本文選題：先天性巨結(jié)腸癥 + 腹腔鏡　； 參考：《河北醫(yī)科大學(xué)》2012年碩士論文

【摘要】：目的：先天性巨結(jié)腸癥（Hirschsprung’s Disease, HD）又稱腸管無神經(jīng)節(jié)細(xì)胞癥，是以消化道遠(yuǎn)端腸壁粘膜下和肌間神經(jīng)叢內(nèi)神經(jīng)節(jié)細(xì)胞缺如為特征的常見發(fā)育畸形。HD的治療經(jīng)歷了Swenson、Duhamel、Soave等術(shù)式的演變，并且隨著微創(chuàng)外科技術(shù)的發(fā)展，腹腔鏡輔助的各種手術(shù)方式也已開展并取得良好效果。雖然單純經(jīng)肛門直腸內(nèi)拖出術(shù)以簡便、微創(chuàng)、美觀而成為短段型和部分常見型HD的主要方法，但腹腔鏡輔助巨結(jié)腸根治術(shù)的適應(yīng)癥更廣泛、并可進(jìn)行術(shù)中活檢確定移行段，處理系膜血管更具有優(yōu)勢。本研究通過總結(jié)我科近年來常用的三種手術(shù)方法治療HD的技術(shù)和結(jié)果，比較并評價腹腔鏡微創(chuàng)技術(shù)特別是經(jīng)臍單孔腹腔鏡監(jiān)視下巨結(jié)腸根治術(shù)治療HD的可行性和安全性，探討其手術(shù)相關(guān)并發(fā)癥的發(fā)生情況及其相應(yīng)處理措施，為避免術(shù)中意外的發(fā)生、減少手術(shù)后并發(fā)癥及防治對策提出可行性建議。 方法：回顧性分析2003～2011年在我科接受HD根治術(shù)治療194例病兒的臨床資料。男142例，女52例，男：女=2.73:1；年齡46天～14歲，平均28.4±34.8月。手術(shù)方法包括開腹Duhamel手術(shù)54例、Ikeda手術(shù)26例、改良Swenson或Soave手術(shù)30例和Boley手術(shù)2例，單純經(jīng)肛門拖出手術(shù)29例，常規(guī)腹腔鏡輔助改良Swenson或Soave手術(shù)29例、單切口腹腔鏡輔助Duhamel手術(shù)3例和經(jīng)臍單孔腹腔鏡監(jiān)視下改良Soave手術(shù)21例。所有病兒根據(jù)典型臨床表現(xiàn)、鋇灌腸和24小時殘留鋇劑檢查、肛管直腸測壓和術(shù)中活檢確定診斷。將具有可比性的開腹、常規(guī)腹腔鏡輔助和經(jīng)臍單孔腹腔鏡輔助下改良Swenson或Soave手術(shù)80例病兒作為研究對象（開腹Swenson或Soave手術(shù)30例、常規(guī)腹腔鏡輔助Swenson或Soave手術(shù)29例和經(jīng)臍單孔腹腔鏡Soave手術(shù)21例），記錄手術(shù)時間、病變類型、術(shù)中和術(shù)后并發(fā)癥、術(shù)后腸功能恢復(fù)時間以及隨訪排便控制情況。 結(jié)果：80例改良Swenson或Soave手術(shù)中HD常見型58例和長段型22例。三種術(shù)式均順利完成手術(shù)，腹腔鏡組無中轉(zhuǎn)開腹及術(shù)中并發(fā)癥出現(xiàn)。男55例，女25例；年齡3個月～14歲，平均25.1±29.0月。各組在性別、年齡和病變類型構(gòu)成比無差別。術(shù)前診斷與術(shù)后病理診斷符合78例，符合率為97.5%。開腹手術(shù)平均耗時185.2±55.9min，術(shù)中平均出血77.8±23.7ml，術(shù)后腸功能恢復(fù)時間3.4±1.1d，術(shù)后并發(fā)癥包括切口感染3例、切口裂開1例、小腸結(jié)腸炎3例和粘連性腸梗阻2例。常規(guī)腹腔鏡輔助手術(shù)平均耗時166.1±56.6min，術(shù)中平均出血23.2±7.9ml，術(shù)后腸功能恢復(fù)時間1.5±0.7d，術(shù)后并發(fā)癥包括小腸結(jié)腸炎2例，回腸末端穿孔1例，不全腸梗阻1例。經(jīng)臍單孔腹腔鏡手術(shù)時間161.0±51.5min，術(shù)中平均出血23.3±8.2ml，術(shù)后腸功能恢復(fù)時間1.3±0.5d，術(shù)后出現(xiàn)并發(fā)癥包括吻合口部分裂開1例，小腸結(jié)腸炎并腹腔殘余感染1例。常規(guī)腹腔鏡組和經(jīng)臍單孔腹腔鏡手術(shù)組較開腹手術(shù)組出血量少(P=0.005)、手術(shù)時間縮短（P=0.036）以及腸蠕動功能恢復(fù)快（P=0.001）；常規(guī)腹腔鏡組和經(jīng)臍單孔腹腔鏡手術(shù)組比較在出血量、手術(shù)時間和腸蠕動功能恢復(fù)時間無差別。