指触引导技术在微创漏斗胸Nuss手术中的临床应用

发布时间：2018-07-05 11:13

本文选题：Nuss手术 + 漏斗胸　；参考：《南方医科大学》2017年硕士论文

【摘要】：研究背景:漏斗胸是一种常见的先天性胸廓畸形,发病率为0.1%～0.3%,其主要特点是以剑突为中心的胸骨下段及相应的肋软骨向后凹陷。严重情况下凹陷的胸骨会压迫心脏和肺组织,降低肺活量,影响患者的心肺功能。同时胸壁畸形的外观,会造成患者自卑感,心理损害。矫治漏斗胸的手术方式有多种,包括胸骨抬举术(Ravitch术)、胸骨翻转手术和微创Nuss手术。几种手术方式都有各自的特点。Nuss手术以其微创、便捷等优势,成为时下外科医生最为推崇的漏斗胸矫治手术方式。在Nuss手术中,通过在患者胸骨后置入矫形钢板,强制性抬高凹陷的胸骨,达到矫正漏斗胸的目的。但近年来Nuss手术并发症发生率并未明显下降,主要并发症包括术后疼痛、伤口感染及气胸等一般并发症和心脏损伤、肺损伤、膈肌损伤及矫形钢板移位等严重并发症。国内外学者为了避免这些并发症的发生,对手术进行了诸多改良和创新,但术中心、肺损伤等灾难性并发症仍有报道。因此,改进Nuss手术使其更为微创、便捷,同时减少严重并发症的发生率,具有重要的临床应用意义。研究目的:本研究旨在探讨新设计的指触引导技术在Nuss手术中的应用,以避免严重并发症的发生,并分析该技术的可行性、便捷性及安全性。方法:回顾性分析2012年1月至2015年12月期间收治的76名漏斗胸患者,男63例,女13例,年龄范围6-29岁,平均13.3岁,将其分为指触组(34例)和对照组(42例)。指触组是在Nuss手术中做双侧腋前线20mm长切口,并建立肌下隧道进胸。手指探查胸腔并在胸骨后与对侧胸腔的引导器尖端接触,在确认其间无心、肺、膈肌等重要组织后,引导器在手指引导下穿过胸骨后组织到相应位置,从而避免心、肺等组织损伤。术中不使用胸腔镜、引流管及钢板固定器。对照组采用经典的Nuss术式。将两组患者的围手术期情况,术中情况,主要并发症的发生率,住院费用和术后满意度进行对比分析。研究结果:(1)76例患者均顺利完成手术,指触组的平均手术时间明显少于对照组(39.10±10.01vs70.15±12.87min,P=0.0280.05)。(2)指触组的术后平均住院天数少于对照组(2.81±0.71vs 4.01±0.81d,P=0.0480.05)。(3)指触组主要并发症发生率明显少于对照组(8.82%vs 26.19%,P=0.0410.05)。(4)两组患者的术后满意度无显著性差异(P=0.7540.05)。(5)指触组平均住院费用少于对照组(34519±2124.12 vs 42240±1520.24,P=0.0430.05)。结论:新设计的指触引导技术通过手指的保护和引导使漏斗胸的Nuss手术中引导器通过胸骨后盲区的过程更为安全,可最大限度地避免术中心、肺及大血管等重要脏器的损伤。手术过程中不需使用胸腔镜、钢板固定片及胸腔引流管。应用该技术使手术的住院费用明显降低,并且更为安全、微创、便捷,值得进一步推广应用。
[Abstract]:Background: funnel chest is a common congenital thoracic malformation with incidence of 0.1% 0.3%. Its main feature is the inferior sternum and the corresponding depressions of costal cartilage centered on the process of the sword. In severe cases, the depressed sternum compresses the heart and lung tissue, reduces vital capacity, and affects the patient's cardiopulmonary function. At the same time, the appearance of the deformity of the chest wall will cause inferiority complex and psychological damage. There are a variety of surgical methods for the correction of funnel chest, including sternum uplift (Ravitch), sternum turnover and minimally invasive Nuss operation. Several surgical methods have their own characteristics. Nuss surgery with its advantages of minimally invasive convenient and so on has become the most respected surgery method of funnel chest surgery. In the Nuss procedure, orthopedic plate was placed behind the sternum of the patient, and the depressed sternum was forced to be raised to correct the funnel chest. However, the incidence of complications in Nuss surgery has not decreased significantly in recent years. The main complications include postoperative pain, wound infection, pneumothorax, heart injury, lung injury, diaphragm injury and orthopedic plate displacement. In order to avoid these complications, scholars at home and abroad have made many improvements and innovations in the operation, but the surgical center, lung injury and other catastrophic complications are still reported. Therefore, improving Nuss operation to make it more minimally invasive and convenient, while reducing the incidence of serious complications, has important clinical significance. Objective: the purpose of this study was to explore the application of the newly designed touch guide technique in Nuss operation in order to avoid serious complications and to analyze the feasibility, convenience and safety of the technique. Methods: from January 2012 to December 2015, 76 patients with funnel chest were retrospectively analyzed, including 63 males and 13 females, aged 6-29 years (mean 13.3 years). The patients were divided into finger touch group (34 cases) and control group (42 cases). The finger contact group underwent bilateral axillary front 20mm long incision and established a submuscular tunnel into the chest. The finger explores the chest and contacts the tip of the contralateral chest with the guide behind the sternum. After confirming that there is no heart, lung, diaphragm, and other important tissues, the guide passes through the sternum to the appropriate position under the guidance of the finger, thus avoiding the heart. Lung and other tissue damage. Thoracoscope, drainage tube and plate fixator were not used during the operation. The control group was treated with classical Nuss procedure. The perioperative period, intraoperative conditions, incidence of major complications, hospitalization costs and postoperative satisfaction were compared between the two groups. The results were as follows: (1) 76 patients completed the operation successfully. The average operation time in the finger touch group was significantly less than that in the control group (39.10 卤12.87min 卤12.87min, P < 0.0280.05). (2). The average postoperative hospitalization days in the finger touch group was significantly less than that in the control group (2.81 卤0.71vs 4.01 卤0.81dP 0.0480.05). (3). The incidence of major complications in the finger touch group was significantly lower than that in the control group (8.82%vs 26.19g P0.0410.05). (4). There was no significant difference in postoperative satisfaction between the two groups. The average hospitalization cost in the touch group was lower than that in the control group (34519 卤2124.12 vs 42240 卤1520.24). (5). Conclusion: the newly designed finger touch guidance technique can make the process of the guide through the posterior blind area of sternum in the Nuss operation of funnel chest more safe through the protection and guidance of the fingers, and can avoid the injury of important organs such as the center of operation, lung and large blood vessels to the maximum extent. There is no need for thoracoscopy, plate fixation and thoracic drainage during surgery. The application of this technique can significantly reduce the hospitalization cost of the operation, and be more safe, minimally invasive, convenient and worthy of further popularization and application.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R655

【参考文献】