本文選題：三維重建 + 腹腔鏡�。� 參考：《浙江大學》2017年碩士論文

【摘要】：目的:近年來,得益于三維重建技術等信息化產(chǎn)業(yè)以及多產(chǎn)業(yè)的融合發(fā)展,肝臟手術逐漸從"徹底切除病灶"至"精準肝切除"理念改變,精準肝切除理念在肝臟外科領域得到諸位大家支持,國內(nèi)黃志強院士以及董家鴻教授等人先后指出,精準肝切除可以使肝臟手術患者達到最優(yōu)的療效及康復體驗。肝臟外科正式迎來精準肝切除時代。文旨在探究微創(chuàng)醫(yī)學領域下的肝臟外科精準外科理念,也就是三維重建聯(lián)合腹腔鏡下肝臟切除手術的優(yōu)劣,進一步推廣普及肝臟三維重建技術以及腹腔鏡肝臟手術,一則減輕術中損傷,提高手術質(zhì)量;二則加快患者康復。資料和方法:浙江大學醫(yī)學院附屬邵逸夫醫(yī)院從1998年開始開展腹腔鏡肝臟手術,至今已經(jīng)積累了腹腔鏡肝臟手術1000余例,有著深厚的腔鏡底蘊。從2014年起本院也逐步采用肝臟三維重建技術用作肝臟手術的術前指導,積累了 100余例病例,技術日益成熟。本文統(tǒng)計從2014年1月到2016年8月行腹腔鏡右半肝切除,腹腔鏡局部肝臟切除病例共94例。所有病例均統(tǒng)計術前指標如一般情況,腫塊位置,腫塊大小,肝內(nèi)脈管走行等。術中指標統(tǒng)計手術方式、手術時間、術中出血、中轉、輸血率等,術后指標統(tǒng)計術后并發(fā)癥和住院時間、住院費用等。分別比較腹腔鏡大部分肝切(以腹腔鏡右半肝為例)和腹腔鏡局部肝切有無術前行三維重建對術前評估,術中指標以及術后指標的影響。結果:將本中心94例肝臟手術患者按照:1.三維重建聯(lián)合腹腔鏡大部分肝臟切除,2.單獨腹腔鏡大部分肝臟切除,3.三維重建聯(lián)合腹腔鏡局部肝臟切除,4.單獨腹腔鏡局部肝臟切除分為四組。對各組病例術前資料進行評估,除了大部分肝臟切除病例患者的ALT水平,以及局部肝臟切除的男女比例這兩項重建組與非重建組有一定的顯著性差異外,其他各組不管是在年齡還是既往腹部手術史、肝硬化等方面都與其他組無明顯統(tǒng)計學差異。同時也對腹腔鏡大部分肝切除和腹腔鏡局部切除的重建組與非重建組手術難度進行了對比分析,采用新難度評分系統(tǒng),得出大部分肝切重建組難度評分10.17±1.528對比非重建組10.61±0.778;P = 0.07;以及局部肝切重建組難度評分5.73±1.849對比非重建組4.94±2.193;P = 0.598;兩組資料對比均無顯著性差異。腹腔鏡大部分肝切除和腹腔鏡局部肝切的重建組與非重建組基本資料以及手術難度一致,術前資料有一定可比性。術前指標如脈管變異,統(tǒng)計結果發(fā)現(xiàn),在所有重建患者中,肝動脈,門靜脈,肝靜脈均正常的患者比值為60.8%;門靜脈Ⅱ型變異13.0%,Ⅲ型變異8.6%,肝動脈Ⅵ型變異4.3%。術中指標如手術時間,術中出血,中轉,在腹腔鏡大部分肝臟切除組中,術中出血指標重建組475±263.3 ml對比非重建組972.2±811.5ml;P=0.044,以及中轉指標重建組0%對比非重建組56%;P = 0.002,均具有顯著性差異。在腹腔鏡局部肝臟切除組中,手術時間重建組172±45.4min對比非重建組186.8±83.3 min;P = 0.014,具有顯著性差異。術后指標如并發(fā)癥,在腹腔鏡大部分肝臟切除組中,Ⅲ級及Ⅲ級以上并發(fā)癥重建組0%比非重建組27.8%;P=0.046,具有顯著性差異。而術后指標在腹腔鏡局部肝切組中對比不明顯,無明顯顯著性差異。結論:腹腔鏡肝大部分切除術的患者術前行三維重建可有利于術者進行術前評估,導航術中操作,減少術中術后并發(fā)癥,加快手術患者康復。但在局部肝切除中的患者中,三維重建所帶來的效益并不是很明顯。
[Abstract]:Objective: in recent years, thanks to the three dimensional reconstruction technology and the integration of multi industry, liver surgery has gradually changed from "complete resection of focus" to "precise liver resection", and the concept of precision hepatectomy has been supported by all people in the field of liver surgery. Academician Huang Zhiqiang and Professor Dong Jiahong, in the country, have pointed out that Para hepatectomy can enable patients with liver surgery to achieve the optimal efficacy and rehabilitation experience. Liver surgery is formally ushered in the era of precision hepatectomy. The aim of this study is to explore the precise surgical philosophy of liver surgery in the field of minimally invasive medicine, that is, the advantages and disadvantages of three-dimensional reconstruction combined with laparoscopic hepatectomy, and further popularize the three-dimensional reconstruction of the liver. Technology and laparoscopic liver surgery, one can reduce the injury in the operation, improve the quality of the operation, and two speed up the patient's recovery. Data and methods: the Sir Run Run Shaw Hospital affiliated to the Zhejiang University medical school began to carry out laparoscopic liver surgery in 1998. So far, more than 1000 cases of laparoscopic liver hand surgery have been accumulated. The hospital has also gradually used three-dimensional reconstruction of the liver as a preoperative guidance for the operation of the liver. More than 100 cases have been accumulated, and the technology is becoming more and more mature. From January 2014 to August 2016, the laparoscopic right hemihepatectomy and 94 cases of laparoscopic local hepatectomy were performed. All cases were statistically analyzed before the operation, such as the general condition, the swelling position, and swelling. The size of the block, the