【摘要】：微創(chuàng)外科是外科領(lǐng)域中發(fā)展的一門新興學(xué)科,是外科發(fā)展史上的里程碑,是21世紀(jì)外科發(fā)展方向之一。腹腔鏡外科是微創(chuàng)外科的重要組成部分,具有微創(chuàng)、視野清晰、出血少、疼痛反應(yīng)輕、術(shù)后機(jī)體恢復(fù)快和組織粘連少等優(yōu)點,該技術(shù)已經(jīng)得到人們的充分認(rèn)識和肯定。人醫(yī)腹腔鏡手術(shù)技術(shù)的研究中,消化道各部位的瘺管手術(shù)已有報道,在動物醫(yī)學(xué)中,腹腔鏡消化道瘺管手術(shù)的開展還相對比較滯后,目前國內(nèi)外尚無腹腔鏡技術(shù)應(yīng)用于小型豬消化道瘺管安裝的報道。因此,本課題進(jìn)行了小型豬腹腔鏡手術(shù)最佳二氧化碳?xì)飧箟旱倪x擇實驗；在最佳氣腹壓條件下設(shè)計并完成小型豬腹腔鏡胃瘺管手術(shù)、小型豬腹腔鏡十二指腸瘺管手術(shù)、小型豬腹腔鏡回腸瘺管手術(shù)；評估小型豬腹腔鏡消化道瘺管手術(shù)的技術(shù)可行性及安全性；進(jìn)行小型豬腹腔鏡消化道瘺管手術(shù)與常規(guī)開腹手術(shù)對機(jī)體影響的比較。 將小型豬隨機(jī)平均分為5組,每組6頭,進(jìn)行最佳氣腹壓的篩選實驗。A組為麻醉組,即OmmHg氣腹壓組；B組為6mmHg氣腹壓組；C組為8mmHg氣腹壓組；D組為10mmHg氣腹壓組；E組為12mmHg氣腹壓組。各組分別于設(shè)定的時間點來監(jiān)測小型豬的呼吸系統(tǒng)、循環(huán)系統(tǒng)、肝腎功能、心肌酶譜、氧化應(yīng)激參數(shù)和神經(jīng)內(nèi)分泌激素,篩選出對機(jī)體影響較小,既安全又適合手術(shù)的最佳氣腹壓值。將小型豬隨機(jī)平均分為6組,每組6頭,進(jìn)行腹腔鏡消化道瘺管手術(shù)和開腹消化道瘺管手術(shù)實驗。通過最佳氣腹壓值充氣腹、手術(shù)通路建立、腹腔鏡下臟器查找、縫合固定、荷包縫合、瘺管插入、瘺管引出及腹腔閉合等操作步驟進(jìn)行小型豬腹腔鏡胃瘺管手術(shù)、小型豬腹腔鏡十二指腸瘺管手術(shù)和小型豬腹腔鏡回腸瘺管手術(shù)。在整個手術(shù)過程中,監(jiān)測小型豬的臨床體征、心率、體溫、收縮壓、舒張壓、平均動脈壓、呼吸頻率、呼吸末二氧化碳分壓、脈搏血氧飽和度。記錄術(shù)中和術(shù)后并發(fā)癥、手術(shù)完成情況、手術(shù)時間、小型豬術(shù)后的精神狀態(tài)、飲食欲、傷口愈合情況和術(shù)后消化液的采集情況,以及腹腔鏡二次探查手術(shù)部位的粘連情況。并于術(shù)后抽取耳緣靜脈血檢測白細(xì)胞總數(shù)、白細(xì)胞介素-6、白細(xì)胞介素-1p和腫瘤壞死因子-α。 實驗結(jié)果表明,低氣腹壓下難以滿足手術(shù)中觀察及操作的要求,高氣腹壓下手術(shù)視野顯露充分,手術(shù)操作方便,但手術(shù)危險性較大。10mmHg氣腹壓表現(xiàn)出對機(jī)體的氧化應(yīng)激水平和神經(jīng)內(nèi)分泌激素影響不大,很快恢復(fù),其中丙二醛和促腎上腺皮質(zhì)激素變化較為明顯,丙二醛在氣腹40mmin一直到放氣后4h還與氣腹前相比差異極顯著,放氣后1d基本恢復(fù)。促腎上腺皮質(zhì)激素在氣腹25min到氣腹60min與氣腹前相比差異極顯著,放氣后10min基本恢復(fù)。所以,小型豬腹腔鏡手術(shù)的最佳氣腹壓值為10mmHg,10mmHg氣腹壓既安全義適合進(jìn)行手術(shù)。 本課題在最佳氣腹壓下成功的完成了小型豬腹腔鏡胃瘺管手術(shù)、小型豬腹腔鏡十二指腸瘺管手術(shù)、小型豬腹腔鏡回腸瘺管手術(shù),以及相應(yīng)的開腹手術(shù)。所有小型豬全部存活,術(shù)中和術(shù)后沒有發(fā)生較大的并發(fā)癥。從手術(shù)結(jié)束到瘺管移除過程中,所有小型豬精神狀態(tài)良好,未發(fā)現(xiàn)任何弓腰、呻吟等疼痛表現(xiàn),飲食欲和排便情況正常。術(shù)后腹壁瘺管引出位點未發(fā)現(xiàn)有消化液滲漏的情況,但存在輕微的炎癥,所有小型豬均于術(shù)后5-7d炎癥消失。