本文選題：小鉗口LigaSure + 連續(xù)術(shù)中神經(jīng)監(jiān)測技術(shù)��； 參考：《中國人民解放軍醫(yī)學院》2017年碩士論文

【摘要】：目的:通過模擬甲狀腺手術(shù)中LigaSure在頸段喉返神經(jīng)(Recurrent laryngeal nerve,RLN)區(qū)域的應用,建立連續(xù)神經(jīng)監(jiān)測(Continuous intraoperative neuromonitoring,CIONM)保護下的小型豬動物模型,從而探討甲狀腺手術(shù)中LigaSure在RLN區(qū)域應用時的安全距離及安全時間間隔。方法:1.實驗動物分組:36頭小型豬隨機分為距離實驗組和間隔實驗組(各18頭)。距離實驗組根據(jù)LigaSure刀頭作用部位與RLN距離不同隨機分為組1 (距RLN3mm)、組2(距RLN2mm)和組3 (距RLN1mm),每組6頭;間隔實驗組根據(jù)LigaSure刀頭室溫下冷卻時間不同隨機分為組1 (冷卻3s)、組2 (冷卻2s)和組3 (冷卻1s),每組6頭。2.實驗動物模型制備:1)麻醉及CIONM的應用實驗動物硫噴妥鈉(15mg/kg)靜脈麻醉滿意后,喉鏡引導下插入6號NIM標準加強型氣管內(nèi)導管,連接心電和血氧監(jiān)測,術(shù)中1～2%七氟醚行麻醉維持。依照CIONM應用標準化步驟,行迷走神經(jīng)(Vagus nerve, VN)暴露、APS電極的留置和RLN暴露,對RLN功能進行實時監(jiān)測。2)距離實驗選取18頭小型豬左側(cè)RLN (右側(cè)對照),作用部位為第2、3氣管環(huán)水平。根據(jù)分組不同,將LigaSure刀頭分別距RLN外側(cè)3mm、2mm和1mm處被激發(fā),均作用4s,應用CIONM對RLN功能進行實時監(jiān)測,作用前后振幅和潛伏期進行對比。連續(xù)監(jiān)測30min,記錄激發(fā)后15min和損傷后30min實時振幅和潛伏期,觀察恢復情況。3)間隔實驗選取18頭小型豬左側(cè)RLN (右側(cè)對照),LigaSure先于胸鎖乳突肌上持續(xù)激活5s,敞開尖端刀頭,根據(jù)分組不同,室溫下分別冷卻3s、2s和1s后,刀頭與第2、3氣管環(huán)水平RLN直接接觸5s,應用CIONM監(jiān)測RLN功能變化。損傷前后EMG對比和神經(jīng)功能恢復情況觀察同距離實驗。3.病理切片:對實驗側(cè)RLN和右側(cè)正常RLN取材,制成病理切片,光鏡下觀察組織學變化。結(jié)果:1.距離實驗組1 LigaSure作用后EMG變化不顯著,振幅和潛伏期在正常范圍內(nèi)波動,無統(tǒng)計學意義。組2和組3出現(xiàn)不同程度振幅降低和潛伏期延長,組2振幅降低均50%,潛伏期延長均10%,監(jiān)測儀未報警,無統(tǒng)計學意義,30min時可恢復至損傷前正常范圍。組3均出現(xiàn)危險EMG,監(jiān)測儀報警,損傷后可見振幅和潛伏期恢復,但30min時未能至警戒閾值水平,有統(tǒng)計學意義。組1、組2和對照組鏡下神經(jīng)結(jié)構(gòu)正常,組3鏡下見神經(jīng)水腫表現(xiàn)。2.間隔實驗組1 LigaSure與RLN接觸后振幅降低50%,潛伏期延長 10%,監(jiān)測儀未報警,無統(tǒng)計學意義,30min后振幅和潛伏期可恢復至作用前正常范圍。組2和組3損傷后EMG迅速改變,監(jiān)測儀報警,振幅和潛伏期變化均有統(tǒng)計學差異,組2損傷后可見振幅和潛伏期恢復,但30min時未能至警戒閾值水平。組3均出現(xiàn)LOS,且損傷后不能恢復。組1和對照組鏡下神經(jīng)結(jié)構(gòu)正常,組2鏡下見神經(jīng)水腫表現(xiàn),組3鏡下可見胞核碎裂及壞死。結(jié)論:基于CIONM對RLN功能評估,甲狀腺手術(shù)中LigaSure在RLN區(qū)域應用的安全距離為距RLN外側(cè)2mm及以上,且單次激發(fā)后,再于RLN區(qū)域應用時間隔應不少于3s。LigaSure應用應予以規(guī)范化和標準化,以避免其不規(guī)范使用造成的RLN熱損傷的發(fā)生。CIONM可敏感的、實時的評估RLN功能變化,早期識別損傷,提醒術(shù)者對損傷進行預判和控制,對神經(jīng)保護意義重大,值得推廣。
[Abstract]:Objective: by simulating the application of LigaSure in the region of Recurrent laryngeal nerve (RLN) during thyroid surgery, a miniature pig animal model under the protection of Continuous intraoperative neuromonitoring (CIONM) was established to explore the safety distance of LigaSure in RLN region during thyroidectomy. Methods: 1. experimental animals were divided into 1. experimental animals: 36 small pigs were randomly divided into the distance experiment group and the interval experimental group (18 heads each). The experimental group was randomly divided into 1 (distance RLN3mm), group 2 (distance RLN2mm) and group 3 (RLN1mm), and each group was 6 heads, and the interval experimental group was based on the room temperature of LigaSure knife head. The lower cooling time was divided randomly into group 1 (cooling 3S), group 2 (cooling 2S) and group 3 (cooling 1s), 6 head of.2. experimental animal model in each group was prepared: 1) anesthesia and CIONM applied experimental animal sodium thiopental (15mg/kg) intravenous anesthesia satisfied, laryngoscope guidance inserted into the 6 NIM standard enhanced endotracheal catheter, connecting ECG and oxygen monitoring, 1~2 during the operation. % sevoflurane was maintained for anesthesia. According to the CIONM application standardization steps, Vagus nerve (VN) exposure, APS electrode retention and RLN exposure, RLN function in real-time monitoring.2) distance experiment selected 18 small pigs left RLN (right control), the action site was the level of the 2,3 trachea. According to the grouping, LigaSure knife head respectively From the lateral 3mm, 2mm and 1mm of RLN, 4S was used, CIONM was used to monitor the function of RLN in real time. The amplitude and incubation period were compared before and after. 