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发布时间：2018-06-18 06:13

本文选题：褥式缝合 + 微血管　；参考：《山东大学》2017年博士论文

【摘要】：论文纲要显微外科的诞生和发展,是20世纪现代外科的一个相当重要的发展历程。1960年,美国的两位学者Jacobson及Suarez首先利用他们所设计的精细的小血管吻合器械进行了 1.6mm-3.2mmm的小血管的吻合。1963年1月,我国上海市第六人民医院的陈中伟等在肉眼下进行了小血管的吻合,实现了一例右前臂完全离断病例的再植手术的成功,翻开了世界创伤外科史上的新的一页,也开辟了显微外科的新纪元。随后,随着临床实践、实验研究以及医疗器械、设备、医用材料等的更精细化和专业化的发展,显微外科逐渐发展壮大,成为骨科、手外科、足踝外科、血管外科、整形外科、神经外科、移植外科、耳鼻喉科、口腔颌面外科、妇产科、泌尿外科、眼科等等的重要组成部分;而且,与显微外科技术与理念的结合也使相关领域发展成为各专业的高精尖方向和前沿阵地。然而,显微外科的基础是血管吻合,血管吻合的质量决定着手术的成败、安全性及手术后的恢复效果。从根本上讲,吻合血管的直接目的就是为了实现血液在血管腔中持久而通畅的流动,从而提供并维持组织的供血。血管的吻合质量,受制于手术显微镜、显微器械、显微缝线以及手术医师等众多因素;如何提高微血管的吻合质量、改进吻合方法一直是显微外科临床工作及基础、理论研究的一项重要内容。虽然各种吻合方法不断提出,各种吻合技巧层出不穷,尤其是血管吻合器(一种机械吻合法)也得到了国内外临床医师的广泛应用;但是,显微外科手工缝合一直获得广泛认同,依然是小、微血管吻合的金标准。但是,在临床实践中,手工缝合小、微血管一直是以单纯间断缝合为主,同时手工缝合仍然是一项比较困难的工作,手术医师的临床经验、技术水平甚至医生的状态都能够很大程度的影响其吻合质量,它需要长期的、专业的、大量的训练。如何能够尽可能的减少各种不确定因素,更大程度上保障小、微血管的吻合质量、提高血管的通畅率,也是我们临床医师的一项重要课题。受皮肤及胃肠道的褥式缝合的启发,我们将褥式缝合(包括水平褥式缝合和垂直褥式缝合)应用到了小、微血管的显微外科手工吻合中,获得了成功。在论文的第一章,回顾了2007年1月至2015年12月的血管吻合中应用褥式缝合的临床病例应用情况,其中包括断指再植316例、手指再造32例及游离皮瓣165例。结果表明小、微血管的褥式缝合,可以显著提高小、微血管的吻合质量,明显增加通畅率,而且其操作难度并不高,稍加练习即可掌握,值得临床推广应用。在1960年,Jacobson及Suarez在临床实践的同时,也成功的进行了小血管吻合的动物实验,并且获得了较高的血管通畅率。而且,对于显微外科医师来讲,为了提高临床手术操作水平和小、微血管的吻合熟练程度,也需要利用实验动物进行必要的显微技术训练。实验动物尤其是大鼠,体型较小,实验操作简单方便,可重复性高,而且成本低廉,获取数据简便。鉴于此,在论文的第二章第一部分,我们以Wister大鼠为实验动物,进行了小、微血管显微外科褥式缝合的动物模型的建立,包括端端缝合、端侧缝合、不同口径的动脉缝合、微血管缝合等。论文第二章的第二部分,在所建立的Wister大鼠端端吻合模型上,对褥式缝合与单纯间断缝合的缝合速度与吻合质量进行了对比性研究,初步探讨了小、微血管的显微褥式缝合的特点及优势。另外,论文还综述了血管吻合方法的历史发展历程、现状与未来展望。第一章小、微血管的显微褥式缝合的临床应用目的:探讨褥式缝合在小、微血管显微缝合中的临床应用效果。方法:我们将水平褥式缝合及垂直褥式缝合应用到小、微血管的显微外科缝合当中。回顾了 2007年1月至2015年12月的血管吻合中应用褥式缝合的游离皮瓣165例、断指再植316例及手指再造32例。结果:164例游离皮瓣完全成活,其中5例出现血管危象,经探查后恢复血运完全成活;1例患者因患者一般情况差,患者及家属拒绝探查,最终皮瓣坏死。316例断指再植病例中,308例再植成活,其中26例出现血管危象急诊探查,仅7例出现包括吻合口在内的血管栓塞,16例血管吻合口未栓塞,系因吻合口近端或远端血管挫伤导致的血管栓塞,3例系因单纯的血管痉挛所致;8例坏死病例均为末节挤压离断再植,其中6例获得血管危象探查,探查见其组织损伤严重,血管广泛栓塞,无保留价值,给以行残端修整术,2例患者拒绝手术探查最终坏死。32例再造手指完全成活,其中2例全形再造术后二趾瓣出现血管危象,探查其系血管扭转引起血管痉挛所致,给以离断调整后重新吻合,最终成活。结论:小、微血管的显微褥式缝合,可以显著提高血管的吻合质量,增加通畅率;而且,其操作难度并不高,稍加练习即可掌握,值得临床推广应用。第二章小、微血管的显微褥式缝合的实验研究第一部分小、微血管的显微褥式缝合的模型建立目的:探讨利用Wister大鼠建立小、微血管的显微褥式缝合的动物模型,包括端端吻合、端侧吻合、微血管吻合、不同口径的血管吻合。方法:以健康成年Wister大鼠(体重250g以上)为实验对象,进行小、微血管的显微褥式缝合模型的建立。以成年大鼠尾中动脉(直径约0.5-1.0mm)的近2/3段作为吻合对象建立端端吻合模型;以略小体型大鼠(体重250-300g)的远1/3段的尾中动脉(直径约0.2-0.5mm)为吻合对象建立微血管吻合模型;以成年大鼠的腹主动脉(直径约1.2-1.8mm)与左肾动脉(直径约0.5-0.9mm)的起始处为吻合对象建立端侧吻合模型;以直接吻合成年大鼠的腹主动脉(直径约1.2-1.8mm)与左肾动脉(直径约0.5-0.9mm)来建立口径不同口径的血管吻合模型。结果:显微褥式缝合的模型可以以Wister大鼠为实验对象进行建立,包括端端吻合、端侧吻合、微血管吻合、口径相差较大的血管吻合。结论:Wister大鼠作为小体型、价格便宜的实验动物,可以建立理想的小、微血管的显微褥式缝合模型,而且所建立的血管吻合模型具有可重复性高、简单快捷、易于操作等优点,尤其是利用大鼠尾中动脉进行褥式缝合的练习可以作为显微技术训练的常用方式。第二部分褥式缝合与单纯间断缝合在小、微血管的显微外科端端吻合中缝合速度与吻合质量的对比性研究目的:探讨褥式缝合与单纯间断缝合在小、微血管的显微外科端端吻合中缝合速度与吻合质量的差异,评估褥式缝合的优缺点。方法:以成年Wister大鼠为实验对象,以其尾中动脉近1/3段(直径约0.8-1.0mm)作为拟吻合的血管。分别将进行血管缝合的医生按从事显微外科年限分为3组:低水平组(从事显微外科不超过6月的临床医生)36人,中等水平组(从事显微外科6月-1年的临床医生)28人,高水平组(从事显微外科1年以上的临床医生)12人。每组医生分别应用单纯间断缝合及褥式缝合各吻合尾中动脉的10个吻合口,分别记录每个吻合口的缝合时间,并剖开吻合口观察有无外膜嵌入管腔,并记录有外膜嵌入管腔的吻合口数量,将各数据进行统计学分析。结果:3组的血管缝合速度分别如下:低水平组医生褥式缝合花费的时间为1843±96秒,单纯间断缝合花费的时间为925±84秒;中等水平组医生褥式缝合花费的时间为752±46秒,单纯间断缝合花费的时间为627±30秒;高水平组医生褥式缝合花费的时间为420±32秒,单纯间断缝合花费的时间为465±27秒。3组医生出现外膜嵌入的比例分别如下:低水平组医生单纯间断缝合的出现率为(2.972±1.028)/10,褥式缝合的出现率为0/10;中等水平组医生单纯间断缝合的出现率为(1.750± 1.005)/10,褥式缝合的出现率为0/10;高水平组医生单纯间断缝合的出现率为(0.167±0.389)/10,褥式缝合的出现率为0/10。结论:对于具有低中程度显微外科水平的临床医生来说,小、微血管的单纯间断缝合速度较褥式缝合为快,而相对具有较高水平的显微外科医生来说,褥式缝合反而比单纯间断缝合速度快。这与褥式缝合打结的速度快、打结的个数少有关。更重要的,小、微血管的褥式缝合不管是对什么水平的显微外科医生来说,只要能够顺利完成血管的褥式缝合就可以完全避免外膜嵌入管腔,实现完全的内膜相对,避免内翻。因而,随着临床医生熟练度的增加及技术水平的提高,采用褥式缝合小、微血管,不管是在吻合速度上还是吻合质量上都有优势,尤其是能实现100%的外翻。
