摘要
目的
由于气管解剖的复杂性,使得气管疾病的外科手术治疗变得极为复杂和困难,目前不能在大多数医院得到普及。将包含病变的部分气管切除后行气管重建是气管外科的主要内容。有学者认为气管的切除长度可达到气管全长的一半(6cm),仍能进行端端吻合。而实际上,由于病员高龄,局部粘连,个体的差异以及手术者、手术技巧等因素,使得气管切除长度受限,造成术者无法在术前及术中对部分较长的气管切除后可否进行端端吻合进行精确判断。而使部分本可采用手术治疗的病例失去手术机会,对于术中进行了较长的气管切除而又无法进行常规端端吻合术的病例就必须应用一种有效、符合生理要求的替代物来解决。此外临床上常有累及较长段气管但仍未累及气管全周的低度恶性肿瘤病例,手术治疗中因恐整段切除无法进行端端吻合而进行一侧壁的切除。同时对切除造成的缺损区域进行重新修补,因而修补组织的选择就成为此类手术的难点。研究一种新的、符合生理要求的气管修补、重建方法,尤其是解决目前国内外尚无有效可行的气管较大面积缺损的修补问题以及长段气管重建问题是本项研究的目的。通过动物实验及临床研究建立一种自体组织行气管修补、重建的新方法—应用自体肺组织瓣行气管修补、重建。
方法
选用杂种成年犬26只,分成两组。
A组:气管整段切除应用自体肺组织瓣内衬金属网架重建气管。经腹腔注入硫贲妥钠(30～50mg/kg)诱导麻醉,快速经口气管插管,用呼吸机维持呼吸。将实验犬固定于手术台上,左侧卧位,右胸在上左肩下垫高。于第五肋间右胸外侧切口,切开皮肤,用电刀切开皮下,向上游离皮瓣至第四肋间水平,用电刀切开胸壁肌群及第四肋间肋间肌,切口用开胸器扩大之。1、游离气管:用电刀将覆盖气管表面的纵隔胸膜打开,并向两侧游离,将距隆
ObjectiveIt is very difficult to popularize the operation of trachea because of the anatomical complexity of it, so few hospital can perform this kind of operation. The main problem that tracheal, surgery should deal with is reconstruction of trachea after the resection. There is an idea that 6cm is the base line whether the end-to-end anastomosis can be performed. , but in practice, because of the senility of patients, local conglutination, individual difference and the techniques of operators , it is hardly to get the base line of end-to-end anastomosis, and so does it for the operators in exactly estimating whether the end-to-end anastomosis should be performed preoperation or intraoperation. This problem may bring some patients on loss of the opportunity of operation, so it is necessary to find a physiologically-suitable method to deal with this kind of problem that long seg-mental circumferential resection of trachea should be performed but routine end-to-end anastomosis can not be carried out. There is another kind of problem that what type of restoration is the best choice for long segmental but not circumferential tracheal defect for postoperation of tracheal malignant tumor. Our purpose is to find out a new and physiologically-suitable method for tracheal repairing and reconstruction, especially to solve the problem of extensive tracheal defect repairing and long-segment circumferential tracheal reconstruction in face of worldwide surgeons. We establish a new method for self-tissue repairing and reconstruction of trachea by using self pulmonary tissue flap (SPTF) what is based on animal trial and clinical study.
Method26 mongrels are divide into 2 groups. A groups: Use alloy mesh stent covered by vascularized pulmonary tissue flap (PTF) to reconstruct the long-segment circumferential tracheal defect. Using sodium pentothal (30 ~50mg/kg) abdominal injection inducts anaesthesia, and intubation via mouth quickly, then maintain ventilation by using respiratory machine. Emplace the mongrel on the operation desk, left lying, right chest upwards, and put pillow under the left should. Choose right lateral incision at 5th incostal level, slice off the skin, use electrotome cutting off subcutaneous tissue, free tissue flap up to 4th intercostal level, cut off muscular groups of chest and 4 th intercostal muscle, pull off the incision by thoracic enlarger. 1. freeing trachea: cut off and free the mediastinal pleura of trachea, free trachea above carina 2cm and put tractive line, at the resection level sew 1 # silk thread on the tracheal fascia (as the tractive line) , near end and distant end 2 lines, respectively. 2. design and prepare the alloy mesh stent covered by vascularized PTF: free right superior lope root, expose right superior bronchia, and ligate it by 7# silk thread at the atelectasis state, and make it forever. According to the length of resection of trachea, make the right superior lobe as a tube and sew it as it, and put alloy mesh stent in it (diameter of tube should be a little larger than that of trachea) , the alloy mesh stent should longer than the pulmonary tissue tube at each end 0. 5 cm. 3. resect the trachea: first, cut off trachea superior carina 2. 0cm as fast as possible, then intubate prepared sterile tube at the distant end of trachea, maintain ventilation by using respiratory machine. Pull out previous intubation and cut off the trache-a at the designed level. According to the resection length of trachea 3cm and 5cm, they are divided into A1 and A2 2 groups. 4. the reconstruction of trache-a: intubate the alloy mesh stent part of substitute complexity into the near end of trachea and fix it up by U type suture, then sew up the near end of trachea with the pulmonary tissue tube at the opposite end of pulmonary hilar, and covered by mediastinal pleura. Use a thinner tube reintubate via mouth and pass through the near end anastomosis and pulmonary tissue tube until reach the distant end of
trachea. Use the same method sew up the distant end of trachea with the other end of pulmonary tissue tube, reinforce the anastomosis with mediastinal pleura. Then accomplish the reconstruction procedure and resume the airway. 5. closure of thoracic cavity: manage hemostasia strictly, swill the thoracic cavity, suck out the sputum and reinflate the lungs, exam leak or not, if has, sew up it and use OB glue reinforce. Put the thoracic drainage tube at the 6th intercostal level , and close the thoracic cavity. B group: use PTF repair lateral defect of trachea: after inductive anaethesia, intubate via mouth, maintain ventilation with respiratory machine. Emplace mongrel on the operation desk, left lying, right chest upwards, and put pillow under the left should. Choose right lateral incision at 5th incostal level, slice off the skin, use electrotome cutting off subcutaneous tissue, free tissue flap up to 4th intercostal level, cut off muscular groups of chest and 4th intercostal muscle, pull off the incision by thoracic enlarger. Explore the thoracic cavity, if there is no conglutination and fluid, perform the repairing operation. 1. freeing trachea: cut off and free the mediastinal pleura of trachea, free trachea above carina 2cm and put tractive line, at the resection level sew 1 # silk thread on the tracheal fascia (as the tractive line) , near end and distant end 2 lines, respectively. 2. design and prepare the vascularized PTF: free right superior lope root, expose right superior bronchia, and ligate it by 7# silk thread at the atelectasis state, and make it forever. 3. resect the trachea: first, cut off trachea superior carina 2. Ocm as fast as possible, then intubate prepared sterile tube at the distant end of trachea, maintain positive pressure ventilation by using respiratory machine. Pull out previous intubation and cut off the tracheal lateral wall at the designed level. According to the resection length of tracheal lateral wall (including cartilage) 2cm and 4cm, B group is divided into B1 and B2. 4. the repair of trachea: put the alloy mesh stent in the normal tracheal cavity, and fix it up by U type suture, then sew up the defect of trachea with the pulmonary tissue tube. Use a thinner tube reintubate via mouth and pass through the near end anastomosis and pulmonary tissue tube until reach the distant end of trachea, reinforce the anastomosis with mediastinal pleura. Then accomplish the reconstruction procedure and resume the airway. Study the local morphological change and the application techniques. Through studying 5
引文
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