馬的腹腔鏡與胸腔鏡手術(shù)的器械與技術(shù)

1、馬的腹腔鏡與胸腔鏡手術(shù)的器械與技術(shù)腹腔鏡和胸腔鏡是類似于關(guān)節(jié)鏡的內(nèi)鏡外科技術(shù)，區(qū)別是分別在腹部和胸部腔進(jìn)行。對于本討論的剩余部分中，腹腔鏡和胸腔鏡均用術(shù)語腹腔鏡來描述。一般來說，這些技術(shù)包括使用一個剛性纖維的鏡頭耦合到一個光源上，用于查看手術(shù)操作和使用的專門儀器。腔鏡外科技術(shù)是基于三角測量的原理，其中，所述內(nèi)鏡和儀器像一個三角形的頂點(diǎn)匯集到手術(shù)部位。 腹腔鏡手術(shù)技術(shù)的發(fā)展促進(jìn)了許多人醫(yī)手術(shù)的發(fā)展，相比開放性手術(shù)，腹腔鏡手術(shù)使機(jī)體恢復(fù)到健康更快速一些。在人類的外科手術(shù)中，腹腔鏡手術(shù)的例子包括膽囊切除，闌尾切除術(shù)，卵巢子宮切除術(shù)，疝修補(bǔ)術(shù)，腸道手術(shù)，一般探查，修復(fù)食管賁門失弛緩癥，和肺活檢。馬的腹

2、腔鏡有著與之相似的好處，在空腹探查中擁有一個更好的視野，和更短的恢復(fù)時間。腹腔鏡在馬已經(jīng)被用來進(jìn)行站立和臥位的卵巢切除術(shù)，腹股溝疝修補(bǔ)，修補(bǔ)破裂的膀胱，站立和橫臥腹部探索，活組織切片檢查，以及胚胎移植。站立腹腔鏡手術(shù)融合了更快恢復(fù)組織功能的優(yōu)點(diǎn)以及不需要考慮與全身麻醉相關(guān)的風(fēng)險(xiǎn)的優(yōu)勢。一般而言，腹腔鏡手術(shù)的好處很多，其中包括：是相對無創(chuàng)的（部分原因是切口較?。?；操作更快速（在掌握了必要的操作技術(shù)之后）；并且恢復(fù)更快。缺點(diǎn)包括必要器械的量和花費(fèi)較高以及對操作步驟和技術(shù)水平要求較高。腹腔鏡手術(shù)的局限性需要被解決。但是大多數(shù)的缺陷都也已通過提升手術(shù)技術(shù)來彌補(bǔ)。首先，視頻圖像是二維的（即沒有深度）并且

3、攝像頭通常由一位助手控制。體壁和腹腔鏡端口充當(dāng)支點(diǎn)。應(yīng)防止手術(shù)器械的自由活動。由于器械臂更長時，外科醫(yī)生與術(shù)部進(jìn)一步遠(yuǎn)離并且支點(diǎn)效應(yīng)被放大。器械的這種特點(diǎn)限制了觸感的準(zhǔn)確性以及難以對力的大小有一個快速的反饋。而技術(shù)例如縫合需要大量的訓(xùn)練才能熟練掌握。為了克服某些限制。很多公司提供“幻影”以提高儀器操作和縫合線捆扎的技巧，并用一個兩三維外科手術(shù)三維顯示器連接。其他公司提供的三維空間觀看環(huán)境與特殊相機(jī)，眼鏡，和顯示器連接成像。設(shè)備與器械腹腔鏡器械存在許多不同的制造商。不同的廠家可能只提供一些必要的部件，或者能夠?yàn)橥饪漆t(yī)生提供了一個完整的系統(tǒng)。為了讀者的便利，一些主要制造商的地址都列在表格1。下面討