[Abstract]:The birth and development of the outline microsurgery is a very important course of development in modern surgery in twentieth Century.1960. Two American scholars, Jacobson and Suarez, first made use of their fine small vascular anastomoses to carry out the anastomosis of small blood vessels of 1.6mm-3.2mmm in January.1963, China's Shanghai No.6 People's Hospital Chen Zhongwei, and so on, anastomosed the small blood vessels under the naked eye, achieved a successful replantation of a case of complete right forearm, opened a new page in the history of world trauma surgery, and opened a new era of microsurgery. Then, with clinical practice, experimental research, medical devices, equipment, medical materials and so on. Microsurgery has gradually developed and became an important component of the Department of orthopedics, hand surgery, ankle surgery, vascular surgery, plastic surgery, Department of Neurosurgery, transplantation surgery, oral and maxillofacial surgery, obstetrics and Gynecology, ophthalmology, and so on; moreover, the combination of microsurgical techniques and ideas also makes the related fields However, the basis of microsurgery is vascular anastomosis, and the quality of the vascular anastomosis determines the success or failure of the operation, the safety and the recovery effect after the operation. Fundamentally, the direct purpose of the anastomosis of blood vessels is to achieve a persistent and smooth flow of blood in the blood vessel cavity, and therefore, Blood supply for and maintenance of tissue. The quality of vascular anastomosis is subject to many factors, such as surgical microscope, microscopic apparatus, microscopic stitch and surgeon. How to improve the quality of microvascular anastomosis and improve the method of anastomosis have always been an important part of the clinical work and foundation of microsurgery. Although various anastomosis methods are constantly raised All kinds of anastomosis techniques emerge in endlessly, especially the vascular stapler (a kind of mechanical kiss), which has also been widely used by clinicians both at home and abroad; however, the microsurgical suture has been widely recognized and still the gold standard for small, microvascular anastomosis. However, in clinical practice, the handmade suture is small and the microvascular is always simple. It is still a difficult job to suture with intermittent suture, while manual suture is still a difficult job. The clinical experience, technical level and even the doctor's state of the surgeon can greatly affect the quality of the anastomosis. It needs long-term, professional, and extensive training. How to reduce all kinds of uncertain factors as much as possible and guarantee to a greater degree It is also an important subject for our clinicians. Inspired by the mattress suture of the skin and gastrointestinal tract, we apply the bedding suture (including horizontal mattress suture and vertical mattress suture) to the microvascular microsurgical manual anastomosis and success in the paper. In the first chapter, the clinical application of bedding suture in vascular anastomosis from January 2007 to December 2015 was reviewed, including 316 cases of finger replantation, 32 cases of finger reconstruction and 165 cases of free flap. The results showed that small, microvascular bedding suture could significantly improve the quality of microvascular anastomosis, and obviously increase patency rate. The difficulty of operation is not high, a little practice can be mastered, and it is worthy of clinical application. In 1960, Jacobson and Suarez were also successful in the experiment of small vascular anastomosis, and obtained high vascular patency. Moreover, for the microsurgeon, in order to improve the clinical operation level and small, In the second chapter of the second chapter of the paper, we take Wister rats as experimental animals. The animal model of