【作者】 孙刚；

【导师】 杨云生；

【作者基本信息】 中国人民解放军军医进修学院 ， 内科学， 2009， 博士

【摘要】 背景与目的:经自然管壁内镜手术(Natural Orifice TranslumenalEndoscopic Surgery,NOTES)是指不经皮肤切口而经人体自然孔道,再经管壁(如胃、结肠及阴道等)造口进行的内镜手术。相对于传统的开腹手术和经皮肤切口的腹腔镜手术,NOTES具有腹壁无斑痕、术后疼痛减少、更加微创及可能缩短住院时间和减少医疗开支等潜在优势。2007年4月法国特拉丝堡大学医院Marescaux小组成功完成了世界首例经阴道内镜胆囊切除术,标志着又一项新的微创治疗时代即将到来。虽然国际上已有较多动物实验报道和少数人体NOTES手术的个案研究,但NOTES在人体的应用价值仍受到很多质疑;其安全性和有效性目前尚待进一步评估。本研究组于2001年在国内首先开展了NOTES的动物实验,截至目前这项研究在国内已有数家单位开始动物实验研究,并且开始尝试于人体的研究。材料与方法:采用五指山雌性小型猪为实验动物共30只,体质量12Kg-15Kg;成年杂种犬12只,体质量15Kg-20Kg。术前禁食1d,不限水;术中应用全身麻醉,气管插管,呼吸机辅助呼吸。内镜进入胃肠道后,选取胃窦体交界前壁小弯侧及距肛门15cm-20cm结肠后壁系膜对侧为造口位置,针状刀切开后用扩张球囊扩张造口至1.2cm-1.5cm;内镜从造口进入腹腔后注气形成人工气腹,进行内镜腹腔探查术和腹部脏器手术;术中应用抗生素预防感染。研究分为两个阶段,第一阶段以五指山小型猪为研究对象开展腹腔和腹膜后脏器探查术、肝脏活检术、输卵管结扎术、卵巢切除术、胃-空肠吻合术和胆囊切除术。对于单一NOTES途径难以完成手术,采用腹腔镜辅助完成,采用钛夹夹闭方法闭合切口。开展急性实验和存活实验初步评价NOTES的可行性和有效性。第二阶段以杂种犬为研究对象开展经脐戳孔辅助经胃途径NOTES胆囊切除术,对其可行性、有效性和安全性进行前瞻性研究。同时研究胃壁造口的新型闭合方法,评价其应用价值。结果:共开展NOTES手术32例次,急性实验7例次,存活实验25例次。第一阶段以五指山小型猪为研究对象,开展NOTES手术20例次,其中经胃途径3例次、经结肠途径2例次、腹腔镜联合经胃途径NOTES手术15例次。经胃或经结肠途径腹腔探查均能较好显示腹腔脏器,如肝脏、胆囊、脾脏、胃、结肠、部分小肠、膀胱、输卵管、卵巢、腹壁、膈肌及网膜组织等;完成肝脏活检术(4/4)、输卵管结扎术(经结肠途径2例次,经胃途径2例次,腹腔镜辅助经胃途径2例次均成功)、卵巢切除术(经结肠途径2例次,经胃途径2例次,腹腔镜辅助经胃途径2例次均成功)、胆囊切除术7例次(经胃或经结肠途径均失败;转为腹腔镜辅助成功3例次);未能完成胰腺探查(0/3)及胃空肠吻合术(0/2)。腹腔镜辅助下降低了输卵管结扎术和卵巢切除术的难度和操作时间,成功率100%(6/6);腹腔镜辅助下完成NOTES胆囊切除术成功率为42.8%(3/7)。第二阶段以杂种犬为研究对象,进行了经脐戳孔辅助下NOTES胆囊切除术12例次,一次因实验设备损坏终止实验,一次腹腔探查发现实验犬腹腔粘连严重终止实验未列入统计。完成胆囊切除术的存活实验10例次,成功率80%(8/10),平均用时80min/例次。手术失败2例次:1例为术中腹压过高致实验犬术中死亡,1例为术后腹腔感染致动物术后一周死亡。闭合管壁造口27例次,其中钛夹夹闭法成功率50%(6/12),用网膜填塞法成功率93.3%(13/14)。结论:①经胃或经结肠途径腹腔探查术均能较好显示肝、脾、胆囊、胃、小肠、大肠、腹膜、网膜、腹壁、附件等腹腔脏器,两条NOTES途径无明显差异;②对腹膜后脏器如胰腺、肾脏、输尿管等NOTES探查难度较大。③NOTES输卵管结扎术、卵巢切除术具有一定的安全性,经胃或经结肠单一途径可完成,腹腔镜辅助可降低输卵管结扎术、卵巢切除术的难度。④腹腔镜辅助下的NOTES胆囊切除术具有一定的可行性,但应用五指山小型猪为动物模型成功率低。⑤杂种犬能较好的模拟人体进行NOTES胆囊切除术研究。⑥经脐戳孔辅助经胃途径NOTES胆囊切除术有一定的可行性、安全性和有效性。⑦应用钛夹直接夹闭管壁造口难度大、结果不可靠,应用网膜填塞闭合法简单、安全和有效。更多还原

