本文選題：腹腔鏡 + 肝外傷��； 參考：《福建醫(yī)科大學》2013年碩士論文

【摘要】：【目的】 1、探討腹腔鏡下射頻消融固化止血治療在肝外傷救治中的應用，有望得出一種可應用于臨床和戰(zhàn)時的安全、有效、簡便、易于推廣的肝外傷止血治療手段。從而實現在傷情的早期判斷和全面評估的基礎上，盡可能的避免不必要的剖腹手術和器官切除手術，盡可能地實現微創(chuàng)的、個體化的、安全有效的治療。 2、通過實驗分析該技術應用于肝外傷救治的適應證、療效、安全性。 3、將當前肝膽外科的新技術、新觀念前伸并應用到戰(zhàn)時和非戰(zhàn)爭軍事行動條件下的肝外傷的救治中，探索野戰(zhàn)條件下肝損傷救治的新途徑、新策略。 【方法】 將進入實驗的20只動物隨機分為兩組，采用自制小型生物撞擊器致傷后，依據美國創(chuàng)傷外科學會(AAST)器官傷分類委員會，1989年提出經1994年修改的肝臟損傷程度分級標準對傷情進行評估。A組于傷后30-60min內行腹腔鏡探查，進一步判斷、評估傷情。在腹腔鏡直視下，結合B超，對出血部位施行經皮射頻消融固化止血治療。治療失敗者或合并其他臟器損傷者，根據傷情，行開腹手術（包括肝葉切除、脾切除術等）。B組經B超檢查后確定肝損傷等級后，予以非手術治療（包括采取液體復蘇、監(jiān)測血流動力學等）。所有動物均按階段采集血常規(guī)、生化指標、影像學復查等。對于血流動力學不穩(wěn)定，影像學提示持續(xù)出血的嚴重肝損傷者，擇機開腹探查，手術止血。治療過程中死亡動物，立即尸檢。第28天處死動物，，尸檢，完整切取肝臟，探查腹腔、胸腔，記錄發(fā)生的并發(fā)癥。標本脫水處理后石蠟包埋，常規(guī)HE染色，光鏡分析，采集組織學資料。 【結果】 1.止血時間及失血量方面 腹腔鏡探查聯合射頻消融治療組與非手術組在止血時間、失血量上除I級肝外傷外均有明顯差異（P0.05）。 2.血糖、胰島素、胰高血糖素 兩組動物傷前血糖、INS、GLU比較均無顯著差異(P0.05)。術后即刻、術后1天、術后2天，兩組動物血糖較傷前均有明顯升高(P0.05)。術后第2天，手術組血糖高于非手術組，差異有統(tǒng)計學意義(P0.05)。術后第4天手術組血糖恢復至正常水平(P0.05)，術后第10天非手術組血糖恢復至正常水平，兩組比較差異有統(tǒng)計學意義(P0.05)。兩組動物INS在術后即刻明顯下降，較致傷前比較差異有統(tǒng)計學意義(P0.05)。術后第1、2天，兩組INS均顯著升高，較致傷前比較有差異性(P0.05)。術后第4天，手術組INS有所下降，與致傷前比較無明顯差異(P0.05)，而非手術組仍顯著高于傷前水平，與傷前和手術組比較差異均有統(tǒng)計學意義(P0.05)。非手術組INS于術后第7天恢復術前水平(P0.05)。兩組動物術后GLU均呈上升趨勢，術后第1天達最高值。兩組動物GLU術后即刻、術后第1、2天與術前比較，差異有統(tǒng)計學意義(P0.05)。術后第4天，手術組恢復至傷前水平，非手術組第7天GLU逐漸恢復至傷前水平(P0.05)，但組間無差異(P0.05)。 3.ALT、AST、Tbil、Dbil 兩組動物傷前ALT、AST比較均無顯著差異(P0.05)。術后即刻、術后第1天、第2天、第4天，兩組動物ALT明顯升高，較傷前比較差異有顯著性(P0.05)。其中，手術組在術后第1天達最高值，非手術組在術后第4天達最高值，非手術組ALT在術后第4天顯著高于手術組(P0.05)。術后第7天兩組ALT接近傷前水平(P0.05)。術后即刻至術后第4天，兩組AST均顯著升高，較傷前比較差異有顯著性(P0.05)，兩組都在術后第1天達最高值。手術組AST在術后第7天接近術前水平(P0.05)，而非手術組AST雖然有所下降，但較傷前和手術組比較，仍有統(tǒng)計學差異(P0.05)。傷后兩組Tbil、Dbil開始緩慢上升，均在術后第2天達高峰，其中非手術組僅Dbil在術后第1、2天較傷前比較差異有統(tǒng)計學意義(P0.05)，術后第4天降至正常。手術組Tbil、Dbil在術后第1、2天較傷前比較，差異有顯著性(P0.05)，術后第7天恢復至正常水平。兩組之間比較均沒有統(tǒng)計學意義(P0.05)。 【結論】 1.腹腔鏡探查聯合射頻消融固化止血治療技術較之傳統(tǒng)保守治療，止血時間明顯縮短，失血量明顯減少，并發(fā)癥發(fā)生率低，適用于不同傷情的肝外傷的救治，值得推廣。 2.腹腔鏡探查聯合射頻消融固化止血治療肝外傷具有創(chuàng)傷小、恢復快、并發(fā)癥少等特點；機體應激反應輕、肝功能影響小。 3.腹腔鏡探查聯合射頻消融有以下技術優(yōu)勢：1、有利于早期全面的傷情判斷，防止遺漏多發(fā)臟器損傷的診斷；2、直視下穿刺射頻針，定位準確，簡便易行，技術難度小而可靠，適用于戰(zhàn)時的特殊要求。
[Abstract]:[Objective]