30min was continuously monitored, the real-time amplitude and latency of 30min after the excitation and the recovery.3) were recorded, and the left RLN (right control) of 18 small pigs was selected. Re first activates 5S on the sternocleidomastoid muscle and opens the cutting-edge knife. After cooling 3S, 2S and 1s at room temperature, the knife head and 2,3 tracheal ring level RLN are directly exposed to 5S, and CIONM monitoring RLN function changes. The EMG contrast before and after injury and the recovery of nerve function before and after injury are observed by the same distance experimental.3. pathological section. On the right side of the normal RLN, the pathological sections were made. The histological changes were observed under the light microscope. Results: the changes of EMG in the 1. distance experimental group were not significant after the action of 1 LigaSure. The amplitude and latency fluctuated in the normal range, and there was no statistical significance. The amplitude and the latent period of the group 2 and group 3 were decreased and the latent period was prolonged, the 2 amplitude of the group decreased 50% and the incubation period was 10. %, the monitor did not alarm, no statistical significance, 30min can be recovered to the normal range before injury. Group 3 appeared dangerous EMG, monitor alarm, the amplitude and latency recovery after injury, but 30min failed to the level of warning threshold, there were statistical significance. Group 1, group 2 and control group under normal neural structure, group 3 endoscopic neuroedema showed.2. performance of neuroedema in the performance of.2. After contact between 1 LigaSure and RLN, the amplitude of amplitude decreased by 50%, the latency prolonged 10%, the monitor did not alarm, no statistical significance. The amplitude and latency of 30min could be recovered to the normal range before action. Group 2 and group 3 after injury, EMG changed rapidly, the monitor alarm, amplitude and latency changes were statistically different, and the amplitude of the 2 injury was visible. And the incubation period recovered, but 30min failed to reach the alert threshold level. Group 3 appeared LOS, and could not recover after injury. Group 1 and control group were normal under the microscope, group 2 under 2 mirror neurosis, 3 mirrors can see the nucleus fragmentation and necrosis. Conclusion: Based on the CIONM evaluation of RLN function, LigaSure in the thyroid operation in RLN area application of safety The whole distance is RLN outside 2mm and above, and after single excitation, the application time interval of RLN should be normalized and standardized to avoid the.CIONM sensitivity of the RLN thermal damage caused by its non standard use, to evaluate the changes of RLN function in real time, identify the damage of the RLN in the early stage, and remind the operator to carry out the damage. Anticipation and control are of great significance for neuroprotection and are worthy of promotion.
【學位授予單位】：中國人民解放軍醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R653