術(shù)后均能有效的取出消化液。術(shù)后35d腹腔鏡二次探查中,胃、十二指腸、回腸與腹壁間分別形成穩(wěn)定的粘連,未見其他異常。 小型豬腹腔鏡胃瘺管手術(shù)的平均手術(shù)時間為50min,手術(shù)套管切口平均長度為2.5cm,相應(yīng)開腹手術(shù)的平均手術(shù)時間為37.67min,切口長度平均約8cm小型豬腹腔鏡十二指腸瘺管手術(shù)的平均手術(shù)時間為44.83min,手術(shù)套管切口平均長度為2cm,相應(yīng)開腹手術(shù)的平均手術(shù)時間為33min,切口長度平均約6cm；小型豬腹腔鏡回腸瘺管手術(shù)的平均手術(shù)時間為43.38mmin,手術(shù)套管切口平均長度為2cm,相應(yīng)開腹手術(shù)的平均手術(shù)時間為33.67min,切口長度平均約6cm。腹腔鏡消化道瘺管手術(shù)和開腹消化道瘺管手術(shù)對機(jī)體循環(huán)系統(tǒng)和呼吸系統(tǒng)都有不同程度的抑制作用,表現(xiàn)為心率、體溫、血壓、呼吸頻率和脈搏血氧飽和度下降,呼吸末二氧化碳分壓升高,所有小型豬都能正常耐受,并且很快恢復(fù)到正常,但是腹腔鏡消化道瘺管手術(shù)對機(jī)體的影響較小。腹腔鏡組和開腹組僅僅短期內(nèi)對機(jī)體炎性反應(yīng)產(chǎn)生影響,表現(xiàn)為術(shù)后全血中白細(xì)胞總數(shù)的升高,血清中IL-6、TNF-α、IL-1β濃度的增加,炎性指標(biāo)含量在術(shù)后一段時間內(nèi)很快就可恢復(fù),但是腹腔鏡消化道瘺管手術(shù)引起的機(jī)體炎性反應(yīng)程度比開腹手術(shù)要輕。 通過實驗結(jié)果,得出以下結(jié)論： 1.在注射小型豬復(fù)合麻醉劑全身麻醉和小型豬自主呼吸的狀態(tài)下,小型豬腹腔鏡手術(shù)的最佳氣腹壓值為1OmmHg,10mmHg氣腹壓既安全又適合進(jìn)行手術(shù)。 2.成功地應(yīng)用腹腔鏡技術(shù)完成小型豬胃瘺管手術(shù)、小型豬十二指腸瘺管手術(shù)和小型豬回腸瘺管手術(shù),證明了腹腔鏡技術(shù)在小型豬消化道瘺管安裝中的可行性。 3.通過手術(shù)期間對小型豬臨床體征、呼吸系統(tǒng)和循環(huán)系統(tǒng)進(jìn)行監(jiān)測,以及術(shù)后對小型豬精神狀態(tài)、飲食欲和傷口愈合等進(jìn)行評估,維持在安全范圍之內(nèi),從而有效地保證了小型豬腹腔鏡消化道瘺管手術(shù)的安全性。 4.與開腹消化道瘺管手術(shù)相比,小型豬腹腔鏡消化道瘺管手術(shù)對動物機(jī)體損傷小,術(shù)后并發(fā)癥少,機(jī)體炎性反應(yīng)程度輕,術(shù)后恢復(fù)較快。
[Abstract]:Minimally invasive surgery is a new subject developed in the field of surgery . It is a milestone in the history of surgical development . Laparoscopic surgery is an important part of minimally invasive surgery .
To design and complete mini - pig laparoscopic gastric fistula operation , mini - pig laparoscopic duodenostomy and mini - pig laparoscopic ileostomy under optimal conditions of abdominal pressure ;
To evaluate the technical feasibility and safety of mini - pig laparoscopic digestive tract fistula operation ;
To compare the effect of mini - pig laparoscopic digestive tract fistula and conventional open surgery on the body .

