發(fā)布時(shí)間：2018-06-18 06:13

  本文選題：褥式縫合 + 微血管��； 參考：《山東大學(xué)》2017年博士論文

【摘要】：論文綱要顯微外科的誕生和發(fā)展,是20世紀(jì)現(xiàn)代外科的一個相當(dāng)重要的發(fā)展歷程。1960年,美國的兩位學(xué)者Jacobson及Suarez首先利用他們所設(shè)計(jì)的精細(xì)的小血管吻合器械進(jìn)行了 1.6mm-3.2mmm的小血管的吻合。1963年1月,我國上海市第六人民醫(yī)院的陳中偉等在肉眼下進(jìn)行了小血管的吻合,實(shí)現(xiàn)了一例右前臂完全離斷病例的再植手術(shù)的成功,翻開了世界創(chuàng)傷外科史上的新的一頁,也開辟了顯微外科的新紀(jì)元。隨后,隨著臨床實(shí)踐、實(shí)驗(yàn)研究以及醫(yī)療器械、設(shè)備、醫(yī)用材料等的更精細(xì)化和專業(yè)化的發(fā)展,顯微外科逐漸發(fā)展壯大,成為骨科、手外科、足踝外科、血管外科、整形外科、神經(jīng)外科、移植外科、耳鼻喉科、口腔頜面外科、婦產(chǎn)科、泌尿外科、眼科等等的重要組成部分;而且,與顯微外科技術(shù)與理念的結(jié)合也使相關(guān)領(lǐng)域發(fā)展成為各專業(yè)的高精尖方向和前沿陣地。然而,顯微外科的基礎(chǔ)是血管吻合,血管吻合的質(zhì)量決定著手術(shù)的成敗、安全性及手術(shù)后的恢復(fù)效果。從根本上講,吻合血管的直接目的就是為了實(shí)現(xiàn)血液在血管腔中持久而通暢的流動,從而提供并維持組織的供血。血管的吻合質(zhì)量,受制于手術(shù)顯微鏡、顯微器械、顯微縫線以及手術(shù)醫(yī)師等眾多因素;如何提高微血管的吻合質(zhì)量、改進(jìn)吻合方法一直是顯微外科臨床工作及基礎(chǔ)、理論研究的一項(xiàng)重要內(nèi)容。雖然各種吻合方法不斷提出,各種吻合技巧層出不窮,尤其是血管吻合器(一種機(jī)械吻合法)也得到了國內(nèi)外臨床醫(yī)師的廣泛應(yīng)用;但是,顯微外科手工縫合一直獲得廣泛認(rèn)同,依然是小、微血管吻合的金標(biāo)準(zhǔn)。但是,在臨床實(shí)踐中,手工縫合小、微血管一直是以單純間斷縫合為主,同時(shí)手工縫合仍然是一項(xiàng)比較困難的工作,手術(shù)醫(yī)師的臨床經(jīng)驗(yàn)、技術(shù)水平甚至醫(yī)生的狀態(tài)都能夠很大程度的影響其吻合質(zhì)量,它需要長期的、專業(yè)的、大量的訓(xùn)練。如何能夠盡可能的減少各種不確定因素,更大程度上保障小、微血管的吻合質(zhì)量、提高血管的通暢率,也是我們臨床醫(yī)師的一項(xiàng)重要課題。受皮膚及胃腸道的褥式縫合的啟發(fā),我們將褥式縫合(包括水平褥式縫合和垂直褥式縫合)應(yīng)用到了小、微血管的顯微外科手工吻合中,獲得了成功。在論文的第一章,回顧了2007年1月至2015年12月的血管吻合中應(yīng)用褥式縫合的臨床病例應(yīng)用情況,其中包括斷指再植316例、手指再造32例及游離皮瓣165例。結(jié)果表明小、微血管的褥式縫合,可以顯著提高小、微血管的吻合質(zhì)量,明顯增加通暢率,而且其操作難度并不高,稍加練習(xí)即可掌握,值得臨床推廣應(yīng)用。在1960年,Jacobson及Suarez在臨床實(shí)踐的同時(shí),也成功的進(jìn)行了小血管吻合的動物實(shí)驗(yàn),并且獲得了較高的血管通暢率。而且,對于顯微外科醫(yī)師來講,為了提高臨床手術(shù)操作水平和小、微血管的吻合熟練程度,也需要利用實(shí)驗(yàn)動物進(jìn)行必要的顯微技術(shù)訓(xùn)練。實(shí)驗(yàn)動物尤其是大鼠,體型較小,實(shí)驗(yàn)操作簡單方便,可重復(fù)性高,而且成本低廉,獲取數(shù)據(jù)簡便。鑒于此,在論文的第二章第一部分,我們以Wister大鼠為實(shí)驗(yàn)動物,進(jìn)行了小、微血管顯微外科褥式縫合的動物模型的建立,包括端端縫合、端側(cè)縫合、不同口徑的動脈縫合、微血管縫合等。論文第二章的第二部分,在所建立的Wister大鼠端端吻合模型上,對褥式縫合與單純間斷縫合的縫合速度與吻合質(zhì)量進(jìn)行了對比性研究,初步探討了小、微血管的顯微褥式縫合的特點(diǎn)及優(yōu)勢。另外,論文還綜述了血管吻合方法的歷史發(fā)展歷程、現(xiàn)狀與未來展望。第一章小、微血管的顯微褥式縫合的臨床應(yīng)用目的:探討褥式縫合在小、微血管顯微縫合中的臨床應(yīng)用效果。方法:我們將水平褥式縫合及垂直褥式縫合應(yīng)用到小、微血管的顯微外科縫合當(dāng)中�；仡櫫� 2007年1月至2015年12月的血管吻合中應(yīng)用褥式縫合的游離皮瓣165例、斷指再植316例及手指再造32例。結(jié)果:164例游離皮瓣完全成活,其中5例出現(xiàn)血管危象,經(jīng)探查后恢復(fù)血運(yùn)完全成活;1例患者因患者一般情況差,患者及家屬拒絕探查,最終皮瓣壞死。316例斷指再植病例中,308例再植成活,其中26例出現(xiàn)血管危象急診探查,僅7例出現(xiàn)包括吻合口在內(nèi)的血管栓塞,16例血管吻合口未栓塞,系因吻合口近端或遠(yuǎn)端血管挫傷導(dǎo)致的血管栓塞,3例系因單純的血管痙攣所致;8例壞死病例均為末節(jié)擠壓離斷再植,其中6例獲得血管危象探查,探查見其組織損傷嚴(yán)重,血管廣泛栓塞,無保留價(jià)值,給以行殘端修整術(shù),2例患者拒絕手術(shù)探查最終壞死。32例再造手指完全成活,其中2例全形再造術(shù)后二趾瓣出現(xiàn)血管危象,探查其系血管扭轉(zhuǎn)引起血管痙攣所致,給以離斷調(diào)整后重新吻合,最終成活。結(jié)論:小、微血管的顯微褥式縫合,可以顯著提高血管的吻合質(zhì)量,增加通暢率;而且,其操作難度并不高,稍加練習(xí)即可掌握,值得臨床推廣應(yīng)用。第二章 小、微血管的顯微褥式縫合的實(shí)驗(yàn)研究第一部分小、微血管的顯微褥式縫合的模型建立目的:探討利用Wister大鼠建立小、微血管的顯微褥式縫合的動物模型,包括端端吻合、端側(cè)吻合、微血管吻合、不同口徑的血管吻合。方法:以健康成年Wister大鼠(體重250g以上)為實(shí)驗(yàn)對象,進(jìn)行小、微血管的顯微褥式縫合模型的建立。以成年大鼠尾中動脈(直徑約0.5-1.0mm)的近2/3段作為吻合對象建立端端吻合模型;以略小體型大鼠(體重250-300g)的遠(yuǎn)1/3段的尾中動脈(直徑約0.2-0.5mm)為吻合對象建立微血管吻合模型;以成年大鼠的腹主動脈(直徑約1.2-1.8mm)與左腎動脈(直徑約0.5-0.9mm)的起始處為吻合對象建立端側(cè)吻合模型;以直接吻合成年大鼠的腹主動脈(直徑約1.2-1.8mm)與左腎動脈(直徑約0.5-0.9mm)來建立口徑不同口徑的血管吻合模型。結(jié)果:顯微褥式縫合的模型可以以Wister大鼠為實(shí)驗(yàn)對象進(jìn)行建立,包括端端吻合、端側(cè)吻合、微血管吻合、口徑相差較大的血管吻合。