CAJ | 학술논문

目的了解建腔器成腔力学变化特征。方法对接受改良Miccoli模式内镜甲状腺一侧腺叶及峡部切除22例，腺叶部分切除15例，行人路制备完成后，统一采用WSM-I型建腔器建腔。首次成腔后拆下提吊钩，换装上牵张力测定器，间插性地行模拟成腔实验：以0.5 cm间距间断提升吊钩，同时测量钩端各高度位置时的肌皮组织牵张力。结果①牵张力的总体变化在0～27.5 N。②当提升吊钩钩端至基础提吊位（Pe，腔室中心高度=1.5 cm）时，对应的牵张力值为(11.2±3.5)N；继续提升吊钩钩端至极限提吊位（Pmax，19/37例的平均腔室中心高度为1.75 cm，另18例为2.0 cm）时，对应牵张力值为(17.5±4.3)N（腔室中心高度不同，但两组对应的力值相近）。③伴随成腔过程牵张力呈两阶段变化：当提吊钩钩端从初始位上提至Pe时，牵张力呈均匀的线性增长；当钩端继续上升至Pmax时，牵张力转呈类指数式的快速增长。最大力值出现在后一阶段。④切口长度对牵张力变化无明显影响，但肌皮组织厚度与牵张力大小呈正相关(P＜0.01)。结论①建腔器成腔时牵张力不大，其成腔近极限时的最大力值＜30 N，远低于皮肤伸展术实施时所产生的力值。②整个成腔过程中力的增加呈二阶段变化，后一阶段增加明显。与之对应，肌皮组织逐步接近其粘弹性和延展性极限，而腔室空间高度也趋于最大值。③鉴于此时的成腔已近极限，再提升吊钩亦徒劳无益，而牵张力还将继续大幅增加。故此，极限提吊位所对应的牵张力值可能是成腔时整体力变化过程中的一个“拐点”。④实际成腔时的牵张力应≤Pmax的对应力值。此时不仅实现了有效成腔和最大化成腔，且可避免因不必要牵张所带来的肌皮组织损伤。
목적 료해건강기성강역학변화특정。방법대접수개량Miccoli모식내경갑상선일측선협급협부절제22례，선협부분절제15례，행인로제비완성후，통일채용WSM-I형건강기건강。수차성강후탁하제조구，환장상견장력측정기，간삽성지행모의성강실험：이0.5 cm간거간단제승조구，동시측량구단각고도위치시적기피조직견장력。결과①견장력적총체변화재0～27.5 N。②당제승조구구단지기출제조위（Pe，강실중심고도=1.5 cm）시，대응적견장력치위(11.2±3.5)N；계속제승조구구단지겁한제조위（Pmax，19/37례적평균강실중심고도위1.75 cm，령18례위2.0 cm）시，대응견장력치위(17.5±4.3)N（강실중심고도불동，단량조대응적력치상근）。③반수성강과정견장력정량계단변화：당제조구구단종초시위상제지Pe시，견장력정균균적선성증장；당구단계속상승지Pmax시，견장력전정류지수식적쾌속증장。최대력치출현재후일계단。④절구장도대견장력변화무명현영향，단기피조직후도여견장력대소정정상관(P＜0.01)。결론①건강기성강시견장력불대，기성강근겁한시적최대력치＜30 N，원저우피부신전술실시시소산생적력치。②정개성강과정중력적증가정이계단변화，후일계단증가명현。여지대응，기피조직축보접근기점탄성화연전성겁한，이강실공간고도야추우최대치。③감우차시적성강이근겁한，재제승조구역도로무익，이견장력환장계속대폭증가。고차，겁한제조위소대응적견장력치가능시성강시정체력변화과정중적일개“괴점”。④실제성강시적견장력응≤Pmax적대응력치。차시불부실현료유효성강화최대화성강，차가피면인불필요견장소대래적기피조직손상。
Objective To comprehend the change of the characteristics of lifting force produced by a working space marker in process of its cavity-forming. Methods 37 patients were successively operated with the surgical mode of minimally invasive video-assisted thyroidectomy (22/37 cases received a lobotomy and others un derwent a partial thyroidectomy) from January to August, 2010. Instead of hand-retraction, a mechanical armworking space marker type I ( WSM-I, MIEO Medinstr Co. Ltd, China) was applied to establish a working space. After pathway making, an interlayer-cavity above the lobe was created by the space maker and endoscopic view was properly built. Following all these steps, a simulated space making procedure was performed in a way of stepwise hook-lifting (5 mm rising per time). The lifting force ( LF)was measured during the process with a modflied force-measure device (FB-50, DESIK company, Germen). Then recorded data were assessed and analyzed statistically. Results ①Ascending scope of LF in the process of entire space-forming was 0-27.5 Newton (N).②Along with hook rising, LF ascended correspondingly and 2 specific values emerged: One was 11. 2 ±3.5 N,as the lifting height approached 1.5 cm ( also a approximate position of essential space-forming ( Pe), at which the musculo-cutaneous tissue just became tight) ; the other was 17.5 ± 4.3 N , as the lifting height approached 1.75 cm ( also a approximate position of maximal space-forming (Pmax), at which the musculo-cutaneous tissue appeared real tight, but not in a status of extreme tightness). ③Two types of LF ascending were found when the values transferred to a curve diagram : a palliative linearity increasing while lifting height varied from 0 to 1.5 cm (PO to Pe) and a rapid exponent-like increasing while lifting height varied from 1.5 to 1.75cm ( Pe to Pmax). ④ Dependability analyses yielded a diverse statistical outcome: negative significance of the comparison between incision length and LF value ( P ＞ 0. 05 ), and positive significance of the comparison between skin thickness and LF value ( P ＜ 0. 01 ). Conclusions ①LF produced by WSM-I while establishing a working space is proper and relatively small, since the maximal value is merely 27.5N, far less than the stress produced by ordinary cosmetic skin expansion. ②The whole space-forming process can be divided into 2 stages according to the characteristic of LF ascending which correspond also separately to the “essential cavity-forming” and “the maximum cavity-forming” in the real establishing of a working space. ③Attention should be paid to the later stage since in which a rapid LF increasing occurs while the appearance of musculo-cutaneous tissue changes from “just become tight” to “real appear tight”. ④LF control, especially the fine readjustment at or about Pmax should be of necessity in individual space-forming, and then, ideal working space establishment can be archived at a pre cisely balanced LF point: maximum cavity volume acquired and minimal tissue expansion stress produced.