腹腔镜技术在猫的泌尿外科临床应用的研究
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摘要
微创外科是21世纪外科发展方向之一,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、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。然而该项技术在兽医领域发展缓慢,腹腔镜外科手术技术在小动物泌尿外科领域的应用则少之又少,目前国内尚无该项技术应用于猫的基础研究或临床应用的报道。基于此,本研究进行了猫的最佳二氧化碳气腹压的选择试验；利用试验确定的最佳气腹压充气腹,完成猫腹腔的探查；并在最佳气腹压条件下完成了膀胱切开缝合术、输尿管切断吻合术和肾脏肾盂切开缝合术,同时与相应的传统开放式手术进行对比研究,以比较腹腔镜手术和开腹手术的优缺点。
本实验选用本地杂种成年猫50只,雌雄各半,平均体重3kg。在同一条件下饲养一个月,经临床和实验室检查健康即开始试验,整个实验过程中饲养管理条件一致。试验在呼吸麻醉下进行,于麻醉前15min,皮下注射硫酸阿托品0.04mg/kg体重；静脉注射丙泊酚1mL/kg体重,诱导麻醉；用3.0号气管插管在喉镜辅助下进行插管,插管固定完毕后即刻吸入1.3MAC异氟烷,维持麻醉,同时设定呼吸麻醉机的吸呼比为1:2,潮气量为15～20ml/kg体重,呼吸次数为15～20次/分钟。
将试验猫随机分成五组,每组10只,A组为麻醉组,即非气腹对照组,B组气腹压为4mmHg,C组气腹压为6mmHg,D组气腹压为8mmHg,E组气腹压为10mmHg。并设定在麻醉后-气腹前(T0)、气腹10min(T1)、20min (T2)、30min (T3)、45min (T4)、60min (T5)、90min (T6)、放气10min(T7)、放气30min (T8),相对应麻醉对照组在麻醉0min(T0)、10min (T1)、20min (T2)、30min (T3)、45min (T4)、60min (T5)、90min (T6)、100min (T7)、120min (T8),以上9个时间点检测这四种气腹压值对猫生理机能的影响,主要包括体温监测、呼吸功能监测、循环功能监测、心电监测、脑电监测等。同时观察并拍摄不同气腹压下,腹腔的膨隆状态和腹腔脏器的暴露程度等。
将试验猫随机分成七组,每组6只,利用试验确定的较理想气腹压值充气腹,完成猫的腹腔镜腹部探查术、腹腔镜膀胱切开缝合术、腹腔镜辅助输尿管断端吻合术、腹腔镜肾脏与肾盂切开缝合术和开放性膀胱切开缝合术、输尿管断端吻合术、肾脏和肾盂切开缝合术,并对腹腔镜和开放性手术进行术前(TO)、术后即刻(T1)、术后1d (T2)、2d (T3)、3d (T4)、4d (T5)、5d (T6)、7d (T7)八个时间点的血常规、血液生化指标、免疫和氧化应激指标、呼吸和循环功能、肝脏和肾脏功能等的监测,以及对精神状态、饮食欲、疼痛情况、伤口愈合情况、并发症等的评价。监测指标中,呼吸循环功能主要测定实验动物的体温、呼吸、脉搏和心律等；血常规和血液生化主要测定白细胞数和肝、肾功能；创伤应激主要检测皮质醇(CORT)和儿茶酚胺(CA)；氧化应激主要检测丙二醛(MDA)、超氧化物歧化酶(SOD)和还原性谷光甘肽(GSH)；免疫指标主要检测白细胞介素-6(IL-6)和C-反应蛋白(CRP)；疼痛主要检测前列腺素E2(PGE2)和5-羟色胺(5-HT),以及SDS评分和VAS评分。
通过试验,得出以下结果：
1.不同C02气腹压对猫生理机能的影响
在气腹过程中,随着气腹压增大、气腹维持时间的延长,各监测指标发生相应的变化。气腹压力维持在6mmHg已能满足猫的部分腹腔镜泌尿系统手术的需要,而且对体温、呼吸、循环、血气、心电和脑电等各参数虽然有变化,但仍在机体代偿的范围之内,是安全的。而高气腹压对机体的影响明显高于低气腹压,应尽量避免选择10mmHg和10mmHg以上的高气腹压。
2.腹腔镜技术在猫腹腔探查术中的应用
在最佳气腹压下行猫的腹腔镜探查术,具有创伤相对小,视野开阔,层次清晰,且具有放大效应,可直接观察腹腔脏器的解剖位置和结构,甚至包括病变情况,确诊率高,减少了探查的盲目性,更有助于决定手术方式及切口部位选择,因此极具临床诊疗价值。
3.腹腔镜技术在猫的泌尿外科临床应用在最佳气腹压下成功的完成了18例猫的腹腔镜膀胱切开缝合术、腹腔镜辅助输尿管吻合术、腹腔镜肾脏肾盂切开缝合术和相应的18例开放性手术,术后均一期愈合,无并发症。并且各项监测指标检测结果证明了腹腔镜手术组具有创伤小、疼痛轻、术后恢复快等优点,相对于传统的开放性术式,有较好的应用前景。
综上所述,本试验首次在国内进行了猫的腹腔镜手术的系统研究。确定了猫腹腔镜手术的最佳气腹压值,并把该试验结果运用到腹腔镜泌尿外科手术中,同时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小动物外科临床中的实用性与可行性,验证了腹腔镜外科的微创特点,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。
