【作者】 马立霜；

【导师】 李龙；

【作者基本信息】 北京协和医学院 ， 儿科学（专业学位）， 2014， 博士

【摘要】 研究背景先天性膈疝是新生儿外科危重症之一。目前病因及发病机制尚未明确。外科手术是从根本上治疗CDH的主要手段。目前先天性膈疝外科手术方式包括开放手术和腔镜手术两种。随着微创外科的日益发展,越来越多的中心开始对新生儿膈疝行腔镜下膈疝修补术治疗。目前有研究认为腔镜手术具有打击小、术后恢复快、切口美观等优点,可作为新生儿先天性膈疝的治疗途径之一。但是,腔镜手术与开放手术治疗新生儿CDH的适应症是否相同,腔镜手术是否会有严重的并发症,应如何防范和处理,经开放和腔镜两种途径手术后患儿的临床疗效是否相当都值得进一步积累更多的患儿资料进行研究。本次研究通过回顾性对比分析2002年-2014年我院收治的先天性膈疝患儿的临床资料,通过比较开放手术与腔镜手术行新生儿膈肌修补术的临床效果,探讨新生儿膈疝腔镜手术的临床疗效、安全性和有效性,从而为进一步开展腔镜下膈肌修补术治疗新生儿CDH提供参考和依据。目的对比腔镜手术和开放手术治疗新生儿膈疝的临床疗效,探讨腔镜下治疗新生儿膈疝的可行性及安全性,为进一步开展腔镜下膈肌修补术治疗新生儿先天性膈疝提供参考和依据。方法本研究回顾性分析我院2002年6月至2014年2月采取手术治疗的59例新生儿膈疝患儿的病例资料。根据手术方式分为腔镜手术组和开放手术组,其中腔镜手术组19例,10例采用胸腔镜,9例采用腹腔镜；开放手术组40例。对比两组患儿的年龄、体重、手术时间、手术出血量、及术后住院时间,术后并发症及有无复发等资料,进行统计学分析比较。为比较术者手术经验对围手术期观察指标的影响,本研究按照腔镜手术开展的时间顺序分为近5年腔镜组(n=11,2009年3月-2014年2月)和以往腔镜组(11=8,2002年6月-2009年2月),比较两组上述观察指标的差异。结果1.两组患儿的年龄[(3.4±0.2)d vs.(4.1±0.5)d,P=0.654]、体重[(3.3±0.3)kgvs.(3.5±0.2)kg, P=0.815]基本相同,无统计学差异。2.腔镜手术组的手术时间(115.6±31.2min),长于开放手术组的(92.5±19.4min)；腔镜手术组术中出血量(1.53±0.22ml)、住院时间(14.2±2.7d)、术后通气时间(1.8±0.2d)、术后抗生素使用时间(2.8±0.2d)均明显少于开放手术组的(6.59±0.94ml)、(21.5±3.5d)、(5.1±0.9d)、(4.8±0.3d),差异有统计学意义(P<0.05)。3.腔镜手术组和开放手术组两组术后24h PCO2[(47.8±1.8mmHg)vs(48.6±1.5mmHg)]、术后胸腔积液发生率(10.5%vs7.5%)、复发率(15.8%vs5%)、存活率(94.7%vs95%)等观察指标的比较,差异无统计学意义(P>0.05)。4.腔镜手术组按手术开展的时间顺序比较,近5年腔镜组在手术时间(103.2±21.4min)、住院时间(13.8±2.1d)、复发率(9%)均少于以往腔镜组的(121.8±35.3min)、(15.2±2.7d)、(25%),但差异无统计学意义。结论1.本研究结果表明腔镜膈疝修补术安全、可行,具有术中出血少、创伤小、恢复快等优点,临床效果与开放手术相当,适用于新生儿先天性膈疝的手术治疗。2.随着术者的经验积累以及腔镜技术的发展,腔镜膈疝修补术的手术操作时间可以逐渐缩短,甚至接近开放膈肌修补术时间。3.采用腹腔镜或胸腔镜膈肌修补术,应该根据术者自身经验以及患者的实际情况进行合理的选择,并且随着腔镜设备的更新换代以及技术的进步,腔镜下膈疝修补术的适应症可以进一步扩大。更多还原