4、論并列出一些可用于腹腔鏡手術(shù)的器械，包括腹腔鏡，冷光源，攝像系統(tǒng)，氣腹針，套管針，插管，和常用的儀器儀表。腹腔鏡有各種型號大小的。最常用的內(nèi)窺鏡直徑是5到10mm，剛性范圍在30到60之間。雖然在使用的柔性內(nèi)窺鏡的介紹中已經(jīng)描述。范圍大的優(yōu)勢是，能夠給術(shù)者在腔的檢查中提供更大的視野。但如果要檢查的結(jié)構(gòu)是靠近插管點(diǎn)附近，這也可能使得操作更難。大多數(shù)的內(nèi)鏡角度是在0和30度之間（圖1B），0度范圍在馬最為常用。大多數(shù)內(nèi)鏡有兩個通道，一個與光學(xué)鏡片相連，另一個連接到光源以照亮被檢查的體腔。手術(shù)用腹腔鏡還有第三個通道用于手術(shù)器械的通過。這個附加的通道排除了需要為儀器提供單獨(dú)的門戶。光源是腹腔鏡儀器的另

5、一個組成部分（圖2）。光源是負(fù)責(zé)體腔內(nèi)的照明。它經(jīng)由柔性光纖光連接到內(nèi)鏡。雖然150W光源對于直接的照明已經(jīng)足夠了，但攝像機(jī)與之一起使用時它只能照亮成年馬的腹部或胸部的一小部分.由我們的經(jīng)驗(yàn)來說，300W的氙光源能提供更好的照明。視頻攝像機(jī)（圖3）能將手術(shù)區(qū)域投影到監(jiān)視器。雖然這對于執(zhí)行手術(shù)并不是必須的，但它們的存在使得外科醫(yī)生可以遠(yuǎn)程監(jiān)控，并使助理得以查看進(jìn)程。它的應(yīng)用在腹腔鏡手術(shù)中比關(guān)節(jié)鏡更重要，因?yàn)橥饪漆t(yī)生可同時使用兩個或更多器械，要求助理持有儀器，內(nèi)鏡中的一個或兩者兼而有之。使用視頻攝像機(jī)的另一個主要好處是消除外科手術(shù)部位的污染的機(jī)會。利用攝像機(jī)能夠允許外科醫(yī)生記錄任一操作錄像帶或拷貝

6、照片，這可能是在法醫(yī)學(xué)上是一個重要的證據(jù)。我們還發(fā)現(xiàn)，客戶端應(yīng)用不僅能接收手術(shù)照片還能觀看錄象帶。幾乎任何類型的錄像機(jī)可以連接到視頻攝像機(jī)，雖然有些攝像機(jī)當(dāng)附連到一個特定的視頻記錄器會有特殊功能。這些功能包括：通過遙控器上的開關(guān)按鈕來打開錄音機(jī)或關(guān)閉相機(jī)。代替這一功能，錄像機(jī)遙控器的功能被放置在一個滅菌的拉鏈鎖袋中供外科醫(yī)生使用。多種彩色影像打印機(jī)可連接到攝像機(jī)，以便于外科醫(yī)生對部分圖像的彩印。其次，一些相機(jī)與影像打印機(jī)連接之后能提供遠(yuǎn)程傳送影像的功能。但如果相機(jī)沒有提供這種類型的連接，遠(yuǎn)程的影像打印機(jī)可放置在消毒拉鏈鎖袋中供外科醫(yī)生使用。當(dāng)使用視頻攝像機(jī)時，視頻監(jiān)視器是必要存在的。視頻監(jiān)視器

7、有多種型號。氣腹系統(tǒng)。通過使用二氧化碳來使腹腔膨脹，二氧化碳相比室內(nèi)空氣，氧氣和一氧化二氮更好一些因?yàn)槎趸季哂懈哐苄?，和肺飽和度，其次，因?yàn)樗鄬τ跉怏w栓子來說，有一個更廣泛的安全性。但是，碳?xì)飧箍梢鹁植亢腿聿涣加绊懭鐨怏w栓塞，高碳酸血癥，酸中毒，心律失常。維持15毫米汞柱腹內(nèi)壓力能降低碳?xì)飧沟母弊饔?。腹部鼓起，提供了一個做手術(shù)的操作空間。如果沒有這個空間，任何可視化進(jìn)程都比較困難，手術(shù)操作甚至更加困難。提供這個空間的最可靠方法是吹入二氧化碳來擴(kuò)張腹部空間（圖4）。制造氣腹有多種方式并具有不同的規(guī)格，例如流量和壓力的速率傳感器。有一種方式是是一開始以1升/分鐘的速率吹入氣體，并預(yù)設(shè)壓

