【作者】 张建涛；

【导师】 王洪斌；

【作者基本信息】 东北农业大学 ， 临床兽医学， 2010， 博士

【摘要】 微创外科是21世纪外科发展方向之一,腹腔镜外科是微创外科重要组成部分,具有微创、视野清晰、出血少、疼痛反应轻、术后机体恢复快和组织粘连少等优点,使腹腔镜外科技术在人的泌尿外科得到了迅速的发展。到目前为止,腹腔镜外科手术技术在小动物泌尿外科领域的应用尚少,目前仅见于犬腹腔镜辅助膀胱固定术、犬腹腔镜辅助膀胱镜膀胱息肉切除、犬腹腔镜膀胱结石的取出以及肾上腺切除术。因此,本课题拟设计并完成犬腹腔镜膀胱造口术、犬腹腔镜辅助输尿管切开术、犬腹腔镜肾脏切除术,改进犬腹腔镜肾上腺切除术,并从手术对犬生理机能的影响来全面、客观评价手术效果,同时进一步深入研究腹腔镜手术和开腹手术对犬氧化应激和免疫系统的影响。本实验选用30条健康杂种犬为实验动物,随机平均分为5组,进行实验。通过气腹、手术通路建立、腹腔镜下器官分离、血管封闭、缝合固定、腹腔冲洗和标本取出以及闭合腹腔等操作步骤进行犬腹腔镜膀胱造口术、犬腹腔镜辅助输尿管切开术、犬腹腔镜肾上腺切除术和犬腹腔镜肾脏切除术四种泌尿外科手术。在整个手术过程中,监测犬的临床体征、心率、体温、收缩压、舒张压、平均动脉压、呼吸频率、呼吸末二氧化碳分压。记录术中和术后并发症,以及术后犬的恢复情况。并于术前、术后抽取前肢静脉血检测白细胞总数、中性粒细胞比率、天门冬氨酸氨基转移酶、丙氨酸氨基转移酶、碱性磷酸酶、尿素氮、尿酸及肌酐。完成犬腹腔镜和开腹肾脏切除术,于术前、术后抽取前肢静脉血检测丙二醛、超氧化物歧化酶、谷胱甘肽过氧化物酶、CD4+和CD8+淋巴细胞亚群。本课题成功的完成了犬腹腔镜膀胱造口术、犬腹腔镜辅助输尿管切开术、犬腹腔镜肾上腺切除术和犬腹腔镜肾脏切除术四种泌尿系统腹腔镜手术,所有犬全部存活,术中和术后没有发生较大的并发症。术中有一条犬穿刺气腹针时损伤到脾脏、2条犬发生皮下气肿和1条犬套管穿刺损伤腹壁血管。术后犬疼痛反应轻,饮食欲在1～2d基本恢复,术后7天拆线,只有一条犬套管口感染,其余均取得一期愈合。说明仅从腹腔镜手术技术方面来说,腹腔镜外科手术技术能够应用于犬的泌尿外科手术。犬腹腔镜膀胱造口术、犬腹腔镜辅助输尿管切开术、犬腹腔镜肾脏切除术和犬腹腔镜肾上腺切除术四种泌尿系统腹腔镜手术对机体的临床体征、循环系统和呼吸系统都有不同程度的抑制作用。在手术过程中,个别犬出现眼睑反射消失,但角膜反射始终存在。个别手术操作中疼痛反射明显或迟钝,大部分手术操作中疼痛反射消失。心率、体温、血压、呼吸频率下降,呼吸末二氧化碳分压升高。其中特别是对体温影响较大,在术后即刻下降了3℃多,术后4h还没有恢复到正常水平,术后1d才恢复到术前水平。四种犬泌尿系统腹腔镜手术对机体的炎性应激和肾功能影响不大,很快恢复。但是对肝功能有一定的影响,表现为天门冬氨酸氨基转移酶和丙氨酸氨基转移酶变化较为明显,在术后3d还与术前相比差异显著,但是在术后5d时就基本恢复。说明腹腔镜手术对动物机体的生理功能影响轻微,所有犬都能正常耐受,并且很快恢复到正常水平。腹腔镜和开腹肾脏切除术都使丙二醛升高,超氧化物歧化酶和谷胱甘肽过氧化物降低,但是腹腔镜组影响较为迅速,在术后4h与术前差异极显著(P<0.01),在术后1d就恢复到术前水平。开腹组在术后1d才与术前差异显著(0.01<P<0.05),术后2d也未能恢复到术前水平。说明腹腔镜和开腹肾脏切除术术后都能造成犬氧化应激反应,与开腹肾脏切除术相比,腹腔镜肾脏切除术迅速引起犬的氧化应激反应,但是恢复的时间也比开腹肾脏切除术迅速,从而证明了腹腔镜手术术后机体恢复快。腹腔镜组肾脏切除术CD4+淋巴细胞亚群在术后1d较术前下降显著(0.01<P<0.05),虽然CD8+淋巴细胞亚群和CD4+/CD8+也下降,但是在各个时间点与术前差异均不显著(P>0.05)。但是开腹组肾脏切除术却不同,开腹组CD4+淋巴细胞亚群、CD4+/CD8+在术后1d较术前下降极显著(P<0.01)。两组之间在术后1d差异显著(0.01<P<0.05)。说明腹腔镜和开腹肾脏手术术后都会使CD4+/CD8+降低,这种降低可很快恢复,并且与开腹肾脏切除术相比,腹腔镜肾脏手术使CD4+/CD8+降低更少,持续时间更短。更多还原