Minimally invasive surgery is the development direction of surgical in21st. And as an important component part of the minimally invasive surgery, laparoscopic technique has been widely used in medicine for the advantages of excellent visualization, less bleeding, minimally invasive, less pain, faster postoperative recovery and so on. However, laparoscopic technique has a slow development in veterinary, especially in urinary surgery of small animal. There is no correlative report about basic research or clinical application of laparoscopic technique to cats in China, so far. Therefore, the purpose of this study was to design and perform a selection trial of the optimum pneumoperitoneum in surgery of cat, to perform laparoscopic abdominal cavity exploration at the optimum CO2pneumoperitoneum pressure, to perform laparoscopic cystotomy and sutura, assistant-laparoscopic anastomosis of ureter, laparoscopic nephrotomy and pyelotomy and sutura at the optimum CO2pneumoperitoneum pressure, and to compare the advantages and disadvantages of laparoscopic surgery (LS) and open surgery (OS).
Fifty cats (female or male) mean weight3kg were selected and breed for one month in the same constitution, and were used as experimental animals after health examination in clinic and laboratory. Aropine sulphate was subcutaneous injected by0.04mg/kg-weight15min before anesthesia. Propofol was intravenous injected by1mL/kg·weight for induction of anaesthesia. No.3.0trachea cannula was intubated with laryngoscope, and attached to the anesthetic gas machine. Isoflurane was inhaled for maintenance of anesthesia. Inspiratory/expiratory was set1:2. Tidal volume (TV) was15～20ml/kg. Respiration rate (RR) was15～20times/min.
Experimental animals were randomly selected for five groups, named group A, group B, group C, group D and group E,10in each group. Group A was anesthesia control group, group B, C, D, and E were respectively subjected to CO2pneumoperitoneum at pressure4mmHg,6mmHg,8mmHg and10mmHg. Body temperature (BT), respiratory function index, cardiovascular function index, electrOSardiogram (ECG) and electroencephalogram (EEG) were recorded at9time points which were before inflation (T0), inflated10min (T1),20min (T2),30min (T3),45min (T4),60min(T5),90min(T6), after deflation10min(T7),30min(T8), and correspondingly anesthetized0min (T0),10min (T1),20min (T2),30min (T3),45min (T4),60min (T5),90min (T6),100min (T7),120min (T8). Meanwhile, abdominal bulge and exposure of abdominal organs were observed at different CO2pneumoperitoneum pressure.
