【作者】 李东顺；

【导师】 张勇；

【作者基本信息】 河北医科大学 ， 外科学， 2012， 硕士

【摘要】 目的：在猪模型腹腔镜肾部分切除术中，采用自制冷盐水囊装置给肾脏降温，使肾动脉阻断后肾实质温度快速降低到20-25℃以下，并能持续稳定维持此种低温状态，达到肾低温保护的目的；在开放手术下采用冰屑降温法给肾脏降温，将两种方法进行对比，进一步评估冷盐水囊降温方法的降温效果。方法：选取健康家猪六头,体重30-35kg，随机分成A、B两组，A组（实验组）：冷盐水囊降温组（3头猪）。B组（对照组）：冰屑降温组（3头猪）。1A组（实验组）：冷盐水囊降温组，在静脉麻醉下模拟腹腔镜肾部分切除术，任选一侧作肾低温保护模型，采用冷盐水囊装置，以肾门为中心包绕肾脏，阻断肾动脉后，将测温探针斜形刺入肾实质，深度为2.5-3.0cm。同时冲入1-2℃冷盐水，给肾脏持续降温。左右水囊分别进水量为150ml。进水结束后夹闭进水管，开放吸水管，快速吸出水囊内盐水，整个进水和出水操作为一次换水过程，时间为1分钟。重复进水和出水操作操作，一分钟更新冷盐水一次。当肾脏温度降到20℃以下后，改为每1-2分钟更新冷盐水一次，进出水间隔时间依据肾实质温度调整，保持肾实质温度波动在15-20℃之间，持续维持肾低温。连续监测肾动脉阻断90分钟内肾实质温度。同时模拟肾部分切除术。90分钟后开放肾动脉，继续记录复温5分钟内肾脏温度。期间于第80分钟切取肾组织标本。选取对侧肾脏，取肾动脉阻断第30分钟、80分钟肾组织标本做对照。2B组（对照组）：冰屑降温组，采用静脉麻醉,任选一侧作肾低温保护模型，阻断肾动脉后，将预先准备好的冰屑外敷肾周围，开始给肾脏持续降温。连续监测肾动脉阻断90分钟内肾实质温度。同时模拟肾部分切除术。90分钟后清除肾周冰屑，开放肾动脉，继续记录复温5分钟内肾脏温度。期间于第80分钟取肾组织标本。选取对侧肾脏，取肾动脉阻断第30分钟、80分钟肾组织标本做对照。3每次实验切取肾组织标本，均修剪成1cm1cm03cm大小，立即投入4%多聚甲醛液(PBS)进行固定，切片行HE染色，选取切片平展、细胞形态和组织结构清晰的肾组织切片在400倍光镜下进行观察，对比病理学改变，初步评判两种方法对肾脏的保护作用。4资料的统计学处理：肾动脉阻断后15分钟为快速降温阶段，选取这一阶段的温度数据，采用重复测量数据的两因素多水平方差分析，比较两种降温方法有无差别，以P<0.05认为有统计学意义。采用SPSS13.0统计软件对实验数据进行处理。结果：1A组（冷盐水囊降温组）：冷盐水温度1-2℃，肾动脉阻断前肾实质温度38℃，肾动脉阻断13分钟后肾实质温度降到25℃以下，20分钟后降到20℃以下。B组（冰屑降温组）：冰屑温度-4℃，肾动脉阻断前肾实质温度38℃，肾动脉阻断8分钟后肾实质温度降到25℃以下，13分钟后降到20℃以下。肾周冰水温度为-2℃。2A组（冷盐水囊降温组）：肾实质温度降到20℃以下后，肾实质温度可稳定维持在17℃-19℃之间。B组（冰屑降温组）：肾实质温度在17分钟内降到15℃以下，之后肾实质温度一直保持在15℃以下的低温状态。3A组（冷盐水囊降温组）：在90分钟肾动脉阻断冷盐水囊降温过程中，中心温度下降不超过1℃。未采取保温措施。B组（冰屑降温组）：中心温度在第一次实验中45分钟内由37.8℃降到35.9℃，下降达1.8℃，遂采用了保温措施。之后两次实验均采取电热毯保温，使中心温度下降不超过1.5℃。4A、B两组降温速度的统计学处理:采用SPSS13.0统计软件，对快速降温阶段（1-15分钟）A、B两组实验数据进行分析，结果：冷盐水囊降温组与冰屑降温组降温速度存在差别，冰屑降温组降温速度快于冷盐水囊降温组，F=19.156，P=0.012＜0.05。5光镜下肾脏显微结构的变化：肾脏热缺血30min肾小球毛细血管扩张，肾小管管壁肿胀，管腔扩张，内可见少量粉染的浆液；热缺血80min肾小球毛细血管扩张、组织水肿，大量炎性细胞浸润；肾小管管壁肿胀，管腔明显扩张，管腔内充满均质红染的渗出物(浆液、脱落的上皮细胞及各种管型），间质充血。A组（冷盐水囊降温组）：冷缺血80min肾小球毛细血管无明显扩张，无明显炎性细胞浸润；肾小管轻度扩张，个别管壁轻度水肿，管腔内无明显渗出物，间质无充血。 B组（冰屑降温组）：冷缺血80min肾小球毛细血管轻度扩张，无明显炎性细胞浸润；肾小管轻度扩张，管壁无肿胀，管腔内无明显渗出物，间质无充血。结论：在猪模型腹腔镜肾部分切除手术中，应用普通腹腔镜设备，通过冷盐水囊装置，可快速降低肾脏实质温度，维持肾低温，达到肾低温保护的目的。冷盐水囊降温操作和手术操作相互独立，互不干扰，手术视野干净，肾动脉阻断后，可连续手术操作。这种局部降温的方法，最大限度的避免了低体温的出现。有效的保护了肾功能。为腹腔镜肾低温保护提供了又一新的思路。更多还原

【Abstract】 Objective: Using Self-Made Cold-Saline-Perfused Bladders in theporcine model of laparoscopic partial nephrectomy, then the renalparenchymal temperature was quickly reduced to below20-25℃after therenal artery occlusion, and maintains a low temperature in order to protectrenal function.Also using ice slush in open surgery to lower renal temperaturethen comparing the two methods to further estimate the cooling effect ofself-made cold-saline-perfused bladders.Methods:Select six healthy pigs, weight30-35kg, and divide themrandomly into GroupA and Group B.Group A (experimental group)is theCold-Saline-Perfused Bladders cooling group and Group B (control group) isthe ice slush cooling group.GroupA: A group of pigs underwent laparoscopic partial nephrectomyand choose one kidney as the protection model of renal low temperature underintravenous anesthesia.After