【作者】 张建文；

【导师】 刘春晓；

【作者基本信息】 南方医科大学 ， 泌尿外科， 2014， 博士

【摘要】 研究背景手术是一种刺激因素,导致机体产生应激、炎症、免疫等反应,从而造成不同程度的机体损伤。与传统外科手术相比,腹腔镜手术具备更小的创伤、更稳定的内环境状态、更短的住院时间以及更好的心理效应等优势；它是现代科技与传统手术相结合的成功典范。经历近20多年的临床实践,腹腔镜技术在泌尿外科领域日臻成熟,应用日益广泛。在诸多传统手术中,腹腔镜手术都取得了革命性的成功：从以往简单的切除性手术(如肾囊肿去顶术、肾上腺肿瘤切除术、无功能肾切除术等),发展到现在操作复杂的功能重建性手术(如肾盂输尿管成形术、肾部分切除术、前列腺癌根治性切除术、全膀胱切除原位新膀胱术等),基本覆盖了所有专科范畴。其中,部分腹腔镜手术优势明显,已取代开放手术而成为临床首选的经典术式(如肾上腺肿瘤切除术)。但腹腔镜手术是一项新创的全新技能,拥有十分鲜明的技术特点。首先,整个手术过程是通过观察监视器画面来完成的；术者所观察的是二维平面图像,缺乏立体感,术者容易导致判断上的不准确、手眼不配合、手手不协调等种种不便。在开始接触腹腔镜操作过程中,外科医师都会表现出明显不适应性,尤其腹腔镜下缝合操作更加难以掌握。其次,从手术入路的选择与建立到脏器的游离、切割、止血和缝合等基本操作,腹腔镜手术都与开放手术有着明显的差异。它通过腹壁为支点,应用腹腔镜器械来完成,镜下器械的运动与术者实际的操作是反向的；并且,由于腹腔镜手术器械较长,这要求操作者实施手术时更具稳定性。此外,从伦理学和患者安全角度考虑,术前也必须进行腹腔镜外科医师规范化技术操作训练。腹腔镜手术器械的熟练操控必须依靠基本训练以及长时间的经验积累,才能熟练掌握应用。这也是成功开展泌尿外科腹腔镜手术的重要基石。腹腔镜基本技能培训可以避免术者操作不熟练而导致的问题,并将出现手术并发症的风险最小化。西方国家临床医师必须接受严格的腹腔镜教学培训,并且经过认证、考核、授权才能获得手术资格。国外文献报道：在经过模拟训练箱、虚拟现实模拟器、动物模型等各类不同情形的培训之后,参与医师腹腔镜手术操作技术都能得到一定程度的提高。国内基于腹腔镜训练设备价格昂贵,亦缺乏正规、标准、统一的培训科目,教学资源也极其有限等因素,如何规范化进行医师腹腔镜基本技能培训问题上并未得到解决。并且,就泌尿外科腹腔镜手术的发展现状,国内各区域还很不平衡,很多医疗单位仍然停留在起始的初级阶段。综上所述,加强临床医师腹腔镜基本操作培训是十分必要的；如何高效地进行技能培训是现代外科教学中的一个重要课题；寻求一种便于实施的自我训练模式更是广大年轻外科医师的迫切要求。第1章应用自制训练箱提高腹腔镜手术基本技能目的采用自制训练箱,针对腹腔镜缝合操作为训练科目,观察初学者应用此种训练模式的培训效果。方法A组实验组12名无腹腔镜手术操作经验的医生参与本次培训。使用自行设计制作的训练箱,应用实际腹腔镜手术使用的影像系统,培训科目为针对腹腔镜缝合的3项操作：即手套间断缝合、肠管连续锁边缝合、鸡皮图形剪切定点缝合。训练以2人1小组,术者与扶镜助手相交替；每天练习2h,每周10h；连续4w,共计40h；动态观察3项操作任务每周的学习曲线。培训结束之后,使用自制的输尿管切开取石模型进行综合测试考核：包括完成切开管壁、取出“结石”、放置内支架双J管、间断缝合切口的综合操作。将A组培训结束时3项缝合操作和输尿管切开取石考核测试的完成时间,分别与B组对照组4名有腹腔镜手术经验副主任医师的完成时间进行比较。结果A组12名医师均顺利完成培训。经过4w培训,各项缝合操作完成时间均明显缩短；其中手套间断缝合、肠管连续锁边缝合、鸡皮图形剪切定点缝合的操作时间分别从第1周(51.93±8.34)min、(34.76±7.32)min、(44.48±8.32)min降至第4周的(32.08±5.59)min、(22.27±4.69)min、(26.42±7.10)min,差异均有统计学意义(P=0.000<0.05)。训练结束时A组3项操作的完成时间分别与B组操作的完成时间(26.48±4.83)min、(16.40±6.36)min、(24.63±5.30)min相比较,差异均无统计学意义(P>0.05)。A组12名医师培训结束后均能完成输尿管切开取石任务考核,手术操作完成时间(29.93±9.03)min与B组完成时间(27.95±6.67)min比较,差异无统计学意义(P=0.696>0.05)。结论应用自制训练箱,针对缝合操作进行的腹腔镜技能培训方式,能较好地综合提高受训者的腹腔镜手术基本操作技能,适合于临床医师进行初级的自我培训。第2章腹腔镜膀胱尿道吻合手术训练模型目的针对泌尿专科高难度的腹腔镜膀胱尿道吻合手术步骤,设计制作一种简便、实效、可操作性强的训练模型；观察初学者利用该模型进行技术训练的效果；并对连续或间断缝合两种不同膀胱尿道吻合方式进行评价。方法采用鸡躯干模拟人体盆腔,鸡腺胃、直肠分别模拟人体的膀胱、尿道,制作成腹腔镜膀胱尿道吻合训练模型。在自制训练箱内利用此模型,12名医师随机分为2组,分别进行10轮膀胱尿道吻合操作培训；其中,A组6名采用连续缝合法：从3点开始顺时针连续缝合至3点结束,共约8针；B组6名采用间断缝合法：首先将鸡直肠与腺胃在6点处做全层间断缝合,同法依次缝合4、8、2、10、12点,共6针；记录每人每次训练操作的完成时间。结果两组学员均顺利地完成10轮培训。训练后完成操作所需时间均较训练前有明显下降：A组从训练首次平均(43.58±6.66)min降至第7次、末次的(32.07±7.00)min.(28.77±3.40)min；B组从训练首次平均(44.92±2.92)min降至第6次、末次的(33.97±6.10)min、(28.55±3.74)min;差异均有统计学意义(P<0.05)。比较两组不同吻合法训练前、后所需完成时间,差异均无统计学意义(P>0.05)。结论该模型制作简易、可操作性强,能有效地帮助学员提高腹腔镜下的缝合技巧,初步掌握腹腔镜膀胱尿道间断或连续吻合技术,适合于临床医师进行该术式的初级培训。第3章腹腔镜离断性肾盂成形术训练模型目的针对泌尿专科腹腔镜离断性肾盂成形的手术步骤,设计制作一种简便、实效、可操作性强的训练模型；观察初学者利用该模型进行腹腔镜基本技术训练的效果。方法利用猪肾、鸡食道嗉囊模拟制作成肾盂输尿管连接部狭窄的模型,在自制训练箱内,对8名年轻医师进行10轮次腹腔镜肾盂成形术模拟训练,记录每人每次操作的完成时间；并根据每次术中缝合操作撕裂针数、术后检查吻合口边距、针距的情况,累计成操作失误评分,以评分高低对吻合口质量进行初步的评估。结果8名学员均成功完成了培训,手术操作时间从起初的(73.75±6.69)min降至结束时的(55.38±6.21)min；吻合口失误评分从起初(7.00±1.86)分降至结束时的(3.13±1.36)分,差异均有统计学意义(P<0.05)结论此训练模型制作简易、可操作性强,能较好地模拟腹腔镜离断性肾盂成形术的手术步骤,适合于临床医师进行该术式的初级培训。第4章兔在泌尿外科腹腔镜手术基本技能培训中的应用目的探讨兔在泌尿外科腹腔镜手术基本技能培训中的应用价值。