肝脏肿瘤的微创治疗——从腹腔镜到机器人

Minimally Invasive Liver Resection:from Laparoscopic to Robotic

目的探讨完全腹腔镜、手助式腹腔镜及机器人三种微创手术方式在肝脏切除术中的可行性、安全性及适用范围。方法回顾性分析上海交通大学医学院附属瑞金医院普外科自2004年9月至20l2年1月期间完成的微创肝脏切除术(minimally invasive liver resection,MILR)128例患者的临床资料,根据手术方式分为完全腹腔镜肝脏切除术(pure laparoscopic resection,PLR)组、手助式腹腔镜肝脏切除术(hand-assisted laparoscopicresection,HALR)组及机器人辅助肝脏切除术(robotic liver resection,RLR)组,分别观察3组患者术中与术后恢复情况并进行对比分析。结果 PLR组82例,中转开腹3例,手术时间为(145.4±54.4)min(40～290 min)、术中出血量为(249.3±255.7)ml(30～1 500 ml),术后并发腹腔感染3例,胆瘘5例,经保守治疗后痊愈,无围手术期死亡,术后住院时间为(7.1±3.8)d(2～34 d)。HALR组35例,中转开腹3例,手术时间为(182.7±59.2)min(60～300 min)、术中出血量为(754.3±785.2)ml(50～3 000 ml),术后并发腹腔感染1例,胆瘘2例,切口感染2例,经保守治疗后痊愈,无二次手术,术后住院时间为(15.4±3.7)d(12～30 d)。RLR组11例,中转开腹2例,手术时间为(129.5±33.5)min(120～200 min)、术中出血量为(424.5±657.5)ml(50～5 000 ml),术后并发腹腔感染1例,胆瘘1例,经保守治疗后痊愈,术后住院时间为(6.4±1.6)d(5～9 d)。3组中,RLR组手术时间最短(P=0.001),术后住院时间最短(P=0.000),PLR组术中出血量最少(P=0.000),其差异均有统计学意义。结论肝脏肿瘤微创切除术安全、可行,临床工作中,需要根据不同的病例选择不同的手术方式。机器人辅助肝脏切除术为肝脏肿瘤的微创治疗带来了新的突破。

Objective To approach feasibility, safety, and the application range of pure laparoscopic resection （PLR）, hand-assisted laparoscopic resection （HALR）, and robotic liver resection （RLR） in the minimally invasive liver resection （MILR）. Methods The clinical data of 128 patients underwent MILR in the Surgical Department of the Shanghai Ruijin Hospital from September 2004 to January 2012 were analyzed retrospectively. According to the dif- ferent methods, the patients were divided into PLR group, HALR group, and RLR group. The intraoperative findings and postoperative recovery of patients in three groups were compared. Results There were 82 cases in PLR group, 3 cases of which were transferred to open surgery; the mean operating time was （145.4±54. 4） minutes （range： 40-290 minutes） ; the mean blood loss was （249.3 ±255.7） ml （range： 30-1 500 ml） ; abdominal infection was found in 3 cases and biliary fistula in 5 cases after operation, but all recovered after conservative treatment; the mean length of hospital stay was （7. 1 ±3.8） days （range： 2-34 days）. There were 35 cases in HALR group, 3 cases of which were transferred to open surgery; the mean operating time was （182.7±59. 2） minutes （range： 60-300 minutes） ; the mean blood loss was （754. 3±785.2） ml （range： 50-3 000 ml） ; abdominal infection was found in 1 case, biliary fistula in 2 cases, and operative incision infection in 2 cases after operation, but all recovered after conservative treatment; the mean length ofhospital stay was （15.4±3.7） days （range： 12-30 days）. There were 11 cases in RLR group, 2 cases of which were transferred to open surgery; the mean operating time was （129.5 ±33.5） minutes （range： 120-200 minutes） ; the mean blood loss was （424.5± 657. 5） ml （range： 50-5 000 ml） ; abdominal infection was found in 1 case and biliary fistula in 1 case after operation, but all recovered after conservative treatment; the mean length of hospital stay was （6. 4± 1.6） days （range： 5-9 days）. The operating time （P=-0. 001） and length of hospital stay （P=-0. 000） of the RLR group were shortest and the blood loss （P=0. 000） of the PLR group was least among three groups. Conclusions Minimally invasive resection is a safe and feasible. Different surgical procedures should be chosen according to different cases. The robotic liver resection provides new development for treatment of liver tumor.