【Abstract】 Minimally invasive surgery is one of the development directions in the 21st century. Laparoscopic surgery is an important component of minimally invasive surgery. The advantages of the laparoscopic surgery is minimally invasive, excellent visualization, less bleeding, less pain, faster recovery and less tissue adhesion. Laparoscopic surgery has been a rapid development in urinary surgery in human medicine, but a slow development in urinary surgery in small animal. Now, Laparoscopic assisted cystopexy, resection of inflammatory polyps using laparoscopic-assisted cystoscopy, Laparoscopic cystotomy for urolith removal and laparoscopic unilateral adrenalectomy. Therefore, the purpose of this study to design and perform laparoscopic cystostomy, laparoscopic assisted ureterotomy, laparoscopic nephrectomy, and improve laparoscopic adrenalectomy. The surgical effects were evaluated comprehensively and objectively by the influence of operation on physiological function of dogs. And further study of the influence of laparoscopic and open surgery on oxidative stress and immune systems in dogs.30 healthy mixed dogs were used as experimental animals. These dogs were divided into two groups randomly, 6 in each group. Laparoscopic cystostomy, laparoscopic assisted ureterotomy, laparoscopic nephrectomy, and laparoscopic adrenalectomy were performed by the procedures of pneumoperitoneum, establishment of surgical approaches, dissecting of organ under laparoscope, vascular closure, suture fixation, irrigation of the abdominal cavity, retrieval of the hepatic specimen and closure of the abdominal cavity. Clinical signs, heart rate, body temperature, systolic blood pressure, diastolic blood pressure, mean arterial pressure, respiratory rate and end-tidal partial pressure of carbon dioxide were monitored during operation. Intraoperative and postoperative complications and recovery were recorded. Peripheral blood samples were obtained before surgery and after surgery for white blood cell and neutrocyte, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, creatinine, blood urea nitraogen.Laparoscopic and open nephrectomy was performed in dogs. Peripheral blood samples were obtained before surgery and after surgery for maleic dialdehyde, superoxide dismutase and glutathione peroxidase, CD4+, and CD8+ lymphocyte subsetsLaparoscopic cystostomy, laparoscopic assisted ureterotomy, laparoscopic adrenalectomy and laparoscopic nephrectomy were accomplished successfully in dogs without major intraoperative and postoperative complications. All dogs were alive. The spleen injury during pneumoperitoneum with a Veress in a dog, subcutaneous emphysema in two dogs and abdominal vascular injury during puncture with trocar/cannula in a dog were observed. Pain was mild after operation. Appetite was recovered within 1-2 day. Stitch removal was at day 7 after the operation. Infection of incision of cannula was observed in a dog. Others had primary healing. They showed: only from the aspects of laparoscopic surgical technique, the laparoscopic surgical technique could be applied to urinary surgery of dogs.Laparoscopic cystostomy, laparoscopic assisted ureterotomy, laparoscopic nephrectomy, and laparoscopic adrenalectomy on clinical signs, respiratory and circulatory system have different degrees of inhibition. The eyelid reflex disappeared in certain dog. But there had been corneal reflex all time. Pain reflex was significant or dull during certain procedure. Pain reflex disappeared during most of procedures. Heart rate, body temperature, blood pressure and respiratory rate decreased, and end-tidal partial pressure of carbon dioxide increased. Especially, the change of the body temperature was higher. Body temperature was decreased immediately after surgery more than 3℃. It did not return to normal levels at 4 hours postoperatively, and return to preoperative levels on 1 day postoperatively. The four laparoscopic surgeries had a little effect on inflammatory stress and renal function. The dogs were rapid recovery. But there was a certain impact on liver function. The aspartate aminotransferase and alanine aminotransferase had a significant change. Compared with before surgery, there were statistically significant differences on 3 days postoperatively. They were recovery on 5 day postoperatively. They showed: Laparoscopic surgery had a slight effect on physiological functions. All dogs could be normal tolerance, and soon returned to normal levels.Laparoscopic and open nephrectomy made maleic dialdehyde decrease, and superoxide dismutase and glutathione peroxidase increase. But laparoscopic group was more rapidly. Compared with before surgery, there were statistically significant differences at 4 hour postoperatively (P<0.01). It was recovery on 1 day postoperatively. Compared with before surgery, there were statistically significant differences on 2 day postoperatively (0.01<P<0.05). It was recovery on 1 day postoperatively, and did not return to normal levels in open group on 2 day postoperatively. They showed: laparoscopic and open nephrectomy could result in oxidative stress in dogs. Compared with open nephrectomy, laparoscopic nephrectomy led to rapid oxidative stress response and rapid recovery, which proved the body had rapid recovery after laparoscopic surgery.Compared with before surgery, CD4+ Lymphocyte subsets decreased significantly at 1 day postoperatively in laparoscopic nephrectomy group (0.01<P<0.05). Thought CD8+ Lymphocyte subsets and CD4+/CD8+ also decreased, compared with before surgery, there was no significant difference at all time (P>0.05). CD4+ Lymphocyte subsets and CD4+/CD8+ decreased significantly (0.01 < P < 0.05). There were statistically significant differences between laparoscopic nephrectomy and open nephrectomy group at 1 day postoperatively (0.01<P<0.05). They showed: the immunity of dogs could be inhibited after laparoscopic and open nephrectomy. The immunosuppressive could be recovery soon. Compared with open nephrectomy, there was a lighter immunosuppressive and shorter duration.更多还原