8、力閥限制吹入氣體的多少。較新的模式有多種充氣速度范圍從1升/分鐘到10L /分鐘或者更大。大多數(shù)新型號的是電子控制的，并允許外科醫(yī)生自己設(shè)定最大腹內(nèi)壓力水平。氣體的吹入是通過最初連接到所述體腔的管道以及一個氣腹針，套管針或?qū)Ч埽▓D5）。胸廓的非手術(shù)側(cè)的選擇性插管也增加了視野。儀器推車，將必要的設(shè)備納入其中對手術(shù)操作是非常有幫助的（圖6）。套管是用來將儀器放置入體腔的.用于腹腔鏡的套管有可重復(fù)使用的（圖7）或一次性的（圖8）并且由一個5至33毫米直徑的管連接到一橡膠套環(huán)，墊圈，和/或一個閥。中空護(hù)套讓腹腔鏡的儀器和工具進(jìn)入體腔。橡膠套環(huán)，墊圈，和閥允許引入和拆除儀器而不破壞含二氧化碳的所需的氣腹

9、。大部分插管包含側(cè)端口為了補(bǔ)充二氧化碳或持續(xù)吹入腹部。套管針是插管系統(tǒng)的一個組成部分，可以是鋒利的或鈍的（圖9）。鋒利的套管針在制造氣腹后，可以防護(hù)或者不做防護(hù)，因?yàn)橹圃鞖飧购竽c或其他器官被套管針穿孔的風(fēng)險(xiǎn)降低。大多數(shù)一次性套管針都得防護(hù)，以保證套管針進(jìn)入腹部的安全性. 該套管針的防護(hù)組件通常是一個塑料護(hù)套，在軟組織被推出，露出鋒利的金屬套針。一旦整個套管針已經(jīng)侵入機(jī)體墻，塑料護(hù)扣回過尖銳的金屬套管針。通常還存在著鎖定裝置，使得一旦防護(hù)組件被推回，這時鎖定裝置啟動，以覆蓋尖銳套管針，其鎖定到位并保護(hù)與它接觸接近的任何結(jié)構(gòu)。這些特性使得使用一次性套管針的非常有吸引力，但套管針的成本往往超過了收益

10、。因此大多數(shù)可重復(fù)利用的套管針是沒有防護(hù)組件的。鈍套管針主要被用于開放式腹腔鏡.這意味著要制造一個非常小的剖腹切口，然后投入到體腔內(nèi)探索，并通過使用鈍套管針的插管被放置到空腔。這種方法的好處是，穿孔深層結(jié)構(gòu)的可能性極小，但這種方法的缺點(diǎn)是，如果切口是太大，造氣腹的二氧化碳可能會通過插管四處溢出體腔外。在大多數(shù)情況下，鈍套管針用于進(jìn)入在臍周的腹部或肋間周圍的胸腔。一次性套管系統(tǒng)（optiview，Ethicon EndoSurgery，Cincinnati，0H or Visiport United States Surgical C orporation，Norwalk，CT）使得進(jìn)入腹部的直

11、接可視化。插管由切割裝置和裝在其頭部的一個光學(xué)透鏡組成，它使得外科醫(yī)生對術(shù)部可視，通過鏡頭，來進(jìn)行每個組織層的剝離。柔性插管也可用于腹腔鏡。某些套管是固定的，通過環(huán)將套管與皮膚縫合在一起，另一種是構(gòu)成穩(wěn)定螺紋，使得所述套管實(shí)際上是“擰”進(jìn)入體壁。這兩種系統(tǒng)用于保證操縱鏡頭或儀器時，所述套管不會被拉出的體壁。在一般情況下，15至20厘米插管是常用于的側(cè)面的手術(shù)，而10厘米插管對于腹腔或胸腔已是足夠長了。最常用的插管的尺寸為5至12毫米直徑。大插管通常用于自動縫合裝置和用于從體腔中取出組織（參見圖8）?？捎糜诟骨荤R的器械有許多不同之處相較普通外科手術(shù)的器械而言。大多數(shù)情況下，常用外科手術(shù)器械通過減

