微创手术技术安装小型猪消化道瘘管的实验研究

发布时间：2018-07-18 10:11

【摘要】：微创外科是外科领域中发展的一门新兴学科,是外科发展史上的里程碑,是21世纪外科发展方向之一。腹腔镜外科是微创外科的重要组成部分,具有微创、视野清晰、出血少、疼痛反应轻、术后机体恢复快和组织粘连少等优点,该技术已经得到人们的充分认识和肯定。人医腹腔镜手术技术的研究中,消化道各部位的瘘管手术已有报道,在动物医学中,腹腔镜消化道瘘管手术的开展还相对比较滞后,目前国内外尚无腹腔镜技术应用于小型猪消化道瘘管安装的报道。因此,本课题进行了小型猪腹腔镜手术最佳二氧化碳气腹压的选择实验；在最佳气腹压条件下设计并完成小型猪腹腔镜胃瘘管手术、小型猪腹腔镜十二指肠瘘管手术、小型猪腹腔镜回肠瘘管手术；评估小型猪腹腔镜消化道瘘管手术的技术可行性及安全性；进行小型猪腹腔镜消化道瘘管手术与常规开腹手术对机体影响的比较。将小型猪随机平均分为5组,每组6头,进行最佳气腹压的筛选实验。A组为麻醉组,即OmmHg气腹压组；B组为6mmHg气腹压组；C组为8mmHg气腹压组；D组为10mmHg气腹压组；E组为12mmHg气腹压组。各组分别于设定的时间点来监测小型猪的呼吸系统、循环系统、肝肾功能、心肌酶谱、氧化应激参数和神经内分泌激素,筛选出对机体影响较小,既安全又适合手术的最佳气腹压值。将小型猪随机平均分为6组,每组6头,进行腹腔镜消化道瘘管手术和开腹消化道瘘管手术实验。通过最佳气腹压值充气腹、手术通路建立、腹腔镜下脏器查找、缝合固定、荷包缝合、瘘管插入、瘘管引出及腹腔闭合等操作步骤进行小型猪腹腔镜胃瘘管手术、小型猪腹腔镜十二指肠瘘管手术和小型猪腹腔镜回肠瘘管手术。在整个手术过程中,监测小型猪的临床体征、心率、体温、收缩压、舒张压、平均动脉压、呼吸频率、呼吸末二氧化碳分压、脉搏血氧饱和度。记录术中和术后并发症、手术完成情况、手术时间、小型猪术后的精神状态、饮食欲、伤口愈合情况和术后消化液的采集情况,以及腹腔镜二次探查手术部位的粘连情况。并于术后抽取耳缘静脉血检测白细胞总数、白细胞介素-6、白细胞介素-1p和肿瘤坏死因子-α。实验结果表明,低气腹压下难以满足手术中观察及操作的要求,高气腹压下手术视野显露充分,手术操作方便,但手术危险性较大。10mmHg气腹压表现出对机体的氧化应激水平和神经内分泌激素影响不大,很快恢复,其中丙二醛和促肾上腺皮质激素变化较为明显,丙二醛在气腹40mmin一直到放气后4h还与气腹前相比差异极显著,放气后1d基本恢复。促肾上腺皮质激素在气腹25min到气腹60min与气腹前相比差异极显著,放气后10min基本恢复。所以,小型猪腹腔镜手术的最佳气腹压值为10mmHg,10mmHg气腹压既安全义适合进行手术。本课题在最佳气腹压下成功的完成了小型猪腹腔镜胃瘘管手术、小型猪腹腔镜十二指肠瘘管手术、小型猪腹腔镜回肠瘘管手术,以及相应的开腹手术。所有小型猪全部存活,术中和术后没有发生较大的并发症。从手术结束到瘘管移除过程中,所有小型猪精神状态良好,未发现任何弓腰、呻吟等疼痛表现,饮食欲和排便情况正常。术后腹壁瘘管引出位点未发现有消化液渗漏的情况,但存在轻微的炎症,所有小型猪均于术后5-7d炎症消失。术后均能有效的取出消化液。术后35d腹腔镜二次探查中,胃、十二指肠、回肠与腹壁间分别形成稳定的粘连,未见其他异常。小型猪腹腔镜胃瘘管手术的平均手术时间为50min,手术套管切口平均长度为2.5cm,相应开腹手术的平均手术时间为37.67min,切口长度平均约8cm小型猪腹腔镜十二指肠瘘管手术的平均手术时间为44.83min,手术套管切口平均长度为2cm,相应开腹手术的平均手术时间为33min,切口长度平均约6cm；小型猪腹腔镜回肠瘘管手术的平均手术时间为43.38mmin,手术套管切口平均长度为2cm,相应开腹手术的平均手术时间为33.67min,切口长度平均约6cm。腹腔镜消化道瘘管手术和开腹消化道瘘管手术对机体循环系统和呼吸系统都有不同程度的抑制作用,表现为心率、体温、血压、呼吸频率和脉搏血氧饱和度下降,呼吸末二氧化碳分压升高,所有小型猪都能正常耐受,并且很快恢复到正常,但是腹腔镜消化道瘘管手术对机体的影响较小。腹腔镜组和开腹组仅仅短期内对机体炎性反应产生影响,表现为术后全血中白细胞总数的升高,血清中IL-6、TNF-α、IL-1β浓度的增加,炎性指标含量在术后一段时间内很快就可恢复,但是腹腔镜消化道瘘管手术引起的机体炎性反应程度比开腹手术要轻。通过实验结果,得出以下结论： 1.在注射小型猪复合麻醉剂全身麻醉和小型猪自主呼吸的状态下,小型猪腹腔镜手术的最佳气腹压值为1OmmHg,10mmHg气腹压既安全又适合进行手术。 2.成功地应用腹腔镜技术完成小型猪胃瘘管手术、小型猪十二指肠瘘管手术和小型猪回肠瘘管手术,证明了腹腔镜技术在小型猪消化道瘘管安装中的可行性。 3.通过手术期间对小型猪临床体征、呼吸系统和循环系统进行监测,以及术后对小型猪精神状态、饮食欲和伤口愈合等进行评估,维持在安全范围之内,从而有效地保证了小型猪腹腔镜消化道瘘管手术的安全性。 4.与开腹消化道瘘管手术相比,小型猪腹腔镜消化道瘘管手术对动物机体损伤小,术后并发症少,机体炎性反应程度轻,术后恢复较快。
[Abstract]:Minimally invasive surgery is a new subject developed in the field of surgery . It is a milestone in the history of surgical development . Laparoscopic surgery is an important part of minimally invasive surgery .
To design and complete mini - pig laparoscopic gastric fistula operation , mini - pig laparoscopic duodenostomy and mini - pig laparoscopic ileostomy under optimal conditions of abdominal pressure ;
To evaluate the technical feasibility and safety of mini - pig laparoscopic digestive tract fistula operation ;
To compare the effect of mini - pig laparoscopic digestive tract fistula and conventional open surgery on the body .

