显微外科技术治疗皮肤大面积脱套伤的实验研究及临床应用
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摘要
[目的]：制作皮肤大面积脱套伤的动物模型,探讨修复脱套皮肤内回流静脉及静脉动脉化对脱套皮肤成活的影响；同时探讨修复回流静脉治疗皮肤脱套伤的临床应用效果。
[方法]：
1动物实验：选取健康日本兔“大耳白”,以盐酸氯胺酮注射液(2ml：0.1g)按0.1-0.12g／kg肌肉注射麻醉,在深筋膜浅层将兔后肢皮肤套状剥离,形成以踝关节为蒂,长宽比例为3.3：1的逆行脱套伤的动物模型。每组10只,左右侧后肢对照。实验组A：将逆行剥脱的皮肤复位后原位缝合,不吻合静脉；实验组B：将逆行剥脱的皮肤复位,以10／0的显微缝合线吻合大隐静脉和小隐静脉,再将皮肤原位缝合；实验组C：将剥脱的皮肤纵向剖开,以10／0的显微缝合线吻合大隐静脉和小隐静脉,再将皮肤原位缝合；实验组D：将小腿近端胫后动静脉发出的皮肤营养血管切断,以10／0的显微缝合线将动脉近端与静脉远端吻合,并吻合大隐静脉和小隐静脉,再将皮肤原位缝合。
术后定期观察兔后肢脱套皮肤的颜色、张力、血管充盈度、肿胀及坏死情况,术后一个月确定脱套皮肤成活比例。
另每组各补充2只日本大耳白兔,于术后一周分别于其双后肢踝关节平面、膝关节平面和腹股沟平面的脱套皮肤上切取皮肤组织标本作HE染色,观察其病理变化。
术后分别自实验组B、C、D的大耳白兔的腹股沟平面抽取大隐静脉内静脉血1ml,踝关节平面抽取静脉血1ml,行血气分析,检测血中PaO2及PaCO2的变化。
2临床应用：以修复回流静脉的方法治疗手部皮肤大面积脱套伤患者7例,上肢皮肤大面积脱套伤患者3例,每位患者修复脱套皮肤内的浅静脉3-5根。
[结果]：
1动物实验：实验组A脱套皮肤平均成活36.3%,较术前挛缩55.9%；实验组B脱套皮肤平均成活51.3%,较术前挛缩30.9%,经成组资料t检验,二者差异有统计学意义(P<0.05)。
实验组C脱套皮肤平均成活50.5%,实验组D脱套皮肤平均成活60.2%,经成组资料t检验,二者差异有统计学意义(P<0.05)。实验组C脱套皮肤较术前挛缩31.9%；实验组D脱套皮肤较术前挛缩26.9%,经成组资料t检验,二者差异没有统计学意义(P>0.05)。
2临床应用：手部皮肤脱套伤患者7例,皮肤全部成活者5例,2例手背侧撕脱皮肤近缘有1～2cm的条形皮肤坏死,中药换药后愈合。术后随访3个月～1年,患手外形好,血供充分,皮肤质地柔软。按手功能评定标准优3例,良3例,中1例,优良率为85.7%,感觉功能评定S44例,S3+1例,S22例。患者对手部外形及功能满意。
上肢皮肤脱套伤患者3例,脱套皮肤大部成活,有散在的浅层坏死,多位于脱套皮肤近端及腕关节附近,经切痂植皮术后愈合。术后随访1.5个月～半年,患肢皮肤质地柔软,血供充分,手指屈伸活动好。患者对肢体外形及功能满意。
[结论]：
1通过吻合脱套皮肤内的浅静脉,重建血液回流通路,可使肢体大面积套状撕脱的皮肤成活面积和成活质量有明显的提高。
2静脉动脉化法可增加脱套皮肤的血液灌注,但这种非生理性的血液循环方式也会造成静脉血管扩张,血液、组织液渗出增加,组织肿胀明显以及纤维化较严重等负面影响,因此在皮肤大面积脱套伤的应用仍需进一步地研究。
[Objectives]:To create the experimental model of extensive degloving injury and evaluate the influence of venous anastomoses and/or arteriovenous for the survival of skin with reversed avulsion injury. To study the consequence of degloving injury of upper extremities treated by venous anastomoses.