Experimental animals were randomly selected for seven groups,6in each group. At the optimum CO2pneumoperitoneum pressure, laparoscopic surgeries were performed such as laparoscopic abdominal cavity exploration, laparoscopic cystotomy and sutura, assistant-laparoscopic anastomosis of ureter, laparoscopic nephrotomy and pyelotomy and sutura. At7time points which were preoperative (T0), postoperative instantly(T1), postoperative1d (T2),2d (T3),3d (T4),4d (T5),5d (T6),7d (T7), body temperature (BT), respiratory rate (RR), heart rate, WBC, liver function (AST, ALT), renal function (Scr, BUN), CORT, CA, MDA, SOD, GSH, IL-6, CRP, PGE2,5-HT, SDS and VAS were recorded to compare with which in opened technique.
The results showed that:
1. The influence of different CO2pneumoperitomeum on physical function of cat
In the study, during the pneumoperitoneum prOSess, along with abdominal pressure inereasing and hold-time extension, the monitoring index had changed accordingly. The much bigger was pneumoperitoneum pressure and the much bigger change was. We found that the6mmHg pneumoperitoneum pressure was safe and satisfied laparoscopic surgery on urinary system.1OmmHg and above pneumoperitoneum pressure should be avoided as far as possible.
2. Application of laparoscopic technique to abdominal cavity exploration of cat.
Laparoscopic approach was performed at6mmHg pneumoperitoneum pressure. It was showed that wide visual field, clear level, scale effect, and clear anatomical position and structure even lesions of abdominal organs, reduced blind exploratory, and MDAe for determining modus operandi and incision lOSation. Therefore, it has a considerable value in clinical diagnosis and treatment.
3. Application of laparoscopic technique to urinary surgery of cat.
At6mmHg pneumoperitoneum pressure,18of cases laparoscopic cystotomy and sutura, assistant-laparoscopic anastomosis of ureter, laparoscopic nephrotomy and pyelotomy and sutura were performed, also and18cases of homologous opened technique. There was all primary healing and no postoperative complication. The monitoring index showed that laparoscopic surgery had much more advantages than open surgery. The fact that laparoscopic techniques could be applied on urinary surgery of cat was verified.
On the whole, the laparoscopic surgery on cats was firstly studied in China. This study determined the optimum PP of cat, compared the effects of laparoscopic and traditional surgery, and certified the practicability and feasibility of laparoscopic techniques applied to urinary surgery of cat. That will be the basis for applying of LS to domestic veterinary clinic.
本实验选用本地杂种成年猫50只,雌雄各半,平均体重3kg。在同一条件下饲养一个月,经临床和实验室检查健康即开始试验,整个实验过程中饲养管理条件一致。试验在呼吸麻醉下进行,于麻醉前15min,皮下注射硫酸阿托品0.04mg/kg体重；静脉注射丙泊酚1mL/kg体重,诱导麻醉；用3.0号气管插管在喉镜辅助下进行插管,插管固定完毕后即刻吸入1.3MAC异氟烷,维持麻醉,同时设定呼吸麻醉机的吸呼比为1:2,潮气量为15～20ml/kg体重,呼吸次数为15～20次/分钟。
