胸腔镜辅助直视下经胸切取膈神经的解剖学研究及临床应用

目的 对膈神经胸腔内的全程解剖关系进行研究,为胸腔镜辅助直视下经胸切取全长膈神经、移位治疗臂丛神经根性损伤提供解剖学依据.方法 选用10%甲醛固定成人尸体标本10具20侧,对膈神经及其周围组织器官进行解剖学观察.临床上对17例臂丛神经损伤患者,于胸腔镜辅助直视下经胸切取膈神经的术式进行总结.结果 经锁骨下第二肋间腋前线处出口引出胸腔膈神经远端在上臂的位置比:左侧(38.60±13.10)%,右侧(52.40±7.90)%.经锁骨上切口引出膈神经远端在上臂的位置比:左侧(25.90±11.50)%,右侧(39.00±6.90)%.切口内缘至胸膜顶处膈神经长度(d)与胸膜顶至膈肌顶长度(f)的比值:第三肋间左侧(0.84±0.23),右侧(0.96±0.15);第四肋间左侧(1.02±0.21),右侧(1.08±0.17).切口内缘至膈神经入肌点长度(e)与胸膜顶至膈肌顶长度(f)的比值:第三肋间左侧(0.66±0.15),右侧(0.60±0.21);第四肋间左侧(0.55±0.04),右侧(0.44±0.05).17例臂丛神经根性损伤患者,经胸腔镜辅助直视下经胸切取全长膈神经移位桥接同侧肌皮神经,术后患者均未出现并发症,肱二头肌肌力恢复(肌力M2～M4).结论 膈神经在胸腔内的解剖特点适合进行经胸全长游离.胸腔镜辅助直视下经胸切取全长膈神经移位操作简单,安全性高,特殊设备要求低,可作为常规手术开展.

Abstract：

Objective To study the anatomic relationship of the thoracic phrenic nerve and provide anatomic basis for harvesting whole length phrenic nerve under direct vision using thoracoscope in the treatment of brachial plexus root injuries. Methods The anatomy of thoracic phrenic nerve and its surrounding tissues were observed on 20 sides of 10 adult cadavers which were embalmed by 10% formalin. Video-assisted thoracoscopic transthoracic phrenic nerve harvesting was carried out in the surgical treatment of 17 cases of brachial plexus injuries. The results in these cases were summarized. Results If the cutting end of phrenic nerve was pulled out of the second intercostal space at the anterior axillary line,the ratio of its location in the upper arm was (38.60±13.10)% on the left side and (52.40±7.90)% on the right side. If the cutting end was pulled out of the thoracic outlet,the location ratio in the upper arm was (25.90±11.50)% on the left side and (39.00±6.90)% on the right side. The ratio of phrenic nerve between d (length from medial edge of the incision to the pleural top) and f (length from pleural top to the top of diaphragm) was (0.84±0.23) on the left and (0.96±0.15) on the right at third intercostal space,(1.02±0.21) on the left and (1.08±0.17) on the right at the fourth intercostals space. The ratio of phrenic nerve between e (length from medial edge of the incision to the insertion of diaphragm) and f (length from pleural top to the top of diaphragm) was (0.66±0.15) on the left and (0.60±0.21) on the right at third intercostal space,(0.55±0.04) on the left and (0.44±0.05) on the right at the fourth intercostals space. Endoscopic-assisted transthoracic phrenic nerve harvesting in 17 cases of brachial plexus root injuries obtained full length of the phrenic nerve that could be directly coapted to the muscle branch of the musculocutaneous nerve. No complications were noted.The strength of the biceps underwent good recovery,which was M2 to M4. Conclusion The phrenic nerve in the thoracic cavity is suitable for full-length dissection based on the anatomical characteristics. Endoscope-assisted transthoracic phrenic nerve harvesting is a simple and safe surgery with low requirement of special equipment,and can be carried out as a routine surgery.     