12、少儀器爪的大小和在儀器上放置長尺寸軸來適應(yīng)手術(shù)。最常見的手柄類型是環(huán)手柄，它類似于持針器的手柄。這種手柄也可用于一些其他的器械例如持針器。一些更常用的儀器包括剪刀，止血，抓鉗，解剖鑷子，牽拉器，和持針器（圖10）。自動和手動裝訂設(shè)備都是可用的，但成本在平均馬手術(shù)病例中可能偏高。大部分儀器的軸都是有5毫米直徑和10毫米直徑兩種型號，長度在約30到45厘米之間。有些儀器有單極電凝適配器，專用儀器可用于雙極電凝。（圖11）專門用于腹腔鏡的縫合材料也被運(yùn)用。特殊縫合針連著常見的縫合材料通過套管進(jìn)入腹腔也被研究出來。因?yàn)樵隗w內(nèi)（體腔內(nèi)）結(jié)扎打結(jié)是非常困難的，縫合公司開發(fā)了預(yù)打結(jié)的繞圈。該結(jié)扎材料被放置并

13、通過一個直徑5毫米的塑料護(hù)套，這有助于其作為一個結(jié)推進(jìn)器引入結(jié)扎到體腔內(nèi)（圖13）。對于更長的線縫合，各種縫線夾被設(shè)計(jì)出來。這些夾子通常連接到縫合線的末端，以防止線從組織滑出。各種裝訂設(shè)備也已經(jīng)被設(shè)計(jì)用于幫助解決關(guān)閉切口的問題。這些設(shè)備包括用于任一切口閉合或止血的單發(fā)（裝訂）的可重復(fù)使用的儀器，以及用于同樣目的的一次性多發(fā)（裝訂）儀器。類似于普通外科用腸切除吻合術(shù)，肺切除術(shù)等手術(shù)的切口閉合，一次性吻合裝置也可提供。附錄1表1 圖1 圖2 圖3 圖4 圖5 圖6 圖7 圖8 圖9 圖10A 圖10B 圖11 圖13附錄2 INSTRUMENTATION AND TECHNIQUES FOR LA

14、PAROSCOPIC AND THORACOSCOPIC SURGERY IN THE HORSELaparoscopy and thoracoscopy are endoscopic surgical techniques similar to arthroscop，but performed in the abdominal and thoracic cavities，respectivelyFor the remainder of this discussion，the term laparoscopy is used interchangeably for both laparosco

15、py and thoracoscopyGenerally these techniques involve the use of a rigid fiberoptic telescope conpled to a light source for Viewing and specialized instruments for surgical manipulationSurgical technioque is based on the principle of triangulation，wherein tne telescope and lnstrument convergeontothe

16、 surgical site like the apex of atriang.Advances in laparoscopic surgery have 1ed to the development of many surgical tecniques in humans that in general allow a faster return to normal activities than do the standard open approachesIn human surgery，examples of laparoscopic surgey include ga11 bladd

17、er exclsion，appendectomy，ovariohysterectomy,hernia repair，intestinal surgery，general exploration，repair of esophageal achalasia，and lung biopsiesLaproscopy in horses promises similar benefits by allowing better visualization of the cavity under exploration coupled with a shorter convalescent timeLap

18、aroscopy in the horse has been used to perform standing and recumbent cryptorchidectqmies,standing and recumbent ovariectomies，inguinal hernia repair,repair of ruptured bladders,standing and recumbent abdomimal exploration.biopsies,and standing embryo transfer.Standing laoaroscopy combines the advan

19、tage of a more rapid return to function with the advantage of not requiring general anesthesia with its associated risks. In general，the benefits of laparoscopic surgery are many and include being relatively noninvasive(due in part to the small incisions)Being quick to perform(once the necessary tec

