本文選題：腹腔鏡　切入點(diǎn)：前列腺癌根治術(shù)　出處：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：研究背景： 自從1990年Clayman及其同事報(bào)道首例后腹腔鏡下腎臟切除術(shù)以來(lái),腹腔鏡技術(shù)在泌尿外科的應(yīng)用越來(lái)越普及,傳統(tǒng)的開(kāi)放手術(shù)逐漸被腹腔鏡手術(shù)所替代,引起泌尿外科手術(shù)領(lǐng)域的革命性變化。進(jìn)入新世紀(jì)后,以腹腔鏡為代表的微創(chuàng)手術(shù)已經(jīng)成為外科發(fā)展的主流,成為當(dāng)代外科醫(yī)生的必修課。據(jù)統(tǒng)計(jì),在所有需手術(shù)治療的泌尿外科病例中,90%以上的患者通過(guò)微創(chuàng)手術(shù)即可達(dá)到開(kāi)放手術(shù)相似的效果。 前列腺癌根治術(shù)是目前微創(chuàng)外科治療領(lǐng)域最為成功的代表,但同時(shí)也是難度最高的術(shù)式之一,術(shù)中操作復(fù)雜極其復(fù)雜,對(duì)外科醫(yī)生的腔鏡技能要求極高。正因如此,直至1997年Schuessler才報(bào)道首例腹腔鏡下前列腺根治性切除術(shù),并且當(dāng)時(shí)也未能體現(xiàn)出腔鏡下治療的優(yōu)勢(shì)所在；但經(jīng)過(guò)過(guò)去十幾年的發(fā)展及相關(guān)輔助技術(shù)的進(jìn)步,腹腔鏡下前列腺根治性切除術(shù)已成為手術(shù)治療早期前列腺癌的金標(biāo)準(zhǔn)。其所具有的手術(shù)創(chuàng)傷小、術(shù)中出血少、視野清晰、術(shù)后恢復(fù)快等優(yōu)點(diǎn),使患者最大程度的免受手術(shù)所帶來(lái)的痛苦,越來(lái)越多的前列腺癌患者患者渴望享有微創(chuàng)治療,而泌尿外科醫(yī)生也無(wú)不渴望能掌握該種技術(shù)。雖然該種手術(shù)已逐漸成為國(guó)際上早期前列腺癌根治術(shù)的主要術(shù)式,但截至目前,腹腔鏡下前列腺癌根治性切除術(shù)依然為泌尿外科手術(shù)的一大瓶頸,僅在我國(guó)部分大型三甲醫(yī)院開(kāi)展。 研究表明,尿道膀胱吻合是腹腔鏡下前列腺癌根治術(shù)中最耗時(shí)耗力、難度最大的步驟之一,也是限制該種技術(shù)發(fā)展的主要原因之一。這不僅是由于腹腔鏡下前列腺癌根治術(shù)術(shù)程較久,尿道膀胱吻合多處于術(shù)者的疲勞期,而且與吻合部位所處于盆腔的位置有較重要的關(guān)系。雖然國(guó)外已經(jīng)有了機(jī)器人輔助下的腹腔鏡下前列腺癌根治術(shù)來(lái)很好的解決了腹腔鏡下尿道膀胱吻合過(guò)程中的困難,但由于購(gòu)買器械、系統(tǒng)維護(hù)及升級(jí)等均較為昂貴,平均高達(dá)3-7萬(wàn)的手術(shù)費(fèi)用難以被廣大患者所承擔(dān),因此至今僅在我國(guó)北京、上海、南京等少數(shù)大型醫(yī)院開(kāi)展。而傳統(tǒng)的腹腔鏡手術(shù)治療效果與機(jī)器人輔助下治療相比,目前研究并無(wú)明顯統(tǒng)計(jì)學(xué)差異；正因如此,傳統(tǒng)的腔鏡下前列腺癌根治術(shù)目前仍為我國(guó)前列腺癌患者的主要治療方案。 正因如此,提高尿道膀胱吻合技術(shù)對(duì)腹腔鏡下前列腺癌根治術(shù)的提升及發(fā)展均具有重要意義。而國(guó)內(nèi)外研究已表明模型訓(xùn)練對(duì)提升手術(shù)技能具有重要實(shí)用價(jià)值,訓(xùn)練中所掌握的手術(shù)技能亦能很好的轉(zhuǎn)化為實(shí)際手術(shù)應(yīng)用中來(lái),這也為我們指明了提升腹腔鏡技能的方向。但是,至今為止,國(guó)內(nèi)外報(bào)道中并無(wú)十分理想的模型來(lái)模擬腔鏡下尿道膀胱吻合過(guò)程。建立好的模型,不僅有助于我們更好地掌握腹腔鏡下尿道膀胱吻合技術(shù),該種模型的建立及普及也能促進(jìn)腹腔鏡下前列腺癌根治術(shù)的發(fā)展與應(yīng)用,為年輕醫(yī)生盡快把握腹腔鏡下前列腺癌根治術(shù)提供捷徑,也有助于提升我們整體的腹腔鏡水平。 目前國(guó)外已有多家機(jī)構(gòu)進(jìn)行規(guī)范化的腹腔鏡培訓(xùn)及開(kāi)展對(duì)初始人員規(guī)范化腹腔鏡技能訓(xùn)練以縮短腹腔鏡學(xué)習(xí)曲線,而模型訓(xùn)練也被各研究機(jī)構(gòu)證實(shí)可提升腹腔鏡技能。