本文選題：腹腔鏡 + 肝外傷　； 參考：《福建醫(yī)科大學(xué)》2013年碩士論文

【摘要】：【目的】 1、探討腹腔鏡下射頻消融固化止血治療在肝外傷救治中的應(yīng)用，有望得出一種可應(yīng)用于臨床和戰(zhàn)時(shí)的安全、有效、簡便、易于推廣的肝外傷止血治療手段。從而實(shí)現(xiàn)在傷情的早期判斷和全面評估的基礎(chǔ)上，盡可能的避免不必要的剖腹手術(shù)和器官切除手術(shù)，盡可能地實(shí)現(xiàn)微創(chuàng)的、個(gè)體化的、安全有效的治療。 2、通過實(shí)驗(yàn)分析該技術(shù)應(yīng)用于肝外傷救治的適應(yīng)證、療效、安全性。 3、將當(dāng)前肝膽外科的新技術(shù)、新觀念前伸并應(yīng)用到戰(zhàn)時(shí)和非戰(zhàn)爭軍事行動條件下的肝外傷的救治中，探索野戰(zhàn)條件下肝損傷救治的新途徑、新策略。 【方法】 將進(jìn)入實(shí)驗(yàn)的20只動物隨機(jī)分為兩組，采用自制小型生物撞擊器致傷后，依據(jù)美國創(chuàng)傷外科學(xué)會(AAST)器官傷分類委員會，1989年提出經(jīng)1994年修改的肝臟損傷程度分級標(biāo)準(zhǔn)對傷情進(jìn)行評估。A組于傷后30-60min內(nèi)行腹腔鏡探查，進(jìn)一步判斷、評估傷情。在腹腔鏡直視下，結(jié)合B超，對出血部位施行經(jīng)皮射頻消融固化止血治療。治療失敗者或合并其他臟器損傷者，根據(jù)傷情，行開腹手術(shù)（包括肝葉切除、脾切除術(shù)等）。B組經(jīng)B超檢查后確定肝損傷等級后，予以非手術(shù)治療（包括采取液體復(fù)蘇、監(jiān)測血流動力學(xué)等）。所有動物均按階段采集血常規(guī)、生化指標(biāo)、影像學(xué)復(fù)查等。對于血流動力學(xué)不穩(wěn)定，影像學(xué)提示持續(xù)出血的嚴(yán)重肝損傷者，擇機(jī)開腹探查，手術(shù)止血。治療過程中死亡動物，立即尸檢。第28天處死動物，，尸檢，完整切取肝臟，探查腹腔、胸腔，記錄發(fā)生的并發(fā)癥。標(biāo)本脫水處理后石蠟包埋，常規(guī)HE染色，光鏡分析，采集組織學(xué)資料。 【結(jié)果】 1.止血時(shí)間及失血量方面 腹腔鏡探查聯(lián)合射頻消融治療組與非手術(shù)組在止血時(shí)間、失血量上除I級肝外傷外均有明顯差異（P0.05）。 2.血糖、胰島素、胰高血糖素 兩組動物傷前血糖、INS、GLU比較均無顯著差異(P0.05)。術(shù)后即刻、術(shù)后1天、術(shù)后2天，兩組動物血糖較傷前均有明顯升高(P0.05)。術(shù)后第2天，手術(shù)組血糖高于非手術(shù)組，差異有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后第4天手術(shù)組血糖恢復(fù)至正常水平(P0.05)，術(shù)后第10天非手術(shù)組血糖恢復(fù)至正常水平，兩組比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)。兩組動物INS在術(shù)后即刻明顯下降，較致傷前比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后第1、2天，兩組INS均顯著升高，較致傷前比較有差異性(P0.05)。術(shù)后第4天，手術(shù)組INS有所下降，與致傷前比較無明顯差異(P0.05)，而非手術(shù)組仍顯著高于傷前水平，與傷前和手術(shù)組比較差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。非手術(shù)組INS于術(shù)后第7天恢復(fù)術(shù)前水平(P0.05)。兩組動物術(shù)后GLU均呈上升趨勢，術(shù)后第1天達(dá)最高值。兩組動物GLU術(shù)后即刻、術(shù)后第1、2天與術(shù)前比較，差異有統(tǒng)計(jì)學(xué)意義(P0.05)。術(shù)后第4天，手術(shù)組恢復(fù)至傷前水平，非手術(shù)組第7天GLU逐漸恢復(fù)至傷前水平(P0.05)，但組間無差異(P0.05)。 3.ALT、AST、Tbil、Dbil 兩組動物傷前ALT、AST比較均無顯著差異(P0.05)。術(shù)后即刻、術(shù)后第1天、第2天、第4天，兩組動物ALT明顯升高，較傷前比較差異有顯著性(P0.05)。其中，手術(shù)組在術(shù)后第1天達(dá)最高值，非手術(shù)組在術(shù)后第4天達(dá)最高值，非手術(shù)組ALT在術(shù)后第4天顯著高于手術(shù)組(P0.05)。術(shù)后第7天兩組ALT接近傷前水平(P0.05)。術(shù)后即刻至術(shù)后第4天，兩組AST均顯著升高，較傷前比較差異有顯著性(P0.05)，兩組都在術(shù)后第1天達(dá)最高值。手術(shù)組AST在術(shù)后第7天接近術(shù)前水平(P0.05)，而非手術(shù)組AST雖然有所下降，但較傷前和手術(shù)組比較，仍有統(tǒng)計(jì)學(xué)差異(P0.05)。傷后兩組Tbil、Dbil開始緩慢上升，均在術(shù)后第2天達(dá)高峰，其中非手術(shù)組僅Dbil在術(shù)后第1、2天較傷前比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)，術(shù)后第4天降至正常。手術(shù)組Tbil、Dbil在術(shù)后第1、2天較傷前比較，差異有顯著性(P0.05)，術(shù)后第7天恢復(fù)至正常水平。兩組之間比較均沒有統(tǒng)計(jì)學(xué)意義(P0.05)。 【結(jié)論】 1.腹腔鏡探查聯(lián)合射頻消融固化止血治療技術(shù)較之傳統(tǒng)保守治療，止血時(shí)間明顯縮短，失血量明顯減少，并發(fā)癥發(fā)生率低，適用于不同傷情的肝外傷的救治，值得推廣。 2.腹腔鏡探查聯(lián)合射頻消融固化止血治療肝外傷具有創(chuàng)傷小、恢復(fù)快、并發(fā)癥少等特點(diǎn)；機(jī)體應(yīng)激反應(yīng)輕、肝功能影響小。 3.腹腔鏡探查聯(lián)合射頻消融有以下技術(shù)優(yōu)勢：1、有利于早期全面的傷情判斷，防止遺漏多發(fā)臟器損傷的診斷；2、直視下穿刺射頻針，定位準(zhǔn)確，簡便易行，技術(shù)難度小而可靠，適用于戰(zhàn)時(shí)的特殊要求。
[Abstract]:[Objective]
1, the application of laparoscopic radiofrequency ablation and hemostasis treatment in the treatment of liver trauma is expected to be a safe, effective, simple and easy to be used for the treatment of liver trauma, which can be used to avoid unnecessary laparotomy on the basis of early judgement and comprehensive assessment of the injury. And organ resection to achieve minimally invasive, individualized, safe and effective treatment as far as possible.
2, we analyzed the indications, efficacy and safety of the technology in the treatment of liver trauma through experiments.
3, to explore new ways and strategies for the treatment of liver injury under the condition of field warfare, the new technology of the current Department of hepatobiliary surgery, new ideas are extended and applied to the treatment of liver trauma under the conditions of wartime and non war military operations.
[method]
20 animals who entered the experiment were randomly divided into two groups. After the injury caused by a self-made small biological impactor, according to the American Society for trauma surgery (AAST) organ injury classification Committee, in 1989, the evaluation of the degree of liver injury revised in 1994 was evaluated for the evaluation of the injury in the group of 30-60min. Under the direct vision of the laparoscope, combined with B-ultrasound, percutaneous radiofrequency ablation and hemostasis was performed on the bleeding site. In the treatment of the losers or those with other organs injury, the.B group was treated after the B-ultrasound examination to determine the grade of liver injury after the B-ultrasound examination. Resuscitation, monitoring hemodynamics, etc. all animals were collected by stage of blood routine, biochemical index, imaging review and so on. For hemodynamic instability, patients with severe liver injury with continuous bleeding, selective laparotomy, surgical hemostasis, and immediate autopsy in the course of treatment. Animals, autopsy and complete removal were executed twenty-eighth days. The liver, the abdominal cavity and the chest cavity were recorded, and complications were recorded. Specimens were dehydrated and paraffin embedded, stained with conventional HE, analyzed by light microscopy, and histologic data were collected.
