单孔腹腔镜手术专用器械研制及相关应用研究

发布时间：2018-05-22 10:59

本文选题：单孔腹腔镜手术 + 多通道套管　；参考：《东南大学》2015年博士论文

【摘要】：目的：单孔腹腔镜手术(Laparoendoscopic Single-Site Surgery. LESS)是微创外科领域的新进展,近年来获得了国内外学者的热切关注。LESS将所有器械以近乎平行的方式通过腹壁唯一切口进出腹腔,造成腹腔内“操作三角”消失,腹腔外器械把手之间相互拥挤碰撞,直线型视野,缺乏有效牵引。目前针对上述制约LESS发展的瓶颈,已经开发出LESS相关专用器械,包括各种类型的多通道鞘卡、不同弯曲型态的操作器械以及各类牵引装置,但尚不能完全适应LESS操作需求。和传统腹腔镜手术(Conventional Laparoscopic Surgery, CLS)相比较,LESS操作存在很大的困难,其基本操作规律、临床获益及并发症的处理仍然没有定论。本研究旨在根据LESS特点研制符合LESS操作需求的专用器械,通过动物实验研究验证所研发的LESS专用器械的可靠性及安全性,探索LESS复杂手术的可行性,并开展LESS临床研究探讨其临床获益,同时利用分子生物学方法加强LESS术后经腱膜切口的愈合,预防LESS术后脐部切口疝的发生。方法：(1)根据LESS特点研制新型柔性多通道套管、多功能解剖器和“鱼钩”式牵引装置,并首次在动物实验中实施单孔腹腔镜胆囊造瘘及胰体尾切除手术,验证所研制的上述LESS专用器械的可靠性和安全性,探讨LESS复杂手术的可行性,总结LESS的基本操作规律。(2)综合利用所研制的LESS专用器械开展单孔腹腔镜对比传统腹腔镜阑尾切除的随机对照研究、单孔腹腔镜对比传统腹腔镜胆囊切除的历史队列研究以及单孔腹腔镜腹股沟疝修补手术病例报道,初步探讨LESS的临床获益。(3)利用骨形态发生蛋白-12 (Bone Morphogenetic Protein-12, BMP-12)诱导间充质干细胞(Mesenchymal Stem Cells, MSCs)向腱细胞分化,体外构建诱导分化的MSCs-胶原蛋白海绵复合物种植于经腹正中白线切口,探讨其加强LESS经腱膜切口愈合的效果。结果：(1)所研制单孔腹腔镜柔性多通道套管符合LESS操作需求,获得相关专利及注册生产许可,其主要特点为：柔性材料制作,气密性可靠,器械活动度大；通道之间的间距大,有效避免器械相互碰撞。单弯曲多功能解剖器具备切割、电凝、止血、分离、冲洗和吸引的功能,避免了LESS中频繁更换器械,节约手术时间,减轻手术者的劳动负荷。“鱼钩”式牵引装置制作材料容易获得,制作方法简单,释放、解除方法容易掌握。使用上述专用器械实施3例单孔腹腔镜胆囊造瘘以及6例单孔腹腔镜胰体尾切除手术。其中1例单孔腹腔镜胆囊造瘘术后2月出现脐部切口疝,1例单孔腹腔镜胰体尾切除动物术中死亡,其余动物术后恢复良好,无明显并发症。该部分动物实验为LESS保胆手术奠定基础并验证了LESS复杂手术的可行性。总结了LESS基本操作规律,即：脐靶屏轴枢原则；“倒金字塔”原则；人体工程学原则；辅助原则；阶段递进原则；全面优化原则。(2)共98名患者纳入LESS对比CLS阑尾切除的随机对照研究。LESS组手术时间比CLS组延长(90.71±33.25min vs 74.9± 46.94min, P=0.057), LESS组有4例病例中转为CLS,和CLS组比较中转率有统计学差异(P=0.041)。术后腹壁美观度评价,LESS组明显优于CLS组(P0.001)。本研究中心共选择性实施了23例单孔腹腔镜胆囊切除病例,将其和传统腹腔镜胆囊切除病例相比较,手术时间、中转率、术中出血、住院时间、并发症两组之间无统计学差异(P0.05),术后腹壁美观度评价,LESS组明显优于CLS组(P=0.021)。本中心实施2例单孔腹腔镜腹股沟疝修补术,随访6个月,无脐部切口疝、疝复发等并发症,脐部疤痕几乎不可见。(3)分离培养骨髓来源MSCs,应用不同浓度BMP-12诱导MSCs向腱细胞分化,利用Real-time PCR检测Scx、collagen Ⅰ、collagen Ⅲ基因表达水平及Western Blot检测Collagen I的表达来确定BMP-12的最佳诱导分化浓度为10ng/ml。Western Blot证实BMP-12通过多条信号通路诱导MSCs向腱细胞分化,Smad通路作用显著,对P38、JNK有很强的活化作用,激活ERK通路的作用甚微。体外构建诱导分化的MSCs-胶原蛋白海绵复合物,种植于大鼠经腹正中白线切口,4周后检测其能承受的最大拉力为正常腹白线组织的69.7%,优于其他不同对照组(P0.05)。HE及Masson染色显示实验组再生胶原蛋白纤维增多,和周围腹壁肌肉分隔清晰,排列紧密有序。结论：(1)所研制的单孔腹腔镜柔性多通道套管、多功能解剖器、“鱼钩”式牵引装置符合LESS操作需求,有效、安全、可靠。(2)总结了LESS基本操作规律：脐靶屏轴枢原则；“倒金字塔”原则；人体工程学原则；辅助原则；阶段递进原则；全面优化原则。(3)临床研究证实相对于CLS, LESS难度增大,手术时间延长,手术中转率升高,并发症发生率未有明显差异,术后理想的腹壁美容效果是LESS最大的优势。(4)BMP-12通过多条信号通路诱导MSCs向腱细胞分化,Smad通路作用显著,对P38、JNK有很强的活化作用,激活ERK通路的作用甚微。BMP-12诱导MSCs成腱细胞分化可促进单孔腹腔镜经腱膜切口愈合。
[Abstract]:Objective: single hole laparoscopic surgery (Laparoendoscopic Single-Site Surgery. LESS) is a new progress in the field of minimally invasive surgery. In recent years, scholars at home and abroad have received the hot attention of.LESS to bring all the instruments in and out of the abdominal cavity through the only incision in the abdominal wall in a near parallel way, resulting in the disappearance of the "operation triangle" in the abdominal cavity and the outside of the abdominal apparatus handle. Among the bottlenecks restricting the development of LESS, LESS related special devices have been developed, including various types of multi-channel sheathing cards, different curved types of operating instruments and various traction devices, but it is still not fully adapted to LESS operation requirements and traditional laparoscopic hands. Compared with Conventional Laparoscopic Surgery (CLS), there is a great difficulty in the operation of