例如一些培訓(xùn)中心應(yīng)用報(bào)道過(guò)的雞皮模型或豬腸吻合模型來(lái)培訓(xùn)年輕的外科醫(yī)生進(jìn)行腹腔鏡下尿道膀胱吻合訓(xùn)練；而在國(guó)內(nèi),專門用于培訓(xùn)年輕外科醫(yī)生腹腔鏡技能的機(jī)構(gòu)依然少見(jiàn),且國(guó)外所建尿道膀胱吻合訓(xùn)練模型在我國(guó)并未得到普及。糾其原由,這主要是雞皮模型制作復(fù)雜,而豬腸模型只能進(jìn)行簡(jiǎn)單的模擬環(huán)形吻合,而不能模擬尿道膀胱吻合術(shù)中所處的較深的環(huán)境及膀胱的活動(dòng)性,且模型訓(xùn)練的價(jià)值未被國(guó)人所重視。因此建立一個(gè)較為實(shí)用且能很好模擬腹腔鏡下尿道膀胱吻合操作環(huán)境的模型對(duì)年輕泌尿外科醫(yī)生縮短腹腔鏡下尿道膀胱吻合學(xué)習(xí)曲線,掌握腹腔鏡下前列腺癌根治術(shù)具有實(shí)用價(jià)值。 我院及我校擁有的臨床技能實(shí)驗(yàn)教學(xué)中心是華南地區(qū)最大的腹腔鏡培訓(xùn)中心之一,內(nèi)有腹腔鏡操作虛擬培訓(xùn)系統(tǒng)、腹腔鏡基本訓(xùn)練器、動(dòng)物實(shí)驗(yàn)室等一大批專門用來(lái)進(jìn)行腹腔鏡手術(shù)培訓(xùn)的教學(xué)及實(shí)驗(yàn)設(shè)備,具備腹腔鏡相關(guān)實(shí)驗(yàn)訓(xùn)練的硬件基礎(chǔ)設(shè)施。 本研究擬利用我院現(xiàn)有設(shè)備及資源,通過(guò)建立新型的尿道膀胱吻合模型,對(duì)參與培訓(xùn)人員開(kāi)展腹腔鏡下尿道膀胱吻合模型的模擬訓(xùn)練,以期通過(guò)訓(xùn)練來(lái)提升參與者的腹腔鏡操作水平,并通過(guò)吻合質(zhì)量對(duì)該模型的實(shí)用性進(jìn)行評(píng)價(jià)；通過(guò)多次訓(xùn)練及針對(duì)不同縫合部位不同的進(jìn)針及持針?lè)绞?探索腹腔鏡下尿道膀胱吻合最有利的縫合方法,以達(dá)到最快縫合速度及最好的縫合效果,通過(guò)把握該吻合方法以期達(dá)到縮短腹腔鏡下前列腺癌根治術(shù)的目的。研究目的： 1、設(shè)計(jì)并制作出能逼真地模擬腹腔鏡下尿道膀胱吻合過(guò)程的新模型。 2、通過(guò)對(duì)學(xué)員的模型訓(xùn)練實(shí)驗(yàn)來(lái)評(píng)價(jià)該模型的有效性,通過(guò)多次訓(xùn)練及針對(duì)不同縫合部位不同的進(jìn)針及持針?lè)绞?探索提高腹腔鏡下尿道膀胱吻合技巧及縫合質(zhì)量的縫合方法,以達(dá)到最快縫合速度及最好的縫合效果。 3、經(jīng)過(guò)訓(xùn)練,使參與者熟悉掌握腹腔鏡外科手術(shù)的理論知識(shí)及基本操作技能,進(jìn)而提升腹腔鏡操作水平,探索初學(xué)者快速掌握腹腔鏡下前列腺癌根治術(shù)的中最耗時(shí)、最費(fèi)力的尿道膀胱吻合的方法,解決尿道膀胱吻合的關(guān)鍵性技術(shù)難題,以期達(dá)到縮短腹腔鏡下前列腺癌根治術(shù)學(xué)習(xí)曲線,提高術(shù)中吻合效果,減少術(shù)后并發(fā)癥。并希望該模型能在臨床腹腔鏡培訓(xùn)中應(yīng)用和推廣,促進(jìn)前列腺癌微創(chuàng)治療技術(shù)的開(kāi)展及普及。 研究方法： (1)理論學(xué)習(xí)與基礎(chǔ)訓(xùn)練：系統(tǒng)學(xué)習(xí)腹腔鏡外科的理論知識(shí),掌握腹腔鏡設(shè)備的工作原理及使用方法。利用我院腹腔鏡培訓(xùn)中心設(shè)備,進(jìn)行腹腔鏡下基本訓(xùn)練操作,具體內(nèi)容如下：腹腔鏡鏡頭聚集訓(xùn)練、夾豆轉(zhuǎn)移訓(xùn)練、剪切紗布訓(xùn)練、模型肉板縫合訓(xùn)練來(lái)掌握腹腔鏡手術(shù)所必需的三維空間感知、手眼分離、雙手協(xié)調(diào)運(yùn)動(dòng)及定位、剪切、縫合、打結(jié)等基本操作的能力。進(jìn)行為期一周每天2小時(shí)的學(xué)習(xí)訓(xùn)練。 (2)模型的設(shè)計(jì)：在既往所報(bào)道的模型構(gòu)建仔細(xì)分析的基礎(chǔ)上,選擇合適的豬膀胱和尿道分別代替人膀胱和尿道,把備吻合部位修剪為直徑一致、直徑約2.0cm左右,并以挖空的內(nèi)臟的雞軀殼模擬盆腔環(huán)境,進(jìn)行腹腔鏡下尿道膀胱吻合新模型。 (3)尿道膀胱吻合模型訓(xùn)練：共20名來(lái)自腹腔鏡培訓(xùn)中心訓(xùn)練人員(均無(wú)腹腔鏡操作經(jīng)驗(yàn))利用我們自制的尿道膀胱吻合模型進(jìn)行縫合訓(xùn)練,記錄完成每次操作所用的時(shí)間、漏出量。