complete occlusion of the renal artery, theSelf-Made Cold-Saline-Perfused Bladders were surrounded onto renal surfaceand keep the kidney in a low temperature.After the occlusion of renalartery,the temperature sensors were placed in the renal parenchyma deeps in2.5-3.0cm.At the same time1-2℃cold saline was added into thebladders.Then each bladder was added150ml water. Turn off the inlet pipeafter the irrigation and turn on the suction pipe which quickly sucks waterintracapsular saline.The operation of the influent and effluent water as anexchange process which lasts1minute. Repeat the process and updates coldsaline once a minute.When the kidney temperature drops to below20℃,changed it to every1-2minutes to update cold saline, and out of the waterinterval time based on renal temperature adjustment, kidney low temperaturebetween15-20℃, continued to maintain to keep the renal temperature fluctuations. Continuous monitoring of renal artery occlusion renalparenchymal temperature for90minutes. Take the cut kidney tissue samples atthe80minute during the continuous monitoring. Open90minutes after therenal artery, kidney temperature continues to record rewarming within fiveminutes. Take the cut kidney tissue samples of the other kidney at the80minute of the renal artery occlusion for comparison.GroupB:Choose one kidney as the protection model of renal lowtemperature under intravenous anesthesia. Using the pre-prepared ice slusharound the topical kidney after complete occlusion the renal artery andcontinued to cool. Continuous monitoring of renal artery occlusion renalparenchymal temperature for90minutes. Take the cut kidney tissue samples atthe80minute during the continuous monitoring.Clear the perirenal pieces ofice and open renal artery after90minutes, renal temperature continues torecord rewarming within five minutes. Take the cut kidney tissue samples ofthe other kidney at the80minute of the renal artery occlusion for comparison.Take each kidney sample and trim it into1cm×1cm×0.3cm size, andimmediately put into4%formaldehyde solution (PBS) HE staining of fixed,sliced, select the slice flat, clear cell morphology and organizational structurerenal biopsy in400times the light microscope observation, comparedpathological changes, the initial judge the two methods on the renal protectiveeffect.The statistical processing of data: The rapid cooling stage is that15minutes after the renal artery occlusion.Select the temperature data of thisstage and compare the two cooling methods with repeated measures designanalysis of variance(ANOVA). to find whether there has difference betweenthe two methods. While P <0.05was considered statistically significant. UseSPSS13.0statistical software to process the experimental data.Results:Group A:The temperature of cold saline is1-2℃while the renalparenchymal temperature before renal artery occlusion is38℃. Therenal parenchyma temperature