将试验猫随机分成五组,每组10只,A组为麻醉组,即非气腹对照组,B组气腹压为4mmHg,C组气腹压为6mmHg,D组气腹压为8mmHg,E组气腹压为10mmHg。并设定在麻醉后-气腹前(T0)、气腹10min(T1)、20min (T2)、30min (T3)、45min (T4)、60min (T5)、90min (T6)、放气10min(T7)、放气30min (T8),相对应麻醉对照组在麻醉0min(T0)、10min (T1)、20min (T2)、30min (T3)、45min (T4)、60min (T5)、90min (T6)、100min (T7)、120min (T8),以上9个时间点检测这四种气腹压值对猫生理机能的影响,主要包括体温监测、呼吸功能监测、循环功能监测、心电监测、脑电监测等。同时观察并拍摄不同气腹压下,腹腔的膨隆状态和腹腔脏器的暴露程度等。
将试验猫随机分成七组,每组6只,利用试验确定的较理想气腹压值充气腹,完成猫的腹腔镜腹部探查术、腹腔镜膀胱切开缝合术、腹腔镜辅助输尿管断端吻合术、腹腔镜肾脏与肾盂切开缝合术和开放性膀胱切开缝合术、输尿管断端吻合术、肾脏和肾盂切开缝合术,并对腹腔镜和开放性手术进行术前(TO)、术后即刻(T1)、术后1d (T2)、2d (T3)、3d (T4)、4d (T5)、5d (T6)、7d (T7)八个时间点的血常规、血液生化指标、免疫和氧化应激指标、呼吸和循环功能、肝脏和肾脏功能等的监测,以及对精神状态、饮食欲、疼痛情况、伤口愈合情况、并发症等的评价。监测指标中,呼吸循环功能主要测定实验动物的体温、呼吸、脉搏和心律等；血常规和血液生化主要测定白细胞数和肝、肾功能；创伤应激主要检测皮质醇(CORT)和儿茶酚胺(CA)；氧化应激主要检测丙二醛(MDA)、超氧化物歧化酶(SOD)和还原性谷光甘肽(GSH)；免疫指标主要检测白细胞介素-6(IL-6)和C-反应蛋白(CRP)；疼痛主要检测前列腺素E2(PGE2)和5-羟色胺(5-HT),以及SDS评分和VAS评分。
通过试验,得出以下结果：
1.不同C02气腹压对猫生理机能的影响
在气腹过程中,随着气腹压增大、气腹维持时间的延长,各监测指标发生相应的变化。气腹压力维持在6mmHg已能满足猫的部分腹腔镜泌尿系统手术的需要,而且对体温、呼吸、循环、血气、心电和脑电等各参数虽然有变化,但仍在机体代偿的范围之内,是安全的。而高气腹压对机体的影响明显高于低气腹压,应尽量避免选择10mmHg和10mmHg以上的高气腹压。
2.腹腔镜技术在猫腹腔探查术中的应用
在最佳气腹压下行猫的腹腔镜探查术,具有创伤相对小,视野开阔,层次清晰,且具有放大效应,可直接观察腹腔脏器的解剖位置和结构,甚至包括病变情况,确诊率高,减少了探查的盲目性,更有助于决定手术方式及切口部位选择,因此极具临床诊疗价值。
3.腹腔镜技术在猫的泌尿外科临床应用在最佳气腹压下成功的完成了18例猫的腹腔镜膀胱切开缝合术、腹腔镜辅助输尿管吻合术、腹腔镜肾脏肾盂切开缝合术和相应的18例开放性手术,术后均一期愈合,无并发症。并且各项监测指标检测结果证明了腹腔镜手术组具有创伤小、疼痛轻、术后恢复快等优点,相对于传统的开放性术式,有较好的应用前景。
综上所述,本试验首次在国内进行了猫的腹腔镜手术的系统研究。确定了猫腹腔镜手术的最佳气腹压值,并把该试验结果运用到腹腔镜泌尿外科手术中,同时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小动物外科临床中的实用性与可行性,验证了腹腔镜外科的微创特点,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。
Minimally invasive surgery is the development direction of surgical in21st. And as an important component part of the minimally invasive surgery, laparoscopic technique has been widely used in medicine for the advantages of excellent visualization, less bleeding, minimally invasive, less pain, faster postoperative recovery and so on. However, laparoscopic technique has a slow development in veterinary, especially in urinary surgery of small animal. There is no correlative report about basic research or clinical application of laparoscopic technique to cats in China, so far. Therefore, the purpose of this study was to design and perform a selection trial of the optimum pneumoperitoneum in surgery of cat, to perform laparoscopic abdominal cavity exploration at the optimum CO2pneumoperitoneum pressure, to perform laparoscopic cystotomy and sutura, assistant-laparoscopic anastomosis of ureter, laparoscopic nephrotomy and pyelotomy and sutura at the optimum CO2pneumoperitoneum pressure, and to compare the advantages and disadvantages of laparoscopic surgery (LS) and open surgery (OS).