所有結(jié)果均由一位腹腔鏡經(jīng)驗(yàn)豐富的高級(jí)醫(yī)師來(lái)評(píng)估并記錄統(tǒng)計(jì)；時(shí)間是指操作者由開(kāi)始到完成某項(xiàng)任務(wù)所經(jīng)歷的時(shí)間,也是由專人記錄。 (4)通過(guò)數(shù)據(jù)統(tǒng)計(jì)分析,分析比較參與培訓(xùn)測(cè)試人員應(yīng)用該新模型縫合前后成績(jī)比較,并對(duì)時(shí)間與漏出量進(jìn)行相關(guān)性分析。計(jì)量資料的比較采用獨(dú)立樣本t檢驗(yàn),結(jié)果數(shù)據(jù)以(x±s)表示,數(shù)值間比較采用方差分析(p0.05有統(tǒng)計(jì)學(xué)意義)。相關(guān)性分析采用直線回歸方法(兩變量間擬合優(yōu)度以決定系數(shù)R20.3視為有統(tǒng)計(jì)學(xué)意義)。 結(jié)果： 1.經(jīng)過(guò)為期1周的基本訓(xùn)練后所有人員均達(dá)到：①3分鐘內(nèi)準(zhǔn)確無(wú)誤地鉗夾轉(zhuǎn)移黃豆大于等于15粒,平均(17±1.32)個(gè)；②縫合長(zhǎng)約10cm模型切口6針,用時(shí)小于等于10分鐘平均(9±0.95)min,且縫合過(guò)程中出現(xiàn)撕裂切口小于2處的要求；③所有操作人員均完成規(guī)定時(shí)間內(nèi)的圖形剪切操作訓(xùn)練,平均時(shí)間為(4±0.86)min。 2.所有人員經(jīng)過(guò)30次縫合,統(tǒng)計(jì)每次縫合的時(shí)間及漏出量,整個(gè)實(shí)驗(yàn)過(guò)程平均手術(shù)時(shí)間：47.22±12.33min,平均漏出量：10.59±3.00ml；而訓(xùn)練第一次與最后一次平均縫合時(shí)間分別為68.42±8.10(分鐘)與25.21±1.88(分鐘),整個(gè)縫合過(guò)程操作時(shí)間呈現(xiàn)逐漸下降趨勢(shì),至24次左右以后基本維持在25min左右水平,第24次以后至第30次縫合時(shí)間,經(jīng)方差分析未見(jiàn)統(tǒng)計(jì)學(xué)差異(F=0.78,P=0.32)；而漏出量由第一次的14.82±4.08(ml)降至最后一次的1.47±0.65(ml),第20次以后至第30次漏出量經(jīng)方差分析未見(jiàn)明顯統(tǒng)計(jì)學(xué)差異(F=0.91,P=0.07),至20次以后基本維持在3ml以下水平；縫合時(shí)間及漏出量實(shí)驗(yàn)前后比較具有顯著統(tǒng)計(jì)學(xué)差異(P0.05)。可見(jiàn)經(jīng)過(guò)訓(xùn)練所有參與者的縫合速度及縫合質(zhì)量均有明顯提高。相關(guān)性分析提示縫合時(shí)間與漏出量呈正相關(guān)性(R2=0.73,F=263.64,P0.01),提示隨著手術(shù)操作熟練,吻合質(zhì)量也相應(yīng)提高。證實(shí)模型訓(xùn)練對(duì)提升腹腔鏡下尿道膀胱吻合訓(xùn)練過(guò)程有顯著效果。 結(jié)論： (1)通過(guò)培訓(xùn)學(xué)習(xí),所有參與者熟悉掌握了腹腔鏡外科手術(shù)的基本理論知識(shí)�；臼煜ち烁骨荤R手術(shù)的各種器械,掌握了腹腔鏡手術(shù)的所必須的剪切、縫合、打結(jié)等基本操作技能。 (2)通過(guò)模型訓(xùn)練,不僅使受訓(xùn)者掌握基本的環(huán)形吻合方法及技巧,更能適應(yīng)盆腔這一特殊部位的操作能力,從而提升尿道膀胱吻合的能力并把握吻合過(guò)程中所需的進(jìn)針角度技巧,提高吻合質(zhì)量。 (3)新型腹腔鏡下膀胱尿道吻合訓(xùn)練模型能有效幫助泌尿外科醫(yī)生掌握腹腔鏡下膀胱尿道吻合技術(shù),而我們通過(guò)實(shí)驗(yàn)訓(xùn)練中所摸索的方法可能會(huì)有利于縮短尿道膀胱吻合曲線。 (4)熟練的腹腔鏡下縫合打結(jié)技術(shù)是手術(shù)能夠成功進(jìn)行的關(guān)鍵因素之一,是術(shù)中止血、縫合、打結(jié)的必備技能。 (5)腹腔鏡培訓(xùn)操作可很好地提高初學(xué)者的腹腔鏡基本技能水平,并有利于培訓(xùn)人員腔鏡技術(shù)進(jìn)一步提升,腹腔鏡下模型訓(xùn)練可針對(duì)性提高某項(xiàng)特定技能,值得對(duì)臨床醫(yī)師在該類手術(shù)初級(jí)培訓(xùn)中推廣。
[Abstract]:Background of Study :