[results]
1. the time of hemostasis and the amount of blood loss
Laparoscopy combined with radiofrequency ablation group and non operation group had significant difference in hemostasis time and blood loss except I grade liver trauma (P0.05).
2. blood glucose, insulin, glucagon
There was no significant difference in blood sugar, INS, GLU before injury in the two groups (P0.05). Immediately after operation, 1 days after operation, 2 days after operation, the blood sugar of two groups were significantly higher than before injury (P0.05). The blood sugar of the operation group was higher than that of non operation group at second days after operation. The difference was statistically significant (P0.05). The blood sugar recovered to normal level (P0.05) in the operation group fourth days after operation (P0.05), first after operation, first after operation. The blood glucose of the non operative group recovered to the normal level in the 0 day, and the difference between the two groups was statistically significant (P0.05). The difference between the two groups of animals was significantly lower than that before the injury (P0.05). The two groups of INS were significantly higher after the postoperative day 1,2, compared with the prior injury (P0.05). Fourth days after the operation, the operation group INS decreased. There was no significant difference between before and before injury (P0.05), but the non operative group was still significantly higher than the pre injury level, and there was significant difference between the pre injury and the operation group (P0.05). The INS in the non operation group recovered before the operation (P0.05) seventh days after the operation. The GLU of the two groups of animals showed a rising trend after operation, and the highest value in first Tianda after the operation. Two groups of animals were immediately after the operation, The difference was statistically significant (P0.05) after 1,2 day after operation (P0.05). The operation group recovered to the level of pre injury fourth days after operation, and the GLU of the non operation group gradually recovered to the pre injury level (P0.05), but there was no difference between the groups (P0.05).
3.ALT, AST, Tbil, Dbil
There was no significant difference in ALT and AST between the two groups before injury (P0.05). Immediately after operation, first days, second days and fourth days after operation, the two groups of animals were significantly higher than before injury (P0.05). Among them, the highest value of the operation group in first Tianda, the highest value of the non operative group in fourth Tianda after the operation, and the ALT in the non operation group was significantly higher than that in the fourth day after the operation. The operation group (P0.05). Seventh days after the operation, two groups of ALT were close to the pre injury level (P0.05). The two groups of AST were significantly increased after the operation and fourth days after the operation. The difference was significant compared with that before the injury (P0.05). The two groups were the highest in first Tianda after the operation. The operation group was close to the preoperative level (P0.05) on the seventh day after the operation, while the AST in the non operative group decreased, but the injury was more severe. Compared with the operation group, there were still statistical differences (P0.05). The two groups of Tbil and Dbil began to rise slowly after the injury, all of which were in the peak of second Tianda after the operation. The difference between the non operative group and the postoperative 1,2 days was statistically significant (P0.05), and the fourth day after the operation was reduced to the normal. The operative group Tbil, Dbil compared with the injury before the operation, the difference was compared with the injury before the operation. The difference was the difference between the operation group and the postoperative day before the injury. Significance (P0.05) returned to normal level seventh days after operation. There was no significant difference between the two groups (P0.05).
[Conclusion]
1. laparoscopy combined with radiofrequency ablation curing hemostasis treatment technology is better than traditional conservative treatment. The time of hemostasis is shortened obviously, the amount of blood loss is reduced obviously, and the incidence of complications is low. It is worth popularizing for the treatment of liver trauma with different injuries.
2. laparoscopy combined with radiofrequency ablation and hemostasis for the treatment of liver trauma has the characteristics of small trauma, quick recovery, less complications, light stress reaction and small effect of liver function.
3. laparoscopy combined with radiofrequency ablation has the following technical advantages: 1, it is beneficial to the early and comprehensive assessment of the injury, to prevent the diagnosis of omission of multiple organ damage; 2, the puncture radiofrequency needle under direct vision is accurate, simple and easy to be used, and the technical difficulty is small and reliable. It is suitable for the special requirements of wartime.
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R82

