【摘要】： 背景與目的:經(jīng)自然管壁內(nèi)鏡手術(shù)(Natural Orifice TranslumenalEndoscopic Surgery,NOTES)是指不經(jīng)皮膚切口而經(jīng)人體自然孔道,再經(jīng)管壁(如胃、結(jié)腸及陰道等)造口進(jìn)行的內(nèi)鏡手術(shù)。相對(duì)于傳統(tǒng)的開腹手術(shù)和經(jīng)皮膚切口的腹腔鏡手術(shù),NOTES具有腹壁無斑痕、術(shù)后疼痛減少、更加微創(chuàng)及可能縮短住院時(shí)間和減少醫(yī)療開支等潛在優(yōu)勢(shì)。2007年4月法國特拉絲堡大學(xué)醫(yī)院Marescaux小組成功完成了世界首例經(jīng)陰道內(nèi)鏡膽囊切除術(shù),標(biāo)志著又一項(xiàng)新的微創(chuàng)治療時(shí)代即將到來。雖然國際上已有較多動(dòng)物實(shí)驗(yàn)報(bào)道和少數(shù)人體NOTES手術(shù)的個(gè)案研究,但NOTES在人體的應(yīng)用價(jià)值仍受到很多質(zhì)疑;其安全性和有效性目前尚待進(jìn)一步評(píng)估。本研究組于2001年在國內(nèi)首先開展了NOTES的動(dòng)物實(shí)驗(yàn),截至目前這項(xiàng)研究在國內(nèi)已有數(shù)家單位開始動(dòng)物實(shí)驗(yàn)研究,并且開始嘗試于人體的研究。 材料與方法:采用五指山雌性小型豬為實(shí)驗(yàn)動(dòng)物共30只,體質(zhì)量12Kg-15Kg;成年雜種犬12只,體質(zhì)量15Kg-20Kg。術(shù)前禁食1d,不限水;術(shù)中應(yīng)用全身麻醉,氣管插管,呼吸機(jī)輔助呼吸。內(nèi)鏡進(jìn)入胃腸道后,選取胃竇體交界前壁小彎側(cè)及距肛門15cm-20cm結(jié)腸后壁系膜對(duì)側(cè)為造口位置,針狀刀切開后用擴(kuò)張球囊擴(kuò)張?jiān)炜谥?.2cm-1.5cm;內(nèi)鏡從造口進(jìn)入腹腔后注氣形成人工氣腹,進(jìn)行內(nèi)鏡腹腔探查術(shù)和腹部臟器手術(shù);術(shù)中應(yīng)用抗生素預(yù)防感染。研究分為兩個(gè)階段,第一階段以五指山小型豬為研究對(duì)象開展腹腔和腹膜后臟器探查術(shù)、肝臟活檢術(shù)、輸卵管結(jié)扎術(shù)、卵巢切除術(shù)、胃-空腸吻合術(shù)和膽囊切除術(shù)。對(duì)于單一NOTES途徑難以完成手術(shù),采用腹腔鏡輔助完成,采用鈦夾夾閉方法閉合切口。開展急性實(shí)驗(yàn)和存活實(shí)驗(yàn)初步評(píng)價(jià)NOTES的可行性和有效性。第二階段以雜種犬為研究對(duì)象開展經(jīng)臍戳孔輔助經(jīng)胃途徑NOTES膽囊切除術(shù),對(duì)其可行性、有效性和安全性進(jìn)行前瞻性研究。同時(shí)研究胃壁造口的新型閉合方法,評(píng)價(jià)其應(yīng)用價(jià)值。 結(jié)果:共開展NOTES手術(shù)32例次,急性實(shí)驗(yàn)7例次,存活實(shí)驗(yàn)25例次。第一階段以五指山小型豬為研究對(duì)象,開展NOTES手術(shù)20例次,其中經(jīng)胃途徑3例次、經(jīng)結(jié)腸途徑2例次、腹腔鏡聯(lián)合經(jīng)胃途徑NOTES手術(shù)15例次。經(jīng)胃或經(jīng)結(jié)腸途徑腹腔探查均能較好顯示腹腔臟器,如肝臟、膽囊、脾臟、胃、結(jié)腸、部分小腸、膀胱、輸卵管、卵巢、腹壁、膈肌及網(wǎng)膜組織等;完成肝臟活檢術(shù)(4/4)、輸卵管結(jié)扎術(shù)(經(jīng)結(jié)腸途徑2例次,經(jīng)胃途徑2例次,腹腔鏡輔助經(jīng)胃途徑2例次均成功)、卵巢切除術(shù)(經(jīng)結(jié)腸途徑2例次,經(jīng)胃途徑2例次,腹腔鏡輔助經(jīng)胃途徑2例次均成功)、膽囊切除術(shù)7例次(經(jīng)胃或經(jīng)結(jié)腸途徑均失敗;轉(zhuǎn)為腹腔鏡輔助成功3例次);未能完成胰腺探查(0/3)及胃空腸吻合術(shù)(0/2)。