腹腔镜下尿道膀胱吻合模型的构建及应用研究

发布时间：2018-03-29 05:11

  本文选题：腹腔镜　切入点：前列腺癌根治术　出处：《南方医科大学》2014年硕士论文

【摘要】：研究背景： 自从1990年Clayman及其同事报道首例后腹腔镜下肾脏切除术以来,腹腔镜技术在泌尿外科的应用越来越普及,传统的开放手术逐渐被腹腔镜手术所替代,引起泌尿外科手术领域的革命性变化。进入新世纪后,以腹腔镜为代表的微创手术已经成为外科发展的主流,成为当代外科医生的必修课。据统计,在所有需手术治疗的泌尿外科病例中,90%以上的患者通过微创手术即可达到开放手术相似的效果。 前列腺癌根治术是目前微创外科治疗领域最为成功的代表,但同时也是难度最高的术式之一,术中操作复杂极其复杂,对外科医生的腔镜技能要求极高。正因如此,直至1997年Schuessler才报道首例腹腔镜下前列腺根治性切除术,并且当时也未能体现出腔镜下治疗的优势所在；但经过过去十几年的发展及相关辅助技术的进步,腹腔镜下前列腺根治性切除术已成为手术治疗早期前列腺癌的金标准。其所具有的手术创伤小、术中出血少、视野清晰、术后恢复快等优点,使患者最大程度的免受手术所带来的痛苦,越来越多的前列腺癌患者患者渴望享有微创治疗,而泌尿外科医生也无不渴望能掌握该种技术。虽然该种手术已逐渐成为国际上早期前列腺癌根治术的主要术式,但截至目前,腹腔镜下前列腺癌根治性切除术依然为泌尿外科手术的一大瓶颈,仅在我国部分大型三甲医院开展。 研究表明,尿道膀胱吻合是腹腔镜下前列腺癌根治术中最耗时耗力、难度最大的步骤之一,也是限制该种技术发展的主要原因之一。这不仅是由于腹腔镜下前列腺癌根治术术程较久,尿道膀胱吻合多处于术者的疲劳期,而且与吻合部位所处于盆腔的位置有较重要的关系。虽然国外已经有了机器人辅助下的腹腔镜下前列腺癌根治术来很好的解决了腹腔镜下尿道膀胱吻合过程中的困难,但由于购买器械、系统维护及升级等均较为昂贵,平均高达3-7万的手术费用难以被广大患者所承担,因此至今仅在我国北京、上海、南京等少数大型医院开展。而传统的腹腔镜手术治疗效果与机器人辅助下治疗相比,目前研究并无明显统计学差异；正因如此,传统的腔镜下前列腺癌根治术目前仍为我国前列腺癌患者的主要治疗方案。 正因如此,提高尿道膀胱吻合技术对腹腔镜下前列腺癌根治术的提升及发展均具有重要意义。而国内外研究已表明模型训练对提升手术技能具有重要实用价值,训练中所掌握的手术技能亦能很好的转化为实际手术应用中来,这也为我们指明了提升腹腔镜技能的方向。但是,至今为止,国内外报道中并无十分理想的模型来模拟腔镜下尿道膀胱吻合过程。建立好的模型,不仅有助于我们更好地掌握腹腔镜下尿道膀胱吻合技术,该种模型的建立及普及也能促进腹腔镜下前列腺癌根治术的发展与应用,为年轻医生尽快把握腹腔镜下前列腺癌根治术提供捷径,也有助于提升我们整体的腹腔镜水平。 目前国外已有多家机构进行规范化的腹腔镜培训及开展对初始人员规范化腹腔镜技能训练以缩短腹腔镜学习曲线,而模型训练也被各研究机构证实可提升腹腔镜技能。例如一些培训中心应用报道过的鸡皮模型或猪肠吻合模型来培训年轻的外科医生进行腹腔镜下尿道膀胱吻合训练；而在国内,专门用于培训年轻外科医生腹腔镜技能的机构依然少见,且国外所建尿道膀胱吻合训练模型在我国并未得到普及。纠其原由,这主要是鸡皮模型制作复杂,而猪肠模型只能进行简单的模拟环形吻合,而不能模拟尿道膀胱吻合术中所处的较深的环境及膀胱的活动性,且模型训练的价值未被国人所重视。因此建立一个较为实用且能很好模拟腹腔镜下尿道膀胱吻合操作环境的模型对年轻泌尿外科医生缩短腹腔镜下尿道膀胱吻合学习曲线,掌握腹腔镜下前列腺癌根治术具有实用价值。 我院及我校拥有的临床技能实验教学中心是华南地区最大的腹腔镜培训中心之一,内有腹腔镜操作虚拟培训系统、腹腔镜基本训练器、动物实验室等一大批专门用来进行腹腔镜手术培训的教学及实验设备,具备腹腔镜相关实验训练的硬件基础设施。 本研究拟利用我院现有设备及资源,通过建立新型的尿道膀胱吻合模型,对参与培训人员开展腹腔镜下尿道膀胱吻合模型的模拟训练,以期通过训练来提升参与者的腹腔镜操作水平,并通过吻合质量对该模型的实用性进行评价；通过多次训练及针对不同缝合部位不同的进针及持针方式,探索腹腔镜下尿道膀胱吻合最有利的缝合方法,以达到最快缝合速度及最好的缝合效果,通过把握该吻合方法以期达到缩短腹腔镜下前列腺癌根治术的目的。研究目的： 1、设计并制作出能逼真地模拟腹腔镜下尿道膀胱吻合过程的新模型。 