本文選題：腹腔鏡 + 微創(chuàng)外科�。� 參考：《中國人民解放軍醫(yī)學(xué)院》2015年博士論文

【摘要】：目的：1、動物實驗研究。A：評價經(jīng)腹腔鏡切取活體豬左半供肝的可行性。B：評價在腹腔鏡解剖性肝切除動物模型中應(yīng)用射頻消融技術(shù)進行肝段定位、入肝血流阻斷以及輔助肝實質(zhì)離斷的可行性、有效性和安全性。2、模式化半肝肝切除。A：建立模式化左半肝切除相關(guān)流程并進行臨床應(yīng)用,分析相關(guān)結(jié)果。B：建立模式化右半肝切除相關(guān)流程并進行臨床應(yīng)用,分析相關(guān)結(jié)果。3、評估對于特殊肝段(S1、S6+S7、S8)腹腔鏡肝切除的技術(shù)。方法：1、A：建立經(jīng)腹腔鏡切取活體豬左半供肝的動物模型,其技術(shù)包括CO2氣腹的建立與戳孔布局,解剖肝十二指腸韌帶,腹腔鏡術(shù)中超聲輔助確定斷肝平面,肝臟的游離,離斷肝實質(zhì),肝內(nèi)管道的處理。將切取的左半供肝進行冷灌注及修整,并取少量肝組織塊行病理學(xué)檢查。B：20頭豬接受超聲引導(dǎo)下肝段門靜脈系統(tǒng)定位及射頻消融輔助肝段血流阻斷下腹腔鏡肝段切除(門靜脈射頻消融輔助組,n=10)與常規(guī)腹腔鏡肝段切除手術(shù)(常規(guī)腹腔鏡切除組),射頻消融輔助肝實質(zhì)離斷腹腔鏡左外葉肝切除(射頻輔助肝實質(zhì)離斷組,n=10)與常規(guī)腹腔鏡左外葉切除(常規(guī)腹腔鏡肝葉切除組)對比研究。2、A：模式化腹腔鏡左半肝切除的相關(guān)流程首先進行體位的擺放、戳孔的布局,其后左側(cè)肝臟的游離,解剖左側(cè)肝蒂并阻斷。在肝實質(zhì)離斷后以切割閉合器離斷左側(cè)門靜脈和肝靜脈,其后進行創(chuàng)面止血和標(biāo)本的取出、放置引流。B：模式化腹腔鏡右半肝切除的相關(guān)流程首先將患者擺放左側(cè)45°臥位、戳孔的布局,其后右側(cè)肝臟的游離,解剖右側(cè)肝蒂并阻斷。在肝實質(zhì)離斷后以切割閉合器離斷右側(cè)門靜脈和肝靜脈,其后進行創(chuàng)面止血和標(biāo)本的取出、放置引流。結(jié)果：1、A：10頭豬接受了手術(shù),除1頭因下腔靜脈出血后發(fā)生氣栓死亡外,其余均成功建立模型。手術(shù)時間為(208±25)min,熱缺血時間為(8±2.3)min,手術(shù)出血量為(313±75)ml。供肝切取后,殘肝重要結(jié)構(gòu)保留完好；供肝管道結(jié)構(gòu)及組織學(xué)形態(tài)正常。B：9頭豬完成超聲引導(dǎo)下肝段門靜脈系統(tǒng)消融輔助腹腔鏡肝段切除,常規(guī)腹腔鏡切除組10頭豬完成手術(shù)。門靜脈射頻消融輔助組和對照組手術(shù)時間為(74±16)min和(104±28)min(t=-2.821,P=0.012),手術(shù)出血量(84±20)ml和(114±32)ml(t=2.416,P=0.027).射頻消融輔助肝實質(zhì)離斷腹腔鏡左外葉肝切除與常規(guī)肝葉切除對比,2組手術(shù)均順利完成。射頻輔助肝實質(zhì)離斷組和常規(guī)腹腔鏡切除組手術(shù)時間無統(tǒng)計學(xué)差異[(136±26)min vs.(124±18)min,t=1.200,P=0.246],術(shù)中出血量無統(tǒng)計學(xué)差異[(110±36)m1 vs.(164±50)ml,t=-2.772,P=0.013]。2、A：共完成模式化左半肝切除23例,其中惡性腫瘤8例,良性腫瘤15例。平均手術(shù)時間95.0±34.6分鐘,平均出血量154.0±36.4m1,無術(shù)中輸血,并發(fā)癥1例,平均術(shù)后住院5.8±1.5天。B：共完成模式化右半肝切除21例,其中惡性疾病15例,良性腫瘤6例。平均手術(shù)時間115.0±44.5分鐘,平均出血量214.0±56.4m1,無術(shù)中輸血,并發(fā)癥2例,平均術(shù)后住院6.3±2.4天。3、共完成特殊區(qū)域肝切除15例,其中惡性疾病4例,良性腫瘤11例。S1段5例,右后葉(S6+S7)6例,S7段2例,S8段2例。平均手術(shù)時間65.0±32.5分鐘,平均出血量154.0±43.4m1,無術(shù)中輸血,并發(fā)癥1例,平均術(shù)后住院4.7±1.8天。結(jié)論：1、A：經(jīng)腹腔鏡切取活體豬左半供肝的技術(shù)是安全可行的。B：超聲引導(dǎo)下肝段門靜脈系統(tǒng)消融輔助肝段入肝血流阻斷后行腹腔鏡肝段切除有助于縮短手術(shù)時間和減少術(shù)中出血量；射頻消融輔助肝實質(zhì)離斷的腹腔鏡肝左外葉切除與常規(guī)肝葉切除比較在不增加手術(shù)時間的基礎(chǔ)上可以減少術(shù)中出血。2、A：我們進一步發(fā)展了新的模式化腹腔鏡左半肝切除的技術(shù)路線并經(jīng)臨床驗證,結(jié)果提示該方法簡便、安全,可重復(fù)性佳,可以作為腹腔鏡左半肝切除的范式進行介紹給國內(nèi)同行。B：模式化腹腔鏡右半肝切除雖然對腹腔鏡手術(shù)技術(shù)的要求較高,但對富有腔鏡和開腹肝臟手術(shù)經(jīng)驗醫(yī)生仍是能夠安全有效地完成。3、涉及S1、S6、S7和S8段的肝臟腫瘤的腹腔鏡切除屬于非常困難的,但通過精心挑選適合進行腔鏡嘗試的患者,仔細(xì)評估,精心準(zhǔn)備后同樣可以完成腹腔鏡下的肝切除手術(shù)。
[Abstract]:Objective: 1, animal experimental study.A: evaluation of the feasibility of laparoscopic removal of left half donor liver in living pigs.B: evaluation of the feasibility, effectiveness and safety of hepatic segment localization, hepatic blood flow blocking and auxiliary hepatic parenchyma disconnection in the laparoscopic anatomical hepatectomy animal model by using radiofrequency ablation technique,.2, and model hemihepatic hepatectomy.A To establish the related process of model left hemihepatectomy and to carry out clinical application, and to