[Method]:
1。Animal experimental:The surgical procedure were carried out with the health Japanese white rabbits under general anaesthesia using Ketamine Hydrochloride. 3.3:1 distal-based avulsion skin was made of the back legs of experimental animal respectively. Each group included 10 rabbits. Group A:the avulsed skin was sutured back to the original size; Group B:two veins were anastomosised and then the avulsed skin was sutured back; Group C:the avulsed skin was cut longitudinally,two veins were anastomosised and then the avulsed skin was sutured back; Group D:the avulsed skin was cut longitudinally,two veins were anastomosised and the other vein was anantomosised with an aretery, then the avulsed skin was sutured back.
Appearance of color, tension, degree of angioplerrosis, ecchymosis, swell and necrosis had been observed during the post-op period. The survival condition was evaluated based on survival area calculating in one month postoperation.
Additional 2 rabbits of each group were prepared for pathological examination of one week postoperation.
The Blood-gas analysis was carried out in group B,C and D.
2.We treated 7 cases of degloving injury of hand and 3 cases of degloving injury of upper limb, and anatomosised 3-5 veins of degloving skin each case.
[Result]:
1。Group A:the degloving skin of one-month-postoperation was contracted 55.9% and 36.3% degloving skin was survived. Group B:the degloving skin of one-month-postoperation was contracted 30.9% and 51.3% degloving skin was survived. There were significant differences between the two groups(P<0.05).
In study 50.5% degloving skin was survived in Group C and 60.2% degloving skin was survived in Group D.There were significant differences between the two groups(P<0.05).31.9% degloving skin was contracted in Group C and 26.9% degloving skin was contracted in Group D.There were not significant differences between the two groups(P>0.05).
2.For the 7 cases of degloving injury of hand, all of the degloving skin is survival in 5 cases and a little necrosis in 2 cases. After follow-up of 3 months to 12 months, good aesthetic and functional results is achieved. The active function examination excellent 3 cases, good 3 cases and fair 1 case.The sensibility examination:4 cases of S4,1 case of S3+ and 2 cases of S2.
For the 3 cases of degloving injury of upper limb, although there is a little necrosis, most of the degloving skin is survival.After follow-up of 1.5 month to 6 months, good aesthetic and functional results is achieved.
[Conclusions]:
1.The venous anatomoses may improve the survival of the degloing skin by reducing the venous congestion and ameliorating the blood supply of degloving skin.
2.Although arteriovenous can augment the blood supply of degloving skin, as a non-physical blood-circulation, it also promotes blood congestion, tissue swollen and fibrosis in the degloving skin. So it would not be used to treat degloving injury until some advancement can be made.
[方法]：
1动物实验：选取健康日本兔“大耳白”,以盐酸氯胺酮注射液(2ml：0.1g)按0.1-0.12g／kg肌肉注射麻醉,在深筋膜浅层将兔后肢皮肤套状剥离,形成以踝关节为蒂,长宽比例为3.3：1的逆行脱套伤的动物模型。每组10只,左右侧后肢对照。实验组A：将逆行剥脱的皮肤复位后原位缝合,不吻合静脉；实验组B：将逆行剥脱的皮肤复位,以10／0的显微缝合线吻合大隐静脉和小隐静脉,再将皮肤原位缝合；实验组C：将剥脱的皮肤纵向剖开,以10／0的显微缝合线吻合大隐静脉和小隐静脉,再将皮肤原位缝合；实验组D：将小腿近端胫后动静脉发出的皮肤营养血管切断,以10／0的显微缝合线将动脉近端与静脉远端吻合,并吻合大隐静脉和小隐静脉,再将皮肤原位缝合。
术后定期观察兔后肢脱套皮肤的颜色、张力、血管充盈度、肿胀及坏死情况,术后一个月确定脱套皮肤成活比例。
另每组各补充2只日本大耳白兔,于术后一周分别于其双后肢踝关节平面、膝关节平面和腹股沟平面的脱套皮肤上切取皮肤组织标本作HE染色,观察其病理变化。
术后分别自实验组B、C、D的大耳白兔的腹股沟平面抽取大隐静脉内静脉血1ml,踝关节平面抽取静脉血1ml,行血气分析,检测血中PaO2及PaCO2的变化。
2临床应用：以修复回流静脉的方法治疗手部皮肤大面积脱套伤患者7例,上肢皮肤大面积脱套伤患者3例,每位患者修复脱套皮肤内的浅静脉3-5根。
[结果]：
1动物实验：实验组A脱套皮肤平均成活36.3%,较术前挛缩55.9%；实验组B脱套皮肤平均成活51.3%,较术前挛缩30.9%,经成组资料t检验,二者差异有统计学意义(P<0.05)。
实验组C脱套皮肤平均成活50.5%,实验组D脱套皮肤平均成活60.2%,经成组资料t检验,二者差异有统计学意义(P<0.05)。实验组C脱套皮肤较术前挛缩31.9%；实验组D脱套皮肤较术前挛缩26.9%,经成组资料t检验,二者差异没有统计学意义(P>0.05)。
