NOTES技术在腹腔探查中应用的动物实验研究
摘要
背景：腹腔探查术是医生用来探查腹腔疾病病因或明确病变程度而普遍采用的一种检查和治疗方法。许多外科医生在临床工作中都会偶尔遇到不明原因的腹痛，无法确定的诊断及可疑的腹腔内肿块，目前临床开展的许多无创检查。例如腹部B超、CT、MR等对于微小病变诊断效果差，仅能发现直径5-10mm以上的腹腔内肿物。且辅助检查结果不能定性，仅起到提示作用，这样容易造成小病变的漏诊及误诊，例如对结核性腹膜炎、转移到腹膜的肿瘤等常不能提示。而这些病人往往无特异性临床表现,行常规内科检查无法及时准确诊断病因,尤其是找不到原因的腹水患者，这不仅容易延误病情也加重了病人经济负担。在这种情况下，腹腔探查作为一种非常有效,重要的手段常常可以帮助医生明确诊断。
腹腔探查的方式很对，其中开腹探查、腹腔镜探查在技术上已经非常成熟，而应用NOTES技术行腹腔探查则是一种新兴的腹腔探查方式。其在腹腔探查及靶向取活检方面可显示出其独特的优势。本研究在总结前人经验基础上，在现有的技术及条件下利用实验猪模型对NOTES在腹腔探查及定向活检方面的可行性及价值做出评价。
目的：腹腔探查及定向活检是诊断腹部疾病非常有效地一种手段，传统的方式对病人损伤大，费用高，病人难以接受。本研究只在评价NOTES在腹腔探查及取活检中的可行性及应用价值。
方法：对3只雌性家猪依据不同入路分组并做好术前准备。术中给予深度麻醉，监护心电、血氧。术者分别从胃入路、肠入路、阴道入路建立切口，进入内镜，对拟定脏器行探查、取活检并留取图片。术后立即解剖，对各个脏器拍照。
结果：实验动物经过禁食及药物处理胃肠道排空情况尚可。在拟定位置顺利完成造口，未发生造口出血。不同入路造口耗费时间及操作难度不同。直肠及阴道入路操作相对容易，造口耗费时间最短；胃入路操作难度大，耗时最长。术后剖腹观察未发现造口周围脏器损伤。气腹建立耗时约10分，完全满足探查视野需要。经胃入路对下腹部脏器如膀胱、卵巢、输卵管观察效果好。翻转镜身时可观察到部分肝脏、胃、胆囊、脾脏及膈肌。经肠及经阴道入路的观察范围几乎一致。对上腹部脏器如肝脏、胆囊、脾脏、胃、膈肌的观察效果理想，可以看见全部，但是探查肝脏的膈肌面操作难度较大。对于下腹部脏器的探查需要翻转镜身，探查仅见部分膀胱，卵巢、输卵管。三种入路对腹膜后脏器肾脏、输尿管、胰腺探查均未成功；对大小肠、大网膜、壁层腹膜探查效果无明显差别，均全部可见。对所见脏器均可顺利进行靶向活检，但同一脏器在不同入路下活检术难度不同。
结论：NOTES在腹腔探查及靶向活检方面具有巨大优势和潜力，不同入路之间对拟定脏器探查范围存在差异，应根据拟探查脏器选择适宜的入路。
Background:The doctors always used abdominal exploration in examination andtreatment abdominal diseases.Many surgeons in the clinical work will occasionally meetunexplained abdominal pain and not sure the diagnosis and suspicious intra-abdominalmass.At present,a lot of the clinical noninvasive inspection,such as the abdominal ultrasoundexamination,CT and MR not good at diagnosis tiny lesions,they Can only found5-10mm indiameter of intra-abdominal mass and the auxiliary examination results can't qualitative,onlya hint role.It is easy to make small lesions misdiagnosis and missed diagnosis,tumors astuberculous peritonitis,the tumor which transfer to peritoneal tumors and these patients oftenmanifestation nonspecific clinical manifestation.Conventional medical examination can'tmake a timely and accurate diagnosis.Especially for ascites patients which can't find thereason.This is not only easy to delay disease diagnosis, but also aggravate the patienteconomic burden.In this situation,abdominal exploration is seen as a very effective andimportant way to help doctors make clear diagnosis.