Fifty cats (female or male) mean weight3kg were selected and breed for one month in the same constitution, and were used as experimental animals after health examination in clinic and laboratory. Aropine sulphate was subcutaneous injected by0.04mg/kg-weight15min before anesthesia. Propofol was intravenous injected by1mL/kg·weight for induction of anaesthesia. No.3.0trachea cannula was intubated with laryngoscope, and attached to the anesthetic gas machine. Isoflurane was inhaled for maintenance of anesthesia. Inspiratory/expiratory was set1:2. Tidal volume (TV) was15～20ml/kg. Respiration rate (RR) was15～20times/min.
Experimental animals were randomly selected for five groups, named group A, group B, group C, group D and group E,10in each group. Group A was anesthesia control group, group B, C, D, and E were respectively subjected to CO2pneumoperitoneum at pressure4mmHg,6mmHg,8mmHg and10mmHg. Body temperature (BT), respiratory function index, cardiovascular function index, electrOSardiogram (ECG) and electroencephalogram (EEG) were recorded at9time points which were before inflation (T0), inflated10min (T1),20min (T2),30min (T3),45min (T4),60min(T5),90min(T6), after deflation10min(T7),30min(T8), and correspondingly anesthetized0min (T0),10min (T1),20min (T2),30min (T3),45min (T4),60min (T5),90min (T6),100min (T7),120min (T8). Meanwhile, abdominal bulge and exposure of abdominal organs were observed at different CO2pneumoperitoneum pressure.
Experimental animals were randomly selected for seven groups,6in each group. At the optimum CO2pneumoperitoneum pressure, laparoscopic surgeries were performed such as laparoscopic abdominal cavity exploration, laparoscopic cystotomy and sutura, assistant-laparoscopic anastomosis of ureter, laparoscopic nephrotomy and pyelotomy and sutura. At7time points which were preoperative (T0), postoperative instantly(T1), postoperative1d (T2),2d (T3),3d (T4),4d (T5),5d (T6),7d (T7), body temperature (BT), respiratory rate (RR), heart rate, WBC, liver function (AST, ALT), renal function (Scr, BUN), CORT, CA, MDA, SOD, GSH, IL-6, CRP, PGE2,5-HT, SDS and VAS were recorded to compare with which in opened technique.
The results showed that:
1. The influence of different CO2pneumoperitomeum on physical function of cat
In the study, during the pneumoperitoneum prOSess, along with abdominal pressure inereasing and hold-time extension, the monitoring index had changed accordingly. The much bigger was pneumoperitoneum pressure and the much bigger change was. We found that the6mmHg pneumoperitoneum pressure was safe and satisfied laparoscopic surgery on urinary system.1OmmHg and above pneumoperitoneum pressure should be avoided as far as possible.
2. Application of laparoscopic technique to abdominal cavity exploration of cat.
Laparoscopic approach was performed at6mmHg pneumoperitoneum pressure. It was showed that wide visual field, clear level, scale effect, and clear anatomical position and structure even lesions of abdominal organs, reduced blind exploratory, and MDAe for determining modus operandi and incision lOSation. Therefore, it has a considerable value in clinical diagnosis and treatment.
3. Application of laparoscopic technique to urinary surgery of cat.
At6mmHg pneumoperitoneum pressure,18of cases laparoscopic cystotomy and sutura, assistant-laparoscopic anastomosis of ureter, laparoscopic nephrotomy and pyelotomy and sutura were performed, also and18cases of homologous opened technique. There was all primary healing and no postoperative complication. The monitoring index showed that laparoscopic surgery had much more advantages than open surgery. The fact that laparoscopic techniques could be applied on urinary surgery of cat was verified.
On the whole, the laparoscopic surgery on cats was firstly studied in China. This study determined the optimum PP of cat, compared the effects of laparoscopic and traditional surgery, and certified the practicability and feasibility of laparoscopic techniques applied to urinary surgery of cat. That will be the basis for applying of LS to domestic veterinary clinic.
引文
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