2、通过对学员的模型训练实验来评价该模型的有效性,通过多次训练及针对不同缝合部位不同的进针及持针方式,探索提高腹腔镜下尿道膀胱吻合技巧及缝合质量的缝合方法,以达到最快缝合速度及最好的缝合效果。 3、经过训练,使参与者熟悉掌握腹腔镜外科手术的理论知识及基本操作技能,进而提升腹腔镜操作水平,探索初学者快速掌握腹腔镜下前列腺癌根治术的中最耗时、最费力的尿道膀胱吻合的方法,解决尿道膀胱吻合的关键性技术难题,以期达到缩短腹腔镜下前列腺癌根治术学习曲线,提高术中吻合效果,减少术后并发症。并希望该模型能在临床腹腔镜培训中应用和推广,促进前列腺癌微创治疗技术的开展及普及。 研究方法： (1)理论学习与基础训练：系统学习腹腔镜外科的理论知识,掌握腹腔镜设备的工作原理及使用方法。利用我院腹腔镜培训中心设备,进行腹腔镜下基本训练操作,具体内容如下：腹腔镜镜头聚集训练、夹豆转移训练、剪切纱布训练、模型肉板缝合训练来掌握腹腔镜手术所必需的三维空间感知、手眼分离、双手协调运动及定位、剪切、缝合、打结等基本操作的能力。进行为期一周每天2小时的学习训练。 (2)模型的设计：在既往所报道的模型构建仔细分析的基础上,选择合适的猪膀胱和尿道分别代替人膀胱和尿道,把备吻合部位修剪为直径一致、直径约2.0cm左右,并以挖空的内脏的鸡躯壳模拟盆腔环境,进行腹腔镜下尿道膀胱吻合新模型。 (3)尿道膀胱吻合模型训练：共20名来自腹腔镜培训中心训练人员(均无腹腔镜操作经验)利用我们自制的尿道膀胱吻合模型进行缝合训练,记录完成每次操作所用的时间、漏出量。所有结果均由一位腹腔镜经验丰富的高级医师来评估并记录统计；时间是指操作者由开始到完成某项任务所经历的时间,也是由专人记录。 (4)通过数据统计分析,分析比较参与培训测试人员应用该新模型缝合前后成绩比较,并对时间与漏出量进行相关性分析。计量资料的比较采用独立样本t检验,结果数据以(x±s)表示,数值间比较采用方差分析(p0.05有统计学意义)。相关性分析采用直线回归方法(两变量间拟合优度以决定系数R20.3视为有统计学意义)。 结果： 1.经过为期1周的基本训练后所有人员均达到：①3分钟内准确无误地钳夹转移黄豆大于等于15粒,平均(17±1.32)个；②缝合长约10cm模型切口6针,用时小于等于10分钟平均(9±0.95)min,且缝合过程中出现撕裂切口小于2处的要求；③所有操作人员均完成规定时间内的图形剪切操作训练,平均时间为(4±0.86)min。 2.所有人员经过30次缝合,统计每次缝合的时间及漏出量,整个实验过程平均手术时间：47.22±12.33min,平均漏出量：10.59±3.00ml；而训练第一次与最后一次平均缝合时间分别为68.42±8.10(分钟)与25.21±1.88(分钟),整个缝合过程操作时间呈现逐渐下降趋势,至24次左右以后基本维持在25min左右水平,第24次以后至第30次缝合时间,经方差分析未见统计学差异(F=0.78,P=0.32)；而漏出量由第一次的14.82±4.08(ml)降至最后一次的1.47±0.65(ml),第20次以后至第30次漏出量经方差分析未见明显统计学差异(F=0.91,P=0.07),至20次以后基本维持在3ml以下水平；缝合时间及漏出量实验前后比较具有显著统计学差异(P0.05)。可见经过训练所有参与者的缝合速度及缝合质量均有明显提高。相关性分析提示缝合时间与漏出量呈正相关性(R2=0.73,F=263.64,P0.01),提示随着手术操作熟练,吻合质量也相应提高。证实模型训练对提升腹腔镜下尿道膀胱吻合训练过程有显著效果。 结论： (1)通过培训学习,所有参与者熟悉掌握了腹腔镜外科手术的基本理论知识。基本熟悉了腹腔镜手术的各种器械,掌握了腹腔镜手术的所必须的剪切、缝合、打结等基本操作技能。 (2)通过模型训练,不仅使受训者掌握基本的环形吻合方法及技巧,更能适应盆腔这一特殊部位的操作能力,从而提升尿道膀胱吻合的能力并把握吻合过程中所需的进针角度技巧,提高吻合质量。 (3)新型腹腔镜下膀胱尿道吻合训练模型能有效帮助泌尿外科医生掌握腹腔镜下膀胱尿道吻合技术,而我们通过实验训练中所摸索的方法可能会有利于缩短尿道膀胱吻合曲线。 (4)熟练的腹腔镜下缝合打结技术是手术能够成功进行的关键因素之一,是术中止血、缝合、打结的必备技能。 (5)腹腔镜培训操作可很好地提高初学者的腹腔镜基本技能水平,并有利于培训人员腔镜技术进一步提升,腹腔镜下模型训练可针对性提高某项特定技能,值得对临床医师在该类手术初级培训中推广。
[Abstract]:Background of Study :