analyze the relevant results.B: establish a standardized right hemihepatectomy related process and carry out clinical application, analyze the related results.3, evaluate the technique of laparoscopic hepatectomy for special hepatic segment (S1, S6+S7, S8). Methods: 1, A: to establish a living pig left half donor by laparoscope The animal model of the liver, including the establishment of the CO2 pneumoperitoneum and the layout of the puncture, the anatomy of the hepatic and duodenal ligaments, the ultrasound assisted determination of the liver disconnection, the dissociation of the liver, the parenchyma of the liver, the treatment of the intrahepatic duct in the laparoscopy. The cold perfusion and repair of the left half donor liver were carried out, and a small amount of liver tissue was taken for pathological examination of the.B:20 head. Porcine underwent ultrasound guided hepatic segmental portal system location and radiofrequency ablation assisted laparoscopic hepatic segment resection (n=10) and conventional laparoscopic hepatic segment resection (routine laparoscopic resection group). Radiofrequency ablation assisted hepatic parenchyma dissection laparoscopic left lateral hepatectomy (radiofrequency assisted liver parenchyma) Group n=10) compared with conventional laparoscopic left lateral lobectomy (conventional laparoscopic hepatectomy group) a comparative study of.2, A: the related process of mode laparoscopic left hemihepatectomy was first carried out with the placement of the body position, the layout of the poke hole, then the left liver free, dissecting the left liver pedicle and blocking the left hepatic parenchyma after the liver parenchyma dissociation. The venous and hepatic veins were followed by the bleeding of the wound and the removal of the specimen, and drainage of the.B: the related process of the mode laparoscopic right hemihepatectomy first placed the patient in the left 45 degree position, the layout of the poke hole, then the right liver was free, and the right hepatic pedicle was dissected and blocked. The right portal vein was dissected with a cutting closure after the liver parenchyma dissociation. The result: 1, A:10 head pigs were operated on. Except for 1 cases of hemorrhage after hemorrhage of the inferior vena cava, the rest were successfully established. The operation time was (208 + 25) min, the time of thermal ischemia was (8 + 2.3) min, and the amount of bleeding was (313 + 75) ml. after the liver resection. The important structure was well preserved; the hepatic duct structure and histology of normal.B:9 head pigs were treated with ultrasound guided hepatic segment portal venous system ablation assisted laparoscopic liver resection, and 10 pigs were operated by conventional laparoscopic resection group. The operation time between the portal vein radiofrequency ablation assisted group and the control group was (74 + 16) min and (104 + 28) min (t=-2.821, P=0.). 