【作者】 刘运枫；

【导师】 王洪斌；

【作者基本信息】 东北农业大学 ， 临床兽医学， 2008， 博士

【摘要】 外科微创化是21世纪外科的发展方向,而做为外科微创化的重要组成部分的腹腔镜技术具有手术视野清晰、出血量少、微创、对机体影响小、疼痛反应轻和术后恢复快等特点,已经广泛的应用于人类医学。在兽医领域国外早就有腹腔镜技术在动物中应用的报道,并且涉及到的动物种属多、应用领域广泛。然而国内腹腔镜技术在动物领域中的应用还很局限,多数都是用于繁殖领域,还未见有关犬的相关基础研究和手术。基于以上原因,本研究进行了犬最佳充气腹所用气腹压的选择试验;利用试验选择确定的最佳气腹压充气腹,完成犬腹腔镜脾脏摘除术、腹腔镜胆囊摘除术、腹腔镜膀胱切开与缝合术、腹腔镜胃切开与缝合术和腹腔镜胃固定术;进行腹腔镜胆囊切除术和开腹胆囊切除术的对比研究,以比较腹腔镜手术和开腹手术的优缺点。30只犬,平均体重18kg,雌雄兼有。在同一条件下饲养21天,经临床和试验室检查健康后,开始进行试验。将试验犬随机分成五组,A组为麻醉组;B组气腹压值为0.80kPa;C组气腹压值为1.06kPa;D组气腹压值为1.33kPa;E组气腹压值为1.60kPa。分别于设定的七个时间点来监测试验犬的一些临床体征、体温（BT）、血压（SBP、SDP）、脉搏血氧饱和度（SpO₂）、呼吸频率（RR）、呼气末CO₂分压（PetCO₂）。同时分别于设定的六个时间点,采静脉血分离血清,检测免疫系统指标:白细胞总数、淋巴细胞总数、白细胞介素-6（IL-6）,白细胞介素-8（IL-8）,C反应蛋白（CRP）、肿瘤坏死因子-α（TNF-α）;检测肝功能:天门冬氨酸氨基转移酶（AST）、谷氨酸氨基转移酶（ALT）、碱性磷酸酶（ALP）、总胆红素（TBIL）;肾功能:肌苷（Crea）、尿素氮（BUN）。除此之外,还分别用0.80、1.06、1.33、1.60kPa四种不同气腹压来充气腹,观察腹腔的膨隆是否能够充分显露术野。通过以上指标的监测与检测,并结合腹腔的膨隆情况确定一个最佳气腹压值。然后利用该气腹压值,进行每组6只犬的腹腔镜脾脏摘除术、腹腔镜胆囊摘除术、腹腔镜膀胱切开与缝合术、腹腔镜胃切开与缝合术和腹腔镜胃固定术。最后进行腹腔镜与开腹胆囊摘除术的对比试验。通过比较两种手术方法所用时间、切口长度和一些免疫应激指标来验证腹腔镜手术的优越性。通过试验,得出以下结果:1.不同CO₂气腹压对犬生理机能的影响在气腹过程中,随着气腹压增大,气腹维持时间的延长,各监测和检测指标发生相应的变化。气腹压越大,这种改变越大。通过不同气腹压来充气腹,观察腹腔的膨隆是否能够充分显露术野的试验得知,压力为1.33 kPa时,术野显露很充分,完全可以进行手术。虽然E组暴露的术野更显著,但其对机体的损伤也明显大于B、C、D组;尽管B、C组对以上临床体征和生理指标的影响最小,但术野暴露不够充分。所以,1.33 kPa是进行腹腔镜手术的最佳气腹压值。2.腹腔镜技术在犬的临床应用选用1.33kPa的气腹压进行的30例手术均顺利完成,且术后均无感染,只有一例膀胱切开与缝合的手术有轻微的粘连,术后第二天食欲、精神状态基本恢复了正常。证明腹腔镜技术可以在兽医临床和外科手术中应用。3.犬腹腔镜和开腹胆囊切除术的对比试验通过试验得知,完成犬腹腔镜胆囊摘除术,平均需30min;而完成开腹胆囊手术平均需要50min;腹腔镜胆囊切摘除术手术切口总长度为3.3cm;手术完成后,只需要进行1针结节缝合直径11mm的穿刺孔,直径为5.5mm的穿刺孔不需要缝合。而开腹胆囊摘除术时,切口长度大约平均15cm,术后要常规结节缝合8-10针。试验结果显示,两种手术方法术后,体温升高,白细胞总数增加,白细胞介素-6、C反应蛋白、肿瘤坏死因子-α逐渐增多,但开腹手术组的这些指标变化都明显高于腹腔镜手术组,免疫球蛋白等免疫指标也发生了相应的变化,所以腹腔镜手术要优于开腹手术。综上所述,本试验首次在国内进行了犬腹腔镜手术的系统研究。确定了犬腹腔镜充气腹的最佳气腹压值为1.33kPa,并把该试验结果运用到腹腔镜手术中,进行了腹腔镜手术与常规开腹手术对机体影响的比较,探讨了腹腔镜技术在兽医临床与外科手术中的实用性与可行性,验证了腹腔镜外科的微创优点,为该技术在国内兽医临床的推广应用提供了科学理论依据。更多还原