intrahepatic vein and so on. In the operation, the operative methods, the operation time, the intraoperative bleeding, the transfer, the rate of blood transfusion, the postoperative complications and hospitalization time, the hospitalization expenses, etc. were statistically compared. The preoperative three dimensional reconstruction of the laparoscopic most liver resection (with the laparoscopic right Hemiliver as an example) and the laparoscopic local liver resection were performed before the operation. Results: 94 cases of liver surgery in the center were treated with 1. three dimensional reconstruction combined with laparoscopic most liver resection, 2. separate laparoscopic hepatectomy, 3. three-dimensional reconstruction combined with laparoscopic partial hepatectomy, and 4. separate laparoscopic partial hepatectomy in four groups. Preoperative data were evaluated. Except for the ALT level of most cases of hepatectomy and the proportion of men and women with local hepatectomy, there was a significant difference between the two reconstructive groups and the non reconstruction group. The other groups were not significantly different from the other groups in age or previous abdominal surgery history and liver cirrhosis. The difficulty of the reconstruction group and the non reconstruction group was compared. The difficulty score of the most liver resection group was 10.17 + 1.528 compared to the non reconstruction group of 10.61 + 0.778, P = 0.07, and the difficulty score of the local liver resection group was 5.73 + 1.849 compared with the local liver resection group. The non reconstructive group was 4.94 + 2.193; P = 0.598; there was no significant difference in the data of the two groups. The basic data and the difficulty of the operation in the reconstructive and non reconstructive groups of the laparoscopic and laparoscopic partial hepatectomy and the non reconstruction group were consistent. The preoperative data were comparable. The ratio of normal patients with vein, portal vein and hepatic vein was 60.8%, the variant of portal vein type II was 13%, type III variant 8.6%, and the index of hepatic artery VI variant 4.3%., such as operation time, intraoperative hemorrhage and transfer, was 475 + 263.3 ml in the rebuilt group of intraoperative bleeding index in the majority of laparoscopic hepatectomy group, compared with 972.2 811.5ml in non reconstruction group; P=0.044, And the reconstructive group 0% compared with non reconstruction group 56%, P = 0.002, with significant differences. In the laparoscopic local hepatectomy group, the operation time reconstruction group was 172 + 45.4min compared to the non reconstructive group of 186.8 + 83.3 min; P = 0.014, with significant difference. 0% of the above complications were compared to non reconstruction group (27.8%) and P=0.046, with significant difference. The postoperative indexes were not obvious in the laparoscopic local liver resection group, and there was no significant difference. Conclusion: the preoperative three-dimensional reconstruction of the patients with laparoscopic hepatectomy can be beneficial to the preoperative assessment, navigation operation, and reduction of the operation. Postoperative complications can accelerate the recovery of patients. However, the effect of three-dimensional reconstruction is not very obvious in patients undergoing local hepatectomy.

【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735.7
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本文編號：1825721