The mini - pigs were randomly divided into 5 groups , 6 heads in each group , and the best air - abdominal pressure was selected .
group B was 6mmHg ;
Group C was 8mmHg .
Group D was 10mmHg .
In the whole procedure , the clinical signs , heart rate , body temperature , systolic pressure , diastolic pressure , average arterial pressure , respiratory rate , systolic pressure , diastolic blood pressure , average arterial pressure , respiratory rate , systolic pressure , diastolic pressure , average arterial pressure , fistula insertion , fistula extraction and abdominal cavity closure were performed .

The experimental results show that it is difficult to meet the requirements of observation and operation in operation under low pressure and abdominal pressure . The operative field of operation is full and the operation is convenient , but the operation risk is high . There is no significant effect on the level of oxidative stress and neuroendocrine hormone in the body .

This study successfully completed mini - pig laparoscopic gastric fistula operation , mini - pig laparoscopic duodenal fistula operation , mini - pig laparoscopic ileostomy fistula operation , and the corresponding laparotomy . All the mini - pigs had good mental state without any major complications during operation .

The mean operative time was 50 min , the mean length of incision was 2 . 5 cm , the mean operative time was 37.67 min , the mean operative time was 44 . 83 min , the mean length of incision was 2 cm , the mean operative time was 33 min and the incision length was about 6 cm .
The average operative time was 43.38mmin , the average length of incision was 2 cm , the mean operative time was 33.67min , the length of incision was about 6 cm .

Through the experimental results , the following conclusions are drawn :

1 . Under the condition of general anesthesia and self - breathing of mini - pigs , the optimal abdominal pressure value of mini - pig laparoscopic surgery is 1OmmHg , and the abdominal pressure of 10mmHg is safe and suitable for operation .

2 . The feasibility of laparoscopic techniques in the installation of small porcine digestive tract fistula was demonstrated successfully by successfully applying laparoscopic techniques to small pig gastric fistula operation , small porcine duodenum fistula operation , and mini - pig ileum fistula operation .

3 . The clinical signs , respiratory system and circulatory system of mini - pigs were monitored during operation , and the mental status , appetite and wound healing of mini - pigs were assessed and maintained within the safe range .

4 . Compared with the open abdominal fistula operation , the small - sized pig laparoscopic digestive tract fistula operation has less damage to the animal body , less postoperative complications , less inflammatory response and faster postoperative recovery .
【學(xué)位授予單位】：東北農(nóng)業(yè)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：S857.12

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本文編號：2131579