【Abstract】 Minimally invasive surgery is the development direction of surgical in 21^st.And as an important component part of the minimally invasive surgery,laparoscopic technology has clear surgery eyesight,less bleeding,minimally invasive,small impact on the body,slight pain response,rapid postoperative recovery and other characteristics.The technology has been widely used in human medicine.There were many reports in veterinary field abroad about laparoscopic technology applying on animals and related to animal species has widespread applications. However,domestic laparoscopic technology applying on aninal field is very limited and most of which were used for breeding areas.There is no conrelated and basic reseach or surgery on dogs in China so far.So the objectives of the study were to choose the optimum pneumoperitoneum on dog’s surgery;to complete the sliver and suture of stomach、cholecystectomy and the sliver and suture of bladder with the best pneumoperitoneum;to understand the advantages and disadvantages of laparoscopic cholecystectomy（LC） and open cholecystectomy（OC） according to comparative analysis of laparoscopic versus open splecectomy.Thirty dogs（male or female） weighing about 18kg were selected and cultivated 7 days in the same constitution,then began to experimentize after the dogs were confirmed healthy in clinical and laboratory examination,randomly selected for five groups,named group A,B,C,D and E.Group A was anesthesia and group B,C,D,E were subjected to CO₂ pneumoperitoneum（PP） at pressure 0.80, 1.06,1.33 and1.60kPa.Body temperature（BT）,blood pressure（SBP and SDP）,SpO₂,respiratory rate（RR）,PetCO₂ were recorded at seven time point after anesthesia.At the same time,each group were collected the blood for measurement of immunity function（WBC,Lym,IL-6,IL-8,CRP, TNF-α）;liver function（AST,ALT,ALP,TBIL）;renal function（Crea,BUN）.Otherwise,we insufflated with different airpressure（0.80、1.06、1.33、1.60kPa） in order to compare which one could reveal the surgery eyesight thoroughly.We determined an optimum pneumoperitoneum according to test the above index and inflation condition.Then with the optimum pneumoperitoneum,laparoscopic surgery was performed such as laparoscopic repair of experimentally ruptured urinary bladder,laparoscopic splenectomy,laparoscopic cholecystectomy, laparoscopic silver and repair of stomach.At last,we did the contrast between laparoscopic cholecystectomy（LC） and open cholecystectomy（OC）.The item of operating time and length of incision and index of immunity-stress were compared in order to test the advantages of laparoscope technique.The results showed that:Firstly,the influence of different CO₂ pneumoperitomeum on physical function.In the study,during the pneumoperitoneum process,along with increased abdominal pressure gas,all index have changed accordingly.The pneumoperitoneum pressure was more bigger and the change is more bigger.We found that the surgery eyesight can be exposed thoroughly at 1.33kPa and the surgery can be carried out with different insufflation in the test selecting the optimum surgery eyesight.Secondly,the clinical application of laparoscope technique on dogs.30 surgery were successfully completed with 1.33kPa pneumoperitoneum,and no postoperative infections,and only one incision and repair of the bladder appeared adhesions,after the second day its appetite,mental state recovered to normal.The fact that Laparoscopic techniques could be applied in veterinary clinical surgery was verified.Thirdly,the contrast between laparoscopic cholecystectomy（LC） and open cholecystectomy（OC）.According to the test,complishing the LC needed 30min,but OC needed 50min.The total operative incision was about 3.3cm in LC and only one scobination could suture puncture hole of 11mm after surgery but the puncture hole of 5.5mm needn’t suture;but operative incision was about 15cm and needed routine scobination suturation about 8-10.The results show that,body tempture and WBC were increased;immunity index such as IL-6,CRP,TNF-α,immunoglobulin were changed accordingly.On the whole,the laparoscopic surgery on dogs was firstly studied in China.The optimum PP of the dog was 1.33kPa,the effects of laparoscopic and traditional surgery was compared.All these revealed that the advantages of laparoscopy was feasible and practical,these will be the basis for applying of LS in domestic veterinary clinic.更多还原