建立经胸切取膈神经全长移位治疗臂丛损伤的动物模型

目的：建立经胸膈神经移位治疗臂丛损伤的动物模型。方法：大鼠经口气管插管,运用动物人工呼吸机辅助呼吸,开胸切取左侧膈神经远端,然后从左侧第2肋间抽出,再与左侧正中神经指深屈肌肌支作直接缝合。结果：10只大鼠全部存活,于术后21－35d起都出现与呼吸节律同步的屈腕、屈指动作。结论：该实验模型是可行的,有效的,可重复性。为临床开胸切取胸腔内膈神经全长作神经移位提供了实验依据。     

胸腔镜下切取膈神经移位重建全臂丛根性撕脱伤手部功能初步报告

目的探讨胸腔镜下膈神经超长切取、移位重建全臂丛根性撕脱伤手部功能的可行性。方法全臂丛根性撕脱伤3例,胸腔镜下于邻膈肌处切断膈神经,逆行游离胸腔内全长膈神经及其血管组织蒂,并由第二肋间引出,经胸大肌下移位至上臂上内侧,分别与尺神经前内侧部吻合2例,与移植股薄肌之闭孔神经前支吻合1例。结果2例膈神经联合第3～6肋间神经运动支移位修复尺神经者,结合短期免疫抑制剂FK506口服治疗,术后12个月手内肌肌电图检测均出现再生电位,1例随访15个月出现手内肌收缩。1例用以重建屈肘、屈指屈拇的移植股薄肌术后7月出现肌肉收缩,随访12个月肌力达M3。结论胸腔镜下全长切取膈神经,作为运动性动力神经移位应用于全臂丛根性撕脱伤的治疗,可在短时间内有效重建屈指屈拇功能,并有使手内肌神经再支配、开始恢复手内肌收缩功能的迹象。     

比较经胸与锁骨上膈神经移位治疗臂丛损伤疗效的实验研究

目的　比较经胸膈神经移位与锁骨上移位治疗臂丛损伤的手术疗效。方法　SD大鼠 48只 ,按手术不同随机分为两组 ,每组 2 4只。实验组 :开胸切断左侧膈神经远端后从第二肋间抽出 ,与左侧正中神经的指深屈肌肌支缝接。对照组 :锁骨上切断左侧膈神经 ,用同侧隐神经桥接后与左侧正中神经的指深屈肌肌支缝合。术后 1、2、3、4个月行肉眼观察并作肌电、组织学检测和图像分析。结果　实验组大鼠于术后 2 1～ 3 5d起出现与呼吸同步的屈腕、屈指动作 ,而对照组则在术后 3 6～ 49d出现。实验组指深屈肌的复合运动动作电位 (CMAP)潜伏期的延迟率和波幅恢复率均优于对照组 ,差异有显著性意义(F =6.84、3 2 .43 ,P <0 .0 5、 <0 .0 1)。肌肉截面积恢复率、有髓神经纤维通过率和有髓神经纤维截面积 ,实验组均优于对照组 (P <0 .0 5 )。结论　经胸切取膈神经移位的疗效优于锁骨上切取膈神经移位治疗臂丛神经损伤     

全长膈神经移位不同路径选择的解剖学研究

目的　对全长膈神经移位的路径进行解剖学研究为电视胸腔镜下切取全长膈神经移位奠定解剖学基础。方法　选用新鲜尸体 10具 2 0侧 ,对锁骨上移位和锁骨下移位两种移位路径进行比较。结果　锁骨上移位 :右侧全长膈神经可移至锁骨中点以远 11.45± 1.64cm ,左侧可至锁骨中点以远 19.1± 1.42cm ,两侧均不能携带伴行血管。锁骨下移位 :右侧全长膈神经可移至锁骨中点以远 6.4±0 .74cm ,左侧可至锁骨中点以远 11.7± 1.5cm ,两侧均可携带伴行血管。结论　两种移位路径各有优缺点。锁骨上移位可以获得神经的最大长度 ,但不能带血管 ,且手术范围大。锁骨下移位虽获得膈神经的长度较短 ,但能携带膈神经伴行血管一同移位 ,确保神经的血供     

