本文選題：單孔腹腔鏡手術(shù) + 多通道套管��； 參考：《東南大學(xué)》2015年博士論文

【摘要】：目的：單孔腹腔鏡手術(shù)(Laparoendoscopic Single-Site Surgery. LESS)是微創(chuàng)外科領(lǐng)域的新進(jìn)展,近年來獲得了國內(nèi)外學(xué)者的熱切關(guān)注。LESS將所有器械以近乎平行的方式通過腹壁唯一切口進(jìn)出腹腔,造成腹腔內(nèi)“操作三角”消失,腹腔外器械把手之間相互擁擠碰撞,直線型視野,缺乏有效牽引。目前針對上述制約LESS發(fā)展的瓶頸,已經(jīng)開發(fā)出LESS相關(guān)專用器械,包括各種類型的多通道鞘卡、不同彎曲型態(tài)的操作器械以及各類牽引裝置,但尚不能完全適應(yīng)LESS操作需求。和傳統(tǒng)腹腔鏡手術(shù)(Conventional Laparoscopic Surgery, CLS)相比較,LESS操作存在很大的困難,其基本操作規(guī)律、臨床獲益及并發(fā)癥的處理仍然沒有定論。本研究旨在根據(jù)LESS特點(diǎn)研制符合LESS操作需求的專用器械,通過動(dòng)物實(shí)驗(yàn)研究驗(yàn)證所研發(fā)的LESS專用器械的可靠性及安全性,探索LESS復(fù)雜手術(shù)的可行性,并開展LESS臨床研究探討其臨床獲益,同時(shí)利用分子生物學(xué)方法加強(qiáng)LESS術(shù)后經(jīng)腱膜切口的愈合,預(yù)防LESS術(shù)后臍部切口疝的發(fā)生。方法：(1)根據(jù)LESS特點(diǎn)研制新型柔性多通道套管、多功能解剖器和“魚鉤”式牽引裝置,并首次在動(dòng)物實(shí)驗(yàn)中實(shí)施單孔腹腔鏡膽囊造瘺及胰體尾切除手術(shù),驗(yàn)證所研制的上述LESS專用器械的可靠性和安全性,探討LESS復(fù)雜手術(shù)的可行性,總結(jié)LESS的基本操作規(guī)律。(2)綜合利用所研制的LESS專用器械開展單孔腹腔鏡對比傳統(tǒng)腹腔鏡闌尾切除的隨機(jī)對照研究、單孔腹腔鏡對比傳統(tǒng)腹腔鏡膽囊切除的歷史隊(duì)列研究以及單孔腹腔鏡腹股溝疝修補(bǔ)手術(shù)病例報(bào)道,初步探討LESS的臨床獲益。(3)利用骨形態(tài)發(fā)生蛋白-12 (Bone Morphogenetic Protein-12, BMP-12)誘導(dǎo)間充質(zhì)干細(xì)胞(Mesenchymal Stem Cells, MSCs)向腱細(xì)胞分化,體外構(gòu)建誘導(dǎo)分化的MSCs-膠原蛋白海綿復(fù)合物種植于經(jīng)腹正中白線切口,探討其加強(qiáng)LESS經(jīng)腱膜切口愈合的效果。結(jié)果：(1)所研制單孔腹腔鏡柔性多通道套管符合LESS操作需求,獲得相關(guān)專利及注冊生產(chǎn)許可,其主要特點(diǎn)為：柔性材料制作,氣密性可靠,器械活動(dòng)度大；通道之間的間距大,有效避免器械相互碰撞。單彎曲多功能解剖器具備切割、電凝、止血、分離、沖洗和吸引的功能,避免了LESS中頻繁更換器械,節(jié)約手術(shù)時(shí)間,減輕手術(shù)者的勞動(dòng)負(fù)荷。“魚鉤”式牽引裝置制作材料容易獲得,制作方法簡單,釋放、解除方法容易掌握。使用上述專用器械實(shí)施3例單孔腹腔鏡膽囊造瘺以及6例單孔腹腔鏡胰體尾切除手術(shù)。其中1例單孔腹腔鏡膽囊造瘺術(shù)后2月出現(xiàn)臍部切口疝,1例單孔腹腔鏡胰體尾切除動(dòng)物術(shù)中死亡,其余動(dòng)物術(shù)后恢復(fù)良好,無明顯并發(fā)癥。該部分動(dòng)物實(shí)驗(yàn)為LESS保膽手術(shù)奠定基礎(chǔ)并驗(yàn)證了LESS復(fù)雜手術(shù)的可行性。總結(jié)了LESS基本操作規(guī)律,即：臍靶屏軸樞原則；“倒金字塔”原則；人體工程學(xué)原則；輔助原則；階段遞進(jìn)原則；全面優(yōu)化原則。(2)共98名患者納入LESS對比CLS闌尾切除的隨機(jī)對照研究。LESS組手術(shù)時(shí)間比CLS組延長(90.71±33.25min vs 74.9± 46.94min, P=0.057), LESS組有4例病例中轉(zhuǎn)為CLS,和CLS組比較中轉(zhuǎn)率有統(tǒng)計(jì)學(xué)差異(P=0.041)。術(shù)后腹壁美觀度評價(jià),LESS組明顯優(yōu)于CLS組(P0.001)。本研究中心共選擇性實(shí)施了23例單孔腹腔鏡膽囊切除病例,將其和傳統(tǒng)腹腔鏡膽囊切除病例相比較,手術(shù)時(shí)間、中轉(zhuǎn)率、術(shù)中出血、住院時(shí)間、并發(fā)癥兩組之間無統(tǒng)計(jì)學(xué)差異(P0.05),術(shù)后腹壁美觀度評價(jià),LESS組明顯優(yōu)于CLS組(P=0.021)。本中心實(shí)施2例單孔腹腔鏡腹股溝疝修補(bǔ)術(shù),隨訪6個(gè)月,無臍部切口疝、疝復(fù)發(fā)等并發(fā)癥,臍部疤痕幾乎不可見。(3)分離培養(yǎng)骨髓來源MSCs,應(yīng)用不同濃度BMP-12誘導(dǎo)MSCs向腱細(xì)胞分化,利用Real-time PCR檢測Scx、collagen Ⅰ、collagen Ⅲ基因表達(dá)水平及Western Blot檢測Collagen I的表達(dá)來確定BMP-12的最佳誘導(dǎo)分化濃度為10ng/ml。Western Blot證實(shí)BMP-12通過多條信號通路誘導(dǎo)MSCs向腱細(xì)胞分化,Smad通路作用顯著,對P38、JNK有很強(qiáng)的活化作用,激活ERK通路的作用甚微。體外構(gòu)建誘導(dǎo)分化的MSCs-膠原蛋白海綿復(fù)合物,種植于大鼠經(jīng)腹正中白線切口,4周后檢測其能承受的最大拉力為正常腹白線組織的69.7%,優(yōu)于其他不同對照組(P0.05)。HE及Masson染色顯示實(shí)驗(yàn)組再生膠原蛋白纖維增多,和周圍腹壁肌肉分隔清晰,排列緊密有序。結(jié)論：(1)所研制的單孔腹腔鏡柔性多通道套管、多功能解剖器、“魚鉤”式牽引裝置符合LESS操作需求,有效、安全、可靠。(2)總結(jié)了LESS基本操作規(guī)律：臍靶屏軸樞原則；“倒金字塔”原則；人體工程學(xué)原則；輔助原則；階段遞進(jìn)原則；全面優(yōu)化原則。(3)臨床研究證實(shí)相對于CLS, LESS難度增大,手術(shù)時(shí)間延長,手術(shù)中轉(zhuǎn)率升高,并發(fā)癥發(fā)生率未有明顯差異,術(shù)后理想的腹壁美容效果是LESS最大的優(yōu)勢。(4)BMP-12通過多條信號通路誘導(dǎo)MSCs向腱細(xì)胞分化,Smad通路作用顯著,對P38、JNK有很強(qiáng)的活化作用,激活ERK通路的作用甚微。BMP-12誘導(dǎo)MSCs成腱細(xì)胞分化可促進(jìn)單孔腹腔鏡經(jīng)腱膜切口愈合。
