【作者】 郭美琴；

【导师】 姜军；

【作者基本信息】 第三军医大学 ， 普通外科， 2006， 博士

【摘要】 随着人们对乳腺癌生物学行为的不断认识,乳腺癌从一开始就是一种全身性疾病的观念已被普遍认同和接受,两组随机的大样本前瞻性临床研究已经确立了Ⅰ～Ⅱ期浸润性乳腺癌保乳手术的首选地位。随着外科微创理念和操作技术、手术设备的改进和完善,近年来乳腺腔镜外科也得到了迅速发展。乳腺癌腔镜手术国、内外虽然已经有报道,但仍然存在手术方法的不规范、效果观察的不一致、肿瘤学安全性的不确定,更缺乏大样本长期的随机多中心研究结果。本研究采用动物实验、临床对照研究以及病理学研究的方法,观察腔镜在包括乳腺癌腋窝淋巴结清扫术、腔镜辅助乳腺癌改良根治术以及胸腔镜内乳淋巴结活检和内乳淋巴链切除等手术的技术要点、安全性和近期疗效,浸润性乳腺癌皮肤和皮下组织受累的相关因素等,总结乳腺癌腔镜手术的适应症、禁忌症、和操作规范等。研究方法和主要结果1.腔镜腋窝淋巴结清扫操作空间建立和胸腔镜内乳淋巴链切除的实验研究以小型猪为实验对象,全麻气管插管,胸前第一对乳头下注射亚甲蓝,采用美国史赛克公司腔镜系统和美国强生公司超声刀,分别用钝性和锐性分离、CO2充气建立操作空间进行腔镜腋窝淋巴结清扫术的实验。结果:两种方法均可行,可以清晰解剖分离出腋窝重要结构腋静脉、腋动脉和臂丛神经及其分支。但是小型猪皮下和腋窝脂肪霏薄,吸脂法腔镜腋窝淋巴结清扫无法进行。同样的设备和实验对象,在胸腔镜下观察内乳前哨淋巴结的蓝染时间、胸腔镜内乳淋巴结活检时间和内乳淋巴链切除时间,探索胸腔镜内乳淋巴链切除的可行性和安全性。6头小型猪共12侧内乳淋巴结均蓝染,平均内乳前哨淋巴结的蓝染时间、活检时间和淋巴链切除时间分别为:8.92min、30.42min、38.17min。手术操作时在第3、4、6肋间隙放置trocar比较合适,无肺脏、大血管和胸腔其它脏器损伤等并发症发生。2.乳腺癌腔镜手术的临床对照研究2.1吸脂法腔镜腋窝淋巴结清扫术的技术探讨自2004年12月至2006年3月采用吸脂法进行完全腔镜腋窝淋巴结清扫手术49例,与传统开放手术43例进行比较。完全腔镜腋窝淋巴结清扫手术组清扫淋巴结8～更多还原

【Abstract】 More recognition of biological characteristic of breast cancer leaded to a conception that breast cancer was a systemic disease at its beginning. This conception was approved and received wildly. Two of large prospective randomized clinical trials have made significant contributions toward breast conserving treatment as the first choice forⅠ～Ⅱstages invasive breast cancer recently. Following the improvement of equipment and technique of minimally invasive surgery, mastoscopy surgery has developed rapidly. There were several reports about endoscopic surgery in breast cancer by now, but identical criterion of its outcome, uniform technique of operation, sufficient evidence of oncologic safety and large randomized clinical trial of long-term outcomes was lack in recent. The aim of this study is to evaluate the safety of endoscopy in breast cancer, to investigate the technique of operation about endoscopic axillary lymph node dissection by liposuction, endoscope-assisted modified radical mastectomy with small incision, to identify the feasibility of thoracoscopic internal mammary sentinel node biopsy and internal mammary chain excision in animal model, to confirm the relevant factors of skin-flap involvement and extension of skin excision by histological observation, to summarize the applicability and contraindication about endoscopic surgery in breast cancer and its criterion of management.Materials, Methods and main results:1. The feasibility and safety of axillary lymph node dissection by endoscopy and thoracoscopic internal mammary sentinel node biopsy and internal mammary chain excision in animal modelAfter intubated and kept anesthetized with ketamine, Methylene blue 4ml was injected subdermally into the upper nipple of small type pig. Working space for endoscopy was made by ultracision (Ethicon, USA) bluntly or sharply and was kept by filling with CO2. Results: Working space for endoscopy could be made easily by two methods. The main更多还原