本文選題：全胸腔鏡手術(shù)　切入點(diǎn)：正中胸骨切開(kāi)手術(shù)　出處：《河北醫(yī)科大學(xué)》2014年碩士論文

【摘要】：二十一世紀(jì)越來(lái)越多的外科醫(yī)生及患者傾向于行微創(chuàng)手術(shù)。應(yīng)用電視胸腔鏡為先天性心臟病患者提供了另一種可行的手術(shù)方式。應(yīng)用電視胸腔鏡的心臟外科手術(shù)在房間隔缺損、室間隔缺損及其他先天性心臟病患者中得以廣泛應(yīng)用。 全胸腔鏡體外循環(huán)下的心臟外科手術(shù)（totally thoracoscopic surgery,TTS）為房間隔缺損、室間隔缺損等心臟手術(shù)提供了一種低損傷的手術(shù)方式。它既有優(yōu)勢(shì)又有缺陷。手術(shù)的成功實(shí)施要求體外循環(huán)、麻醉等手術(shù)設(shè)備的完備，手術(shù)者的技術(shù)過(guò)硬及術(shù)中突發(fā)情況處理的能力。 作為眾多心臟微創(chuàng)手術(shù)方法之一，全胸腔鏡體外循環(huán)下的心臟外科手術(shù)在縮短手術(shù)切口的同時(shí)，保證了手術(shù)質(zhì)量。與傳統(tǒng)胸部正中切口心臟直視手術(shù)相比較，全胸腔鏡體外循環(huán)下的心臟手術(shù)切口小、創(chuàng)傷輕，電視胸腔鏡提供了更加清晰的圖片、開(kāi)闊的視野、更加簡(jiǎn)便的記錄及播放方式，更加重要的是它有著與之相同的手術(shù)效果。但是，這同時(shí)給手術(shù)者在手眼協(xié)調(diào)操作方面提出了更高的要求。電視胸腔鏡的缺陷之一便是只能提供二維的圖像。 自2012年6月以來(lái)，我醫(yī)院心臟外科已經(jīng)成功為12名房間隔缺損及室間隔缺損患者實(shí)施了全胸腔鏡體外循環(huán)下的房室間隔缺損修補(bǔ)手術(shù)，并取得了良好的手術(shù)效果。在此研究中，對(duì)這些患者進(jìn)行了分析及經(jīng)驗(yàn)總結(jié)。 目的：通過(guò)對(duì)全胸腔鏡體外循環(huán)下的心臟房室間隔缺損修補(bǔ)術(shù)與傳統(tǒng)正中胸骨切開(kāi)的心臟房室間隔缺損修補(bǔ)術(shù)在手術(shù)相關(guān)時(shí)間、術(shù)后臨床指標(biāo)、體外循環(huán)轉(zhuǎn)流中各項(xiàng)指標(biāo)結(jié)果的比較，明確全胸腔鏡體外循環(huán)下的房室間隔缺損修補(bǔ)術(shù)的可行性、安全性及優(yōu)缺點(diǎn)。 方法：右側(cè)胸壁打孔行全胸腔鏡體外循環(huán)下的心臟房室間隔缺損修補(bǔ)術(shù)12例為胸腔鏡手術(shù)組（TTS組），采用經(jīng)股血管插管建立體外循環(huán)；同時(shí)期傳統(tǒng)正中胸骨切開(kāi)、體外循環(huán)、心臟停跳條件下心臟房室間隔缺損修補(bǔ)術(shù)13例為正中胸骨切開(kāi)手術(shù)組（MS組），采用經(jīng)主動(dòng)脈、上腔靜脈、下腔靜脈插管建立體外循環(huán)。分析比較兩組患者手術(shù)時(shí)間（min）、術(shù)后清醒所用時(shí)間（min）、術(shù)后呼吸機(jī)輔助時(shí)間（min）、返回病房所用天數(shù)、術(shù)后住院天數(shù)、術(shù)后24小時(shí)引流量（ml）、術(shù)后庫(kù)血用量（ml）、術(shù)后應(yīng)用嗎啡類止痛藥物的頻次[例（%）]、術(shù)后抗生素應(yīng)用天數(shù)、體外循環(huán)時(shí)間（min）、主動(dòng)脈阻斷時(shí)間（min）、術(shù)中平均最低鼻溫（℃）、術(shù)中尿量（ml）、術(shù)中灌注流量（ml/m2/min）、術(shù)中平均灌注壓（kPa）、心臟自動(dòng)復(fù)跳例數(shù)等。 結(jié)果：TTS組患者的平均年齡為31.08±12.14歲，平均體重為59.29±15.07千克，其中包括房間隔缺損患者11例，室間隔缺損患者1例。MS組患者的平均年齡為27.77±12.67歲，平均體重為48.42±13.91千克，13名患者均為房間隔缺損。 在TTS手術(shù)組患者中，手術(shù)時(shí)間為302.50±42.82分鐘，，術(shù)后呼吸機(jī)輔助時(shí)間為343.33±274.97分鐘，術(shù)后清醒所用時(shí)間為150.00±65.88分鐘，術(shù)后患者由重癥監(jiān)護(hù)室返回普通病房的時(shí)間為1.50±0.60天，術(shù)后住院天數(shù)為7.58±1.62天。在MS手術(shù)組患者中，手術(shù)時(shí)間為260.00±49.49分鐘，術(shù)后清醒所用時(shí)間為90.00±58.66分鐘，術(shù)后呼吸機(jī)輔助時(shí)間為349.23±191.50分鐘，術(shù)后患者由重癥監(jiān)護(hù)室返回普通病房的時(shí)間為1.92±3.44天，術(shù)后住院天數(shù)為9.69±2.25天。 在TTS手術(shù)組中,患者的體外循環(huán)時(shí)間為87.50±20.96分鐘，術(shù)后應(yīng)用嗎啡類止痛藥物的頻率為17%，術(shù)后24小時(shí)引流量為111.33±86.86毫升，術(shù)后庫(kù)血用量為400.00±147.70毫升，術(shù)中主動(dòng)脈阻斷時(shí)間為32.00±9.83分鐘，術(shù)中最低鼻溫為28.29±2.66攝氏度，術(shù)中尿量為791.66±487.03毫升，術(shù)中灌注流量為69.58±14.84ml/m2/min，術(shù)中灌注壓為9.41±1.38千帕，12例患者術(shù)中心臟均自動(dòng)復(fù)跳。在MS手術(shù)組中,患者的體外循環(huán)時(shí)間為54.00±10.77分鐘，術(shù)后應(yīng)用嗎啡類止痛藥物的頻率為42%，術(shù)后24小時(shí)引流量為228.46±105.74毫升，術(shù)后庫(kù)血用量為692.30±446.20毫升，術(shù)中主動(dòng)脈阻斷時(shí)間為24.46±16.16分鐘，術(shù)中最低鼻溫為30.23±1.09攝氏度，術(shù)中尿量為719.23±399.75毫升，術(shù)中灌注流量為83.08±10.32ml/m2/min，術(shù)中灌注壓為9.62±1.98千帕，13例患者術(shù)中心臟均自動(dòng)復(fù)跳。 兩組均無(wú)手術(shù)死亡，均順利出院。TTS手術(shù)組較MS手術(shù)組在術(shù)后呼吸機(jī)輔助時(shí)間、術(shù)后抗生素應(yīng)用天數(shù)、主動(dòng)脈阻斷時(shí)間上無(wú)明顯統(tǒng)計(jì)學(xué)差異（P＞0.05）；而TTS手術(shù)組手術(shù)時(shí)間、術(shù)后清醒所需時(shí)間較長(zhǎng)（P＜0.05），返回病房所用時(shí)間、術(shù)后住院時(shí)間較短（P＜0.05），術(shù)后24小時(shí)引流量、術(shù)后庫(kù)血用量較少（P＜0.05），術(shù)后嗎啡類止痛藥物的應(yīng)用頻次較少（P＜0.05），體外循環(huán)轉(zhuǎn)流時(shí)間較長(zhǎng)（P＜0.05），開(kāi)放升主動(dòng)脈后兩組患者心臟均能夠自動(dòng)復(fù)跳。 結(jié)論：全胸腔鏡體外循環(huán)下的心臟房室間隔缺損修補(bǔ)術(shù)雖然在手術(shù)時(shí)間、術(shù)后清醒所用時(shí)間、體外循環(huán)轉(zhuǎn)流時(shí)間上較常規(guī)正中胸骨切開(kāi)手術(shù)組長(zhǎng)，但其手術(shù)切口小、術(shù)后恢復(fù)快、疼痛輕、輸血量少、嗎啡類止痛藥物用量少，此種手術(shù)方法安全可行。
[Abstract]:More and more surgeons and patients tend to be minimally invasive in the twenty - first century . The application of video - assisted thoracoscopic surgery in patients with congenital heart disease provides another possible way of surgery . Cardiac surgery using video - assisted thoracoscopic surgery is widely used in atrial septal defects , ventricular septal defects and other congenital heart disease .