結(jié)論:Wister大鼠作為小體型、價(jià)格便宜的實(shí)驗(yàn)動物,可以建立理想的小、微血管的顯微褥式縫合模型,而且所建立的血管吻合模型具有可重復(fù)性高、簡單快捷、易于操作等優(yōu)點(diǎn),尤其是利用大鼠尾中動脈進(jìn)行褥式縫合的練習(xí)可以作為顯微技術(shù)訓(xùn)練的常用方式。第二部分褥式縫合與單純間斷縫合在小、微血管的顯微外科端端吻合中縫合速度與吻合質(zhì)量的對比性研究目的:探討褥式縫合與單純間斷縫合在小、微血管的顯微外科端端吻合中縫合速度與吻合質(zhì)量的差異,評估褥式縫合的優(yōu)缺點(diǎn)。方法:以成年Wister大鼠為實(shí)驗(yàn)對象,以其尾中動脈近1/3段(直徑約0.8-1.0mm)作為擬吻合的血管。分別將進(jìn)行血管縫合的醫(yī)生按從事顯微外科年限分為3組:低水平組(從事顯微外科不超過6月的臨床醫(yī)生)36人,中等水平組(從事顯微外科6月-1年的臨床醫(yī)生)28人,高水平組(從事顯微外科1年以上的臨床醫(yī)生)12人。每組醫(yī)生分別應(yīng)用單純間斷縫合及褥式縫合各吻合尾中動脈的10個吻合口,分別記錄每個吻合口的縫合時(shí)間,并剖開吻合口觀察有無外膜嵌入管腔,并記錄有外膜嵌入管腔的吻合口數(shù)量,將各數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:3組的血管縫合速度分別如下:低水平組醫(yī)生褥式縫合花費(fèi)的時(shí)間為1843±96秒,單純間斷縫合花費(fèi)的時(shí)間為925±84秒;中等水平組醫(yī)生褥式縫合花費(fèi)的時(shí)間為752±46秒,單純間斷縫合花費(fèi)的時(shí)間為627±30秒;高水平組醫(yī)生褥式縫合花費(fèi)的時(shí)間為420±32秒,單純間斷縫合花費(fèi)的時(shí)間為465±27秒。3組醫(yī)生出現(xiàn)外膜嵌入的比例分別如下:低水平組醫(yī)生單純間斷縫合的出現(xiàn)率為(2.972±1.028)/10,褥式縫合的出現(xiàn)率為0/10;中等水平組醫(yī)生單純間斷縫合的出現(xiàn)率為(1.750± 1.005)/10,褥式縫合的出現(xiàn)率為0/10;高水平組醫(yī)生單純間斷縫合的出現(xiàn)率為(0.167±0.389)/10,褥式縫合的出現(xiàn)率為0/10。結(jié)論:對于具有低中程度顯微外科水平的臨床醫(yī)生來說,小、微血管的單純間斷縫合速度較褥式縫合為快,而相對具有較高水平的顯微外科醫(yī)生來說,褥式縫合反而比單純間斷縫合速度快。這與褥式縫合打結(jié)的速度快、打結(jié)的個數(shù)少有關(guān)。更重要的,小、微血管的褥式縫合不管是對什么水平的顯微外科醫(yī)生來說,只要能夠順利完成血管的褥式縫合就可以完全避免外膜嵌入管腔,實(shí)現(xiàn)完全的內(nèi)膜相對,避免內(nèi)翻。因而,隨著臨床醫(yī)生熟練度的增加及技術(shù)水平的提高,采用褥式縫合小、微血管,不管是在吻合速度上還是吻合質(zhì)量上都有優(yōu)勢,尤其是能實(shí)現(xiàn)100%的外翻。
[Abstract]:The birth and development of the outline microsurgery is a very important course of development in modern surgery in twentieth Century.1960. Two American scholars, Jacobson and Suarez, first made use of their fine small vascular anastomoses to carry out the anastomosis of small blood vessels of 1.6mm-3.2mmm in January.1963, China's Shanghai No.6 People's Hospital Chen Zhongwei, and so on, anastomosed the small blood vessels under the naked eye, achieved a successful replantation of a case of complete right forearm, opened a new page in the history of world trauma surgery, and opened a new era of microsurgery. Then, with clinical practice, experimental research, medical devices, equipment, medical materials and so on. Microsurgery has gradually developed and became an important component of the Department of orthopedics, hand surgery, ankle surgery, vascular surgery, plastic surgery, Department of Neurosurgery, transplantation surgery, oral and maxillofacial surgery, obstetrics and Gynecology, ophthalmology, and so on; moreover, the combination of microsurgical techniques and ideas also makes the related fields However, the basis of microsurgery is vascular anastomosis, and the quality of the vascular anastomosis determines the success or failure of the operation, the safety and the recovery effect after the operation. Fundamentally, the direct purpose of the anastomosis of blood vessels is to achieve a persistent and smooth flow of blood in the blood vessel cavity, and therefore, Blood supply for and maintenance of tissue. The quality of vascular anastomosis is subject to many factors, such as surgical microscope, microscopic apparatus, microscopic stitch and surgeon. How to improve the quality of microvascular anastomosis and improve the