经自然管壁内镜手术实验动物研究
发布时间：2018-09-08 16:11
【摘要】： 背景与目的:经自然管壁内镜手术(Natural Orifice TranslumenalEndoscopic Surgery,NOTES)是指不经皮肤切口而经人体自然孔道,再经管壁(如胃、结肠及阴道等)造口进行的内镜手术。相对于传统的开腹手术和经皮肤切口的腹腔镜手术,NOTES具有腹壁无斑痕、术后疼痛减少、更加微创及可能缩短住院时间和减少医疗开支等潜在优势。2007年4月法国特拉丝堡大学医院Marescaux小组成功完成了世界首例经阴道内镜胆囊切除术,标志着又一项新的微创治疗时代即将到来。虽然国际上已有较多动物实验报道和少数人体NOTES手术的个案研究,但NOTES在人体的应用价值仍受到很多质疑;其安全性和有效性目前尚待进一步评估。本研究组于2001年在国内首先开展了NOTES的动物实验,截至目前这项研究在国内已有数家单位开始动物实验研究,并且开始尝试于人体的研究。 材料与方法:采用五指山雌性小型猪为实验动物共30只,体质量12Kg-15Kg;成年杂种犬12只,体质量15Kg-20Kg。术前禁食1d,不限水;术中应用全身麻醉,气管插管,呼吸机辅助呼吸。内镜进入胃肠道后,选取胃窦体交界前壁小弯侧及距肛门15cm-20cm结肠后壁系膜对侧为造口位置,针状刀切开后用扩张球囊扩张造口至1.2cm-1.5cm;内镜从造口进入腹腔后注气形成人工气腹,进行内镜腹腔探查术和腹部脏器手术;术中应用抗生素预防感染。研究分为两个阶段,第一阶段以五指山小型猪为研究对象开展腹腔和腹膜后脏器探查术、肝脏活检术、输卵管结扎术、卵巢切除术、胃-空肠吻合术和胆囊切除术。对于单一NOTES途径难以完成手术,采用腹腔镜辅助完成,采用钛夹夹闭方法闭合切口。开展急性实验和存活实验初步评价NOTES的可行性和有效性。第二阶段以杂种犬为研究对象开展经脐戳孔辅助经胃途径NOTES胆囊切除术,对其可行性、有效性和安全性进行前瞻性研究。同时研究胃壁造口的新型闭合方法,评价其应用价值。 结果:共开展NOTES手术32例次,急性实验7例次,存活实验25例次。第一阶段以五指山小型猪为研究对象,开展NOTES手术20例次,其中经胃途径3例次、经结肠途径2例次、腹腔镜联合经胃途径NOTES手术15例次。经胃或经结肠途径腹腔探查均能较好显示腹腔脏器,如肝脏、胆囊、脾脏、胃、结肠、部分小肠、膀胱、输卵管、卵巢、腹壁、膈肌及网膜组织等;完成肝脏活检术(4/4)、输卵管结扎术(经结肠途径2例次,经胃途径2例次,腹腔镜辅助经胃途径2例次均成功)、卵巢切除术(经结肠途径2例次,经胃途径2例次,腹腔镜辅助经胃途径2例次均成功)、胆囊切除术7例次(经胃或经结肠途径均失败;转为腹腔镜辅助成功3例次);未能完成胰腺探查(0/3)及胃空肠吻合术(0/2)。腹腔镜辅助下降低了输卵管结扎术和卵巢切除术的难度和操作时间,成功率100%(6/6);腹腔镜辅助下完成NOTES胆囊切除术成功率为42.8%(3/7)。第二阶段以杂种犬为研究对象,进行了经脐戳孔辅助下NOTES胆囊切除术12例次,一次因实验设备损坏终止实验,一次腹腔探查发现实验犬腹腔粘连严重终止实验未列入统计。完成胆囊切除术的存活实验10例次,成功率80%(8/10),平均用时80min/例次。手术失败2例次:1例为术中腹压过高致实验犬术中死亡,1例为术后腹腔感染致动物术后一周死亡。闭合管壁造口27例次,其中钛夹夹闭法成功率50%(6/12),用网膜填塞法成功率93.3%(13/14)。 结论:①经胃或经结肠途径腹腔探查术均能较好显示肝、脾、胆囊、胃、小肠、大肠、腹膜、网膜、腹壁、附件等腹腔脏器,两条NOTES途径无明显差异;②对腹膜后脏器如胰腺、肾脏、输尿管等NOTES探查难度较大。③NOTES输卵管结扎术、卵巢切除术具有一定的安全性,经胃或经结肠单一途径可完成,腹腔镜辅助可降低输卵管结扎术、卵巢切除术的难度。④腹腔镜辅助下的NOTES胆囊切除术具有一定的可行性,但应用五指山小型猪为动物模型成功率低。⑤杂种犬能较好的模拟人体进行NOTES胆囊切除术研究。⑥经脐戳孔辅助经胃途径NOTES胆囊切除术有一定的可行性、安全性和有效性。⑦应用钛夹直接夹闭管壁造口难度大、结果不可靠,应用网膜填塞闭合法简单、安全和有效。
[Abstract]:BACKGROUND AND OBJECTIVE: Natural Orifice Translumenal Endoscopic Surgery (NOTES) refers to endoscopic surgery performed through the natural canal of the human body and through the canal wall (such as stomach, colon and vagina) without a skin incision. Compared with traditional laparoscopic surgery and skin incision, NOTES has abdominal wall. The Marescaux team of the University Hospital of Trasbourg, France, successfully completed the world's first transvaginal endoscopic cholecystectomy in April 2007, marking the advent of a new era of minimally invasive treatment. Many animal experiments and a few cases of human NOTES surgery have been reported, but the value of NOTES in human body is still questioned; its safety and effectiveness are yet to be further evaluated. Experimental research, and began to try the human body research.