在胸腔内窥镜镜视下切取膈神经的实验研究

目的研究在胸腔内窥镜镜视下切取尸体膈神经的行径,提供足够长度的膈神经作为动力神经。方法新鲜尸体１５具,１５侧作膈神经在胸腔内走行与毗邻关系的解剖研究;１５侧作实验用。胸腔镜从第５、６肋间锁骨中线外侧插入胸腔,于膈肌上２ｃｍ处切断膈神经后,从锁骨上臂丛切口内拉出膈神经。结果膈肌上２ｃｍ处可见膈神经４～５支分支,距膈肌２ｃｍ以上处切断膈神经,可顺利抽出长度为１９～２５ｃｍ的膈神经。在抽出过程中膈神经无１根断裂。结论该术式在尸体实践中操作安全,膈神经长度足以作为修复臂丛神经根性撕脱伤的动力神经。为临床应用提供了一个切取膈神经的新术式。     

肋间神经移位肩胛上神经的解剖学研究

目的探讨第3～6肋间神经移位肩胛上神经重建肩关节外展功能的可行性。方法取15具30侧成人躯干标本,解剖测量第3～6肋间神经自腋中线至锁骨中线可切取长度以及自腋中线至锁骨中点(拟定神经吻合点)的移位距离,并进行统计学比较。结果 30侧标本中,第3、4肋间神经均可切取自腋中线至锁骨中线范围内的全段神经,且可切取长度均较移位距离长(P<0.01)。6侧第5肋间神经及16侧第6肋间神经在未到达锁骨中线时被肋软骨覆盖,其中第5肋间神经可切取长度与移位距离相似(P>0.01),第6肋间神经可切取长度较移位距离短(P<0.01)。肩胛上神经通过游离切断,可翻转至锁骨中点下方2 cm以上。第5肋间神经切取长度与肩胛上神经翻转长度(2 cm)之和,可超过移位距离(P<0.01),但第6肋间神经总长度仍较移位距离短(P<0.01)。结论第3～5肋间神经可直接移位肩胛上神经重建肩关节外展功能,而第6肋间神经需增加游离切取长度范围或采用神经移植修复。     

膈神经和肋间神经移位术中呼吸功能的变化

了解一侧膈神经和部分肋间神经同时移位治疗臂丛神经损伤后对呼吸功能的影响。选择２８例臂丛神经根损伤，行膈神经和肋间神经同时切断前后，测量呼吸潮气量，频率，呼气未二氧化碳分压和脉搏血氧饱和度的变化。结果：该两种经同时切断后，Ｖｔ，ｆ有所下降，ＰｅｔＣＯ２升高，表示呼吸功能受到抑制。     

胸腔镜视下切取膈神经移位治疗臂丛神经损伤的临床应用报告

目的 首创在胸腔镜视下切断膈神经远端移接于肌皮神经的新术式。方法 临床应用５例。在胸腔镜视下于人膈肌近端切断膈神经,游离在胸腔内的膈神经全长。膈神经自锁骨上抽出经皮下引至肌皮神经３例,于锁骨下自第二肋间引起移位于肌皮神经２例。移接于肌皮神经主干２例,移接于肌皮神经肌支３例。首例于术后１１０ｄ,检测肱二头肥肥电图出现再生电位。结论 胸腔镜视下切并游离胸腔内膈神经全长,是膈神经移位术中切取膈神经的最佳     