There are many ways of abdominal exploration,in those ways of exploratorylaparotomy,laparoscopic abdominal exploration in the technology has been very mature.Butusing NOTES in abdominal exploration is a new and developing way.Showing its uniqueadvantage in the abdominal cavity detection and targeted biopsy.The study in this articlebased on Predecessors' experience,in the existing technology and conditions utilization of thepig model to make evaluation of the feasibility and directional biopsy value use NOTES inabdominal exploration.
Objective:Abdominal exploration and targeted biopsy is a very effectively method intargeted biopsy abdominal disease diagnosis,the traditional way of abdominal explorationhave too many defects,such as too much damage, high costs, so the patient unable tobear.This study purpose is evaluation the feasibility and biopsy application value withNOTES.
Method:According to the different way random numbers of three experimental sows andprepare for the operation.Preoperative give depth anesthesia，monitoring ECG and bloodoxygen,Performer respectively from the stomach,vaginal and bowel into abdomen,carry out Exploration to protocol viscera,take the biopsy and pictures.Immediately anatomy afterabdominal exploration, take pictures of organs.
Results： Experimental animals after fasting and drug treatment make thegastrointestinal tract emptying well.In protocol position successfully completed creates road,not occurred bleeding.Different road into the celiac in time-consuming and operationdifficulty appear difference.The way of rectum and vaginal relatively easy operation,time-consuming shortest;The way of stomach operation difficulty,time-consuminglongest.Postoperative laparotomy observation not found visceral injury around the road.Ittook about10minutes established pneumoperitoneum,can meet meet the need to explorationvision.The way of stomach make well exploration in lower abdominal viscera such asbladder, ovarian,oviduct.Overturn lens can observed part of the liver,gallbladder,spleen,stomach,and the diaphragmatic.The way of bowel and transvaginal observation almostunanimously range.Observation results are ideal in upper abdominal viscera as to the liver,gallbladder and spleen, stomach, the diaphragmatic,but detection of liver diaphragmatic faceoperation seem difficult.For lower abdominal viscera need to overturn lens, detection onlypart of the bladder, ovarian, fallopian tube.All of the road can not exploration retroperitonealorgans such as kidney, pancreas, ureteral.For large large intestine, small intestine, omental,the parietal peritoneum no obvious difference,all visible.All organs can perform targetedbiopsy successfully, but the same viscera in different approaches biopsy appera differentdifficulty.
Conclusion：NOTES in the abdominal exploration and targeted biopsy have show itsbig advantages and potential,different way into abdomen can make different observationrange,we should select suitable way according to purpose viscera.
腹腔探查的方式很对，其中开腹探查、腹腔镜探查在技术上已经非常成熟，而应用NOTES技术行腹腔探查则是一种新兴的腹腔探查方式。其在腹腔探查及靶向取活检方面可显示出其独特的优势。本研究在总结前人经验基础上，在现有的技术及条件下利用实验猪模型对NOTES在腹腔探查及定向活检方面的可行性及价值做出评价。
目的：腹腔探查及定向活检是诊断腹部疾病非常有效地一种手段，传统的方式对病人损伤大，费用高，病人难以接受。本研究只在评价NOTES在腹腔探查及取活检中的可行性及应用价值。
方法：对3只雌性家猪依据不同入路分组并做好术前准备。术中给予深度麻醉，监护心电、血氧。术者分别从胃入路、肠入路、阴道入路建立切口，进入内镜，对拟定脏器行探查、取活检并留取图片。术后立即解剖，对各个脏器拍照。
结果：实验动物经过禁食及药物处理胃肠道排空情况尚可。在拟定位置顺利完成造口，未发生造口出血。不同入路造口耗费时间及操作难度不同。直肠及阴道入路操作相对容易，造口耗费时间最短；胃入路操作难度大，耗时最长。术后剖腹观察未发现造口周围脏器损伤。气腹建立耗时约10分，完全满足探查视野需要。经胃入路对下腹部脏器如膀胱、卵巢、输卵管观察效果好。翻转镜身时可观察到部分肝脏、胃、胆囊、脾脏及膈肌。经肠及经阴道入路的观察范围几乎一致。对上腹部脏器如肝脏、胆囊、脾脏、胃、膈肌的观察效果理想，可以看见全部，但是探查肝脏的膈肌面操作难度较大。对于下腹部脏器的探查需要翻转镜身，探查仅见部分膀胱，卵巢、输卵管。三种入路对腹膜后脏器肾脏、输尿管、胰腺探查均未成功；对大小肠、大网膜、壁层腹膜探查效果无明显差别，均全部可见。对所见脏器均可顺利进行靶向活检，但同一脏器在不同入路下活检术难度不同。
结论：NOTES在腹腔探查及靶向活检方面具有巨大优势和潜力，不同入路之间对拟定脏器探查范围存在差异，应根据拟探查脏器选择适宜的入路。
