肾动脉三维重建在mPCNL穿刺定位中的数字解剖研究

发布时间：2019-01-05 20:03

【摘要】： 目的: 通过肾动脉和肾盂的三维重建来探讨微创经皮肾镜碎石取石术(mPCNL)的最佳穿刺部位,从而指导临床进行合理的穿刺,以预防大出血的并发症出现。材料与方法: 选取正常成人6例12个新鲜肾脏标本,男4例,女2例。 1、对新鲜标本进行大体解剖,取腹部正中切口,上至剑突,下至耻骨联合,依次切开皮肤、浅筋膜、肌层,显露腹膜。切开腹膜后,将腹腔内容物翻向对侧,切开后腹膜,暴露肾周筋膜,钝性游离肾脏及周围结缔组织(尽量远离肾脏实质),确定肾动脉后,尽量靠近腹主动脉和下腔静脉切断肾蒂,再游离输尿管后,切断输尿管,将新鲜肾脏取出后,进行肾动脉和输尿管插管,予以生理盐水进行反复冲洗数遍后,以备灌注。 2、将事先配制好的灌注材料以均匀压力,用20ml注射器进行肾动脉灌注,直至肾动脉内出现明显阻力,肾实质表面出现橘红色点状物。再从输尿管断端对肾盂进行灌注,直至阻力增大为止。 3、采用16排多层螺旋进行CT扫描,再用Mimics软件进行肾动脉及肾盂三维重建。 4、三维重建后的图像进行数据测量,并对数据结果进行统计学分析。结果: 1、运用CMC/LO对肾动脉进行灌注扫描后,Mimics三维重建能够清晰、连续地显示肾动脉的4-6级分支。从三维图像上我们能够清晰地分辨出肾动脉的各个分支和分布范围。 2、对肾盂进行灌注扫描后,Mimics三维重建能够清晰、饱满地显示肾盂以及上、中、下各个肾盏和肾小盏。 3、将三维重建的肾段动脉与肾盂进行结合后,明确肾动脉在肾脏表面“乏血管区”的存在,为微创经皮肾镜碎石取石术提供依据。 4、通过对12例新鲜肾脏标本三维重建的数据进行测量测得肾皮质距离各盏的穿刺深度为23.75±0.22mm。 5、测得的肾脏各组后盏与背部冠状面和肾脏长轴所形成的穿刺角度以及变化范围分别是:上组后盏:67.85±0.20°～70.64±0.15°、57.20±0.06°～60.27±0.10°;中组后盏:49.10±0.14°～70.24±0.08°、75.25±0.12°～92.84±0.11°;下组后盏:62.60±0.12°～67.37±0.13°、107.34±0.14°～114.47±0.18°。以上结果显示穿刺肾中后组盏的范围明显大于肾上、下后组盏。 6、将腹部CT平扫后三维重建的骨、双肾及皮肤图像与单独重建的肾动脉和肾盂图像进行融合,能够很好的显示肾以及肾内动脉的载体位置,为模拟穿刺手术提供可靠的依据。结论: 1、灌注材料具有良好的稳定性,通过CT扫描能很好的显示细小血管的分支走向,为进一步了解肾动脉在肾实质内的分布规律提供了可靠地保障。 2、通过对肾段动脉及其分支以及肾盂的三维重建,进一步明确了肾动脉在肾实质内的分布规律。 3、通过对肾动脉的三维重建和对经皮肾穿刺最佳通道的测量和比较,发现穿刺肾中组后盏相比而言更为安全。
[Abstract]:Objective: to explore the best puncture site of (mPCNL) for minimally invasive percutaneous nephrolithotripsy by three dimensional reconstruction of renal artery and renal pelvis so as to guide the rational puncture in clinic and prevent the complication of massive hemorrhage. Materials and methods: 12 fresh kidney specimens were collected from 6 normal adults, including 4 males and 2 females. 1. The fresh specimens were dissected, the median abdominal incision was taken, the upper to the xiphoid process and the lower part to the pubic symphysis, then the skin, superficial fascia, muscular layer and peritoneal membrane were cut in turn. After incision of the peritoneum, the contents of the abdominal cavity are turned over to the opposite side, the posterior peritoneum is cut off, the perirenal fascia is exposed, the blunt free kidney and its surrounding connective tissue (away from the renal parenchyma as far as possible), and the posterior renal artery is determined. The renal pedicle was cut off as close as possible to the abdominal aorta and inferior vena cava, then the ureter was cut off after the ureter was free. After the fresh kidney was removed, the renal artery and ureter were intubated, and then the renal artery and ureter were intubated with physiological saline for several times for perfusion. (2) the pre-prepared perfusion materials were perfused into the renal artery with 20ml syringe under uniform pressure until there was obvious resistance in the renal artery and orange spots appeared on the surface of the renal parenchyma. The renal pelvis was perfused from the ureteral end until the resistance increased. 3. 16 rows of multislice helix were used for CT scanning, and Mimics software was used to reconstruct renal artery and renal pelvis. 4. The three-dimensional reconstruction images were measured and the results were analyzed statistically. Results: 1. After perfusion scanning of renal artery with CMC/LO, Mimics 3D reconstruction could clearly and continuously display 4-6 grade branches of renal artery. We can clearly distinguish the branches and distribution of renal artery from three-dimensional images. 2. After perfusion scan of renal pelvis, Mimics 3D reconstruction can show the renal pelvis, upper, middle and lower calyces and calices. 3. After the 3D reconstruction of renal segmental artery was combined with renal pelvis, the presence of renal artery in the surface of kidney was determined, which provided the basis for minimally invasive percutaneous nephrolithotomy. 4. The puncture depth of each calyx was 23.75 卤0.22mm. 5. The puncture angle and change range of posterior calyceal and dorsal coronal plane and long renal axis in each group were 67.85 卤0.20 掳~ 70.64 卤0.15 掳, 57.20 卤0.06 掳~ 60.27 卤0.10 掳, respectively. In the middle group, 49.10 卤0.14 掳~ 70.24 卤0.08 掳, 75.25 卤0.12 掳~ 92.84 卤0.11 掳, 62.60 卤0.12 掳~ 67.37 卤0.13 掳, 107.34 卤0.14 掳~ 114.47 卤0.18 掳. The above results showed that the range of calyces in the posterior group was significantly larger than that in the upper and lower renal groups. 6. Fusion of three-dimensional reconstruction bone, bilateral kidney and skin images with single reconstructed renal artery and pelvis images after plain scan of abdominal CT can well display the carrier position of kidney and internal renal artery, and provide reliable basis for simulating puncture operation. Conclusion: 1. The perfusion material has good stability. CT scan can show the direction of branches of small vessels, which provides a reliable guarantee for further understanding the distribution of renal artery in renal parenchyma. 2. The distribution of renal artery in renal parenchyma was further determined by 3D reconstruction of renal segmental artery, its branches and renal pelvis. 3. Through the 3D reconstruction of renal artery and the measurement and comparison of the best channel of percutaneous renal puncture, it was found that the posterior calyx of the middle renal puncture group was safer than that of the middle renal puncture group.
【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2010
【分类号】：R699;R322.6

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