本文選題：全胸腔鏡手術(shù) + 胸骨正中切開術(shù)��； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：全胸腔鏡心臟手術(shù)是指術(shù)野完全依靠胸腔鏡進(jìn)行顯露,胸腔內(nèi)手術(shù)操作均在胸腔鏡所提供的術(shù)野下進(jìn)行。過去20余年來,隨著體外循環(huán)技術(shù)的發(fā)展、手術(shù)器械的改進(jìn),二尖瓣置換術(shù)(mitral valve replacement MVR)已經(jīng)由原來的胸骨正中切口逐漸向全胸腔鏡化發(fā)展。對于許多病人來說全胸腔鏡體外循環(huán)(cardiopulmonary bypass CPB)下二尖瓣置換術(shù)已經(jīng)成為一個(gè)安全、有效的手術(shù)方式,同傳統(tǒng)開胸行二尖瓣置換相比,全胸腔鏡體外循環(huán)行二尖瓣置換術(shù)在保證手術(shù)安全及療效的同時(shí),并沒有增加圍手術(shù)期的死亡率,病人則獲得了降低手術(shù)創(chuàng)傷,更輕微的疼痛,更少的術(shù)后住院天數(shù)以及更快的恢復(fù)到術(shù)前狀態(tài)等諸多好處。如今全胸腔鏡二尖瓣置換術(shù)已經(jīng)是許多心臟中心的常規(guī)手術(shù)。我院心臟外科在2012到2106年間成功為20例二尖瓣病變的患者實(shí)施了全胸腔鏡體外循環(huán)下二尖瓣置換術(shù),此研究對這些患者的臨床結(jié)果進(jìn)行了分析并總結(jié)了全胸腔鏡體外循環(huán)下二尖瓣置換術(shù)的經(jīng)驗(yàn)。目的:通過比較全胸腔鏡體外循環(huán)下二尖瓣置換術(shù)與常規(guī)開胸行二尖瓣置換術(shù)的術(shù)中及術(shù)后指標(biāo),探討全胸腔鏡體外循環(huán)下二尖瓣置換術(shù)的優(yōu)勢及臨床應(yīng)用價(jià)值。方法:將20例行全胸腔鏡體外循環(huán)下二尖瓣置換術(shù)的患者定為全胸腔鏡(totally thoracoscopy TT)組,以年齡、性別、左室射血分?jǐn)?shù)(left ventricular ejection fractions LVEF)、二尖瓣疾病類型及體重指數(shù)(body mass index BMI)為匹配因素按成組匹配原則,選取同期行胸骨正中切口、體外循環(huán)下二尖瓣置換術(shù)20例作為傳統(tǒng)開胸(conventional sternotomy CS)組,選取總手術(shù)時(shí)間、體外循環(huán)時(shí)間、升主動(dòng)脈阻斷時(shí)間作為術(shù)中指標(biāo),選取呼吸機(jī)輔助呼吸時(shí)間、重癥監(jiān)護(hù)室(intensive care unit ICU)停留時(shí)間、術(shù)后應(yīng)用杜冷丁、嗎啡等阿片類鎮(zhèn)痛藥的病人比例、術(shù)后尿管留置時(shí)間、術(shù)后總引流量、術(shù)后住院天數(shù)、半年后復(fù)查超聲心動(dòng)圖觀察兩組患者機(jī)械瓣功能及心功能情況作為術(shù)后指標(biāo)。對比兩組患者術(shù)中及術(shù)后指標(biāo),以α=0.05為檢驗(yàn)水準(zhǔn)。此研究在取得我院倫理委員會(huì)許可且在家屬知情同意情況下進(jìn)行。結(jié)果:TT組與CS組患者相比,平均總手術(shù)時(shí)間(250.1±7.5min vs.225.4±9.1min;P0.001);平均體外循環(huán)時(shí)間(113.1±6.4min vs.84.1±4.6min;P0.001);平均升主動(dòng)脈阻斷時(shí)間(85.2±3.1min vs.59.8±2.2min;P0.001),上述指標(biāo)TT組均明顯長于CS組且經(jīng)統(tǒng)計(jì)學(xué)檢驗(yàn)有統(tǒng)計(jì)學(xué)意義。TT組術(shù)后呼吸機(jī)輔助呼吸時(shí)間平均為(12.5±0.8)h,明顯長于CS組(11.0±0.7)h(P0.001),且有統(tǒng)計(jì)學(xué)意義。TT組與CS組相比平均監(jiān)護(hù)室停留時(shí)間和平均術(shù)后住院天數(shù)分別為(38.2±1.5h vs.44.0±1.8h;P0.001)和(8.0±0.8d vs.9.4±0.9d;P0.001),TT組明顯短于CS組,TT組術(shù)后總引流量平均為(366.5±29.8ml),明顯少于CS組(499.9±29.5ml P0.001)。TT組術(shù)后導(dǎo)尿管留置天數(shù)平均為(3.7±0.7d),明顯短于CS組(4.4±0.5d P=0.02)。TT組術(shù)后使用杜冷丁、嗎啡等阿片類鎮(zhèn)痛藥的病人比例為20%,亦明顯低于CS組60%(P=0.02)。兩組患者均恢復(fù)順利,傷口愈合良好,順利出院,術(shù)后6個(gè)月復(fù)查超聲心動(dòng)圖,兩組患者機(jī)械瓣功能均未見異常,兩組EF值無顯著性差異。結(jié)論:同開胸手術(shù)相比,全胸腔鏡體外循環(huán)下二尖瓣置換術(shù)總手術(shù)時(shí)間、體外循環(huán)時(shí)間、升主動(dòng)脈阻斷時(shí)間和術(shù)后輔助呼吸時(shí)間較長,但胸腔鏡手術(shù)創(chuàng)傷小,ICU停留時(shí)間短、住院時(shí)間短,恢復(fù)時(shí)間快,美容效果好。
[Abstract]:Full thoracoscopic surgery means that the operation field is fully exposed by thoracoscopy, and the intrathoracic surgery is performed under the operation field provided by the thoracoscope. Over the past 20 years, with the development of the cardiopulmonary bypass technique, the improvement of the surgical instruments and the mitral valve replacement (mitral valve replacement MVR) have evolved from the original median sternum incision. For many patients, full thoracoscopic cardiopulmonary bypass CPB mitral valve replacement has become a safe and effective surgical procedure. Compared with the traditional thoracotomy for mitral valve replacement, full thoracoscopic cardiopulmonary bypass for mitral valve replacement can ensure the safety and efficacy of the operation. There was no increase in the peri operative mortality rate, and the patient received many advantages, such as lower surgical trauma, less pain, less postoperative hospitalization, and faster recovery to the pre operation state. Now full thoracoscopic mitral valve replacement has been a routine hand in many heart centers. Our hospital has a success of 2 between 2012 and 2106. 