右腋下直切口手术治疗先天性心脏病
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摘要
先天性心脏病(congenital heart disease)是遗传和环境因素等复杂关系相互作用的结果,下列因素可能影响到胎儿的发育而产生先天性性畸形。1.胎儿发育的环境因素: (1)感染; (2)其它:如羊膜的病变,胎儿受压,妊娠早期先兆流产,母体营养不良、糖尿病、苯酮尿、高血钙,放射线和细胞毒性药物在妊娠早期的应用,母亲年龄过大等。2.遗传因素。3.其它:有些先天性心脏病在高原地区较多,有些先天性心脏病有显著的男女性别间发病差异,说明出生地海拔高度和性别也与本病的发生有关。
在先天性心脏病的情况下,心脏的结构发生了改变,血流动力学发生了障碍,首先可以出现机体组织器官供血障碍,造成组织缺氧,影响患儿生长发育,其次,可造成肺部血流增加,容易反复发生肺部感染,第三,血流动力学异常还可加重心脏的负担,发生心力衰竭,诱发恶性心律失常甚至猝死,第四,心脏结构异常造成的血液湍流,可造成局部心内膜结构受损,容易滋生细菌,发生感染性心内膜炎。此外,先心病除了会造成以上身体方面的损害外,还可给患儿造成心理上的伤害,严重的可造成人格缺陷。
先天性心脏病(congenital heart disease)的患者多为婴幼儿,为避免心功能受损及相应并发症,绝大多数患儿需手术治疗。
近年来心脏外科技术的发展和体外循环下心内直视手术安全性不断提高,国内外学者开始采用包括腔镜及腔镜辅助系统,达芬奇机器人系统及小切口直视手术方式等各种微创伤切口代替传统心脏手术的胸骨正中切口。
传统的手术径路为胸骨正中切口,在保证手术质量和安全的前提下,手术后的美观越来越受到患者的重视。微创伤切口在先天性心脏病治疗上的应用系指手术入径切口长度为6～10cm,切口可位于一侧腋下、胸骨中下段、胸骨左或右缘以及一侧胸前区[1]。而其中的右腋下直切口,则有隐蔽性好、美容效果佳、手术易操作的特点并不破坏胸廓的连续性,防止术后鸡胸、不影响乳腺发育、痛苦小、并发症少、恢复快、对患者身心影响小,相对于其他微创心脏手术方式具有费用低并对手术器械及辅助硬件设备要求低等优点,易于开展,越来越受到医生患者的认同。国内刘迎龙教授等人,积极开展此类工作,并获得了大量的实践经验。
目的:通过对两种切口术中体外循环时间及术后胸腔引流量和住院天数的比较,观察先天性脏病患儿经右腋下小切口剖胸体外循环下行心内直视手术的疗效。
方法:选择2009年5月至2010年10月期间在赤峰学院附属一院心外科采用直视手术治疗小儿先天性心脏病的病例。A组19例患者采用右腋下微创小切口,B组22例同期采用正中剖胸入路行心内直视术,术后均给予胸腔及心包、纵隔引流管的常规护理。对比两种切口术后胸腔引流量和住院天数的比较,观先天性脏病患儿经右腋下直切口手术治疗先天性心脏病的疗效。
结果:A组与B组的患者相比,胸腔引流量分别为A组平均80ml;B组平均210ml;术后A组住院天数平均7d,B组住院天数平均9.2d,胸腔引流量及住院天数A组较B组均明显降低,差异有统计学意义(p<0.05,p<0.01)。通过这一结果,我们看到右腋下直切口手术方式具有,痛苦小、并发症少、恢复快、对患者身心影响小,费用低适合在基层医院用于先天性心脏病患者治疗。
结论:
In recent years the development of cardiac surgery and heart surgery with cardiopulmonary bypass continue to improve security, domestic and foreign scholars, including endoscopic and laparoscopic use of auxiliary systems, da Vinci robotic system and method with small incision surgery and other Minimally invasive incision types of heart surgery to replace the traditional median sternotomy incision. The traditional surgical approach was median sternotomy incision, the quality and safety of operation in ensuring the premise, more and more beautiful after surgery in patients with attention. Minimally invasive incision in the application of the treatment of congenital heart disease refers to the length of surgical incision into the diameter of 6 ~ 10cm, armpit incision can be located on one side, middle and lower sternum, left or right edge of the sternum and the side of the chest area [1] . Which the right axillary straight incision, there are good for hiding, excellent cosmetic results, surgical characteristics of easy operation does not destroy the continuity of the thorax, to prevent postoperative chicken, does not affect mammary gland development, less pain, fewer complications, recovery fast, physical and psychological impact on patients is small, compared with other minimally invasive cardiac surgical procedure and surgical instruments with low cost and support advantages of low hardware requirements, easy to carry, more and more doctors were recognized. And others Domestic Professor Liu Yinglong, actively carry out such work, and get a great deal of practical experience.