LESS. The basic rules of operation, the clinical benefit and the treatment of complications are still unsettled. The purpose of this study is to develop a special instrument to meet the requirements of the LESS operation according to the characteristics of LESS and to verify the available LESS equipment developed by the animal experiment. To explore the feasibility of LESS complex surgery and to explore the clinical benefits of LESS clinical study, and to strengthen the healing of the aponeurosis incision after LESS and to prevent the occurrence of umbilical incisional hernia after LESS. Methods: (1) a new flexible multichannel cannula, a multifunctional dissection and a multi-functional dissection is developed according to the LESS special point. "Fish hook" type traction device, and for the first time in animal experiments to implement single hole laparoscopic cholecystostomy and pancreatic body tail resection, verify the reliability and safety of the developed LESS special equipment, explore the feasibility of LESS complex operation and summarize the basic operation rules of LESS. (2) comprehensive use of the developed LESS special instruments to carry out a single instrument. A randomized controlled study of laparoscopic appendectomy compared to traditional laparoscopic appendectomy. Single hole laparoscopy compared to traditional laparoscopic cholecystectomy history cohort study and single hole laparoscopic inguinal herniorrhaphy cases report, preliminary study of the clinical benefits of LESS. (3) using bone morphogenetic -12 (Bone Morphogenetic Protein-12, BMP-12) Mesenchymal Stem Cells (MSCs) was induced to differentiate into the tendon cells. In vitro, the induced MSCs- collagen sponge complex was planted in the Fu Zhengzhong white line incision to explore the effect of enhancing the healing of LESS through the aponeurosis incision. Results: (1) the single hole laparoscopic flexible multichannel casing was developed to meet the requirement of LESS operation. The main features of relevant patents and registered production licenses are: flexible material making, reliable air tightness, large equipment activity, large distance between channels and effective avoidance of collision between instruments. Single bending multi-functional dissection has the functions of cutting, electrocoagulation, hemostasis, separation, flushing and attraction, avoiding frequent replacement of instruments in LESS. The operation time alleviated the labor load of the surgeon. The "fish hook" traction device was easy to obtain, the production method was simple, the release method was easy to master. 3 cases of single hole laparoscopic cholecystostomy and 6 cases of single hole laparoscopic pancreatic body tail resection were performed with the special equipment mentioned above. Of them, 1 cases of single hole laparoscopic cholecystostomy were 2. 