The mini - pigs were randomly divided into 5 groups , 6 heads in each group , and the best air - abdominal pressure was selected .
group B was 6mmHg ;
Group C was 8mmHg .
Group D was 10mmHg .
In the whole procedure , the clinical signs , heart rate , body temperature , systolic pressure , diastolic pressure , average arterial pressure , respiratory rate , systolic pressure , diastolic blood pressure , average arterial pressure , respiratory rate , systolic pressure , diastolic pressure , average arterial pressure , fistula insertion , fistula extraction and abdominal cavity closure were performed .

The experimental results show that it is difficult to meet the requirements of observation and operation in operation under low pressure and abdominal pressure . The operative field of operation is full and the operation is convenient , but the operation risk is high . There is no significant effect on the level of oxidative stress and neuroendocrine hormone in the body .

This study successfully completed mini - pig laparoscopic gastric fistula operation , mini - pig laparoscopic duodenal fistula operation , mini - pig laparoscopic ileostomy fistula operation , and the corresponding laparotomy . All the mini - pigs had good mental state without any major complications during operation .

The mean operative time was 50 min , the mean length of incision was 2 . 5 cm , the mean operative time was 37.67 min , the mean operative time was 44 . 83 min , the mean length of incision was 2 cm , the mean operative time was 33 min and the incision length was about 6 cm .
The average operative time was 43.38mmin , the average length of incision was 2 cm , the mean operative time was 33.67min , the length of incision was about 6 cm .

Through the experimental results , the following conclusions are drawn :

1 . Under the condition of general anesthesia and self - breathing of mini - pigs , the optimal abdominal pressure value of mini - pig laparoscopic surgery is 1OmmHg , and the abdominal pressure of 10mmHg is safe and suitable for operation .

2 . The feasibility of laparoscopic techniques in the installation of small porcine digestive tract fistula was demonstrated successfully by successfully applying laparoscopic techniques to small pig gastric fistula operation , small porcine duodenum fistula operation , and mini - pig ileum fistula operation .

3 . The clinical signs , respiratory system and circulatory system of mini - pigs were monitored during operation , and the mental status , appetite and wound healing of mini - pigs were assessed and maintained within the safe range .

4 . Compared with the open abdominal fistula operation , the small - sized pig laparoscopic digestive tract fistula operation has less damage to the animal body , less postoperative complications , less inflammatory response and faster postoperative recovery .
【学位授予单位】：东北农业大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：S857.12

【参考文献】