Background:The doctors always used abdominal exploration in examination andtreatment abdominal diseases.Many surgeons in the clinical work will occasionally meetunexplained abdominal pain and not sure the diagnosis and suspicious intra-abdominalmass.At present,a lot of the clinical noninvasive inspection,such as the abdominal ultrasoundexamination,CT and MR not good at diagnosis tiny lesions,they Can only found5-10mm indiameter of intra-abdominal mass and the auxiliary examination results can't qualitative,onlya hint role.It is easy to make small lesions misdiagnosis and missed diagnosis,tumors astuberculous peritonitis,the tumor which transfer to peritoneal tumors and these patients oftenmanifestation nonspecific clinical manifestation.Conventional medical examination can'tmake a timely and accurate diagnosis.Especially for ascites patients which can't find thereason.This is not only easy to delay disease diagnosis, but also aggravate the patienteconomic burden.In this situation,abdominal exploration is seen as a very effective andimportant way to help doctors make clear diagnosis.
There are many ways of abdominal exploration,in those ways of exploratorylaparotomy,laparoscopic abdominal exploration in the technology has been very mature.Butusing NOTES in abdominal exploration is a new and developing way.Showing its uniqueadvantage in the abdominal cavity detection and targeted biopsy.The study in this articlebased on Predecessors' experience,in the existing technology and conditions utilization of thepig model to make evaluation of the feasibility and directional biopsy value use NOTES inabdominal exploration.
Objective:Abdominal exploration and targeted biopsy is a very effectively method intargeted biopsy abdominal disease diagnosis,the traditional way of abdominal explorationhave too many defects,such as too much damage, high costs, so the patient unable tobear.This study purpose is evaluation the feasibility and biopsy application value withNOTES.
Method:According to the different way random numbers of three experimental sows andprepare for the operation.Preoperative give depth anesthesia，monitoring ECG and bloodoxygen,Performer respectively from the stomach,vaginal and bowel into abdomen,carry out Exploration to protocol viscera,take the biopsy and pictures.Immediately anatomy afterabdominal exploration, take pictures of organs.
Results： Experimental animals after fasting and drug treatment make thegastrointestinal tract emptying well.In protocol position successfully completed creates road,not occurred bleeding.Different road into the celiac in time-consuming and operationdifficulty appear difference.The way of rectum and vaginal relatively easy operation,time-consuming shortest;The way of stomach operation difficulty,time-consuminglongest.Postoperative laparotomy observation not found visceral injury around the road.Ittook about10minutes established pneumoperitoneum,can meet meet the need to explorationvision.The way of stomach make well exploration in lower abdominal viscera such asbladder, ovarian,oviduct.Overturn lens can observed part of the liver,gallbladder,spleen,stomach,and the diaphragmatic.The way of bowel and transvaginal observation almostunanimously range.Observation results are ideal in upper abdominal viscera as to the liver,gallbladder and spleen, stomach, the diaphragmatic,but detection of liver diaphragmatic faceoperation seem difficult.For lower abdominal viscera need to overturn lens, detection onlypart of the bladder, ovarian, fallopian tube.All of the road can not exploration retroperitonealorgans such as kidney, pancreas, ureteral.For large large intestine, small intestine, omental,the parietal peritoneum no obvious difference,all visible.All organs can perform targetedbiopsy successfully, but the same viscera in different approaches biopsy appera differentdifficulty.
Conclusion：NOTES in the abdominal exploration and targeted biopsy have show itsbig advantages and potential,different way into abdomen can make different observationrange,we should select suitable way according to purpose viscera.
引文
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