1 cases of single hole laparoscopic pancreatectomy were killed in 1 cases, and the rest of the animals recovered well and had no obvious complications. This part of the animal experiment laid the foundation for the biliary operation and verified the feasibility of the LESS complex operation. The basic operation rules of the LESS were summarized, that is, the principle of the umbilical target screen axis armature; "inverted Pyramid". "Principle; ergonomics principle; auxiliary principle; progressive principle; comprehensive optimization principle. (2) a total of 98 patients were included in LESS contrast CLS appendectomy randomized controlled study longer than group CLS (90.71 + 33.25min vs 74.9 + 46.94min, P=0.057), LESS group had 4 cases transferred to CLS, and CLS group rate of transfer rate. There were statistical differences (P=0.041). The beauty of abdominal wall was evaluated and group LESS was obviously superior to group CLS (P0.001). 23 cases of single hole laparoscopic cholecystectomy were carried out in this study center. Compared with the traditional laparoscopic cholecystectomy, the operation time, transfer rate, intraoperative bleeding, hospitalization time and complications were not statistically significant between the two groups. The difference (P0.05), the postoperative abdominal wall beauty evaluation, group LESS was obviously better than group CLS (P=0.021). 2 cases of single hole laparoscopic inguinal hernia repair was performed in this center, and followed up for 6 months, no umbilical hernia, hernia recurrence and other complications, umbilical scars were almost invisible. (3) the separation and culture of bone marrow derived MSCs, the use of different concentrations of BMP-12 to induce MSCs to the tendon cell points Real-time PCR was used to detect Scx, collagen I, collagen III gene expression level and Western Blot to detect Collagen I expression to determine the optimal inducible differentiation concentration of BMP-12. The effect of activating the ERK pathway is very small. In vitro, the induced MSCs- collagen sponge complex is constructed and planted in the midline white line incision in the rat. After 4 weeks, the maximum pulling force can be detected in 69.7% of the normal abdominal white line, which is superior to the other control groups (P0.05).HE and Masson staining to show the regenerated collagen fiber in the experimental group. Conclusion: (1) the single hole laparoscopic flexible multi channel casing, multifunctional dissection apparatus and "fish hook" traction device are in conformity with the requirements of LESS operation, effective, safe and reliable. (2) the principle of LESS basic operation is summed up: the principle of axis pivot axis of the umbilical target screen and the principle of "inverted Pyramid" The principle of ergonomics; auxiliary principle; progressive principle; comprehensive optimization principle. (3) clinical research confirmed that relative to CLS, the difficulty of LESS increased, the operation time was prolonged, the rate of operation was increased, the incidence of complications was not significantly different, and the ideal abdominal wall beauty effect after operation was the greatest advantage of LESS. (4) BMP-12 through multiple signals The pathway induces MSCs to differentiate into the tendon cells, and the Smad pathway plays a significant role. It has a strong activation effect on P38 and JNK. The activation of the ERK pathway with little.BMP-12 induced MSCs induced tendon differentiation can promote the healing of single pore peritoneoscope through the aponeurosis incision.
【学位授予单位】：东南大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R608

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