1, the application of laparoscopic radiofrequency ablation and hemostasis treatment in the treatment of liver trauma is expected to be a safe, effective, simple and easy to be used for the treatment of liver trauma, which can be used to avoid unnecessary laparotomy on the basis of early judgement and comprehensive assessment of the injury. And organ resection to achieve minimally invasive, individualized, safe and effective treatment as far as possible.
2, we analyzed the indications, efficacy and safety of the technology in the treatment of liver trauma through experiments.
3, to explore new ways and strategies for the treatment of liver injury under the condition of field warfare, the new technology of the current Department of hepatobiliary surgery, new ideas are extended and applied to the treatment of liver trauma under the conditions of wartime and non war military operations.
[method]
20 animals who entered the experiment were randomly divided into two groups. After the injury caused by a self-made small biological impactor, according to the American Society for trauma surgery (AAST) organ injury classification Committee, in 1989, the evaluation of the degree of liver injury revised in 1994 was evaluated for the evaluation of the injury in the group of 30-60min. Under the direct vision of the laparoscope, combined with B-ultrasound, percutaneous radiofrequency ablation and hemostasis was performed on the bleeding site. In the treatment of the losers or those with other organs injury, the.B group was treated after the B-ultrasound examination to determine the grade of liver injury after the B-ultrasound examination. Resuscitation, monitoring hemodynamics, etc. all animals were collected by stage of blood routine, biochemical index, imaging review and so on. For hemodynamic instability, patients with severe liver injury with continuous bleeding, selective laparotomy, surgical hemostasis, and immediate autopsy in the course of treatment. Animals, autopsy and complete removal were executed twenty-eighth days. The liver, the abdominal cavity and the chest cavity were recorded, and complications were recorded. Specimens were dehydrated and paraffin embedded, stained with conventional HE, analyzed by light microscopy, and histologic data were collected.