【參考文獻】

相關(guān)期刊論文 前10條

1 張燕妮;陳建強;鄒堅定;魯杰;熊華;;喉返神經(jīng)術(shù)中實時監(jiān)護在甲狀腺手術(shù)中的應用[J];中國眼耳鼻喉科雜志;2015年06期

2 龐毅;單士崗;;術(shù)中神經(jīng)監(jiān)測技術(shù)在甲狀腺手術(shù)中的應用與進展[J];中國普通外科雜志;2015年11期

3 龍淼云;梁施華;安富麗;羅定遠;彭新治;黃明清;黃楷;黎洪浩;;鉗式LigaSure和傳統(tǒng)方法在開放性甲狀腺全切除術(shù)中的應用比較[J];中華普通外科學文獻(電子版);2015年04期

4 鄧巧蓮;朱精強;;神經(jīng)電生理監(jiān)測技術(shù)在甲狀腺及甲狀旁腺手術(shù)中的應用進展[J];中國普外基礎(chǔ)與臨床雜志;2015年07期

5 李海鵬;劉新洪;魏福國;張建立;呂斌;陳波;;術(shù)中喉返神經(jīng)監(jiān)測技術(shù)在完全腔鏡甲狀腺手術(shù)中的應用研究[J];腹腔鏡外科雜志;2015年04期

6 臧宇;田文;姚京;;術(shù)中神經(jīng)監(jiān)測對分化型甲狀腺癌再次手術(shù)中保護喉返神經(jīng)的作用[J];解放軍醫(yī)學院學報;2015年05期

7 王軍;李玉鋒;孫松;路旭;;甲狀腺手術(shù)暴露與非暴露術(shù)式對喉返神經(jīng)的保護作用比較[J];武警醫(yī)學;2015年01期

8 張翼;徐鯤;何領(lǐng);朱永康;陳晨;;喉返神經(jīng)顯露在甲狀腺手術(shù)中的臨床意義[J];臨床醫(yī)藥實踐;2014年12期

9 李可亮;李進讓;;甲狀腺術(shù)中喉返神經(jīng)實時監(jiān)測對預防喉返神經(jīng)損傷的Meta分析[J];臨床耳鼻咽喉頭頸外科雜志;2014年24期

10 聶鑫;姚壯凱;;甲狀腺手術(shù)中喉返神經(jīng)監(jiān)測的臨床應用現(xiàn)狀與前景[J];中國腫瘤外科雜志;2014年03期

相關(guān)碩士學位論文 前3條

1 王碩;喉返神經(jīng)監(jiān)測在再次甲狀腺手術(shù)中的臨床應用[D];吉林大學;2015年

2 趙詣深;甲狀腺手術(shù)中喉返神經(jīng)損傷機制及神經(jīng)監(jiān)測技術(shù)的應用研究[D];吉林大學;2014年

3 陳文龍;困難甲狀腺手術(shù)喉返神經(jīng)解剖的臨床應用研究[D];安徽醫(yī)科大學;2014年

，

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