開腹手術(shù)切口感染率高、并發(fā)癥多。62例獲得隨訪3個月～10年，除開腹組1例遠(yuǎn)期污糞外，排便功能隨著術(shù)后時間的延長逐漸恢復(fù)，各種術(shù)式在各時段排便功能均無明顯差異；手術(shù)后3個月各組病兒肛門直腸功能基本恢復(fù)正常。無死亡病例發(fā)生。 結(jié)論：通過典型臨床癥狀、鋇灌腸和24小時殘留鋇劑檢查以及肛管直腸測壓可初步診斷HD，手術(shù)中取活檢可以更加精準(zhǔn)地確定病變范圍。腹腔鏡輔助手術(shù)較開腹手術(shù)創(chuàng)傷小、并發(fā)癥少、恢復(fù)快。經(jīng)臍單孔腹腔鏡監(jiān)視下HD根治術(shù)與常規(guī)腹腔鏡手術(shù)相比具有相似的手術(shù)效果和圍手術(shù)期并發(fā)癥的發(fā)生率，，同樣安全可靠，可進(jìn)一步減少腹壁創(chuàng)傷，臍部疤痕隱蔽使美容效果更佳。雖然腹腔鏡HD根治手術(shù)已十分普遍，但依然存在需要注意的細(xì)節(jié)問題，在選擇治療HD腹腔鏡手術(shù)方式時，需要同時考慮到病兒病情和醫(yī)生能力兩方面因素，個體化地選擇熟練技術(shù)，以最小的創(chuàng)傷和痛苦，最徹底的去除病因?yàn)橹委熢瓌t。此外，HD根治術(shù)后需仔細(xì)護(hù)理，若發(fā)生術(shù)后并發(fā)癥應(yīng)早診斷和早治療，從而達(dá)到最佳的治療效果。
[Abstract]:Objective: congenital megacolon (Hirschsprung 's Disease, HD), also known as intestinal anaglioblastic disease, is a common developmental malformed.HD, characterized by the absence of ganglion cells in the distal intestinal wall of the digestive tract and intermuscular plexus, and has undergone the evolution of Swenson, Duhamel, Soave, and with the development of minimally invasive surgery. All kinds of laparoscopic assisted surgery have also been carried out and achieved good results. Although simple, minimally invasive, and beautiful, simple, minimally invasive, and beautiful, the main method of short segment and partial common HD is simple through anorectal dragging, but the indications of laparoscopic assisted megacolectomy are more extensive and can be identified by intraoperative biopsy. In this study, the techniques and results of the treatment of HD in our department in recent years were summarized, and the feasibility and safety of the laparoscopic minimally invasive technique, especially in the treatment of megacolon under the monitoring of megacolon under umbilical single hole laparoscopy, were compared and evaluated, and the incidence of the complications of the operation and the corresponding complications of the operation of the HD were evaluated. In order to avoid intraoperative accidents, reduce postoperative complications, and put forward feasible suggestions for prevention and treatment.