Laparoscopic surgery has become more and more popular in the field of urology since the first post - laparoscopic nephrectomies reported by clay man and his colleagues in 1990 . Traditional open surgery has gradually been replaced by laparoscopic surgery , leading to a revolutionary change in the field of urology surgery . After entering the new century , minimally invasive surgery represented by laparoscopy has become a compulsory course for contemporary surgeons . According to statistics , more than 90 % of patients in surgical treatment can achieve similar effects by minimally invasive surgery .

Radical resection of prostate cancer is one of the most successful cases in minimally invasive surgical treatment , but it is also one of the most difficult surgical procedures . The operation is complicated and complicated , and the requirements for the surgeon ' s endoscopic skills are extremely high .
However , as of the present time , radical resection of prostate cancer is still a major bottleneck in urology surgery , and it is only carried out in some large 3A hospitals in China .

The study shows that the urinary bladder anastomosis is one of the most time consuming and difficult steps in laparoscopic radical prostatectomy , and is one of the main reasons for limiting the development of the technique .
Because of this , radical prostatectomy for prostate cancer is still the primary treatment for prostate cancer patients in China .

So far , it is not only helpful for us to grasp the development and application of laparoscopic radical prostatectomy , but also to help us grasp the development and application of laparoscopic radical prostatectomy . So far , the establishment and popularization of this model can also promote the development and application of laparoscopic radical prostatectomy .