2临床应用：手部皮肤脱套伤患者7例,皮肤全部成活者5例,2例手背侧撕脱皮肤近缘有1～2cm的条形皮肤坏死,中药换药后愈合。术后随访3个月～1年,患手外形好,血供充分,皮肤质地柔软。按手功能评定标准优3例,良3例,中1例,优良率为85.7%,感觉功能评定S44例,S3+1例,S22例。患者对手部外形及功能满意。
上肢皮肤脱套伤患者3例,脱套皮肤大部成活,有散在的浅层坏死,多位于脱套皮肤近端及腕关节附近,经切痂植皮术后愈合。术后随访1.5个月～半年,患肢皮肤质地柔软,血供充分,手指屈伸活动好。患者对肢体外形及功能满意。
[结论]：
1通过吻合脱套皮肤内的浅静脉,重建血液回流通路,可使肢体大面积套状撕脱的皮肤成活面积和成活质量有明显的提高。
2静脉动脉化法可增加脱套皮肤的血液灌注,但这种非生理性的血液循环方式也会造成静脉血管扩张,血液、组织液渗出增加,组织肿胀明显以及纤维化较严重等负面影响,因此在皮肤大面积脱套伤的应用仍需进一步地研究。
[Objectives]:To create the experimental model of extensive degloving injury and evaluate the influence of venous anastomoses and/or arteriovenous for the survival of skin with reversed avulsion injury. To study the consequence of degloving injury of upper extremities treated by venous anastomoses.
[Method]:
1。Animal experimental:The surgical procedure were carried out with the health Japanese white rabbits under general anaesthesia using Ketamine Hydrochloride. 3.3:1 distal-based avulsion skin was made of the back legs of experimental animal respectively. Each group included 10 rabbits. Group A:the avulsed skin was sutured back to the original size; Group B:two veins were anastomosised and then the avulsed skin was sutured back; Group C:the avulsed skin was cut longitudinally,two veins were anastomosised and then the avulsed skin was sutured back; Group D:the avulsed skin was cut longitudinally,two veins were anastomosised and the other vein was anantomosised with an aretery, then the avulsed skin was sutured back.
Appearance of color, tension, degree of angioplerrosis, ecchymosis, swell and necrosis had been observed during the post-op period. The survival condition was evaluated based on survival area calculating in one month postoperation.
Additional 2 rabbits of each group were prepared for pathological examination of one week postoperation.
The Blood-gas analysis was carried out in group B,C and D.
2.We treated 7 cases of degloving injury of hand and 3 cases of degloving injury of upper limb, and anatomosised 3-5 veins of degloving skin each case.
[Result]:
1。Group A:the degloving skin of one-month-postoperation was contracted 55.9% and 36.3% degloving skin was survived. Group B:the degloving skin of one-month-postoperation was contracted 30.9% and 51.3% degloving skin was survived. There were significant differences between the two groups(P<0.05).
In study 50.5% degloving skin was survived in Group C and 60.2% degloving skin was survived in Group D.There were significant differences between the two groups(P<0.05).31.9% degloving skin was contracted in Group C and 26.9% degloving skin was contracted in Group D.There were not significant differences between the two groups(P>0.05).
2.For the 7 cases of degloving injury of hand, all of the degloving skin is survival in 5 cases and a little necrosis in 2 cases. After follow-up of 3 months to 12 months, good aesthetic and functional results is achieved. The active function examination excellent 3 cases, good 3 cases and fair 1 case.The sensibility examination:4 cases of S4,1 case of S3+ and 2 cases of S2.
For the 3 cases of degloving injury of upper limb, although there is a little necrosis, most of the degloving skin is survival.After follow-up of 1.5 month to 6 months, good aesthetic and functional results is achieved.
[Conclusions]:
1.The venous anatomoses may improve the survival of the degloing skin by reducing the venous congestion and ameliorating the blood supply of degloving skin.
2.Although arteriovenous can augment the blood supply of degloving skin, as a non-physical blood-circulation, it also promotes blood congestion, tissue swollen and fibrosis in the degloving skin. So it would not be used to treat degloving injury until some advancement can be made.
引文
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