microvascular microsurgical mattress suture was established, including end to end suture, end to side suture, different caliber arterial suture, microvascular suture, and so on. The second part of the second chapter of the paper. On the established Wister rat end to end anastomosis model, the suture speed and anastomosis quality of the bedding suture and the simple suture were carried out. In contrast, the characteristics and advantages of microvascular microvascular suture were preliminarily discussed. In addition, the history of the vascular anastomosis, the present situation and the future prospect were also reviewed. The first chapter was the clinical application of microvascular suture: the clinical application of mattress suture in small and microvascular suture. Methods: We applied horizontal mattress suture and vertical mattress suture to microvascular microsurgical suture. We reviewed 165 cases of free flap with bedding suture, 316 cases of finger replantation and 32 cases of finger reengineering in vascular anastomosis from January 2007 to December 2015. Results: 164 cases of free flap survived completely, of which 5 cases were out. There were 1 cases of vascular crisis and 308 cases of replantation of.316, of which 26 cases had an emergency exploration of vascular crisis, only 7 cases had vascular embolism including anastomotic stoma, 16 cases of vascular anastomosis did not. Emboles were caused by vascular embolism caused by proximal or distal vascular contusion of the anastomotic stoma. 3 cases were caused by simple vascular spasm; 8 cases of necrotic cases were all of the distal extrusion and severed replantation, of which 6 cases were detected by vascular crisis. Surgical exploration of the final necrosis of.32 cases of reconstruction of the fingers completely survived, of which 2 cases of total reconstruction of the two toe after reconstruction of vascular crisis, exploration of vascular spasm caused by blood vessel torsion caused by vascular spasm, reanastomose after the adjustment, and finally live. Conclusion: small, microvascular mattress suture, can significantly improve the quality of vascular anastomosis, increased passages The difficulty of operation is not high, and it is difficult to operate with a little practice. It is worthy of clinical application. The second chapter is small, the experimental study of microvascular mattress suture is the first part, and the model of microvascular mattress suture is set up to establish the animal model of microvascular mattress suture by using Wister rats. End-to-end anastomosis, end to side anastomosis, microvascular anastomosis, and different caliber vascular anastomosis. Methods: a healthy adult Wister rat (more than 250g) was used as the experimental object to establish microvascular mattress suture model. The proximal 2/3 segment of the middle caudal artery (about 0.5-1.0mm in diameter) in adult rats was used as the anastomosis object to establish the end to end anastomosis model. A microvascular anastomosis model was established with the middle tail of the distal 1/3 segment of a slightly somatotype rat (body weight 250-300g) (about 0.2-0.5mm in diameter). The abdominal aorta (about 1.2-1.8mm in diameter) in adult rats and the origin of the left renal artery (diameter about 0.5-0.9mm) were anastomosed to the image of the end to side anastomosis, and the abdomen of the adult rat was directly anastomosed to the abdomen of the adult rat. The aorta (diameter about 1.2-1.8mm) and the left renal artery (diameter about 0.5-0.9mm) were used to establish the vascular anastomosis model with different caliber. Results: the model of the mattress suture can be built with Wister rats as the experimental