Objective: Two incision through the chest drainage and postoperative hospital stay compared the number of days to observe the children with congenital heart disease through right axillary thoracotomy incision for open heart cardiopulmonary bypass surgery patients.
Research Methods: from May 2009 to October 2010 during the First Affiliated Hospital of Chifeng College open heart surgery for cardiac surgery in children with congenital heart disease cases. A group of 19 patients using minimally invasive right axillary, B group of 22 cases over the same period median thoracotomy approach with the line open heart surgery, patients were treated with chest and pericardium, mediastinal drainage tube of conventional care. Comparison of the two incision postoperative pleural drainage and hospital stay compared with congenital heart disease in children view straight through the right axillary incision surgery for congenital heart disease patients.
Results: A group and B group compared with patients, pleural drainage group A were an average of 110ml; B group, the average 280ml; A group of hospital stay after an average of 9.8d, B group the average number of hospital days 14.2d, the difference was statistically significant ( P <0.01). With this result, we see that the right way with axillary straight incision, less pain, fewer complications, quicker recovery, physical and psychological impact on patients with small, low cost for the primary hospital for the treatment of congenital heart disease.
Conclusion:
在先天性心脏病的情况下,心脏的结构发生了改变,血流动力学发生了障碍,首先可以出现机体组织器官供血障碍,造成组织缺氧,影响患儿生长发育,其次,可造成肺部血流增加,容易反复发生肺部感染,第三,血流动力学异常还可加重心脏的负担,发生心力衰竭,诱发恶性心律失常甚至猝死,第四,心脏结构异常造成的血液湍流,可造成局部心内膜结构受损,容易滋生细菌,发生感染性心内膜炎。此外,先心病除了会造成以上身体方面的损害外,还可给患儿造成心理上的伤害,严重的可造成人格缺陷。
先天性心脏病(congenital heart disease)的患者多为婴幼儿,为避免心功能受损及相应并发症,绝大多数患儿需手术治疗。
近年来心脏外科技术的发展和体外循环下心内直视手术安全性不断提高,国内外学者开始采用包括腔镜及腔镜辅助系统,达芬奇机器人系统及小切口直视手术方式等各种微创伤切口代替传统心脏手术的胸骨正中切口。
传统的手术径路为胸骨正中切口,在保证手术质量和安全的前提下,手术后的美观越来越受到患者的重视。微创伤切口在先天性心脏病治疗上的应用系指手术入径切口长度为6～10cm,切口可位于一侧腋下、胸骨中下段、胸骨左或右缘以及一侧胸前区[1]。而其中的右腋下直切口,则有隐蔽性好、美容效果佳、手术易操作的特点并不破坏胸廓的连续性,防止术后鸡胸、不影响乳腺发育、痛苦小、并发症少、恢复快、对患者身心影响小,相对于其他微创心脏手术方式具有费用低并对手术器械及辅助硬件设备要求低等优点,易于开展,越来越受到医生患者的认同。国内刘迎龙教授等人,积极开展此类工作,并获得了大量的实践经验。
目的:通过对两种切口术中体外循环时间及术后胸腔引流量和住院天数的比较,观察先天性脏病患儿经右腋下小切口剖胸体外循环下行心内直视手术的疗效。
方法:选择2009年5月至2010年10月期间在赤峰学院附属一院心外科采用直视手术治疗小儿先天性心脏病的病例。A组19例患者采用右腋下微创小切口,B组22例同期采用正中剖胸入路行心内直视术,术后均给予胸腔及心包、纵隔引流管的常规护理。对比两种切口术后胸腔引流量和住院天数的比较,观先天性脏病患儿经右腋下直切口手术治疗先天性心脏病的疗效。
结果:A组与B组的患者相比,胸腔引流量分别为A组平均80ml;B组平均210ml;术后A组住院天数平均7d,B组住院天数平均9.2d,胸腔引流量及住院天数A组较B组均明显降低,差异有统计学意义(p<0.05,p<0.01)。通过这一结果,我们看到右腋下直切口手术方式具有,痛苦小、并发症少、恢复快、对患者身心影响小,费用低适合在基层医院用于先天性心脏病患者治疗。
结论:
In recent years the development of cardiac surgery and heart surgery with cardiopulmonary bypass continue to improve security, domestic and foreign scholars, including endoscopic and laparoscopic use of auxiliary systems, da Vinci robotic system and method with small incision surgery and other Minimally invasive incision types of heart surgery to replace the traditional median sternotomy incision. The traditional surgical approach was median sternotomy incision, the quality and safety of operation in ensuring the premise, more and more beautiful after surgery in patients with attention. Minimally invasive incision in the application of the treatment of congenital heart disease refers to the length of surgical incision into the diameter of 6 ~ 10cm, armpit incision can be located on one side, middle and lower sternum, left or right edge of the sternum and the side of the chest area [1] . Which the right axillary straight incision, there are good for hiding, excellent cosmetic results, surgical characteristics of easy operation does not destroy the continuity of the thorax, to prevent postoperative chicken, does not affect mammary gland development, less pain, fewer complications, recovery fast, physical and psychological impact on patients is small, compared with other minimally invasive cardiac surgical procedure and surgical instruments with low cost and support advantages of low hardware requirements, easy to carry, more and more doctors were recognized. And others Domestic Professor Liu Yinglong, actively carry out such work, and get a great deal of practical experience.