[Abstract]:Objective: single hole laparoscopic surgery (Laparoendoscopic Single-Site Surgery. LESS) is a new progress in the field of minimally invasive surgery. In recent years, scholars at home and abroad have received the hot attention of.LESS to bring all the instruments in and out of the abdominal cavity through the only incision in the abdominal wall in a near parallel way, resulting in the disappearance of the "operation triangle" in the abdominal cavity and the outside of the abdominal apparatus handle. Among the bottlenecks restricting the development of LESS, LESS related special devices have been developed, including various types of multi-channel sheathing cards, different curved types of operating instruments and various traction devices, but it is still not fully adapted to LESS operation requirements and traditional laparoscopic hands. Compared with Conventional Laparoscopic Surgery (CLS), there is a great difficulty in the operation of LESS. The basic rules of operation, the clinical benefit and the treatment of complications are still unsettled. The purpose of this study is to develop a special instrument to meet the requirements of the LESS operation according to the characteristics of LESS and to verify the available LESS equipment developed by the animal experiment. To explore the feasibility of LESS complex surgery and to explore the clinical benefits of LESS clinical study, and to strengthen the healing of the aponeurosis incision after LESS and to prevent the occurrence of umbilical incisional hernia after LESS. Methods: (1) a new flexible multichannel cannula, a multifunctional dissection and a multi-functional dissection is developed according to the LESS special point. "Fish hook" type traction device, and for the first time in animal experiments to implement single hole laparoscopic cholecystostomy and pancreatic body tail resection, verify the reliability and safety of the developed LESS special equipment, explore the feasibility of LESS complex operation and summarize the basic operation rules of LESS. (2) comprehensive use of the developed LESS special instruments to carry out a single instrument. A randomized controlled study of laparoscopic appendectomy compared to traditional laparoscopic appendectomy. Single hole laparoscopy compared to traditional laparoscopic cholecystectomy history cohort study and single hole laparoscopic inguinal herniorrhaphy cases report, preliminary study of the clinical benefits of LESS. (3) using bone morphogenetic -12 (Bone Morphogenetic Protein-12, BMP-12) Mesenchymal Stem Cells (MSCs) was induced to differentiate into the tendon cells. In vitro, the induced MSCs- collagen sponge complex was planted in the Fu Zhengzhong white line incision to explore the effect of enhancing the healing of LESS through the aponeurosis incision. Results: (1) the single hole laparoscopic flexible multichannel casing was developed to meet the requirement of LESS operation. The main features of relevant patents and registered production licenses are: flexible material making, reliable air tightness, large equipment activity, large distance between channels and effective avoidance of collision between instruments. Single bending multi-functional dissection has the functions of cutting, electrocoagulation, hemostasis, separation, flushing and attraction, avoiding frequent replacement of instruments in LESS. The operation time alleviated the labor load of the surgeon. The "fish hook" traction device was easy to obtain, the production method was simple, the release method was easy to master. 3 cases of single hole laparoscopic cholecystostomy and 6 cases of single hole laparoscopic pancreatic body tail resection were performed with the special equipment mentioned above. Of them, 1 cases of single hole laparoscopic cholecystostomy were 2. 