膈神经及肋间神经移位后肱二头肌的组织形态学研究

临床上常用膈神经或肋间神经移位来治疗臂丛神经损伤引起的肱二头肌麻痹；其中膈神经移位肱二头肌后的治疗效果较好，目前认为这是由于膈神经高频率、大振幅的自发性电活动和具有较多粗大运动神经纤维所引起的。本实验采用组化染色（ＡＴＰ酶，ＮＡＤＨ－ＴＲ），图像分析的方法对５例肋间神经移位、６例膈神经移位后的肱二头肌进行组织形态学研究。发现膈神经移位后肱二头肌肌纤维粗大，各纤维型比例接近，与正常生理状态相似。肋间神经移位后的肱二头肌肌纤维细小，ＳＯ型纤维明显增多（达８２．２％）。由于Ⅱ型纤维的等长收缩力大于Ⅰ型纤维，因此这个结果进一步解释了膈神经移位后的肱二头肌较肋间神经移位后的肱二头肌恢复好的原因。此外，本实验还发现失神经肌神经再支配后纤维型的组化现象同样存在于人体骨骼肌，结合肌纤维粗细差别较大的特点，提示它可用于失神经肌神经再支配过程中对肌肉的神经支配状态的评估。     

Mobilization of the phrenic nerve in the thoracic cavity by video-assisted thoracic surgery

Background: The use of video-assisted thoracic surgery (VATS) techniques to mobilize the phrenic nerve in the thoracic cavity for neurotization after brachial plexus injury was studied. Methods: From August 1999 to January 2000, 10 men and 1 woman with brachial plexus injury (left side in 5 and right side in 6) joined the study group. Their ages ranged from 20 to 38 years (average, 28 years). Supine after general anesthesia, all the patients had double-lumen trachea cannulas to guarantee complete lung collapse on the operative side. Three port incisions were made to allow introduction of the following: a 10-mm Stryker endoscope through the sixth intercostal space 2 cm medial to the anterior axillary line, one instrument for manipulation in the anterior axillary line of the third intercostal space, and another in the second intercostal space about 2 cm lateral to the parasternal line. The nerve was mobilized with two common long Mixter clamps and some endoscopic instruments by blunt and sharp dissection. Results: All patients were managed successfully without severe complications. The mean additional length of phrenic nerves by this technique was 16 cm. Conclusions: Mobilization of the phrenic nerve by VATS is a safe and minimally invasive method for elongating the nerve for neurotization after brachial plexus injury.     

臂丛撕脱伤患者同侧膈神经诱发电位的研究

目的研究臂丛撕脱伤患者同侧膈神经的功能状态，为临床选用膈神经移位治疗臂丛撕脱伤提供依据。方法测定１００例臂丛神经撕脱伤膈肌诱发电位的潜伏期、波幅，并对其功能进行评价。将表面电极置在胸锁乳突肌后缘，在平环状软骨水平进行电刺激，于腋前线水平在第７、８肋间记录肌肉诱发电位。同时在膈神经移位术中取一段膈神经，观察其病理变化。结果诱发电位的资料证实，有１８例膈神经存在不同程度的损伤，其中１１例为完全损伤，７例为不全损伤。病理学观察发现膈神经部分损伤时，光镜下见神经纤维部分髓鞘崩解，髓鞘之间散在性地分布着瘢痕化组织。膈神经完全损伤时，可见神经髓鞘崩解，髓鞘之间布满瘢痕化组织。结论１００例臂丛撕脱伤中１８％的膈神经有损伤，其中７％为不全损伤。应重视这部分病例中膈神经的部分损伤，以便改进手术方法，提高移位术的疗效     

全长膈神经移位重建屈指功能的临床报告

目的 探讨在胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后屈指功能的可行性,为全臂丛根性撕脱伤后屈指功能的恢复提供新思路.方法 对3例全臂丛根性撕脱伤的患者,采用胸腔镜视下游离胸腔内的全长膈神经,于入膈肌处切断膈神经,将全长膈神经直接移位于正中神经内侧头,术后每3个月随访肺功能和临床功能恢复情况.结果 3例患者随访时间均超过3年,拇长屈肌及2～5指指浅屈肌肌力均恢复至3～4级,掌长肌肌力2例为2级,1例为1级;桡侧腕屈肌、旋前圆肌、鱼际肌肌力为0级.肺功能显示患者在术后6个月内有不同程度的肺功能降低,但在1年内都恢复到术前水平.结论 胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后的屈指功能是一种可行的新术式.     