Objective: Two incision through the chest drainage and postoperative hospital stay compared the number of days to observe the children with congenital heart disease through right axillary thoracotomy incision for open heart cardiopulmonary bypass surgery patients.
Research Methods: from May 2009 to October 2010 during the First Affiliated Hospital of Chifeng College open heart surgery for cardiac surgery in children with congenital heart disease cases. A group of 19 patients using minimally invasive right axillary, B group of 22 cases over the same period median thoracotomy approach with the line open heart surgery, patients were treated with chest and pericardium, mediastinal drainage tube of conventional care. Comparison of the two incision postoperative pleural drainage and hospital stay compared with congenital heart disease in children view straight through the right axillary incision surgery for congenital heart disease patients.
Results: A group and B group compared with patients, pleural drainage group A were an average of 110ml; B group, the average 280ml; A group of hospital stay after an average of 9.8d, B group the average number of hospital days 14.2d, the difference was statistically significant ( P <0.01). With this result, we see that the right way with axillary straight incision, less pain, fewer complications, quicker recovery, physical and psychological impact on patients with small, low cost for the primary hospital for the treatment of congenital heart disease.
Conclusion:
引文
1.Burke R P. Reducing the trauma of congenital heart surgery. Semin T horac CardiovascSurg Pediatrerd S urg Annu,2001;4: 216.
2.苏肇伉.先天性心脏病微创手术的发展趋势.中国胸心血管外科临床杂志.2005;12(4):229.
3.张瑞成,法宪恩,张大新等.胸部不同部位小切口体外循环下心脏手术184例体会.中国综合临床.2002;18( 1) : 64- 65.
4.郭光伟,李家成,唐进等.右前侧胸小切口心内直视手术106例.中国心血管杂志.1999;2( 4) : 97-98.
5.Massetti M, Babatasi G, Rossi A et al. Operation for a trial septal defect through a right antero lateral thoracotomy: current outcome. Ann Thorac Surg , 1996;62(4) : 1100-1103.
6.Stark D.先天性心脏病外科学.朱晓东译.人民卫生出版社.
7.白凯,苏肇伉.微创外科在儿童先心病治疗中的应用进展.中华小儿外科杂志.2004;25(4): 360.
8.RIEW K D, H ILIBRAND A S, PALUMBO M A, BOH LMANH H , et al. Ant erior Cervical C or pect omy in Pati ent s Pr eviously Man aged w ith a Laminect om y: Short term Complicat ions . J Bone Joint Surg AM.1999;81(7):950-957.
9.Nich ol son IA,BichellDP, Bacha EA,et al.Minimal sternotomy approach for congenital heart operations.An n Thorac Su rg.2001;71:469-472.
10.吴延虎,陈亦江,陆小虎等.微创小切口体外循环在先天性心脏病手术中的应用.中国体外循环杂志.2005; 3:213-215.
11.王东进,曹彬,贾朝相等.右腋下小切口在心脏瓣膜手术中的应用.南京大学学报. 2002;38:606-609.
12.Laussen PC, Bichell DP. Post operat ive recovery in chi ldren aft er minium versus full length st ern ot omy. An n T horac Surg,2000;69:591-596.
13.张德奎,单清华,樊键等.右腋下小切口胸骨下段小切口与胸骨正中切口的对比研究.中华实验外科杂志.2006; 23:52.
14.Bichell DP, Geva T , Bacha EA, et al . Minimal access approach for the repair of atrial septal defect : the initial 135 patient s. Ann Thorac Surg.2000;70: 115-118.
15.刘迎龙,苏俊武,于存涛等.右外侧小切口剖胸根治小儿法乐四联症.中华胸心血管外科杂志. 1999;15( 4) : 200- 202.
16.清玉,罗国华,李守军等.胸部不同切口治疗小儿常见先天性心脏病的比较.中国胸心血管外科临床杂志.2004;11(2):81-83.
