能量器械LigaSure在甲状腺手术中安全应用的研究

发布时间：2018-06-01 08:24

本文选题：小钳口LigaSure + 连续术中神经监测技术　；参考：《中国人民解放军医学院》2017年硕士论文

【摘要】：目的:通过模拟甲状腺手术中LigaSure在颈段喉返神经(Recurrent laryngeal nerve,RLN)区域的应用,建立连续神经监测(Continuous intraoperative neuromonitoring,CIONM)保护下的小型猪动物模型,从而探讨甲状腺手术中LigaSure在RLN区域应用时的安全距离及安全时间间隔。方法:1.实验动物分组:36头小型猪随机分为距离实验组和间隔实验组(各18头)。距离实验组根据LigaSure刀头作用部位与RLN距离不同随机分为组1 (距RLN3mm)、组2(距RLN2mm)和组3 (距RLN1mm),每组6头;间隔实验组根据LigaSure刀头室温下冷却时间不同随机分为组1 (冷却3s)、组2 (冷却2s)和组3 (冷却1s),每组6头。2.实验动物模型制备:1)麻醉及CIONM的应用实验动物硫喷妥钠(15mg/kg)静脉麻醉满意后,喉镜引导下插入6号NIM标准加强型气管内导管,连接心电和血氧监测,术中1～2%七氟醚行麻醉维持。依照CIONM应用标准化步骤,行迷走神经(Vagus nerve, VN)暴露、APS电极的留置和RLN暴露,对RLN功能进行实时监测。2)距离实验选取18头小型猪左侧RLN (右侧对照),作用部位为第2、3气管环水平。根据分组不同,将LigaSure刀头分别距RLN外侧3mm、2mm和1mm处被激发,均作用4s,应用CIONM对RLN功能进行实时监测,作用前后振幅和潜伏期进行对比。连续监测30min,记录激发后15min和损伤后30min实时振幅和潜伏期,观察恢复情况。3)间隔实验选取18头小型猪左侧RLN (右侧对照),LigaSure先于胸锁乳突肌上持续激活5s,敞开尖端刀头,根据分组不同,室温下分别冷却3s、2s和1s后,刀头与第2、3气管环水平RLN直接接触5s,应用CIONM监测RLN功能变化。损伤前后EMG对比和神经功能恢复情况观察同距离实验。3.病理切片:对实验侧RLN和右侧正常RLN取材,制成病理切片,光镜下观察组织学变化。结果:1.距离实验组1 LigaSure作用后EMG变化不显著,振幅和潜伏期在正常范围内波动,无统计学意义。组2和组3出现不同程度振幅降低和潜伏期延长,组2振幅降低均50%,潜伏期延长均10%,监测仪未报警,无统计学意义,30min时可恢复至损伤前正常范围。组3均出现危险EMG,监测仪报警,损伤后可见振幅和潜伏期恢复,但30min时未能至警戒阈值水平,有统计学意义。组1、组2和对照组镜下神经结构正常,组3镜下见神经水肿表现。2.间隔实验组1 LigaSure与RLN接触后振幅降低50%,潜伏期延长 10%,监测仪未报警,无统计学意义,30min后振幅和潜伏期可恢复至作用前正常范围。组2和组3损伤后EMG迅速改变,监测仪报警,振幅和潜伏期变化均有统计学差异,组2损伤后可见振幅和潜伏期恢复,但30min时未能至警戒阈值水平。组3均出现LOS,且损伤后不能恢复。组1和对照组镜下神经结构正常,组2镜下见神经水肿表现,组3镜下可见胞核碎裂及坏死。结论:基于CIONM对RLN功能评估,甲状腺手术中LigaSure在RLN区域应用的安全距离为距RLN外侧2mm及以上,且单次激发后,再于RLN区域应用时间隔应不少于3s。LigaSure应用应予以规范化和标准化,以避免其不规范使用造成的RLN热损伤的发生。CIONM可敏感的、实时的评估RLN功能变化,早期识别损伤,提醒术者对损伤进行预判和控制,对神经保护意义重大,值得推广。
[Abstract]:Objective: by simulating the application of LigaSure in the region of Recurrent laryngeal nerve (RLN) during thyroid surgery, a miniature pig animal model under the protection of Continuous intraoperative neuromonitoring (CIONM) was established to explore the safety distance of LigaSure in RLN region during thyroidectomy. Methods: 1. experimental animals were divided into 1. experimental animals: 36 small pigs were randomly divided into the distance experiment group and the interval experimental group (18 heads each). The experimental group was randomly divided into 1 (distance RLN3mm), group 2 (distance RLN2mm) and group 3 (RLN1mm), and each group was 6 heads, and the interval experimental group was based on the room temperature of LigaSure knife head. The lower cooling time was divided randomly into group 1 (cooling 3S), group 2 (cooling 2S) and group 3 (cooling 1s), 6 head of.2. experimental animal model in each group was prepared: 1) anesthesia and CIONM applied experimental animal sodium thiopental (15mg/kg) intravenous anesthesia satisfied, laryngoscope guidance inserted into the 6 NIM standard enhanced endotracheal catheter, connecting ECG and oxygen monitoring, 1~2 during the operation. % sevoflurane was maintained for anesthesia. According to the CIONM application standardization steps, Vagus nerve (VN) exposure, APS electrode retention and RLN exposure, RLN function in real-time monitoring.2) distance experiment selected 18 small pigs left RLN (right control), the action site was the level of the 2,3 trachea. According to the grouping, LigaSure knife head respectively From the lateral 3mm, 2mm and 1mm of RLN, 4S was used, CIONM was used to monitor the function of RLN in real time. The amplitude and incubation period were compared before and after. 