20、hnical skills are learned)，and allowing rapid return to functionDisadvantages include theamount and expense of necessary instrumentation and the skill level needed to perform the procedures wellThe limitations of laparoscopic surgery should be addressedMost of these limitations can be overcome by in

21、creasing surgeon skill leve1To begin with，the video image is two-dimensional(that is，without depth)，and the camera is often directed by an assistant.The body wall and laparoscopic port act as a fulcrumstopping free movement of the lnstrumentAS the instruments become longer,the surgeon is further awa

22、y from the object of interest and thefulcrum effect is magnifiedThe instruments restrict sense of touch and do not allow accurate feedback on the amount of force being：appliedskill such as intracorporeal(within the body cavity)suturing require considerable practice to masterTo overcome some of these

23、 limitationsmany companies provide，"phantoms”to improve skills in instrument handling,suture tying，and threedimensional surgery using a two-dimensional monitorOther companies provide a threedimensional viewing environment with the use of special cameras，glasses，and monitors.InstrumentationMany

24、different manufacturers of laparoscopic instrumentation existthe various manufacturers may supply onlya few of the necessary components，or may be able to provide the surgeon with a complete systerm .The addresses of some of the major mandfacturers are listed infor the readers convenienceThe followin

25、g discussion outlines some of the instrumentation available for laparoscopicsurgery,including telescopes,light sources, videocamera, insufflator,t rochars, cannulas, and commonly used instrument.telescopes for laparoscopy come in a variety of sizesThe most commonly used telescope is a 5 to 10 mm in

26、diameter rigid scope that is between 30 and 60 long(Fig.1A),although the use of a flexible endoscope has been described.the longer scopes have the advantage of allowing the operator to view a greater portion of the cavity under examination because of the reach of the telescope，but may be more awkwar

27、d to use if the structure of interest is close to the cannula sitethe viewing angle for most telescopes is between 0 and 30 degrees(Fig.1B)with the 0-degree scope being most commonly used in horses.many telescopes have two channels，one for optical lenses and the other toconnect to the light source t

28、o illuminate the body cavity being examined.Operating telescopes have a third channel for the introduction of instruments.This extra channel may preclude the need for a separate instrument portal.although specialized instruments that fit through the channel are required. the light source is an integ

29、ral portion of the laparoscopy instrumentation(Fig,2).the light source is responsible for illumination of the body cavity .It is connected to the telescope via a flexible fiberoptic light.Although a 150一W light source may be adequate for direct viewing，when used with a video camera it illuminates on

30、ly a small portion of the abdomen or thorax in an adult horseIn our experience,a 300一W xenon light source provides much better illumination.Video cameras(Fig3)allow projection of the surgical field onto aI monitorAlthough not necessary to perform surgery，they allow the surgeon to keep a distance fro

31、m the operating field and allow assistant to view the procedureThis is more important in laparoscopy than arthroscopy because the surgeon may be using two or more instrument at the same time，requiring an assistant to hold either an instrument,the telescope，or bothThe other main benefit of using a vi

32、deo camera is reducing the chance of contamination of the surgical siteUse Of a video camera allows the surgeon to record the operation on either Video tape or nard copy photographs，which may be important for medicolegal reasons.We have also found that clients apporeciate either receving a photograp

33、h 0f the surgery or having the opportunity to view the video tapeAlmost any type of video recorder can be attached to the video calhera，although some video cameras permit special features when attached to a specific video recorderThese features include a remote on-off button that allows you to turn

34、the recorder on or off fromthe camera1n lieu of this feature，the video recorder remote control can be placed in a sterilized Ziplock bag to be used by the surgeonVarious color video printers are available that can be connected to the video camera to allow color prints of various portions of the surg

35、eonOnceagain,some cameras offer remote capabilities when attached to the video printer.If the camera does not provide this type of connection the remote for the video printer can be placed in a sterilized Ziplock bag for use by the SUrgeonWheD using a video camera，a video monitoris a necessityMonito

36、rs are available in various sizesdistension of the abdomen or pneumoperitoneum is generally achieved by use of carbon dioxide(CO2).Carbon dioxide is perferred over room air,oxygen,and nitrous oxide because it is preferred highly blood soluble,and expired in the lungs and because it has a wider margi