经纵隔内切取长段膈神经与下干后股直接吻合重建全臂丛撕脱伤的伸指功能

目的 为全臂丛神经撕脱伤的伸指功能重建寻找一种新的有效的神经移位方法.方法 经纵隔直视下切取一段膈神经,以增加其长度.锁骨上、下臂丛神经探查联合切口,截断锁骨,找到下干后股,向近端干支分离后切断,将膈神经与下干后股直接吻合.本组12例臂丛神经撕脱伤,男10例,女2例;年龄6～39岁,平均28岁.伤后到手术时间2～11个月,平均6个月,其中全臂丛神经撕脱伤11例,中、下干撕脱伴上干不全损伤1例.术前需胸透及电生理检查均证实患侧膈神经功能良好.结果 经纵隔内直视下切取膈神经可使其长度增加3～7cm,平均4cm.12例均实施了膈神经与下干后股的直接吻合,其中3例术后随访1年以上,有2例指总伸肌肌力恢复到2级,另1例吸气时指总伸肌内有新生电位出现.结论 经纵隔内切取膈神经可使其长度明显延长,可与下干后股进行直接吻合重建伸指功能,初步临床应用证实是可行的.     

Pulmonary function after complete unilateral phrenic nerve transection

OBJECT: The status of pulmonary function following phrenic nerve transfer surgery is still largely unknown because of the high degree of variability in the accessory phrenic nerve that may be involved. In the present study, pulmonary functions were assessed in patients before and after full-length phrenic nerve transfer surgery, in whom the phrenic nerve was severed at a location just before its entry into the diaphragm. METHODS: Fifteen patients (average age 27.4 years) with complete brachial plexus palsy underwent full-length phrenic nerve transfer. The phrenic nerve was harvested from the thoracic cavity by means of video-assisted thoracic surgery and then transferred to the musculocutaneous nerve. Postoperative pulmonary functions were retrospectively analyzed. Patients underwent follow-up evaluation for 42 to 48 months; four patients were eventually lost to follow up. Although no patient experienced pulmonary problems following the surgery, all sustained varying degrees of diaphragmatic paralysis and elevation (for 1-1.5 intercostal spaces) on the surgically treated side as seen on chest x-ray films. Pulmonary functional parameters, including vital capacity, vital capacity in percentage of predicted values, residual volume, total lung capacity, forced vital capacity, and forced expiratory volume in 1 second, recovered to preoperative levels by 1 year postsurgery. In contrast, the postoperative maximal inspiratory pressure value was significantly decreased compared with the predicted values (average decrease approximately 20%) in all of the patients, even at 4 years after the surgery. CONCLUSIONS: In young patients with healthy lung function, unilateral phrenic nerve transection surgery can cause unilateral diaphragmatic paralysis and reduce the inspiration muscle force; however, most pulmonary function parameters gradually recover to preoperative levels within 1 year.     

进胸膈神经全长切断后的肺功能变化观察

目的 研究全长膈神经移位术对肺功能的影响。方法 对15例行全长膈神经移位肌皮神经术的全臂丛根性撕脱伤病人的术后肺功能进行回顾性分析。11例共随访42～48个月，4例在随访过程中失访。结果 所有病例术后无呼吸功能障碍，胸部X线片中均出现不同程度的术侧膈肌麻痹和抬高（高1．0～1．5个肋间）。肺功能参数如肺活量、肺活量占预期值的百分比、残气量、肺总量、功能残余量、第1秒用力呼气量在术后1年均恢复到术前水平，但所有病例的最大吸气压值即使在术后4年仍比预期值有明显降低（平均降低20％）。结论 单侧膈神经完全切断后的肺功能参数均在术后1年内逐渐恢复到术前水平。