Methods: retrospective analysis of the clinical data of 194 cases of children treated with HD radical operation for 2003~2011 years. 142 men, 52 women, male: female =2.73:1; age 46 to 14 years old, with an average of 28.4 + 34.8 months, including 54 open abdominal Duhamel surgery, 26 cases of Ikeda operation, 30 cases of improved Swenson or Soave operation and 2 cases of Boley operation, simple via anus. 29 cases of open door surgery, 29 cases of conventional laparoscopic assisted modified Swenson or Soave surgery, 3 cases of single incision laparoscopic assisted Duhamel surgery and 21 cases of improved Soave operation under single umbilical laparoscopy were performed. All cases were diagnosed according to typical clinical manifestations, barium enema and 24 hour residual barium examination, anorectal manometry and intraoperative biopsy. With comparability, 80 cases of Swenson or Soave surgery were treated as subjects (30 cases of open Swenson or Soave, 29 cases of Swenson or Soave surgery and 21 cases of single hole laparoscope Soave hand operation). The operative time, type of operation and neutralization were recorded. Postoperative complications, postoperative bowel function recovery time and follow-up defecation control were observed.
Results: in 80 cases of improved Swenson or Soave, there were 58 cases of common HD and 22 cases of long segment. Three kinds of operation were all successfully completed. The laparoscopy group had no transfer to open the abdomen and the complications occurred. 55 men and 25 women; the age 3 months to 14 years, with an average of 25.1 + 29 months. The postoperative pathological diagnosis accords with 78 cases. The average time of 97.5%. laparotomy is 185.2 + 55.9min, the average bleeding in the operation is 77.8 + 23.7ml, and the recovery time of intestinal function is 3.4 + 1.1d. The postoperative complications include 3 cases of incision infection, 1 incision split, 3 cases of enterocolitis and 2 cases of adhesive ileus. The average time of routine laparoscopy assisted surgery is 166.1. The average bleeding was 23.2 + 7.9ml and the recovery time of intestinal function was 1.5 + 0.7d. The postoperative complications included 2 cases of enterocolitis, 1 cases of ileum perforation and 1 cases of incomplete ileus. The time of operation was 161 + 51.5min, the average bleeding was 23.3 + 8.2ml, the recovery time of intestinal function was 1.3 + 0.5d after operation, and postoperative complications occurred. There were 1 cases of anastomosis, 1 cases of enterocolitis and 1 cases of abdominal residual infection. There were less bleeding (P=0.005), shorter operation time (P=0.036) and rapid recovery of intestinal peristalsis (P=0.001) in the conventional laparoscopy group and the single laparoscope operation group, and the routine laparoscopy group and the umbilical single hole laparoscopic operation group were compared to the bleeding. There was no difference in the amount, the time of operation and the recovery time of the intestinal peristalsis. The infection rate of the incision in the open operation was high and the complications were followed up for 3 months to 10 years. Except for the 1 cases of the open faeces in the open group, the defecation function was gradually restored with the extension of the postoperative time. The anorectal function basically returned to normal. No deaths occurred.
Conclusion: barium enema, barium enema, 24 hour barium enema and anorectal manometry can be used to diagnose HD preliminarily, and the range of lesions can be accurately determined by biopsy in the operation. Laparoscopic assisted surgery is less traumatic, less complications and faster recovery. HD radical operation and conventional abdominal cavity under laparoscopy under laparoscopy are used. Endoscopic surgery is similar to the surgical effect and the incidence of perioperative complications. It is also safe and reliable. It can further reduce abdominal trauma and improve the beauty of the umbilical scar. Although laparoscopic HD radical surgery is very common, there is still a problem that needs attention. In the choice of the treatment of HD laparoscopic surgery, It is necessary to take into account the two factors of the illness and the ability of the doctor at the same time, individual choice of skilled technology, with minimal trauma and pain, the most thorough removal of the disease because of the principle of treatment. In addition, after HD radical mastectomy, careful nursing should be taken, and early diagnosis and early treatment should be taken to achieve the best treatment effect if the postoperative complications should be diagnosed and treated.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R726.5

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 湯紹濤;王國斌;阮慶蘭;;腹腔鏡輔助技術(shù)在先天性巨結(jié)腸手術(shù)中的應(yīng)用價值[J];中華小兒外科雜志;2007年07期

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