17.新明,朱洪玉.右腋下直切口治疗先天性心脏病.中国胸心血管外科临床杂志.2000;7:10-11.
18.Grinda JM, Folliguet TA, Dervanian P, et a.l R igh t anterolateral thoracotomy for repair of atrial septal defect[ J] . Ann Thorac Surg.1996;62( 1 ): 175- 178.
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6.苏肇伉.先天性心脏病微创手术的发展趋势.中国胸心血管外科临床杂志.2005;12(4):229.
7.张瑞成,法宪恩,张大新等.胸部不同部位小切口体外循环下心脏手术184例体会.中国综合临床.2002;18(1):64-65.
8.郭光伟,李家成,唐进等.右前侧胸小切口心内直视手术106例.中国心血管杂志. 1999;2(4):97-98.
9.Massetti M, Babatasi G, Rossi A et al. Operation for a trial septal defect through a right antero lateral thoracotomy: current outcome. Ann Thorac Surg , 1996;62(4):1100-1103.
10.Stark D.先天性心脏病外科学.朱晓东译.人民卫生出版社
11.白凯,苏肇伉.微创外科在儿童先心病治疗中的应用进展.中华小儿外科杂志.2004;25(4): 360.
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15.张德奎,单清华,樊键等.右腋下小切口胸骨下段小切口与胸骨正中切口的对比研究.中华实验外科杂志.2006;23(2):52.
16.Massett iM, Babatas iG, RossiA, et a.l Opration for atrialSeptal defect through a righ t anterolater althoracotom y: Cu rren t ou tcom e. Ann Thorac Surg.1996;62(4):1100-1103.
17.Grinda JM, Folliguet TA, Dervanian P, et a.l R igh t anterolateral thoracotomy for repair of atrial septal defect.Ann Thorac Surg.1996,62(1): 175-178.
18.张希,姚尖平,王治平等.胸骨正中小切口在心脏直视手术中的应用.中国胸心血管外科临床杂志.2002;9(1):60.
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21.RIEW K D, H ILIBRAND A S, PALUMBO M A, BOH LMANH H , et al. Ant erior Cervical C or pect omy in Pati ent s Pr eviously Man aged w ith a Laminect om y: Short term Complicat ions.J Bone Joint Surg AM.1999;81(7):950-957.
2.苏肇伉.先天性心脏病微创手术的发展趋势.中国胸心血管外科临床杂志.2005;12(4):229.
3.张瑞成,法宪恩,张大新等.胸部不同部位小切口体外循环下心脏手术184例体会.中国综合临床.2002;18( 1) : 64- 65.
4.郭光伟,李家成,唐进等.右前侧胸小切口心内直视手术106例.中国心血管杂志.1999;2( 4) : 97-98.
5.Massetti M, Babatasi G, Rossi A et al. Operation for a trial septal defect through a right antero lateral thoracotomy: current outcome. Ann Thorac Surg , 1996;62(4) : 1100-1103.
6.Stark D.先天性心脏病外科学.朱晓东译.人民卫生出版社.
7.白凯,苏肇伉.微创外科在儿童先心病治疗中的应用进展.中华小儿外科杂志.2004;25(4): 360.
8.RIEW K D, H ILIBRAND A S, PALUMBO M A, BOH LMANH H , et al. Ant erior Cervical C or pect omy in Pati ent s Pr eviously Man aged w ith a Laminect om y: Short term Complicat ions . J Bone Joint Surg AM.1999;81(7):950-957.
9.Nich ol son IA,BichellDP, Bacha EA,et al.Minimal sternotomy approach for congenital heart operations.An n Thorac Su rg.2001;71:469-472.
10.吴延虎,陈亦江,陆小虎等.微创小切口体外循环在先天性心脏病手术中的应用.中国体外循环杂志.2005; 3:213-215.
11.王东进,曹彬,贾朝相等.右腋下小切口在心脏瓣膜手术中的应用.南京大学学报. 2002;38:606-609.
12.Laussen PC, Bichell DP. Post operat ive recovery in chi ldren aft er minium versus full length st ern ot omy. An n T horac Surg,2000;69:591-596.
13.张德奎,单清华,樊键等.右腋下小切口胸骨下段小切口与胸骨正中切口的对比研究.中华实验外科杂志.2006; 23:52.
14.Bichell DP, Geva T , Bacha EA, et al . Minimal access approach for the repair of atrial septal defect : the initial 135 patient s. Ann Thorac Surg.2000;70: 115-118.
15.刘迎龙,苏俊武,于存涛等.右外侧小切口剖胸根治小儿法乐四联症.中华胸心血管外科杂志. 1999;15( 4) : 200- 202.
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