method of anastomosis have always been an important part of the clinical work and foundation of microsurgery. Although various anastomosis methods are constantly raised All kinds of anastomosis techniques emerge in endlessly, especially the vascular stapler (a kind of mechanical kiss), which has also been widely used by clinicians both at home and abroad; however, the microsurgical suture has been widely recognized and still the gold standard for small, microvascular anastomosis. However, in clinical practice, the handmade suture is small and the microvascular is always simple. It is still a difficult job to suture with intermittent suture, while manual suture is still a difficult job. The clinical experience, technical level and even the doctor's state of the surgeon can greatly affect the quality of the anastomosis. It needs long-term, professional, and extensive training. How to reduce all kinds of uncertain factors as much as possible and guarantee to a greater degree It is also an important subject for our clinicians. Inspired by the mattress suture of the skin and gastrointestinal tract, we apply the bedding suture (including horizontal mattress suture and vertical mattress suture) to the microvascular microsurgical manual anastomosis and success in the paper. In the first chapter, the clinical application of bedding suture in vascular anastomosis from January 2007 to December 2015 was reviewed, including 316 cases of finger replantation, 32 cases of finger reconstruction and 165 cases of free flap. The results showed that small, microvascular bedding suture could significantly improve the quality of microvascular anastomosis, and obviously increase patency rate. The difficulty of operation is not high, a little practice can be mastered, and it is worthy of clinical application. In 1960, Jacobson and Suarez were also successful in the experiment of small vascular anastomosis, and obtained high vascular patency. Moreover, for the microsurgeon, in order to improve the clinical operation level and small, In the second chapter of the second chapter of the paper, we take Wister rats as experimental animals. The animal model of microvascular microsurgical mattress suture was established, including end to end suture, end to side suture, different caliber arterial suture, microvascular suture, and so on. The second part of the second chapter of the paper. On the established Wister rat end to end anastomosis model, the suture speed and anastomosis quality of the bedding suture and the simple suture were carried out. In contrast, the characteristics and advantages of microvascular microvascular suture were preliminarily discussed. In addition, the history of the vascular anastomosis, the present situation and the future prospect were also reviewed. The first chapter was the clinical application of microvascular suture: the clinical application of mattress suture in small and microvascular suture. Methods: We applied horizontal mattress suture and vertical mattress suture to microvascular microsurgical suture. We reviewed 165 cases of free flap with bedding suture, 316 cases of finger replantation and 32 cases of finger reengineering in vascular anastomosis from January 2007 to December 2015. Results: 164 cases of free flap survived completely, of which 5 cases were out. There were 1 cases of vascular crisis and 308 cases of replantation of.316, of which 26 cases had an emergency exploration of vascular crisis, only 7 cases had vascular embolism including anastomotic stoma, 16 cases of vascular anastomosis did not. Emboles were caused by vascular embolism caused by proximal or distal vascular contusion of the anastomotic stoma. 