0 patients with mitral valve disease performed mitral valve replacement under full thoracoscopic cardiopulmonary bypass. This study analyzed the clinical results of these patients and summarized the experience of mitral valve replacement under full thoracoscopic cardiopulmonary bypass. Objective: To compare mitral valve replacement and conventional thoracotomy for mitral valve replacement under full thoracoscopic extracorporeal circulation. The advantage and clinical value of intraoperative and postoperative mitral valve replacement under full thoracoscopic cardiopulmonary bypass were discussed. Methods: 20 patients were treated with total thoracoscopic mitral valve replacement (totally thoracoscopy TT), with age, sex, and left ventricular ejection fraction (left ventricular ejection fract). Ions LVEF), the type of mitral valve disease and the body mass index (body mass index BMI) as matching factors according to the group matching principle, select the median sternum incision in the same period, and 20 cases of mitral valve replacement under extracorporeal circulation as the traditional open chest (conventional sternotomy CS) group, select the total operation time, the extracorporeal circulation time, the ascending aorta blocking time. Intraoperative indexes, ventilator assisted respiration time, intensive care unit ICU stay time, the proportion of opioid analgesics such as dopenin and morphine, postoperative indwelling time of urethral catheterization, postoperative total flow rate, postoperative hospitalization days, and two groups of patients with mechanical valve function and heart after half a year were examined by echocardiography. Function as a postoperatively. Compared to the two groups of patients during and after the operation and postoperative indicators, the level of alpha =0.05 was tested. This study was carried out under the permission of the ethics committee of our hospital and under the informed consent of the family members. Results: the average total operation time (250.1 + 7.5min vs.225.4 + 9.1min; P0.001) was compared with the CS group, and the average extracorporeal circulation was compared. Between (113.1 + 6.4min vs.84.1 + 4.6min, P0.001), the mean ascending aorta blocking time (85.2 + 3.1min vs.59.8 + 2.2min; P0.001), the above indexes were significantly longer in the CS group than in the CS group and statistically significant in the.TT group (12.5 + 0.8) h, which was significantly longer than that of the group (11 + 0.7). The average length of stay of the.TT group and the average postoperative hospital stay were (38.2 + 1.5h vs.44.0 + 1.8h, P0.001) and (8 + 0.8d vs.9.4 + 0.9d, P0.001), and the TT group was significantly shorter than that of the CS group. The average flow rate after operation was (366.5 +), which was significantly less than that of the group (499.9 +). The average number of days was (3.7 + 0.7d), obviously shorter than group CS (4.4 + 0.5d P=0.02).TT, the proportion of opioid analgesics, such as morphine, was 20%, and 60% (P=0.02) in the group CS. The two groups recovered smoothly, the wound healed well, was discharged from the hospital smoothly, the ultrasonic cardiogram was rechecked 6 months after the operation, and the function of the two group of the mechanical valves was not. There was no significant difference in the EF value of the two groups. Conclusion: compared with the open thoracotomy, the total operation time, the time of extracorporeal circulation, the time of extracorporeal circulation, the interruption time of the ascending aorta and the time of assisted respiration were longer, but the thoracoscopic surgery was small, the time of ICU was short, the time of hospitalization was short, the time of recovery was fast, and the beauty effect was improved. OK.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R654.2

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