【Abstract】 BackgroundCongenital diaphragmatic hernia (CDH) continues to be a critical problem in neonatal surgery. The cause of CDH is unknown. Surgery is the main treatment for CDH. The surgical models of congenital diaphragmatic hernia including open and MIS approach. The arrival of small videoscopic instrumentation allowed the management of neonatal CDH by pediatric surgeons trained to perform MIS procedures. The MIS approach can lead to less postoperative morbidity, faster recovery, and shorter hospitalization, but it also can precipitate complications. Because of the short time of laparoscopy applied in CDH, the prognosis needs distant observation. Whether the indication, security and efficacy of laparoscopy in CDH needs more studies.ObjectiveThe aim of this study was to evaluate outcome of neonatal with congenital diaphragmatic hernia undergoing open versus minimally invasive surgery.Methods59neonatal congenital diaphragmatic hernia cases collected from June.2002to February.2014. These patients were divided into2groups, minimally invasive surgery group and open-group.19cases were repaired by minimally invasive surgery,10cases were repaired by thoracoscopy,9cases were repaired by laparoscopy.40cases were treated by open surgery. Clinical data including preoperative data, treatments, postoperative management were retrospectively reviewed. The comparison of clinical data was made between minimally invasive surgery and open-group. Outcome and recurrence were evaluated.According to the operation period,19patients underwent MIS are divided into two groups:11patients operated in the last five years surgery group(2009.3-2014.2) and8patients operated in previous surgery group(2002.6-2009.2), they are compared in the aspects the above-mentioned.Results1. The difference between the groups is not statistically significant at the aspects of the patients’age[(3.4±0.2)d vs.(4.1±0.5)d,P=0.654],body weight[(3.3±0.3)kg vs.(3.5±0.2)kg, P=0.815]2.Compared with the patients in open-group, the patients in MIS group had a longer operative duration(115.6±31.2min vs92.5±19.4min, P=0.023), less blood loss(1.53±0.22ml vs6.59±0,94ml, P=0.044), less antibiotics consumption time(2.8±0.2d vs4.8±0.3d, P=0.042), shorter the in-hospital time[(14.2±2.7)d vs.(21.5±3.5)d, P=0.042], less postoperative duration of mechanical ventilation time[(1.8±0.2)d vs.(5.1±0.9)d, P=0.034].3.The difference between the groups is not statistically significant in the followings: survival rate (94.7%vs95%), recurrence rate(15.8%vs5%), postoperative PCO2with in24h[(47.8±1.8mmHg)vs(48.6±1.5mmHg)], the incidence of postoperative hydrothorax(10.5%vs7,5%).4.Compared with the patients underwent MIS in previous surgery group, the last five years surgery group had a shoter operative duration(103.2±21.4min vs121.8±35.3min), shorter the in-hospital time(13.8±2.1d vs15.2±2.7d), recurrence rate (9%vs25%), but the above indicators between the two groups had no significant statistic differences(P<0.05).Conclusion1.The indication of minimally invasive surgery group in Congenital diaphragmatic hernia is similar to open surgery group. It can provide the basis of random cohort study of minimally invasive surgery and open surgery in CDH.2. To compare with open surgery, minimally invasive surgery repair have no increase in the incidence rate of operation-related complication. And two groups’ survival rate is equated. We consider that the minimally invasive surgery repair is safe and valid.3.Shorter operative duration and less blood loss can be found in minimally invasive surgery with the advance of operative technology. It indicates that enhancing minimally invasive surgery training can raise the operative quality and is favourable to the applying of minimally invasive surgery in Congenital diaphragmatic hernia.更多还原