机器人胸腺扩大切除术在老年重症肌无力患者中的应用

Robotic-assisted Extended Thymectomy for Myasthenia Gravis in Elderly Patients

目的评价达芬奇S(da Vinci S)机器人胸腺扩大切除术在老年重症肌无力患者中的应用价值。方法 2009年5月～2011年12月,使用da Vinci S机器人手术系统完成9例老年重症肌无力胸腺及胸腺瘤切除并进行胸腺周围脂肪组织清扫术。全身麻醉下双腔气管插管,仰卧位,一侧胸部垫高30°,术侧胸壁腋前线第5肋间皮肤切开1.5 cm,置入trocar作为观察孔,左右侧各约10 cm的距离(在腋前线第3肋间和锁骨中线第6肋间)置入左右机械手臂trocar,在腋中线第7肋间置入trocar作为辅助操作孔,连接机械手臂。人工气胸压力6～12 mm Hg。胸腺及周围脂肪组织置入一次性取物袋,经辅助操作孔取出。结果 9例均手术成功,无中转开胸。麻醉时间平均180 min(60～210 min),机器人手术时间平均60 min(30～110min),术中出血量平均100 ml(30～200 ml)。无手术输血,住ICU时间平均1 d(1～3 d)。9例随访5～32个月,平均12个月,DeFilippi分级1级2例,2级2例,3例5例,有效率100%。结论选择合适的老年患者,使用da Vinci S机器人手术系统行胸腺扩大切除术安全可行,效果确切。

Objective To evaluate the efficacy of robotic-assisted extended thymectomy for myasthenia gravis in elderly patients. Methods From May 2009 to December 2011, 9 elderly patients with myasthenia gravis, including 4 cases of thymoma, received extended thymectomy by using Da Vinci S surgical system with a double-lumen endobronchial intubation under general anesthesia. All the patients were set at a supine position with one side of the chest rising up by 30°. An 1.5-cm incision was made on the anterior axillary line, at the fifth intercostal space so that to insert a trocar as a observation hole. And then on the anterior axillary line, at the third intercostal space, and on the midclavicular line, at the sixth intercostal space, two incisions were made （both were 10 cm away from the observation hole） to introduce the left and fight mechanical arm. Finally, a fourth trocar was placed through an incision on the midaxillary line at the seventh intercostal space, as an assistant operation hole. Artificial pneumothorax was established with a pressure set at 6 - 12 mm Hg. The thymus and surrounding fat tissues were all removed via the assistant operation hole. Results The procedlure was completed successfully without conversion to open surgery. The mean anesthesia time was 180 min （ranged from 60 to 210 rain） , and the mean time for robotic-assisted procedure was 60 rain （ranged from 30 to 110 min）. The mean intraoperative blood loss was 100 ml （ ranged from 30 to 200 ml） ,and no patient received blood transfusion. The mean ICU stay of the cases ranged from 1 to 3 days （mean, 1 day）. Nine patients were followed up for 5 to 32 months with a mean of 12 months. According to DeFilippi standards,two patients got grade one,two grade two, three grade three, and the effective rate was 100%. Conclusion Robotic-assited extended thymectomy is effective and safe for selected elderly patients.