Laparoscopic surgery has become more and more popular in the field of urology since the first post - laparoscopic nephrectomies reported by clay man and his colleagues in 1990 . Traditional open surgery has gradually been replaced by laparoscopic surgery , leading to a revolutionary change in the field of urology surgery . After entering the new century , minimally invasive surgery represented by laparoscopy has become a compulsory course for contemporary surgeons . According to statistics , more than 90 % of patients in surgical treatment can achieve similar effects by minimally invasive surgery .

Radical resection of prostate cancer is one of the most successful cases in minimally invasive surgical treatment , but it is also one of the most difficult surgical procedures . The operation is complicated and complicated , and the requirements for the surgeon ' s endoscopic skills are extremely high .
However , as of the present time , radical resection of prostate cancer is still a major bottleneck in urology surgery , and it is only carried out in some large 3A hospitals in China .

The study shows that the urinary bladder anastomosis is one of the most time consuming and difficult steps in laparoscopic radical prostatectomy , and is one of the main reasons for limiting the development of the technique .
Because of this , radical prostatectomy for prostate cancer is still the primary treatment for prostate cancer patients in China .

So far , it is not only helpful for us to grasp the development and application of laparoscopic radical prostatectomy , but also to help us grasp the development and application of laparoscopic radical prostatectomy . So far , the establishment and popularization of this model can also promote the development and application of laparoscopic radical prostatectomy .