方法建立兔腹腔镜肾切除、输尿管吻合以及肾盂输尿管成形手术的动物模型；在自制模拟训练箱内,对8名医师分别进行10轮此三种术式的模拟训练,记录每人每次手术操作完成时间,动态观察3项术式的训练效果。结果8名医师均顺利完成了培训。其中腹腔镜肾切除、输尿管吻合、肾盂输尿管成形手术时间分别从首次的(45.75±6.88)min、(56.75±7.13)min、(77.38±5.34)min降至末次的(25.86±3.31)min、(35.50±4.04)min、(59.13±7.26)min；训练前后相比较均有统计学意义(P<0.05)；三种术式的手术操作完成时间曲线均呈进行性下降趋势。并且训练后期参与者缝合操作总体上出现重缝、撕裂组织的机率明显下降,控制的针距和边距也更精确,完成的质量和外观上都有了明显的改善。结论兔可以便利地用来建立腹腔镜肾切除、输尿管吻合以及肾盂输尿管成形手术训练的动物模型；适合于泌尿外科临床医师进行腹腔镜手术基本技能操作培训。第二部分带线双J管在男性经尿道腔内碎石术中的临床应用研究背景我国是全球泌尿系结石高发区之一,发病率约1%～5%,南方甚至高达5%-10%,年新发病率约为150-200/10万人。其中以输尿管结石最为多见,并且极易引起输尿管梗阻,导致同侧肾积水、上尿路感染以及肾功能损害,严重地威胁到患者的身体健康。随着现代科技的发展,优质的输尿管镜、医用钬激光等高科技产品先后应用于临床。目前,经尿道输尿管镜腔内钬激光碎石术广泛用于治疗各类输尿管结石。考虑到结石常导致周围输尿管管壁粘膜水肿、炎症、息肉和狭窄,引起不同程度的肾积水、肾功能损害等诸多因素,留置双J管是碎石手术中的标准程序之一。其目的在于保持术后上尿路通畅引流、减少腰背部疼痛、减少感染、保护肾功能、预防输尿管狭窄；并有被动扩张输尿管的作用,可能有利于碎石在术后有序地排出。但是,经尿道腔内碎石术中放置的输尿管内支架双J管必然带来一个的问题：术后需再次入院行膀胱镜取管。然而,临床上膀胱镜是一种侵入性极强的操作；并且由于男性尿道长、存在两个弯曲、三个狭窄等生理解剖上的因素,膀胱镜取管尤其痛苦。而且,可能引发尿道膀胱损伤、严重血尿、尿痛、排尿困难、尿路感染和尿道狭窄等一系列医源性并发症。文献已报道：由于患者普遍对膀胱镜相关认识的缺乏,以及膀胱镜操作自身的致痛性,、几乎所有患者在检查前后都存在着严重的焦虑与恐惧心理。另有学者对门诊患者硬性膀胱镜的耐受性进行了研究,他们采用数字分级法评估患者检查前、检查中、检查后15分钟和3天的疼痛指数,结果显示膀胱镜操作疼痛感显著；而且,多数在3天后才能恢复到检查前水平。因此,对于采用经尿道腔内碎石,术中留置了双J管的男性输尿管结石患者,在充分保证手术安全的同时,是否能避免术后常规的膀胱镜取管值得临床进一步的研究探讨。目的探讨男性输尿管结石患者,在经尿道输尿管镜腔内碎石手术中留置带线双J管,术后通过预留尾线取管的临床应用价值。方法80例男性输尿管结石接受经尿道输尿管镜碎石取石的手术患者,随机分为A、B两组,每组40例。在完成腔内碎石工作后,A组术中放置带尾线双J管,术后通过牵拉预留线拔管；B组术中放置不带线双J管,术后通过常规膀胱镜拔管。观察比较两组留管期间的并发症、就排尿症状的生活质量评分、拔管时视觉模拟疼痛评分以及恢复正常排尿所需时间。结果比较两组患者的年龄构成、结石直径、手术完成时间、结石一期清除率,差异均无统计学意义(P>0.05)。术后留管期间,两组患者就排尿症状的生活质量指数评分为(2.63±0.93)分VS(2.53±0.75)分、出现血尿、尿频、尿急、尿痛等下尿路刺激症状为87.5%(35/40)VS82.5%(33/40),比较差异均无统计学意义(P>0.05)。取管时两组患者的视觉模拟疼痛评分(VAS)为(2.73±1.01)分VS(5.98±1.76)分、恢复正常排尿所需时间为(23.23±4.49)hVS(47.25±6.83)h,比较差异均有统计学意义(P<0.05)。结论对于经尿道输尿管镜腔内碎石的男性输尿管结石患者,术中应用带尾线双J管,留管期间并不增加并发症和影响生活质量；但是,可明显减轻取管时的疼痛以及更快地恢复正常排尿。更多还原

【Abstract】 BackgroundAs a stimulating factor, surgery may produce stress, inflammation, immunity response, leading to a certain degree of damage to the body. For surgical patients, how to implement the best therapeutic effect with minimal damage has been the target of the clinical surgeons.The development of modern minimally invasive surgical techniques deeply affects the concept of surgical treatment. Among them, laparoscopic surgery is a successful combination of modern technology and traditional operation. As the main content of minimally invasive surgery, it has become the important direction in the future.Compared with the traditional surgery, it have less trauma, better stable internal environment, the more accurate results, the shorter length of hospital stay and better psychological effect, opened a new era of modern surgery.Over the past20years, laparoscopic surgery in the field of clinical urology has become more mature, and increasingly widely used. At present, in many traditional operations, laparoscopic surgery has achieved a revolutionary success. From the past simple removal damaged surgery, such as renal cyst unroofing, adrenal tumor resection, no function renal resection, etc, to the present complicated functional reconstruction surgery, such as renal pelvis