本文選題：小鉗口LigaSure + 連續(xù)術(shù)中神經(jīng)監(jiān)測(cè)技術(shù)��； 參考：《中國(guó)人民解放軍醫(yī)學(xué)院》2017年碩士論文

【摘要】：目的:通過(guò)模擬甲狀腺手術(shù)中LigaSure在頸段喉返神經(jīng)(Recurrent laryngeal nerve,RLN)區(qū)域的應(yīng)用,建立連續(xù)神經(jīng)監(jiān)測(cè)(Continuous intraoperative neuromonitoring,CIONM)保護(hù)下的小型豬動(dòng)物模型,從而探討甲狀腺手術(shù)中LigaSure在RLN區(qū)域應(yīng)用時(shí)的安全距離及安全時(shí)間間隔。方法:1.實(shí)驗(yàn)動(dòng)物分組:36頭小型豬隨機(jī)分為距離實(shí)驗(yàn)組和間隔實(shí)驗(yàn)組(各18頭)。距離實(shí)驗(yàn)組根據(jù)LigaSure刀頭作用部位與RLN距離不同隨機(jī)分為組1 (距RLN3mm)、組2(距RLN2mm)和組3 (距RLN1mm),每組6頭;間隔實(shí)驗(yàn)組根據(jù)LigaSure刀頭室溫下冷卻時(shí)間不同隨機(jī)分為組1 (冷卻3s)、組2 (冷卻2s)和組3 (冷卻1s),每組6頭。2.實(shí)驗(yàn)動(dòng)物模型制備:1)麻醉及CIONM的應(yīng)用實(shí)驗(yàn)動(dòng)物硫噴妥鈉(15mg/kg)靜脈麻醉滿意后,喉鏡引導(dǎo)下插入6號(hào)NIM標(biāo)準(zhǔn)加強(qiáng)型氣管內(nèi)導(dǎo)管,連接心電和血氧監(jiān)測(cè),術(shù)中1～2%七氟醚行麻醉維持。依照CIONM應(yīng)用標(biāo)準(zhǔn)化步驟,行迷走神經(jīng)(Vagus nerve, VN)暴露、APS電極的留置和RLN暴露,對(duì)RLN功能進(jìn)行實(shí)時(shí)監(jiān)測(cè)。2)距離實(shí)驗(yàn)選取18頭小型豬左側(cè)RLN (右側(cè)對(duì)照),作用部位為第2、3氣管環(huán)水平。根據(jù)分組不同,將LigaSure刀頭分別距RLN外側(cè)3mm、2mm和1mm處被激發(fā),均作用4s,應(yīng)用CIONM對(duì)RLN功能進(jìn)行實(shí)時(shí)監(jiān)測(cè),作用前后振幅和潛伏期進(jìn)行對(duì)比。連續(xù)監(jiān)測(cè)30min,記錄激發(fā)后15min和損傷后30min實(shí)時(shí)振幅和潛伏期,觀察恢復(fù)情況。3)間隔實(shí)驗(yàn)選取18頭小型豬左側(cè)RLN (右側(cè)對(duì)照),LigaSure先于胸鎖乳突肌上持續(xù)激活5s,敞開(kāi)尖端刀頭,根據(jù)分組不同,室溫下分別冷卻3s、2s和1s后,刀頭與第2、3氣管環(huán)水平RLN直接接觸5s,應(yīng)用CIONM監(jiān)測(cè)RLN功能變化。損傷前后EMG對(duì)比和神經(jīng)功能恢復(fù)情況觀察同距離實(shí)驗(yàn)。3.病理切片:對(duì)實(shí)驗(yàn)側(cè)RLN和右側(cè)正常RLN取材,制成病理切片,光鏡下觀察組織學(xué)變化。結(jié)果:1.距離實(shí)驗(yàn)組1 LigaSure作用后EMG變化不顯著,振幅和潛伏期在正常范圍內(nèi)波動(dòng),無(wú)統(tǒng)計(jì)學(xué)意義。組2和組3出現(xiàn)不同程度振幅降低和潛伏期延長(zhǎng),組2振幅降低均50%,潛伏期延長(zhǎng)均10%,監(jiān)測(cè)儀未報(bào)警,無(wú)統(tǒng)計(jì)學(xué)意義,30min時(shí)可恢復(fù)至損傷前正常范圍。組3均出現(xiàn)危險(xiǎn)EMG,監(jiān)測(cè)儀報(bào)警,損傷后可見(jiàn)振幅和潛伏期恢復(fù),但30min時(shí)未能至警戒閾值水平,有統(tǒng)計(jì)學(xué)意義。組1、組2和對(duì)照組鏡下神經(jīng)結(jié)構(gòu)正常,組3鏡下見(jiàn)神經(jīng)水腫表現(xiàn)。2.間隔實(shí)驗(yàn)組1 LigaSure與RLN接觸后振幅降低50%,潛伏期延長(zhǎng) 10%,監(jiān)測(cè)儀未報(bào)警,無(wú)統(tǒng)計(jì)學(xué)意義,30min后振幅和潛伏期可恢復(fù)至作用前正常范圍。組2和組3損傷后EMG迅速改變,監(jiān)測(cè)儀報(bào)警,振幅和潛伏期變化均有統(tǒng)計(jì)學(xué)差異,組2損傷后可見(jiàn)振幅和潛伏期恢復(fù),但30min時(shí)未能至警戒閾值水平。組3均出現(xiàn)LOS,且損傷后不能恢復(fù)。組1和對(duì)照組鏡下神經(jīng)結(jié)構(gòu)正常,組2鏡下見(jiàn)神經(jīng)水腫表現(xiàn),組3鏡下可見(jiàn)胞核碎裂及壞死。結(jié)論:基于CIONM對(duì)RLN功能評(píng)估,甲狀腺手術(shù)中LigaSure在RLN區(qū)域應(yīng)用的安全距離為距RLN外側(cè)2mm及以上,且單次激發(fā)后,再于RLN區(qū)域應(yīng)用時(shí)間隔應(yīng)不少于3s。LigaSure應(yīng)用應(yīng)予以規(guī)范化和標(biāo)準(zhǔn)化,以避免其不規(guī)范使用造成的RLN熱損傷的發(fā)生。CIONM可敏感的、實(shí)時(shí)的評(píng)估RLN功能變化,早期識(shí)別損傷,提醒術(shù)者對(duì)損傷進(jìn)行預(yù)判和控制,對(duì)神經(jīng)保護(hù)意義重大,值得推廣。
[Abstract]:Objective: by simulating the application of LigaSure in the region of Recurrent laryngeal nerve (RLN) during thyroid surgery, a miniature pig animal model under the protection of Continuous intraoperative neuromonitoring (CIONM) was established to explore the safety distance of LigaSure in RLN region during thyroidectomy. Methods: 1. experimental animals were divided into 1. experimental animals: 36 small pigs were randomly divided into the distance experiment group and the interval experimental group (18 heads each). The experimental group was randomly divided into 1 (distance RLN3mm), group 2 (distance RLN2mm) and group 3 (RLN1mm), and each group was 6 heads, and the interval experimental group was based on the room temperature of LigaSure knife head. The lower cooling time was divided randomly into group 1 (cooling 3S), group 2 (cooling 2S) and group 3 (cooling 1s), 6 head of.2. experimental animal model in each group was prepared: 1) anesthesia and CIONM applied experimental animal sodium thiopental (15mg/kg) intravenous anesthesia satisfied, laryngoscope guidance inserted into the 6 NIM standard