3 cases were caused by simple vascular spasm; 8 cases of necrotic cases were all of the distal extrusion and severed replantation, of which 6 cases were detected by vascular crisis. Surgical exploration of the final necrosis of.32 cases of reconstruction of the fingers completely survived, of which 2 cases of total reconstruction of the two toe after reconstruction of vascular crisis, exploration of vascular spasm caused by blood vessel torsion caused by vascular spasm, reanastomose after the adjustment, and finally live. Conclusion: small, microvascular mattress suture, can significantly improve the quality of vascular anastomosis, increased passages The difficulty of operation is not high, and it is difficult to operate with a little practice. It is worthy of clinical application. The second chapter is small, the experimental study of microvascular mattress suture is the first part, and the model of microvascular mattress suture is set up to establish the animal model of microvascular mattress suture by using Wister rats. End-to-end anastomosis, end to side anastomosis, microvascular anastomosis, and different caliber vascular anastomosis. Methods: a healthy adult Wister rat (more than 250g) was used as the experimental object to establish microvascular mattress suture model. The proximal 2/3 segment of the middle caudal artery (about 0.5-1.0mm in diameter) in adult rats was used as the anastomosis object to establish the end to end anastomosis model. A microvascular anastomosis model was established with the middle tail of the distal 1/3 segment of a slightly somatotype rat (body weight 250-300g) (about 0.2-0.5mm in diameter). The abdominal aorta (about 1.2-1.8mm in diameter) in adult rats and the origin of the left renal artery (diameter about 0.5-0.9mm) were anastomosed to the image of the end to side anastomosis, and the abdomen of the adult rat was directly anastomosed to the abdomen of the adult rat. The aorta (diameter about 1.2-1.8mm) and the left renal artery (diameter about 0.5-0.9mm) were used to establish the vascular anastomosis model with different caliber. Results: the model of the mattress suture can be built with Wister rats as the experimental objects, including end to end anastomosis, end to side anastomosis, microvascular anastomosis, and large diameter vascular anastomosis. Conclusion: Wister rats As a small, inexpensive experimental animal, the ideal small, microvascular mattress suture model can be established, and the established vascular anastomosis model has the advantages of high repeatability, simple and quick, easy to operate and so on. Especially, the practice of the mattress suture using the middle tail artery of the rat can be used as a common