ureteroplasty, partial nephrectomy, radical resection of prostate cancer, bladder resection with new bladder in situ technique, etc, it basically covers all the category of specialized operation.Part of the laparoscopic surgery has replaced traditional surgery, become the preferred classic such as adrenal tumor resection. Minimally invasive advantage of the laparoscopic surgery quickly won the wide recognition of surgeon and patient. This specialized subject is indispensable important component of modern surgery.But, laparoscopic surgery is a new skill totally, fundamentally different from the traditional surgery. It has a very distinctive technical characteristic. Demand in the operation of three-dimensional space perception, hand-eye coordination and so on ability, must be gradually improved through training. Among them, the laparoscopic suture operation is particularly difficult to grasp, limiting the technology in clinical application extremely.Researches have been reported: after all kinds of different laparoscopic training, the ability of trainers can be a certain degree of increase. Training is very important for operation safety of laparoscopic surgery, and can avoid the problems caused by the surgery skills unskilled, and can minimise the risk of surgical complications.In view of factors of expensive training equipments and the lack of formal, standard, unified training courses, limited teaching resources extremely, how to train basic laparoscopic skills for clinical doctors has not been solved. The development status of urologic laparoscopic surgery in the domestic various regions is unbalanced, and lots of medical units are still in the initial stage.Thus, strengthening laparoscopic training of clinical surgeons is necessary extremely. How to improve efficiently laparoscopic surgical training is an important subject. Seeking a convenient mode for self training is the urgent request of clinicians also.Chapter1:Application of homemade training box to improve basic skills of laparoscopic surgeryObjectiveTo introduce a homemade training box to acquire basic laparoscopic skills by the way of3training courses of laparoscopic suturing operation.MethodsGroup A is made of12young doctors without the experience of laparoscopic procedure, participating the training program. Through using this kind of homemade training box,3training items are gloves intermittent, intestinal continuous and chicken skin graphic suture. Trainees practice2h every day,10h weekly, including continuous4w. Learning curves of3tasks weekly were observed. At the end of training, participants were assessed by the use of a self-made training model of ureteral calculi, including opening wall, removing stone, placing internal double J tube and intermittent suturing incision. The time of3operations and the test in group A at the end of the training respectively, compared with the completion time in group B who are4doctors having all kinds of laparoscopic experiences at least100cases.Results12young doctors in group A are successfully