At present , several institutions have standardized laparoscopic training and standardized laparoscopic skills training for the initial personnel to shorten the laparoscopic learning curve , and the model training is also confirmed by the research institutions to improve the laparoscopic skills . For example , some training centers have applied the reported chicken skin model or porcine intestinal anastomosis model to train young surgeons to perform the laparoscopic urinary bladder anastomosis training ;
It is still rare in China to train young surgeons ' laparoscopic skills , and the model of urinary bladder anastomosis training abroad has not been popularized in our country . It is mainly that the chicken skin model is complicated , and the model can only carry out simple simulated circular anastomosis , and the value of the model training is not recognized by the Chinese . Therefore , a model for the younger urological surgeon to shorten the laparoscopic urinary bladder anastomosis learning curve can be shortened by a model which can simulate the operation environment of the urinary bladder anastomosis under the laparoscope , and the method has practical value for the radical operation of the prostate cancer under the laparoscope .

Our hospital and our own clinical skill experiment teaching center is one of the largest laparoscopic training centers in South China . There are a large number of teaching and experimental equipment specially used for laparoscopic surgery training , such as laparoscopic operation virtual training system , laparoscope basic trainer , animal laboratory , etc . , and has the hardware infrastructure of laparoscopic related experimental training .

This study intends to use the existing equipment and resources of our hospital , and to establish a new model of urinary bladder anastomosis through the establishment of a new anastomosis model of urinary bladder , in order to improve the level of laparoscopic operation of the participant through training , and to evaluate the practicability of the model by the quality of anastomosis ;
Through multiple training and different needle and needle holding methods for different suture sites , this paper explores the most favorable suture method of laparoscopic lower urinary bladder anastomosis , so as to achieve the fastest suture speed and the best suture effect , and by grasping the anastomosis method , the aim of shortening the radical operation of the prostate cancer under the laparoscope is achieved .

1 . To design and produce a new model which can realistically simulate the anastomosis procedure of urinary bladder under laparoscope .

2 . To evaluate the effectiveness of the model by model training experiment , and to explore the methods of improving the anastomosis skill and suture quality of the urinary bladder under laparoscope through multiple training and different needle and needle holding methods aiming at different suture parts , so as to achieve the fastest suture speed and the best sewing effect .

3 . After training , the participants are familiar with the theoretical knowledge and basic operating skills of laparoscopic surgery , so as to improve the level of laparoscopic operation , and to explore the most time - consuming and labor - consuming method of the primary scholar to grasp the most time - consuming and labor - consuming urethral bladder anastomosis in the laparoscopic radical prostatectomy , so as to shorten the learning curve of the radical operation of the prostate cancer under the laparoscope , improve the anastomosis effect in the operation and reduce postoperative complications .

Study method :

( 1 ) Theory study and basic training : The system learns the theory knowledge of laparoscopic surgery , grasps the working principle and the using method of the laparoscope equipment , uses the laparoscope training center equipment of our hospital to carry out the basic training operation under the laparoscope , the concrete contents are as follows : laparoscope lens gathering training , bean clamping transfer training , shearing gauze training , model meat plate suture training to master the three - dimensional space perception , the hand - eye separation , the hand coordination movement and the positioning , shearing , sewing , tying and other basic operations necessary for the laparoscopic surgery .

( 2 ) The design of the model : Based on the analysis of the previously reported model , the appropriate porcine bladder and urethra were selected to replace the urinary bladder and the urethra respectively . The anastomosis site was cut into a uniform diameter and approximately 2.0cm in diameter .

( 3 ) Training of urinary bladder anastomosis model : a total of 20 training personnel from the laparoscopic training center ( no experience in laparoscopic operation ) were trained using our self - made urethra bladder anastomosis model to record the time and leakage of each operation . All the results were evaluated and recorded by a highly experienced senior physician ;
Time means the time experienced by the operator from the beginning to the completion of a task , as well as by a specially assigned person .

( 4 ) By means of statistical analysis and statistical analysis , the results are compared with the results obtained before and after the application of the new model , and the correlation between time and leakage is analyzed . The comparison of the measured data adopts independent sample t test , and the result data is expressed by ( x 卤 s ) . The correlation analysis adopts linear regression method ( the goodness of fit between the two variables is considered statistically significant with the coefficient of determination 202.3 ) .

Results :

1 . After 1 week of basic training , all the personnel have reached : 鈶，

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