【Abstract】 Backgrounds and Objectives:Natural Orifices Translumenal Endoscopic Surgery(NOTES) is a relatively new concept describing endoscopic procedures performed via natural orifices(stomach,colon or vagina) without skin incisions. NOTES seems to provide a large potential benefits over currently available surgical interventions,such as improved cosmesis,decreased incidence of wound infection,decreased need for sedation,decreased incidence of incisional hernias and so on.On March 13,2007,the first clinical transvaginal cholecystectomy was performed in a 43-year-old female patient with symptomatic cholelithiasis by J.Marescaux’s group in France,which indicated a new era of minimally invasive surgery coming.Despite accumulated significant NOTES-related knowledge more systematic studies are necessary before translumenal procedures can be recommended into the clinical practice.Unfortunately in our country,the NOTES study is still in the elementary stge.To evaluate the models,techniques,outcomes,pitfalls,and applicability to the natural orifice translumenal endoscopic surgery(NOTES) for performing intra-abdominal surgery,systemic animal experimental studies were designed in this project.In the first phrase,the exploration and multiple procedures were performed on live animal model of wuzhishan small pork(WZSSP) to gain more knowledge and experience.In the second phrase,the transgastric cholecystectomy with the assistance of a tissue forcep introduced through an infraumbilical port was performed on live animal model of mongrel dogs to investigate the feasibility,safety and efficiency.Meanwhile,the role of omentum tamping for gastrotomy closure was investigated compared with endoclips closure.Methods:30 female WZSSPs and 12 mongrel dogs were involved in the study. Gastrotomies or colotomy were performed using a needle knife to make an initial gastric incision,which was usually enlarged with either a sphincterotome or dilation balloon.Then,the endoscope inserted into the abdominal cavity through the access via mouth or anus and the pneumoperitoneum were created with endoscopic insufflation to allow visibility of the working space subsequently. The NOTES procedures included abdominal exploration,liver biopsy,tubal ligation,oophorectomy gastrojejunal anastomosis and cholecystectomy were attempted with or without the laparoscopic assistance on 20 WZSSPs in the first phrase.In the second phrase,the transgastric cholecystectomy with the assistance of a tissue forceps introduced through an infraumbilical port was performed on 12 mongrel dogs.We compared the efficacy of gastrotomy closure between omentum tamping and endoclips closure at last.Results:32 procedures were finished in the project,7 non-survival experiments and 25 survival experiments.In the first phrase,3 times per-orally route,2 times transanusly route and 15 times hybrid technique of laparoscopic assistance pre-orally procedures were performed.In the diagnostic peritoneoscopy,the liver, gallbladder,spleen,stomach,colon,part of intestine,bladder,tubal uterine, ovary,abdominal wall,diaphragm and omentum could be visualized through per-orally route or transanusly route.The success of NOTES procedures included liver biopsy(4/4),tubal ligation(6/6) and oophorectomy(6/6) and cholecystectomy(3/7) through single route or with the assistance of laparoscopy. The unsuccessful procedures included retroperitoneal exploration(0/3) and gastrojejunal anastomosis(0/2).In the second phrase,12 times NOTES Cholecystectomy were performed.Except 2 excluded procedures,once due to instruments damages,once due to the primary disease and celiac adhesion, among 10 times finished procedures,8 animal models survived 2w postoperation. The success rate of omentum tamping for gastrotomy closure was better than endoclips closure(93%vs.50%).Conclusions:The per-orally route and treasonously route peritoneoscopy is feasible with safety to explore the celiac organs like liver,gallbladder,spleen, stomach,colon,part of intestine,bladder,tuba uterine,ovary,abdominal wall, diaphragm and omentum,but the exploration to the retroperitoneal cavity appears difficult.The female reproductive procedures were able to be successfully completed in animal models of WZSSPs using per-orally route, transanusly route respectively with safety.Laparoscopic assistance could facilitate these procedures.The laparoscopic assisted NOTES Cholecystectomy is fastidious and complex,and the success rate was low because of the anatomic variability in WZSSPs.Dissection and mobilization of the gallbladder was feasible and safe in the transgastric NOTES with the assistance of a tissue forceps introduced through an infraumbilical port in mongrel dogs model. Omentum tamping was an effective and convenient for gastrotomy closure with safety.更多还原