腹腔鏡輔助下降低了輸卵管結(jié)扎術(shù)和卵巢切除術(shù)的難度和操作時(shí)間,成功率100%(6/6);腹腔鏡輔助下完成NOTES膽囊切除術(shù)成功率為42.8%(3/7)。第二階段以雜種犬為研究對(duì)象,進(jìn)行了經(jīng)臍戳孔輔助下NOTES膽囊切除術(shù)12例次,一次因?qū)嶒?yàn)設(shè)備損壞終止實(shí)驗(yàn),一次腹腔探查發(fā)現(xiàn)實(shí)驗(yàn)犬腹腔粘連嚴(yán)重終止實(shí)驗(yàn)未列入統(tǒng)計(jì)。完成膽囊切除術(shù)的存活實(shí)驗(yàn)10例次,成功率80%(8/10),平均用時(shí)80min/例次。手術(shù)失敗2例次:1例為術(shù)中腹壓過高致實(shí)驗(yàn)犬術(shù)中死亡,1例為術(shù)后腹腔感染致動(dòng)物術(shù)后一周死亡。閉合管壁造口27例次,其中鈦夾夾閉法成功率50%(6/12),用網(wǎng)膜填塞法成功率93.3%(13/14)。 結(jié)論:①經(jīng)胃或經(jīng)結(jié)腸途徑腹腔探查術(shù)均能較好顯示肝、脾、膽囊、胃、小腸、大腸、腹膜、網(wǎng)膜、腹壁、附件等腹腔臟器,兩條NOTES途徑無明顯差異;②對(duì)腹膜后臟器如胰腺、腎臟、輸尿管等NOTES探查難度較大。③NOTES輸卵管結(jié)扎術(shù)、卵巢切除術(shù)具有一定的安全性,經(jīng)胃或經(jīng)結(jié)腸單一途徑可完成,腹腔鏡輔助可降低輸卵管結(jié)扎術(shù)、卵巢切除術(shù)的難度。④腹腔鏡輔助下的NOTES膽囊切除術(shù)具有一定的可行性,但應(yīng)用五指山小型豬為動(dòng)物模型成功率低。⑤雜種犬能較好的模擬人體進(jìn)行NOTES膽囊切除術(shù)研究。⑥經(jīng)臍戳孔輔助經(jīng)胃途徑NOTES膽囊切除術(shù)有一定的可行性、安全性和有效性。⑦應(yīng)用鈦夾直接夾閉管壁造口難度大、結(jié)果不可靠,應(yīng)用網(wǎng)膜填塞閉合法簡(jiǎn)單、安全和有效。
[Abstract]:BACKGROUND AND OBJECTIVE: Natural Orifice Translumenal Endoscopic Surgery (NOTES) refers to endoscopic surgery performed through the natural canal of the human body and through the canal wall (such as stomach, colon and vagina) without a skin incision. Compared with traditional laparoscopic surgery and skin incision, NOTES has abdominal wall. The Marescaux team of the University Hospital of Trasbourg, France, successfully completed the world's first transvaginal endoscopic cholecystectomy in April 2007, marking the advent of a new era of minimally invasive treatment. Many animal experiments and a few cases of human NOTES surgery have been reported, but the value of NOTES in human body is still questioned; its safety and effectiveness are yet to be further evaluated. Experimental research, and began to try the human body research.
