马的腹腔镜与胸腔镜手术的器械与技术

1、马的腹腔镜与胸腔镜手术的器械与技术腹腔镜和胸腔镜是类似于关节镜的内镜外科技术，区别是分别在腹部和胸部腔进行。对于本讨论的剩余部分中，腹腔镜和胸腔镜均用术语腹腔镜来描述。一般来说，这些技术包括使用一个刚性纤维的镜头耦合到一个光源上，用于查看手术操作和使用的专门仪器。腔镜外科技术是基于三角测量的原理，其中，所述内镜和仪器像一个三角形的顶点汇集到手术部位。 腹腔镜手术技术的发展促进了许多人医手术的发展，相比开放性手术，腹腔镜手术使机体恢复到健康更快速一些。在人类的外科手术中，腹腔镜手术的例子包括胆囊切除，阑尾切除术，卵巢子宫切除术，疝修补术，肠道手术，一般探查，修复食管贲门失弛缓症，和肺活检。马的腹

2、腔镜有着与之相似的好处，在空腹探查中拥有一个更好的视野，和更短的恢复时间。腹腔镜在马已经被用来进行站立和卧位的卵巢切除术，腹股沟疝修补，修补破裂的膀胱，站立和横卧腹部探索，活组织切片检查，以及胚胎移植。站立腹腔镜手术融合了更快恢复组织功能的优点以及不需要考虑与全身麻醉相关的风险的优势。一般而言，腹腔镜手术的好处很多，其中包括：是相对无创的（部分原因是切口较小）；操作更快速（在掌握了必要的操作技术之后）；并且恢复更快。缺点包括必要器械的量和花费较高以及对操作步骤和技术水平要求较高。腹腔镜手术的局限性需要被解决。但是大多数的缺陷都也已通过提升手术技术来弥补。首先，视频图像是二维的（即没有深度）并且

3、摄像头通常由一位助手控制。体壁和腹腔镜端口充当支点。应防止手术器械的自由活动。由于器械臂更长时，外科医生与术部进一步远离并且支点效应被放大。器械的这种特点限制了触感的准确性以及难以对力的大小有一个快速的反馈。而技术例如缝合需要大量的训练才能熟练掌握。为了克服某些限制。很多公司提供“幻影”以提高仪器操作和缝合线捆扎的技巧，并用一个两三维外科手术三维显示器连接。其他公司提供的三维空间观看环境与特殊相机，眼镜，和显示器连接成像。设备与器械腹腔镜器械存在许多不同的制造商。不同的厂家可能只提供一些必要的部件，或者能够为外科医生提供了一个完整的系统。为了读者的便利，一些主要制造商的地址都列在表格1。下面讨

4、论并列出一些可用于腹腔镜手术的器械，包括腹腔镜，冷光源，摄像系统，气腹针，套管针，插管，和常用的仪器仪表。腹腔镜有各种型号大小的。最常用的内窥镜直径是5到10mm，刚性范围在30到60之间。虽然在使用的柔性内窥镜的介绍中已经描述。范围大的优势是，能够给术者在腔的检查中提供更大的视野。但如果要检查的结构是靠近插管点附近，这也可能使得操作更难。大多数的内镜角度是在0和30度之间（图1B），0度范围在马最为常用。大多数内镜有两个通道，一个与光学镜片相连，另一个连接到光源以照亮被检查的体腔。手术用腹腔镜还有第三个通道用于手术器械的通过。这个附加的通道排除了需要为仪器提供单独的门户。光源是腹腔镜仪器的另

5、一个组成部分（图2）。光源是负责体腔内的照明。它经由柔性光纤光连接到内镜。虽然150W光源对于直接的照明已经足够了，但摄像机与之一起使用时它只能照亮成年马的腹部或胸部的一小部分.由我们的经验来说，300W的氙光源能提供更好的照明。视频摄像机（图3）能将手术区域投影到监视器。虽然这对于执行手术并不是必须的，但它们的存在使得外科医生可以远程监控，并使助理得以查看进程。它的应用在腹腔镜手术中比关节镜更重要，因为外科医生可同时使用两个或更多器械，要求助理持有仪器，内镜中的一个或两者兼而有之。使用视频摄像机的另一个主要好处是消除外科手术部位的污染的机会。利用摄像机能够允许外科医生记录任一操作录像带或拷贝

6、照片，这可能是在法医学上是一个重要的证据。我们还发现，客户端应用不仅能接收手术照片还能观看录象带。几乎任何类型的录像机可以连接到视频摄像机，虽然有些摄像机当附连到一个特定的视频记录器会有特殊功能。这些功能包括：通过遥控器上的开关按钮来打开录音机或关闭相机。代替这一功能，录像机遥控器的功能被放置在一个灭菌的拉链锁袋中供外科医生使用。多种彩色影像打印机可连接到摄像机，以便于外科医生对部分图像的彩印。其次，一些相机与影像打印机连接之后能提供远程传送影像的功能。但如果相机没有提供这种类型的连接，远程的影像打印机可放置在消毒拉链锁袋中供外科医生使用。当使用视频摄像机时，视频监视器是必要存在的。视频监视器