[results]
1. the time of hemostasis and the amount of blood loss
Laparoscopy combined with radiofrequency ablation group and non operation group had significant difference in hemostasis time and blood loss except I grade liver trauma (P0.05).
2. blood glucose, insulin, glucagon
There was no significant difference in blood sugar, INS, GLU before injury in the two groups (P0.05). Immediately after operation, 1 days after operation, 2 days after operation, the blood sugar of two groups were significantly higher than before injury (P0.05). The blood sugar of the operation group was higher than that of non operation group at second days after operation. The difference was statistically significant (P0.05). The blood sugar recovered to normal level (P0.05) in the operation group fourth days after operation (P0.05), first after operation, first after operation. The blood glucose of the non operative group recovered to the normal level in the 0 day, and the difference between the two groups was statistically significant (P0.05). The difference between the two groups of animals was significantly lower than that before the injury (P0.05). The two groups of INS were significantly higher after the postoperative day 1,2, compared with the prior injury (P0.05). Fourth days after the operation, the operation group INS decreased. There was no significant difference between before and before injury (P0.05), but the non operative group was still significantly higher than the pre injury level, and there was significant difference between the pre injury and the operation group (P0.05). The INS in the non operation group recovered before the operation (P0.05) seventh days after the operation. The GLU of the two groups of animals showed a rising trend after operation, and the highest value in first Tianda after the operation. Two groups of animals were immediately after the operation, The difference was statistically significant (P0.05) after 1,2 day after operation (P0.05). The operation group recovered to the level of pre injury fourth days after operation, and the GLU of the non operation group gradually recovered to the pre injury level (P0.05), but there was no difference between the groups (P0.05).
3.ALT, AST, Tbil, Dbil
There was no significant difference in ALT and AST between the two groups before injury (P0.05). Immediately after operation, first days, second days and fourth days after operation, the two groups of animals were significantly higher than before injury (P0.05). Among them, the highest value of the operation group in first Tianda, the highest value of the non operative group in fourth Tianda after the operation, and the ALT in the non operation group was significantly higher than that in the fourth day after the operation. The operation group (P0.05). Seventh days after the operation, two groups of ALT were close to the pre injury level (P0.05). The two groups of AST were significantly increased after the operation and fourth days after the operation. The difference was significant compared with that before the injury (P0.05). The two groups were the highest in first Tianda after the operation. The operation group was close to the preoperative level (P0.05) on the seventh day after the operation, while the AST in the non operative group decreased, but the injury was more severe. Compared with the operation group, there were still statistical differences (P0.05). The two groups of Tbil and Dbil began to rise slowly after the injury, all of which were in the peak of second Tianda after the operation. The difference between the non operative group and the postoperative 1,2 days was statistically significant (P0.05), and the fourth day after the operation was reduced to the normal. The operative group Tbil, Dbil compared with the injury before the operation, the difference was compared with the injury before the operation. The difference was the difference between the operation group and the postoperative day before the injury. Significance (P0.05) returned to normal level seventh days after operation. There was no significant difference between the two groups (P0.05).
[Conclusion]
1. laparoscopy combined with radiofrequency ablation curing hemostasis treatment technology is better than traditional conservative treatment. The time of hemostasis is shortened obviously, the amount of blood loss is reduced obviously, and the incidence of complications is low. It is worth popularizing for the treatment of liver trauma with different injuries.
2. laparoscopy combined with radiofrequency ablation and hemostasis for the treatment of liver trauma has the characteristics of small trauma, quick recovery, less complications, light stress reaction and small effect of liver function.
3. laparoscopy combined with radiofrequency ablation has the following technical advantages: 1, it is beneficial to the early and comprehensive assessment of the injury, to prevent the diagnosis of omission of multiple organ damage; 2, the puncture radiofrequency needle under direct vision is accurate, simple and easy to be used, and the technical difficulty is small and reliable. It is suitable for the special requirements of wartime.
【學位授予單位】：福建醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2013
【分類號】：R82

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