1.腹腔镜肝叶切除动物（兔）模型的建立及实验研究　2.刮吸断肝法应用于腹腔镜下解剖性肝叶切除的临床研究

【作者】 郑雪咏；

【导师】 蔡秀军；

【作者基本信息】 浙江大学 ， 外科学， 2006， 博士

【摘要】 近年来,随着腹腔镜外科技术的不断成熟,腹腔镜手术已向腹部外科的各个领域发展。腹腔镜技术在肝脏外科领域的应用亦不断扩大,但目前真正较大范围的腹腔镜肝切除手术仍不多。同时随着腹腔镜手术的发展,相关的腹腔镜基础研究也不断增多。大多数基于腹腔镜胆囊切除术及其他空腔脏器等手术进行的研究表明腹腔镜手术相对于开腹手术在术后应激、炎症、免疫等反应上具有一定的优势,而临床报道也表明腹腔镜手术相对于开腹手术具有术后疼痛轻,住院时间短、恢复快等优点。而对于腹腔镜肝脏手术,因其目前仍处于探索阶段,相关的临床及基础研究仍旧需要我们进行研究。 综上所述,客观上需要从建立动物模型上着手,建立一个简单、易行,又能进行较大范围肝脏切除,可操作性强,可大量复制的动物模型,以便进行相关的实验研究。同时细胞因子在手术和外伤引起的炎症反应中起着重要作用,动态观察血清TNF-a和IL-6的变化,对于评估、比较手术的炎症反应,对于今后的进一步相关研究都具有重要的意义。 由此我们设计了本实验,试图利用新西兰大白兔建立一个简易的腹腔镜肝叶切除的动物模型。并针对肝切除量的不同,设置了不同的腔镜手术组与相对应开腹手术组分别比较,并动态观察、比较血清TNF-a和IL-6的变化。 材料与方法 新西兰大耳白兔40只,雄性,体重2.0-2.5kg,随机分成4组。A组:腹腔镜左肝内叶切除组(10只);B组:开腹左肝内叶切除组(10只);C组:腹腔镜左肝内、外叶切除组(10只);D组:开腹左肝内、外叶切除组(10只)。采用速眠新Ⅱ注射液,0.3ml/kg,经耳缘静脉注射麻醉。手术方法:A、C组(腔更多还原