completed training and assessment. After4w training, the time of suturing tasks significantly shortened. The time of gloves intermittent, intestinal continuous and chicken skin graphic suturing declined respectively from the first week (51.93±8.34)min,(34.76±7.32)min and (44.48±8.32)min to the final (32.08±5.59)min,(22.27±4.69)min and (26.42± 7.10)min, and the difference was statistically significant (P<0.05). Compared the final time in group A with the completion time in group B (26.48±4.83)min,(16.40±6.36)min and (24.63±5.30)min, the difference was not statistically significant (P>0.05).Otherwise, during the course of training process later, we observed that participants controlling stitch and edge distance are more accurate when sewing, and quality of appearance has been improved. At last, group A can complete successfully the testing task, and operational completion time (29.93±9.03)min compared with the time (27.95±6.67)min in group B. The difference was not statistically significant (P=0.696>0.05).ConclusionThe application of homemade laparoscopic training box by the way of training of suturing operation can well improve the comprehensive basic skills of surgery, suitable for clinical doctors to perform primary self training. Chapter2:To introduce a kind of model for intensive training laparoscopic bladder-urethral anastomosisObjectiveTo introduce a kind of model for intensive training laparoscopic bladder-urethral anastomosis, and evaluate two different ways of anastomosis of continuous suture and intermittent suture. MethodsThe human pelvic was simulated by the chicken trunk, and bladder and urinary tract were simulated by chicken proventriculus and rectum respectively. Using this model placed in homemade training box, 12residents without the experience of laparoscopic procedure who have completed some basic technologic training were randomly divided into2groups, training with10rounds of anastomosis.6residents in group A suture from3:00to3:00clockwise;6residents in group B suture the chicken rectum and proventriculus at6:00first, followed by suturing4,8,2,10,12. Each operating time was recorded.ResultsParticipants in two groups have successfully completed the entire training. The time of group A declined from the first (43.58±6.66)min to7th times, the final (32.07±7.00) min,(28.77±3.40)min; the time of group B from the first (44.92±2.92)min to6th times, the final (33.97±6.10) min,(28.55±3.74)min; the differences were statistically significant(P<0.05). Compared the operating time of two groups, the differences were not statistically significant (P>0.05).ConclusionThe simple realistic and effective model can simulate operation steps of laparoscopic bladder-urethral anastomosis, suitable for no laparoscopic experience student to improve the suturing techniques. Chapter3:To introduce a kind of model for training laparoscopic dismembered pyeloplastyObjectiveTo introduce a kind of model for training laparoscopic dismembered pyeloplasty.MethodsThe model of ureteropelvic junction obstruction was simulated