technique for the microscopic training. Methods. Comparison of second parts of mattress suture and simple intermittent suture in small, microvascular microsurgical end-to-end anastomosis: a comparative study of the suture speed and the quality of anastomosis: To explore the difference between the suture speed and the quality of the anastomosis in the microvascular microsurgical end-to-end anastomosis in the microvascular and the microvascular microsurgery, and to evaluate the advantages of the mattress suture. Methods: the adult Wister rats were used as the experimental object, with the proximal 1/3 segment of the middle tail artery (diameter about 0.8-1.0mm) as the vascular anastomosis. The doctors who performed the vascular suture were divided into 3 groups according to the microsurgical years: the low level group (microsurgery not more than the June clinician), and the medium level group (in microsurgery June - 1 years of clinicians) 28, a high level group (a clinician for more than 1 years of microsurgery) 12. Each group of doctors used 10 anastomotic anastomosis of the middle tail artery of each anastomosis, respectively, with discontinuous suture and mattress suture, respectively, to record the suture time of each anastomosis, and to open the anastomotic stoma without outer membrane, and record the outer membrane inlay. The number of anastomoses into the lumen was statistically analyzed. Results: the 3 groups of vascular suture speed were as follows: the time for the low level group of doctors and bedding sutures was 1843 + 96 seconds, and the time for the simple suture was 925 + 84 seconds; the time of the middle level group doctor's mattress suture was 752 + 46 seconds. The time of the fee was 627 + 30 seconds; the time spent by the high level group of doctors with mattress suture was 420 + 32 seconds. The proportion of the outer membrane embedded in the.3 group was 465 + 27 seconds. The rate of simple intermittent suture was (2.972 + 1.028) /10 and the occurrence rate of the bedding suture was 0/10; the middle level group was the middle level group. The incidence of simple intermittent suture was (1.750 + 1.005) /10, and the occurrence rate of bedding suture was 0/10; the incidence of simple intermittent suture was (0.167 + 0.389) /10 in the high level group, and the occurrence rate of bedding suture was 0/10. conclusion: for clinicians with low and middle degree microsurgical level, small, microvascular simple suture speed Compared to the higher level microsurgeon, the mattress suture is faster than the simple suture. It is faster than the mattress suture, and is less related to the number of knots. The mattress suture of the blood vessel can completely avoid the embed membrane of the outer membrane to achieve complete intimal relative and avoid varus. As a result, with the increase of the proficiency of the clinician and the improvement of the technical level, the mattress suture is small and the microvascular, regardless of the anastomosis speed, is also superior to the quality of the anastomosis, especially to achieve 100%. Ectropion.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R658

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