dropped to below25℃in13minutes after renal arteryocclusion, and down to below20℃in20minutes. Group B:The temperature of ice slush is-4℃while the renal parenchymal temperature before renal artery occlusion is38℃. The renal parenchyma temperature dropped to below25℃in8minutes after renal artery occlusion, and down to below20℃in13minutes.The temperature of ice water mixture surrounded by the kidney is-2℃.Group A: When the renal temperature dropped to below20℃,it canremain stable between17℃-19℃. Group B:When the renal temperaturedropped to below15℃within17minutes after the renal parenchymatemperature has remained at a low temperature below15℃.Group A: During the90-minute cooling process, the central temperaturedrop no more than1°C thus insulation measures are not taken.Group B:In thefirst experiment, the center temperature dropped from37.8°C to35.9°C in45minutes decreased by1.8℃.Then the insulation measures were taken.Subsequencely the blanket insulation were taken in the following twoexperiments to ensure the central temperature drop won’t exceed1.5°C.The statistical processing of the cooling rate with group A and B: UseSPSS13.0statistical software to anaylze experimental data of Group A and Bduring the rapid cooling phase (1-15minutes).The result is Group B coolsquicker than Group A as F=19.156, P=0.012<0.05.Light microscopic changes in renal microstructure: renal warm ischemiafor30min expansion of the glomerulus capillary and tubular wall swelling,luminal expansion, seen in a small amount of powder dye slurry; warmischemia80min expansion of the glomerulus capillary, tissue edema,inflammatory cell infiltration; swelling of the renal tubular wall, lumenexpansion and lumen filled with homogeneous red dye exudate (serous,shedding of epithelial cells and a variety of tube), interstitial congestion.Group A: cold ischemia80min glomerular capillary no obvious expansion, noobvious inflammatory cell infiltration; tubular mildly dilated with mild edemaof the individual renal wall within the lumen without obvious oozing matter,interstitial congestion. Group B: cold ischemia80min slight expansion of theglomerular capillary, no significant inflammatory cell infiltration; renal tubularmild expansion of the wall no swelling, no significant exudate within the lumen, quality is no congestion.Conclusion:Using Self-Made Cold-Saline-Perfused Bladders during the laparoscopic partialnephrectomy in the porcine model,the temperature of renalparenchyma drops quicklyand creates acceptable renal tissue temperatures forpreservation of renal function.TheCold-Saline-Perfused Bladders cooling operations and surgical operations are independent of each other,after renal arteryocclusion surgical procedures can be continued. This partial cooling methodavoids the emergence of low body temperature also protect the renal functioneffectively and provides another new way of preservation of renal function.更多还原