Materials and methods: * there were 30 female miniature pigs in Five Fingers Group as experimental animals. The body weight was 12Kg-15Kg. 12 adult crossbred dogs, body weight 15Kg-20Kg., fasting 1D before operation, without water restriction. General anesthesia, tracheal intubation and ventilator assisted respiration were applied during operation. After endoscopic access to the gastrointestinal tract, the small curvature of the anterior wall of the antral body junction and the 15cm-20cm from the anus were selected. The contralateral side of the posterior mesentery is the stoma site. After the needle knife is cut, the dilated balloon is used to dilate the stoma to 1.2cm-1.5cm. The endoscope is injected into the abdominal cavity to form an artificial pneumoperitoneum after the stoma is injected into the abdominal cavity. * endoscopic peritoneoscopy and abdominal organ surgery are performed. Antibiotics are used to prevent infection during the operation. The research is divided into two stages. The first stage is the study of miniature pigs in Five Fingers Group. The subjects underwent abdominal and retroperitoneal organ exploration, liver biopsy, tubal ligation, ovariectomy, gastrojejunostomy and cholecystectomy. Laparoscopic-assisted closure of the incision with titanium clip was used for the single NOTES approach. Acute and survival experiments were conducted to evaluate NOTES. In the second stage, the feasibility, efficacy and safety of NOTES cholecystectomy assisted by umbilical puncture in hybrid dogs were prospectively studied, and a new closure method of gastrostomy was studied to evaluate its application value.
Results: a total of 32 NOTES operations were performed, including 7 acute cases and 25 survival tests. * in the first stage, 20 cases of NOTES operation were carried out in Five Fingers Group miniature pigs, including 3 cases through the stomach channel, 2 cases via the colon channel, and 15 cases with NOTES operation via laparoscopy combined with gastric route. It shows the abdominal organs, such as liver, gallbladder, spleen, stomach, colon, part of small intestine, bladder, fallopian tube, ovary, abdominal wall, diaphragm and omentum, etc. It completes liver biopsy (4/4), tubal ligation (2 times via colon, 2 times via stomach, 2 times via laparoscopy), ovariectomy (2 times via colon, 2 times via stomach). Laparoscopic-assisted transgastric approach was successful in 2 cases, laparoscopic-assisted transgastric approach in 2 cases, cholecystectomy in 7 cases (all failed through gastric or transcolonic approach; laparoscopic-assisted approach in 3 cases); pancreatic exploration (0/3) and gastrojejunostomy (0/2) were not completed. The success rate of laparoscopic-assisted NOTES cholecystectomy was 42.8% (3/7). In the second stage, 12 cases of NOTES cholecystectomy assisted by umbilical puncture were performed in mongrel dogs. The successful rate of cholecystectomy was 80%(8/10) and the average time of operation was 80 min/time. The operation failed in 2 cases: 1 case died during operation due to excessive abdominal pressure, 1 case died one week after operation due to abdominal infection, 27 cases of closed tube wall stoma, of which the success rate of titanium clip occlusion was 50%(6/12) and the omentum was used to fill in. The success rate was 93.3% (13/14).
CONCLUSION: The two NOTES pathways have no significant difference in the abdominal organs, such as liver, spleen, gallbladder, stomach, small intestine, large intestine, peritoneum, omentum, abdominal wall, appendix and so on. The retroperitoneal organs such as pancreas, kidney, ureter and so on are difficult to explore. Laparoscopic cholecystectomy can reduce the difficulty of Oviduct Ligation and oophorectomy. Laparoscopy assisted NOTES cholecystectomy is feasible, but the success rate of using Five Fingers Group miniature pig as animal model is low. * hybrid dogs can better simulate human body for NOTES. Study on cholecystectomy._Transumbilical notch-assisted transgastric NOTES cholecystectomy is feasible, safe and effective._It is difficult to clip the stoma directly with titanium clip, and the result is unreliable.
【學(xué)位授予單位】：中國人民解放軍軍醫(yī)進(jìn)修學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2009
【分類號(hào)】：R616;R-332

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1 孫剛;經(jīng)自然管壁內(nèi)鏡手術(shù)實(shí)驗(yàn)動(dòng)物研究[D];中國人民解放軍軍醫(yī)進(jìn)修學(xué)院;2009年

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本文編號(hào)：2231028