enhanced endotracheal catheter, connecting ECG and oxygen monitoring, 1~2 during the operation. % sevoflurane was maintained for anesthesia. According to the CIONM application standardization steps, Vagus nerve (VN) exposure, APS electrode retention and RLN exposure, RLN function in real-time monitoring.2) distance experiment selected 18 small pigs left RLN (right control), the action site was the level of the 2,3 trachea. According to the grouping, LigaSure knife head respectively From the lateral 3mm, 2mm and 1mm of RLN, 4S was used, CIONM was used to monitor the function of RLN in real time. The amplitude and incubation period were compared before and after. 30min was continuously monitored, the real-time amplitude and latency of 30min after the excitation and the recovery.3) were recorded, and the left RLN (right control) of 18 small pigs was selected. Re first activates 5S on the sternocleidomastoid muscle and opens the cutting-edge knife. After cooling 3S, 2S and 1s at room temperature, the knife head and 2,3 tracheal ring level RLN are directly exposed to 5S, and CIONM monitoring RLN function changes. The EMG contrast before and after injury and the recovery of nerve function before and after injury are observed by the same distance experimental.3. pathological section. On the right side of the normal RLN, the pathological sections were made. The histological changes were observed under the light microscope. Results: the changes of EMG in the 1. distance experimental group were not significant after the action of 1 LigaSure. The amplitude and latency fluctuated in the normal range, and there was no statistical significance. The amplitude and the latent period of the group 2 and group 3 were decreased and the latent period was prolonged, the 2 amplitude of the group decreased 50% and the incubation period was 10. %, the monitor did not alarm, no statistical significance, 30min can be recovered to the normal range before injury. Group 3 appeared dangerous EMG, monitor alarm, the amplitude and latency recovery after injury, but 30min failed to the level of warning threshold, there were statistical significance. Group 1, group 2 and control group under normal neural structure, group 3 endoscopic neuroedema showed.2. performance of neuroedema in the performance of.2. After contact between 1 LigaSure and RLN, the amplitude of amplitude decreased by 50%, the latency prolonged 10%, the monitor did not alarm, no statistical significance. The amplitude and latency of 30min could be recovered to the normal range before action. Group 2 and group 3 after injury, EMG changed rapidly, the monitor alarm, amplitude and latency changes were statistically different, and the amplitude of the 2 injury was visible. And the incubation period recovered, but 30min failed to reach the alert threshold level. Group 3 appeared LOS, and could not recover after injury. Group 1 and control group were normal under the microscope, group 2 under 2 mirror neurosis, 3 mirrors can see the nucleus fragmentation and necrosis. Conclusion: Based on the CIONM evaluation of RLN function, LigaSure in the thyroid operation in RLN area application of safety The whole distance is RLN outside 2mm and above, and after single excitation, the application time interval of RLN should be normalized and standardized to avoid the.CIONM sensitivity of the RLN thermal damage caused by its non standard use, to evaluate the changes of RLN function in real time, identify the damage of the RLN in the early stage, and remind the operator to carry out the damage. Anticipation and control are of great significance for neuroprotection and are worthy of promotion.
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R653

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