by pig kidney and chicken crop. Using the model placed in homemade training box, eight residents without the experience of laparoscopic procedure who have completed some basic technologic training were trained with10rounds of anastomosis according to the standard operation steps. Each operating time and quality were recorded.Results8trainees completed the entire training successfully. The operating time decreased from (73.75±6.69)min to (55.38±6.21)min, and anastomotic errors score decreased from (7.00±1.86) min to (3.13±1.36) min. The difference was statistically significant (P<0.05).ConclusionThis simple, realistic and effective model can simulate the operation steps of laparoscopic pyeloplasty, suitable for no laparoscopic experience student. Chapter4:Development of rabbit models for training basic skills of urologic laparoscopic surgeryObjectiveTo value rabbit models for training basic skills of urologic laparoscopic surgery.MethodsRabbit models of laparoscopic nephrectomy, ureteral anastomosis and pyeloplasty were developed. In the self-made simulation, eight trainees with no actual laparoscopic surgery participated10rounds of simulation training by taking the models according to the standard steps. Each operating time was recorded. The learning curves of laparoscopic nephrectomy, ureteral anastomosis and pyeloplasty were observed.ResultsEight doctors are successfully completed training. The time of laparoscopic nephrectomy declined from the first (45.75±6.88)min to the final (25.86±3.31)min; the time of laparoscopic ureteral anastomosis from the first (56.75±7.13) min to the final (35.50±4.04) min; the time of laparoscopic pyeloplasty from the first (77.38±5.34)min to the final (59.13±7.26) min. The differences were statistically significant (P<0.05). Otherwise, sewing mistakes declined obviously, and controlling stitch and edge distance were more accurate, and the quality and appearance were significantly improved in the training later.ConclusionRabbit can be conveniently used to set up some animal models to train laparoscopic nephrectomy, ureteral anastomosis and pyeloplasty, suitable for clinical urologic doctors to train basic skills of laparoscopic surgery. Section2:Clinical application of double J tube with line in the male transurethral lithotripsyBackgroundChina is one of high incidence of urinary calculi in the world, and its incidence is about1%～5%, and the south about5%-10%. New incidence is about150～200/100,000. Ureteral calculi is the most common urinary tract stone, and often causes acute unbearable renal pain suddenly. Ipsilateral kidney seeper, urinary tract infection and kidney damage can been caused by obstruction easily. It is a serious threat to the health of the patient.With the development of modern science and technology, the high quality of ureteroscopy and medical holmium laser and other high-tech products successively have been used in clinical. Currently, transurethral ureteroscopy cavity operation widely has been used in the treatment of ureteral calculi.Considering