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 陳孝平;張志偉;;肝外傷的診斷和治療[J];腹部外科;2006年04期

2 任培土;沈志宏;;腹腔鏡在診治腹部外科肝破裂中的應(yīng)用[J];腹腔鏡外科雜志;2009年06期

3 李宜雄,呂新生,勞學(xué)軍,王前;肝外傷的診斷和治療[J];肝膽外科雜志;1999年02期

4 儲文軍;馬大喜;朱建華;韓江;顧勤;張智平;劉峰;王偉峰;陳益鳴;郝繼東;王煒;汪運(yùn)節(jié);;損傷控制性手術(shù)在嚴(yán)重肝臟外傷中的應(yīng)用價(jià)值[J];肝膽胰外科雜志;2012年04期

5 史堅(jiān)強(qiáng);仲海燕;王海霞;劉楊;劉嵐云;康曉保;;閉合性肝外傷76例非手術(shù)治療分析[J];臨床軍醫(yī)雜志;2011年03期

6 董家鴻,王槐志;肝外傷治療的新觀念[J];臨床外科雜志;2005年06期

7 詹世林;陳建雄;彭林輝;霍楓;陸樹桐;何鄒俊;;血管介入技術(shù)在嚴(yán)重肝外傷損傷控制中的應(yīng)用[J];嶺南現(xiàn)代臨床外科;2012年01期

8 王曉磊;姚志清;哈斯;;彩超引導(dǎo)下介入治療在肝外傷中的應(yīng)用價(jià)值[J];內(nèi)蒙古醫(yī)學(xué)雜志;2006年09期

9 王全楚;申德林;劉文德;;創(chuàng)傷后應(yīng)激性肝損傷發(fā)病情況調(diào)查分析[J];實(shí)用醫(yī)藥雜志;2006年01期

10 王全暉;王全楚;郭樹軍;;嚴(yán)重腹部創(chuàng)傷致肝損害臨床資料分析[J];實(shí)用醫(yī)藥雜志;2010年04期

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