7、有多种型号。气腹系统。通过使用二氧化碳来使腹腔膨胀，二氧化碳相比室内空气，氧气和一氧化二氮更好一些因为二氧化碳具有高血溶性，和肺饱和度，其次，因为它相对于气体栓子来说，有一个更广泛的安全性。但是，碳气腹可引起局部和全身不良影响如气体栓塞，高碳酸血症，酸中毒，心律失常。维持15毫米汞柱腹内压力能降低碳气腹的副作用。腹部鼓起，提供了一个做手术的操作空间。如果没有这个空间，任何可视化进程都比较困难，手术操作甚至更加困难。提供这个空间的最可靠方法是吹入二氧化碳来扩张腹部空间（图4）。制造气腹有多种方式并具有不同的规格，例如流量和压力的速率传感器。有一种方式是是一开始以1升/分钟的速率吹入气体，并预设压

8、力阀限制吹入气体的多少。较新的模式有多种充气速度范围从1升/分钟到10L /分钟或者更大。大多数新型号的是电子控制的，并允许外科医生自己设定最大腹内压力水平。气体的吹入是通过最初连接到所述体腔的管道以及一个气腹针，套管针或导管（图5）。胸廓的非手术侧的选择性插管也增加了视野。仪器推车，将必要的设备纳入其中对手术操作是非常有帮助的（图6）。套管是用来将仪器放置入体腔的.用于腹腔镜的套管有可重复使用的（图7）或一次性的（图8）并且由一个5至33毫米直径的管连接到一橡胶套环，垫圈，和/或一个阀。中空护套让腹腔镜的仪器和工具进入体腔。橡胶套环，垫圈，和阀允许引入和拆除仪器而不破坏含二氧化碳的所需的气腹

9、。大部分插管包含侧端口为了补充二氧化碳或持续吹入腹部。套管针是插管系统的一个组成部分，可以是锋利的或钝的（图9）。锋利的套管针在制造气腹后，可以防护或者不做防护，因为制造气腹后肠或其他器官被套管针穿孔的风险降低。大多数一次性套管针都得防护，以保证套管针进入腹部的安全性. 该套管针的防护组件通常是一个塑料护套，在软组织被推出，露出锋利的金属套针。一旦整个套管针已经侵入机体墙，塑料护扣回过尖锐的金属套管针。通常还存在着锁定装置，使得一旦防护组件被推回，这时锁定装置启动，以覆盖尖锐套管针，其锁定到位并保护与它接触接近的任何结构。这些特性使得使用一次性套管针的非常有吸引力，但套管针的成本往往超过了收益

10、。因此大多数可重复利用的套管针是没有防护组件的。钝套管针主要被用于开放式腹腔镜.这意味着要制造一个非常小的剖腹切口，然后投入到体腔内探索，并通过使用钝套管针的插管被放置到空腔。这种方法的好处是，穿孔深层结构的可能性极小，但这种方法的缺点是，如果切口是太大，造气腹的二氧化碳可能会通过插管四处溢出体腔外。在大多数情况下，钝套管针用于进入在脐周的腹部或肋间周围的胸腔。一次性套管系统（optiview，Ethicon EndoSurgery，Cincinnati，0H or Visiport United States Surgical C orporation，Norwalk，CT）使得进入腹部的直

11、接可视化。插管由切割装置和装在其头部的一个光学透镜组成，它使得外科医生对术部可视，通过镜头，来进行每个组织层的剥离。柔性插管也可用于腹腔镜。某些套管是固定的，通过环将套管与皮肤缝合在一起，另一种是构成稳定螺纹，使得所述套管实际上是“拧”进入体壁。这两种系统用于保证操纵镜头或仪器时，所述套管不会被拉出的体壁。在一般情况下，15至20厘米插管是常用于的侧面的手术，而10厘米插管对于腹腔或胸腔已是足够长了。最常用的插管的尺寸为5至12毫米直径。大插管通常用于自动缝合装置和用于从体腔中取出组织（参见图8）。可用于腹腔镜的器械有许多不同之处相较普通外科手术的器械而言。大多数情况下，常用外科手术器械通过减

12、少仪器爪的大小和在仪器上放置长尺寸轴来适应手术。最常见的手柄类型是环手柄，它类似于持针器的手柄。这种手柄也可用于一些其他的器械例如持针器。一些更常用的仪器包括剪刀，止血，抓钳，解剖镊子，牵拉器，和持针器（图10）。自动和手动装订设备都是可用的，但成本在平均马手术病例中可能偏高。大部分仪器的轴都是有5毫米直径和10毫米直径两种型号，长度在约30到45厘米之间。有些仪器有单极电凝适配器，专用仪器可用于双极电凝。（图11）专门用于腹腔镜的缝合材料也被运用。特殊缝合针连着常见的缝合材料通过套管进入腹腔也被研究出来。因为在体内（体腔内）结扎打结是非常困难的，缝合公司开发了预打结的绕圈。该结扎材料被放置并

13、通过一个直径5毫米的塑料护套，这有助于其作为一个结推进器引入结扎到体腔内（图13）。对于更长的线缝合，各种缝线夹被设计出来。这些夹子通常连接到缝合线的末端，以防止线从组织滑出。各种装订设备也已经被设计用于帮助解决关闭切口的问题。这些设备包括用于任一切口闭合或止血的单发（装订）的可重复使用的仪器，以及用于同样目的的一次性多发（装订）仪器。类似于普通外科用肠切除吻合术，肺切除术等手术的切口闭合，一次性吻合装置也可提供。附录1表1 图1 图2 图3 图4 图5 图6 图7 图8 图9 图10A 图10B 图11 图13附录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