1 cases of single hole laparoscopic pancreatectomy were killed in 1 cases, and the rest of the animals recovered well and had no obvious complications. This part of the animal experiment laid the foundation for the biliary operation and verified the feasibility of the LESS complex operation. The basic operation rules of the LESS were summarized, that is, the principle of the umbilical target screen axis armature; "inverted Pyramid". "Principle; ergonomics principle; auxiliary principle; progressive principle; comprehensive optimization principle. (2) a total of 98 patients were included in LESS contrast CLS appendectomy randomized controlled study longer than group CLS (90.71 + 33.25min vs 74.9 + 46.94min, P=0.057), LESS group had 4 cases transferred to CLS, and CLS group rate of transfer rate. There were statistical differences (P=0.041). The beauty of abdominal wall was evaluated and group LESS was obviously superior to group CLS (P0.001). 23 cases of single hole laparoscopic cholecystectomy were carried out in this study center. Compared with the traditional laparoscopic cholecystectomy, the operation time, transfer rate, intraoperative bleeding, hospitalization time and complications were not statistically significant between the two groups. The difference (P0.05), the postoperative abdominal wall beauty evaluation, group LESS was obviously better than group CLS (P=0.021). 2 cases of single hole laparoscopic inguinal hernia repair was performed in this center, and followed up for 6 months, no umbilical hernia, hernia recurrence and other complications, umbilical scars were almost invisible. (3) the separation and culture of bone marrow derived MSCs, the use of different concentrations of BMP-12 to induce MSCs to the tendon cell points Real-time PCR was used to detect Scx, collagen I, collagen III gene expression level and Western Blot to detect Collagen I expression to determine the optimal inducible differentiation concentration of BMP-12. The effect of activating the ERK pathway is very small. In vitro, the induced MSCs- collagen sponge complex is constructed and planted in the midline white line incision in the rat. After 4 weeks, the maximum pulling force can be detected in 69.7% of the normal abdominal white line, which is superior to the other control groups (P0.05).HE and Masson staining to show the regenerated collagen fiber in the experimental group. Conclusion: (1) the single hole laparoscopic flexible multi channel casing, multifunctional dissection apparatus and "fish hook" traction device are in conformity with the requirements of LESS operation, effective, safe and reliable. (2) the principle of LESS basic operation is summed up: the principle of axis pivot axis of the umbilical target screen and the principle of "inverted Pyramid" The principle of ergonomics; auxiliary principle; progressive principle; comprehensive optimization principle. (3) clinical research confirmed that relative to CLS, the difficulty of LESS increased, the operation time was prolonged, the rate of operation was increased, the incidence of complications was not significantly different, and the ideal abdominal wall beauty effect after operation was the greatest advantage of LESS. (4) BMP-12 through multiple signals The pathway induces MSCs to differentiate into the tendon cells, and the Smad pathway plays a significant role. It has a strong activation effect on P38 and JNK. The activation of the ERK pathway with little.BMP-12 induced MSCs induced tendon differentiation can promote the healing of single pore peritoneoscope through the aponeurosis incision.
【學(xué)位授予單位】：東南大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R608

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