Materials and methods: * there were 30 female miniature pigs in Five Fingers Group as experimental animals. The body weight was 12Kg-15Kg. 12 adult crossbred dogs, body weight 15Kg-20Kg., fasting 1D before operation, without water restriction. General anesthesia, tracheal intubation and ventilator assisted respiration were applied during operation. After endoscopic access to the gastrointestinal tract, the small curvature of the anterior wall of the antral body junction and the 15cm-20cm from the anus were selected. The contralateral side of the posterior mesentery is the stoma site. After the needle knife is cut, the dilated balloon is used to dilate the stoma to 1.2cm-1.5cm. The endoscope is injected into the abdominal cavity to form an artificial pneumoperitoneum after the stoma is injected into the abdominal cavity. * endoscopic peritoneoscopy and abdominal organ surgery are performed. Antibiotics are used to prevent infection during the operation. The research is divided into two stages. The first stage is the study of miniature pigs in Five Fingers Group. The subjects underwent abdominal and retroperitoneal organ exploration, liver biopsy, tubal ligation, ovariectomy, gastrojejunostomy and cholecystectomy. Laparoscopic-assisted closure of the incision with titanium clip was used for the single NOTES approach. Acute and survival experiments were conducted to evaluate NOTES. In the second stage, the feasibility, efficacy and safety of NOTES cholecystectomy assisted by umbilical puncture in hybrid dogs were prospectively studied, and a new closure method of gastrostomy was studied to evaluate its application value.
Results: a total of 32 NOTES operations were performed, including 7 acute cases and 25 survival tests. * in the first stage, 20 cases of NOTES operation were carried out in Five Fingers Group miniature pigs, including 3 cases through the stomach channel, 2 cases via the colon channel, and 15 cases with NOTES operation via laparoscopy combined with gastric route. It shows the abdominal organs, such as liver, gallbladder, spleen, stomach, colon, part of small intestine, bladder, fallopian tube, ovary, abdominal wall, diaphragm and omentum, etc. It completes liver biopsy (4/4), tubal ligation (2 times via colon, 2 times via stomach, 2 times via laparoscopy), ovariectomy (2 times via colon, 2 times via stomach). Laparoscopic-assisted transgastric approach was successful in 2 cases, laparoscopic-assisted transgastric approach in 2 cases, cholecystectomy in 7 cases (all failed through gastric or transcolonic approach; laparoscopic-assisted approach in 3 cases); pancreatic exploration (0/3) and gastrojejunostomy (0/2) were not completed. The success rate of laparoscopic-assisted NOTES cholecystectomy was 42.8% (3/7). In the second stage, 12 cases of NOTES cholecystectomy assisted by umbilical puncture were performed in mongrel dogs. The successful rate of cholecystectomy was 80%(8/10) and the average time of operation was 80 min/time. The operation failed in 2 cases: 1 case died during operation due to excessive abdominal pressure, 1 case died one week after operation due to abdominal infection, 27 cases of closed tube wall stoma, of which the success rate of titanium clip occlusion was 50%(6/12) and the omentum was used to fill in. The success rate was 93.3% (13/14).
CONCLUSION: The two NOTES pathways have no significant difference in the abdominal organs, such as liver, spleen, gallbladder, stomach, small intestine, large intestine, peritoneum, omentum, abdominal wall, appendix and so on. The retroperitoneal organs such as pancreas, kidney, ureter and so on are difficult to explore. Laparoscopic cholecystectomy can reduce the difficulty of Oviduct Ligation and oophorectomy. Laparoscopy assisted NOTES cholecystectomy is feasible, but the success rate of using Five Fingers Group miniature pig as animal model is low. * hybrid dogs can better simulate human body for NOTES. Study on cholecystectomy._Transumbilical notch-assisted transgastric NOTES cholecystectomy is feasible, safe and effective._It is difficult to clip the stoma directly with titanium clip, and the result is unreliable.