30min was continuously monitored, the real-time amplitude and latency of 30min after the excitation and the recovery.3) were recorded, and the left RLN (right control) of 18 small pigs was selected. Re first activates 5S on the sternocleidomastoid muscle and opens the cutting-edge knife. After cooling 3S, 2S and 1s at room temperature, the knife head and 2,3 tracheal ring level RLN are directly exposed to 5S, and CIONM monitoring RLN function changes. The EMG contrast before and after injury and the recovery of nerve function before and after injury are observed by the same distance experimental.3. pathological section. On the right side of the normal RLN, the pathological sections were made. The histological changes were observed under the light microscope. Results: the changes of EMG in the 1. distance experimental group were not significant after the action of 1 LigaSure. The amplitude and latency fluctuated in the normal range, and there was no statistical significance. The amplitude and the latent period of the group 2 and group 3 were decreased and the latent period was prolonged, the 2 amplitude of the group decreased 50% and the incubation period was 10. %, the monitor did not alarm, no statistical significance, 30min can be recovered to the normal range before injury. Group 3 appeared dangerous EMG, monitor alarm, the amplitude and latency recovery after injury, but 30min failed to the level of warning threshold, there were statistical significance. Group 1, group 2 and control group under normal neural structure, group 3 endoscopic neuroedema showed.2. performance of neuroedema in the performance of.2. After contact between 1 LigaSure and RLN, the amplitude of amplitude decreased by 50%, the latency prolonged 10%, the monitor did not alarm, no statistical significance. The amplitude and latency of 30min could be recovered to the normal range before action. Group 2 and group 3 after injury, EMG changed rapidly, the monitor alarm, amplitude and latency changes were statistically different, and the amplitude of the 2 injury was visible. And the incubation period recovered, but 30min failed to reach the alert threshold level. Group 3 appeared LOS, and could not recover after injury. Group 1 and control group were normal under the microscope, group 2 under 2 mirror neurosis, 3 mirrors can see the nucleus fragmentation and necrosis. Conclusion: Based on the CIONM evaluation of RLN function, LigaSure in the thyroid operation in RLN area application of safety The whole distance is RLN outside 2mm and above, and after single excitation, the application time interval of RLN should be normalized and standardized to avoid the.CIONM sensitivity of the RLN thermal damage caused by its non standard use, to evaluate the changes of RLN function in real time, identify the damage of the RLN in the early stage, and remind the operator to carry out the damage. Anticipation and control are of great significance for neuroprotection and are worthy of promotion.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R653

【参考文献】