012) the amount of bleeding (84 + 20) ml and (114 + 32) ml (t=2.416, P=0.027). Compared with conventional lobectomy, the 2 groups were successfully completed by radiofrequency ablation assisted hepatic parenchyma resection and conventional lobectomy. There was no statistical difference between the radiofrequency assisted hepatic parenchyma dissection group and the conventional laparoscopic excision group [(136 + 26) min vs. (124 + 18) min, t=1.20 0, P=0.246], there was no significant difference in the amount of bleeding during the operation [(110 + 36) M1 vs. (164 + 50) ml, t=-2.772, P=0.013].2, A: 23 cases of complete mode left hemi hepatectomy, including 8 malignant tumors and 15 benign tumors. The average operation time was 95 + 34.6 minutes, average bleeding was 154 + 36.4m1, no intraoperative blood transfusion, complication 1 cases, average postoperative 5.8 + 1.5 days after operation. .B: 21 cases of right hemi hepatectomy were completed. Among them, there were 15 cases of malignant disease and 6 cases of benign tumors. The average operation time was 115 + 44.5 minutes, the average bleeding amount was 214 + 56.4m1, no intraoperative blood transfusion, 2 cases had complications, and the average postoperative hospitalization was 6.3 + 2.4 days.3. 15 cases were completed in special area liver resection, among them, 4 cases of malignant diseases and 11 cases of benign tumor 11 segment 5, There were 6 cases of right posterior lobe (S6+S7), 2 cases of S7 segment and 2 cases of S8 segment. The mean operation time was 65 + 32.5 minutes, the average bleeding amount was 154 + 43.4m1, no intraoperative blood transfusion, 1 cases of complications, and average postoperative hospitalization 4.7 + 1.8 days. Conclusion: 1, A: the technique of laparoscopic removal of living pig left half donor liver by laparoscopy is a safe and feasible.B: ultrasound guided hepatic portal venous system ablation assistant under the guidance of ultrasound Laparoscopic hepatic resection is helpful to shorten the operation time and reduce the amount of bleeding in the hepatic segment of the liver after occlusion of the liver. The laparoscopic liver left excision with radiofrequency ablation assisted liver parenchyma disconnection and conventional lobectomy can reduce intraoperative bleeding.2 on the basis of no increased operation time, A: we further developed a new model. The technical route of laparoscopic left hemihepatectomy and clinical validation showed that the method was simple, safe and reproducible, and could be used as a paradigm for laparoscopic left hemihepatectomy to be introduced to domestic.B. The experience of visceral surgery is still safe and effective to complete.3. Laparoscopic resection of liver tumors in the S1, S6, S7 and S8 segments is very difficult, but carefully selected patients who are suitable for endoscopic attempts are carefully evaluated, and the hepatectomy under the celioscope can be completed after careful preparation.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R657.3
，

本文編號：1924340