【学位授予单位】：中国人民解放军军医进修学院
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R616;R-332
本文编号：2231028
[Abstract]:BACKGROUND AND OBJECTIVE: Natural Orifice Translumenal Endoscopic Surgery (NOTES) refers to endoscopic surgery performed through the natural canal of the human body and through the canal wall (such as stomach, colon and vagina) without a skin incision. Compared with traditional laparoscopic surgery and skin incision, NOTES has abdominal wall. The Marescaux team of the University Hospital of Trasbourg, France, successfully completed the world's first transvaginal endoscopic cholecystectomy in April 2007, marking the advent of a new era of minimally invasive treatment. Many animal experiments and a few cases of human NOTES surgery have been reported, but the value of NOTES in human body is still questioned; its safety and effectiveness are yet to be further evaluated. Experimental research, and began to try the human body research.
Materials and methods: * there were 30 female miniature pigs in Five Fingers Group as experimental animals. The body weight was 12Kg-15Kg. 12 adult crossbred dogs, body weight 15Kg-20Kg., fasting 1D before operation, without water restriction. General anesthesia, tracheal intubation and ventilator assisted respiration were applied during operation. After endoscopic access to the gastrointestinal tract, the small curvature of the anterior wall of the antral body junction and the 15cm-20cm from the anus were selected. The contralateral side of the posterior mesentery is the stoma site. After the needle knife is cut, the dilated balloon is used to dilate the stoma to 1.2cm-1.5cm. The endoscope is injected into the abdominal cavity to form an artificial pneumoperitoneum after the stoma is injected into the abdominal cavity. * endoscopic peritoneoscopy and abdominal organ surgery are performed. Antibiotics are used to prevent infection during the operation. The research is divided into two stages. The first stage is the study of miniature pigs in Five Fingers Group. The subjects underwent abdominal and retroperitoneal organ exploration, liver biopsy, tubal ligation, ovariectomy, gastrojejunostomy and cholecystectomy. Laparoscopic-assisted closure of the incision with titanium clip was used for the single NOTES approach. Acute and survival experiments were conducted to evaluate NOTES. In the second stage, the feasibility, efficacy and safety of NOTES cholecystectomy assisted by umbilical puncture in hybrid dogs were prospectively studied, and a new closure method of gastrostomy was studied to evaluate its application value.
Results: a total of 32 NOTES operations were performed, including 7 acute cases and 25 survival tests. * in the first stage, 20 cases of NOTES operation were carried out in Five Fingers Group miniature pigs, including 3 cases through the stomach channel, 2 cases via the colon channel, and 15 cases with NOTES operation via laparoscopy combined with gastric route. It shows the abdominal organs, such as liver, gallbladder, spleen, stomach, colon, part of small intestine, bladder, fallopian tube, ovary, abdominal wall, diaphragm and omentum, etc. It completes liver biopsy (4/4), tubal ligation (2 times via colon, 2 times via stomach, 2 times via laparoscopy), ovariectomy (2 times via colon, 2 times via stomach). Laparoscopic-assisted transgastric approach was successful in 2 cases, laparoscopic-assisted transgastric approach in 2 cases, cholecystectomy in 7 cases (all failed through gastric or transcolonic approach; laparoscopic-assisted approach in 3 cases); pancreatic exploration (0/3) and gastrojejunostomy (0/2) were not completed. The success rate of laparoscopic-assisted NOTES cholecystectomy was 42.8% (3/7). In the second stage, 12 cases of NOTES cholecystectomy assisted by umbilical puncture were performed in mongrel dogs. The successful rate of cholecystectomy was 80%(8/10) and the average time of operation was 80 min/time. The operation failed in 2 cases: 1 case died during operation due to excessive abdominal pressure, 1 case died one week after operation due to abdominal infection, 27 cases of closed tube wall stoma, of which the success rate of titanium clip occlusion was 50%(6/12) and the omentum was used to fill in. The success rate was 93.3% (13/14).
CONCLUSION: The two NOTES pathways have no significant difference in the abdominal organs, such as liver, spleen, gallbladder, stomach, small intestine, large intestine, peritoneum, omentum, abdominal wall, appendix and so on. The retroperitoneal organs such as pancreas, kidney, ureter and so on are difficult to explore. Laparoscopic cholecystectomy can reduce the difficulty of Oviduct Ligation and oophorectomy. Laparoscopy assisted NOTES cholecystectomy is feasible, but the success rate of using Five Fingers Group miniature pig as animal model is low. * hybrid dogs can better simulate human body for NOTES. Study on cholecystectomy._Transumbilical notch-assisted transgastric NOTES cholecystectomy is feasible, safe and effective._It is difficult to clip the stoma directly with titanium clip, and the result is unreliable.
【学位授予单位】：中国人民解放军军医进修学院
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R616;R-332
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1 孙刚;经自然管壁内镜手术实验动物研究[D];中国人民解放军军医进修学院;2009年
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