Total thoracoscopic surgery ( TTS ) provides a low - injury surgical approach for cardiac surgery such as atrial septal defect and ventricular septal defect . It has both advantages and disadvantages . The successful implementation of the operation requires the complete operation of surgical equipment such as extracorporeal circulation , anesthesia and the like , and the skill of the operator and the ability of the operation during operation .

As one of the methods of minimally invasive operation of cardiac surgery , the operation of cardiac surgery under the open - heart surgery of the thoracoscopic surgery is to shorten the operation incision and ensure the quality of operation . Compared with the conventional open heart surgery of the chest , the operation incision is small and the trauma is light . The video - assisted thoracoscopic surgery provides a clearer picture , a wide field of view , a more convenient recording and playing mode , and more importantly , it has the same operation effect as it .

Since June 2012 , the cardiac surgery in our hospital has been successfully implemented for 12 patients with atrial septal defect and ventricular septal defect , and has achieved good surgical results . In this study , these patients have been analyzed and summarized .

Objective : To compare the feasibility , safety and advantages and disadvantages of the repair of ventricular septal defect under thoracoscopic cardiopulmonary bypass by comparing the operative time , postoperative clinical index , and cardiopulmonary bypass flow in the repair of the ventricular septal defect of the atrium under the cardiopulmonary bypass of the thoracoscopic surgery .

Methods : 12 cases underwent thoracoscopic surgery group ( TTS group ) by thoracoscopic surgery under thoracoscopic cardiopulmonary bypass ( thoracoscopic surgery ) , and cardiopulmonary bypass was established with femoral vascular cannula .
The operative time ( min ) , the time ( min ) after operation , the time of postoperative ventilator ( ml ) , the time of postoperative antibiotic use ( ml ) , the time of postoperative hospital stay ( ml ) , the time of operation ( ml ) , the mean lowest nasal temperature ( 鈩

本文編號(hào)：1723512