and lung tissue was found in 3 cases in the transumbilical group. There were no obvious signs of chest and abdominal cavity infection in each group. A total of 36 cases of umbilical thoracic sympathectomy were performed successfully. The average operative time was 54 minutes and all patients were discharged on the first day after operation. The cure rates of hand sweat and axillary sweat were 100% and 76% respectively. There were 13 cases of compensatory sweating. No recurrence of hand sweat, no diaphragmatic hernia, umbilical hernia, Horner's syndrome and other serious complications occurred in all patients. Conclusion 1. Although the transesophageal approach has the advantage of short operating path, it is difficult to access the route. In terms of current technology, the selection and closure of incision are still not safe. 2. The incision and suture of vagina approach can be completed under the direct vision, the safety is high, but the intrathoracic operation path is too long, and the controllability of the instrument is poor. 3. The transumbilical approach has high feasibility and safety. In the treatment of palmar hyperhidrosis, thoracic sympathetic neurotomy can obtain the same effective rate as thoracoscopic surgery, and the cosmetic effect is significant, but the operation time is longer. Its potential risks and advantages need to be further evaluated.
【学位授予单位】：福建医科大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R655

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