At present , several institutions have standardized laparoscopic training and standardized laparoscopic skills training for the initial personnel to shorten the laparoscopic learning curve , and the model training is also confirmed by the research institutions to improve the laparoscopic skills . For example , some training centers have applied the reported chicken skin model or porcine intestinal anastomosis model to train young surgeons to perform the laparoscopic urinary bladder anastomosis training ;
It is still rare in China to train young surgeons ' laparoscopic skills , and the model of urinary bladder anastomosis training abroad has not been popularized in our country . It is mainly that the chicken skin model is complicated , and the model can only carry out simple simulated circular anastomosis , and the value of the model training is not recognized by the Chinese . Therefore , a model for the younger urological surgeon to shorten the laparoscopic urinary bladder anastomosis learning curve can be shortened by a model which can simulate the operation environment of the urinary bladder anastomosis under the laparoscope , and the method has practical value for the radical operation of the prostate cancer under the laparoscope .

Our hospital and our own clinical skill experiment teaching center is one of the largest laparoscopic training centers in South China . There are a large number of teaching and experimental equipment specially used for laparoscopic surgery training , such as laparoscopic operation virtual training system , laparoscope basic trainer , animal laboratory , etc . , and has the hardware infrastructure of laparoscopic related experimental training .

This study intends to use the existing equipment and resources of our hospital , and to establish a new model of urinary bladder anastomosis through the establishment of a new anastomosis model of urinary bladder , in order to improve the level of laparoscopic operation of the participant through training , and to evaluate the practicability of the model by the quality of anastomosis ;
Through multiple training and different needle and needle holding methods for different suture sites , this paper explores the most favorable suture method of laparoscopic lower urinary bladder anastomosis , so as to achieve the fastest suture speed and the best suture effect , and by grasping the anastomosis method , the aim of shortening the radical operation of the prostate cancer under the laparoscope is achieved .

1 . To design and produce a new model which can realistically simulate the anastomosis procedure of urinary bladder under laparoscope .

2 . To evaluate the effectiveness of the model by model training experiment , and to explore the methods of improving the anastomosis skill and suture quality of the urinary bladder under laparoscope through multiple training and different needle and needle holding methods aiming at different suture parts , so as to achieve the fastest suture speed and the best sewing effect .

3 . After training , the participants are familiar with the theoretical knowledge and basic operating skills of laparoscopic surgery , so as to improve the level of laparoscopic operation , and to explore the most time - consuming and labor - consuming method of the primary scholar to grasp the most time - consuming and labor - consuming urethral bladder anastomosis in the laparoscopic radical prostatectomy , so as to shorten the learning curve of the radical operation of the prostate cancer under the laparoscope , improve the anastomosis effect in the operation and reduce postoperative complications .

Study method :

( 1 ) Theory study and basic training : The system learns the theory knowledge of laparoscopic surgery , grasps the working principle and the using method of the laparoscope equipment , uses the laparoscope training center equipment of our hospital to carry out the basic training operation under the laparoscope , the concrete contents are as follows : laparoscope lens gathering training , bean clamping transfer training , shearing gauze training , model meat plate suture training to master the three - dimensional space perception , the hand - eye separation , the hand coordination movement and the positioning , shearing , sewing , tying and other basic operations necessary for the laparoscopic surgery .

( 2 ) The design of the model : Based on the analysis of the previously reported model , the appropriate porcine bladder and urethra were selected to replace the urinary bladder and the urethra respectively . The anastomosis site was cut into a uniform diameter and approximately 2.0cm in diameter .

( 3 ) Training of urinary bladder anastomosis model : a total of 20 training personnel from the laparoscopic training center ( no experience in laparoscopic operation ) were trained using our self - made urethra bladder anastomosis model to record the time and leakage of each operation . All the results were evaluated and recorded by a highly experienced senior physician ;
Time means the time experienced by the operator from the beginning to the completion of a task , as well as by a specially assigned person .

( 4 ) By means of statistical analysis and statistical analysis , the results are compared with the results obtained before and after the application of the new model , and the correlation between time and leakage is analyzed . The comparison of the measured data adopts independent sample t test , and the result data is expressed by ( x 鹵 s ) . The correlation analysis adopts linear regression method ( the goodness of fit between the two variables is considered statistically significant with the coefficient of determination 202.3 ) .

Results :

1 . After 1 week of basic training , all the personnel have reached : 鈶，

本文編號(hào)：1679681