37、n of safety with respect to gas emboli.However，the carbondioxide pneumoperitoneum can cause adverse local and systemic effects such as gas embolism，hypercapnia，acidosis，or arrhythmiaMaintaining an intra-abdomina1 pressure of 15 mm Hg decreases the unwanted side effectsThe abdomen is distended to all

38、ow a working space within in which to do surgical manipulationsWithout this space，visualizing virtually anything isdifficult，and performing surgery is even more difficultThe most reliable way to achieve this distension is with a carbon dioxide insuffla tor(Fig4)Insufflators come in various style and

39、 have different specifications such as rate of flow and pressure sensorsSome early insufflators had a rate of flow of 1 Lmin and had preset pressure valves to Iimit insufflationNewer modeIs have variable rate of flow from 1 Lmin up to 10 Lmin or more.Most of the newer models are electronic and allow

40、 the surgeon to set the mximal intraabdominal pressure levelInsufflation is generally not required during thoracoscopy because of the rigid thoracic wallSelective intubation of the nonsurgical side of the!horax also increases the field of viewEquipment carts that allow the incorporation of the neces

41、sary equipment can be very helpful(Fig6) A cannula is used to place instruments into the body cavity.The cannulas that are used for laparoscopy may be either reusable(Fig.7) or disposable(Fig.8) and consist of a5一to 33一mm diameter tube connected to a rubber collar，a gasket，and/or a valve.The hollow

42、sheaths allow instruments of the telescope and instruments into the body cavityThe rubber collars，gaskets，and valves permit introduction and removal of instruments without loss of carbon dioxide and，therefor，the desired pneumoperitoneumMost cannulas contain a side port for the introduction of carbon

43、 dioxide for continued insufflation of the abdomenTrochars are an integfal component of the cannula system and may be either sharp or blunt(Fig9)Sharp trochars may be either guarded or unguarded and are primarily used after insufflation has been achieved and risk of perforation of the intestine or o

44、ther organs is reducedThe majority of disposable trochars are guarded，making entry into the abdomen saferThe guarded component of the trochar iS usuallya plastic sheath that iS pushed back by the soft tissues to reveal the sharp metal trocharOnce the entire trochar has penetrated the body wall，the p

45、lastic guard snaps back over the sharp metal trocharA locking device is usually present SO that once the guard has been pushedback and then allowed to cover the sharp trochar，it 10cks in place and protects any further structures that it comes in contact withThese features make the use of disposable

46、trochars very attractive，but the cost of the trochars often outweighs the benefitsThe majority of reusabletrochars are unguarded.Blunt trochars are primarily used for what is termed open laparoscopyThis means that a very small laparotomy incision is made into the body cavity under exploration，and th

47、e cannula is placed into the cavity by use of a blunt trocharThe benefit of this approach is that perforation of deeper structures iS very unlikelyThe disadvantage of this approach is that if the incision is too largecarbon dioxide escapes from around the cainnulaIn most cases，blunt trochars are use

48、d to enter the abdomen at the umbilicus or the thorax within the intercostal spacesDisposable cannula systems are availabie that allow direct Visualization of the entry into the abdomen(optiview，Ethicon Endo一Surgery，Cincinnati，0H or Visiport United States Surgical C orporation，Norwalk，CT)These cannu

49、las incorporate cutting devices and an optical lens on the end of the trochar that allows the surgeon to visualize，by use of the telescope，dissetion of each tissue layerFlexible cannulas are also available for thoracoscopySome cannulas come with stabilizing；rings to SUture the cannula to the skin，wh

50、ereas others come with stabilizing threads such that the cannula is actually“screwed”into the body wallBoth systems are used to keep the cannula from being pulled out of the body wall while manipularing the telescope or the instruments.In general，15-to 20cm cannulas are desirable for flank surgery，whereas 10 cm cannulas are long enough for ventral abdominal or thoracic approaches.The size of the most commonly used cannulas is between 5 and 12 mm in diameter.The large c