【Abstract】 Laparoscopic surgery has evolved and expanded greatly over the past decade. Since its first successful entry into general surgery with the advent of laparoscopic cholecystectomy in the late 1980s, laparoscopic surgery has been incorporated to various degrees into almost every aspect of abdominal surgery. Laparoscopic liver surgery is in a developing field now but formal segmental resections are still remaining diminutive percentage. There is an abundance of evidence reflecting the benefits of laparoscopic cholecystectomy and some of these benefits have been linked to the decreased metabolic and immune responses involved. Multiple clinical studies initially comparing open to laparoscopic cholecystectomy clearly demonstrated a significant reduction in postoperative pain, hospital stay, perioperative morbidity, and convalescence. Laparoscopic liver surgery is a field in its infancy, such basic and clinical studies are still needed to investigate.At first, we need a animal model of laparoscopic hepatectomy for basic research.. It is required that the procedure is feasible, safe, reproducible, and formal segmental resection can be accomplished. At the same time, it is reported that cytokines present important influence in inflammatory response induced by operation and trauma, so it is significant to observe dynamic change of serum TNF-a & IL-6 level.So we planned to develop a new animal model of laparoscopic partial hepatectomy in the rabbit. Corresponding to various resection volume, various laparoscopic groups and corresponding open groups were installed, dynamic change of serum TNF-a & IL-6 level was observed and compared simultaneously.Materials and Methods40 male New Zealand big rabbits provided by animal center of ZhejiangUniversity with body weight ranged from 2.0-2.5kg were divided into 4 groups randomly. Group A(n=10): underwent laparoscopic liver resection of left internal lobe;Group B(n=10): underwent open liver resection of left internal lobe;Group C(n=10): underwent laparoscopic liver resection of left internal and lateral lobe;Group D(n=10): underwent open liver resection of left internal and lateral lobe. All groups were anesthetized by intravenous injection(0.3ml/kg) of 846 mixture liquid. Operation procedure: Group A> C(laparoscopic groups), as it is a gasless laparoscopic operation, a subcutaneous suture was firmly placed subcutaneously in the umbilical abdominal wall and it is attached to a lifting device to create a sufficiently wide working space. The 0° laparoscope(Smith & Nephew ?) used was 2mm in diameter. All the instruments (endo grasp and endo shears)(Auto Suture ?) were 5mm in diameter. Three ports were made longitudinal from xiphoid process to umbilical region. A pretied loop ligature: 2-0 Surgitie(Auto Suture ?) was then placed around the base of liver lobe under endoscopic guidance. The ligature was tied firmly. Resection was performed with endo shears about 3-5 mm distal to the ligature;Group B> D(open groups), the conventional operation was done with a long incision about 7cm. The operative time, blood loss, mortality or morbidity, specimen weight and residual liver weight of 7th day, body weight of preoperative and 7th day, abdominal adhesion formation, healing of incision and liver were measured or estimated. Serum levels of ALT, AST, TNF-a(ELISA), IL-6(ELISA) were investigated at preoperative, 12h, 24h, 48h, 72h, 7d after operation. HE stain liver specimen was observed under microscope.Results All four groups received operation favorably, no conversion to the opentechnique was necessary in Group A&C. All rabbits received normal diets and showed sensitive feedback the day after operation. No intra- or perioperative mortality or morbidity (bleeding, biliary leakage, infection) was observed. All animals survived in 7 days and showed no wound infections. Group A(laparoscopic left internal lobectomy) was compared to Group B(open left internal lobectomy);while Group C(laparoscopic left internal & lateral lobectomy) was compared to Group D(open leftinternal & lateral lobectomy): there is no apparent difference in blood loss during the intervention(P>0.05) while operative time was significant prolonged(P<0.01). All rabbits had a significant weight loss on 7th day(P<0.01) regardless of whether one or two lobes had been resected, but no difference among the four groups in body eight(P>0.05). There is no apparent difference in specimen weight and residual liver weight between Group A and Group B while Group C and Group D(P>0.05).Serum ALT and AST change: serum ALT concentration elevated significantly in each groups postoperatively during 24h (P<0.01) and went back to normal level in 7days;serum AST concentration elevated significantly in each groups postoperatively during 12h (P<0.01) and went back to normal level in 3-7days, while no difference in ALT & AST change among the four groups(P>0.05).Serum TNF-a change: Group A(laparoscopic left internal lobectomy) was compared to Group B(open left internal lobectomy), serum TNF-a concentration elevated postoperatively in two groups, serum TNF-a concentration 72h after operation in Group A was significant lower than Group B(P<0.05);Group C(laparoscopic left internal & lateral lobectomy) was compared to Group D(open left internal & lateral lobectomy), serum TNF-a concentration elevated postoperatively in two groups, serum TNF-a concentration 72h after operation in Group C was compared to Group D(P=0.08);There is no apparent difference in TNF-a change between Group A and Group C while Group B and Group D.Serum IL-6 change: Group A(laparoscopic left internal lobectomy) was compared to Group B(open left internal lobectomy), serum IL-6 concentration elevated significantly postoperatively in two groups, serum IL-6 concentration 24h & 48h after operation in Group A was significant lower than Group B(P<0.05);Group C(laparoscopic left internal & lateral lobectomy) was compared to Group D(open left internal & lateral lobectomy), serum IL-6 concentration elevated significantly postoperatively in two groups, serum IL-6 concentration 48h & 72h after operation in Group C was significant lower than Group D(P<0.05);There is no apparent difference in IL-6 change between Group A and Group C while Group B and Group D.Pathologic change: adhesion formation under incision was apparent in opengroups(B & D) while no difference around hepatic region between laparoscopic groups and open groups;the residual liver was swelled and the margin was a little blunt, the resection margin healed well surrounding by some connected tissue, no intra-abdominal abscess formation and no sign of former bleeding at the resection margins, there was no sign of bile leakage encountered in the abdominal cavity or on the resection surface of the liver;observed under microscope, hepatic lobule kept integrated after operation, enlarged liver cells could be seen in side zone of lobule, which was more apparent in left internal & lateral lobectomy groups(C & D), the nuclear and nucleoli were enlarged, the karyoplasm and cytoplasm were stained weak, vesicle can be seen in some liver cells.Conclusions1. Set up a new animal model of laparoscopic partial hepatectomy in the rabbit.2. Compare to open hepatectomy, laparoscopic hepatectomy showed more diminutiveinfluence on serum TNF-a & IL-6 change.更多还原