objects, including end to end anastomosis, end to side anastomosis, microvascular anastomosis, and large diameter vascular anastomosis. Conclusion: Wister rats As a small, inexpensive experimental animal, the ideal small, microvascular mattress suture model can be established, and the established vascular anastomosis model has the advantages of high repeatability, simple and quick, easy to operate and so on. Especially, the practice of the mattress suture using the middle tail artery of the rat can be used as a common technique for the microscopic training. Methods. Comparison of second parts of mattress suture and simple intermittent suture in small, microvascular microsurgical end-to-end anastomosis: a comparative study of the suture speed and the quality of anastomosis: To explore the difference between the suture speed and the quality of the anastomosis in the microvascular microsurgical end-to-end anastomosis in the microvascular and the microvascular microsurgery, and to evaluate the advantages of the mattress suture. Methods: the adult Wister rats were used as the experimental object, with the proximal 1/3 segment of the middle tail artery (diameter about 0.8-1.0mm) as the vascular anastomosis. The doctors who performed the vascular suture were divided into 3 groups according to the microsurgical years: the low level group (microsurgery not more than the June clinician), and the medium level group (in microsurgery June - 1 years of clinicians) 28, a high level group (a clinician for more than 1 years of microsurgery) 12. Each group of doctors used 10 anastomotic anastomosis of the middle tail artery of each anastomosis, respectively, with discontinuous suture and mattress suture, respectively, to record the suture time of each anastomosis, and to open the anastomotic stoma without outer membrane, and record the outer membrane inlay. The number of anastomoses into the lumen was statistically analyzed. Results: the 3 groups of vascular suture speed were as follows: the time for the low level group of doctors and bedding sutures was 1843 + 96 seconds, and the time for the simple suture was 925 + 84 seconds; the time of the middle level group doctor's mattress suture was 752 + 46 seconds. The time of the fee was 627 + 30 seconds; the time spent by the high level group of doctors with mattress suture was 420 + 32 seconds. The proportion of the outer membrane embedded in the.3 group was 465 + 27 seconds. The rate of simple intermittent suture was (2.972 + 1.028) /10 and the occurrence rate of the bedding suture was 0/10; the middle level group was the middle level group. The incidence of simple intermittent suture was (1.750 + 1.005) /10, and the occurrence rate of bedding suture was 0/10; the incidence of simple intermittent suture was (0.167 + 0.389) /10 in the high level group, and the occurrence rate of bedding suture was 0/10. conclusion: for clinicians with low and middle degree microsurgical level, small, microvascular simple suture speed Compared to the higher level microsurgeon, the mattress suture is faster than the simple suture. It is faster than the mattress suture, and is less related to the number of knots. The mattress suture of the blood vessel can completely avoid the embed membrane of the outer membrane to achieve complete intimal relative and avoid varus. As a result, with the increase of the proficiency of the clinician and the improvement of the technical level, the mattress suture is small and the microvascular, regardless of the anastomosis speed, is also superior to the quality of the anastomosis, especially to achieve 100%. Ectropion.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R658

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