that ureteral calculi often leads to the surrounding ureteral wall mucosal edema, inflammation, polyp, narrow, upper tract expansion and impaired renal function, indwelling double J tube is one of the standard procedure in the course of operation. Its purpose is to keep the upper tract unobstructed drainage after operation, protect renal function, reduce waist back pain and infection, prevent ureteral stricture. It also has the effect of passive expansion of the ureter, and may be help gravel out of body in an orderly fashion. But, indwelling double J tube is bound to bring a serious problem: it must be taken by cystoscopy in the postoperative. Clinically, cystoscopy is a highly invasive operation. Because there are more length, two bending, three physiological anatomical narrow in male urethral, cystoscopy must be particularly painful. And it may cause serious hematuria, urinary pain, urethra injury and urinary tract infection, urethral stricture and iatrogenic complications.The literature reported that patients were serious anxiety and pain before and after checking due to the lack of understanding of the cystoscopy. The study of other scholars to cystoscopy tolerance of outpatients show that cystoscopy operation is painful significantly, adopting digital classification method used to evaluate patients.Therefore, for male patients with ureteral calculi of intraoperative indwelling double J tube, whether can avoid postoperative routine cystoscopy is worthy of clinical research.ObjectiveTo explore clinical value of double J tube with line in the male transurethral lithotripsy extubating tube by reserved line.Methods80cases of male patients with ureteral calculi, according to the operational time, were randomly divided into A, B groups, and each group has40cases. After transurethral holmium laser lithotripsy, group A was placed double J tube with line, extubating tube by reserved line after surgery; group B was placed double J tube without line, extubating tube by cystoscopy. Quality of life and lower urinary tract symptoms with double J tube, the visual analog pain score extubating tube and the recovery time of normal urination were observed. ResultsAge structure, the stone diameter, operation completion time and clearance rate of stone in two groups were no statistically significant (P>0.05). Quality of life score and lower urinary tract symptoms with double J tube were (2.63±0.93) points VS (2.53±0.75) points and87.5%(35/40) VS82.5%(33/40), and the differences were no statistically significant (P>0.05). Visual analog pain score extubating tube and recovery time of normal urination were (2.73±1.01) points VS (5.98±1.76) points and (23.23±4.49)h VS (47.25±6.83)h, and the differences were statistically significant (P<0.05).ConclusionDouble J tube with line in the urethra holmium laser lithotripsy to male patients with ureteral calculi does not affect quality of life, and increase complications. But the degree of pain extubating tube reduced significantly and normal urination can be recovered fastly.更多还原