应用达芬奇机器人诊治肺周围小结节病变

Treatmeant of pulmonary nodule with Da Vinci Surgical System

目的探索达芬奇机器人在肺周围小结节病变诊治中的价值和技术问题。方法从2011年11月至2012年10月,我院应用达芬奇机器人治疗肺周围小结节病变29例,其中男19例,女10例,年龄39～80岁,平均(58.5±9.4)岁。术中切取病变送冰冻病理检查,证实为恶性病变者行肺叶切除并常规清除肺门和纵隔淋巴结。手术采用全麻、双腔管气管插管,健侧卧位,胸部垫高,双手屈曲抱枕于头前,折刀位。健侧单肺通气。床旁机械臂系统从患者头上入位。孔位根据病变位置适当调整,腋后线第8肋间为进镜孔,肩胛线第8肋间、腋前线与锁骨中线第5肋间为器械孔。腋中线第7肋间为辅助口。结果术后病理为良性病变10例(炎性假瘤4例,结核或肉芽肿5例,错构瘤1例),恶性病变19例(腺癌15例,鳞状细胞癌2例,腺鳞癌1例,黏液表皮样癌1例),手术包括楔形切除9例,右肺上叶切除5例,右肺下叶切除8例,右肺中叶切除1例,左肺下叶切除6例。29例均顺利完成机器人手术,肺叶切除平均术中出血15～200ml(中位数50ml),无输血。所有患者均顺利拔除气管插管。所有患者无严重术后并发症,平均带胸腔引流管时间1～15d[(8.7±3.5)d]。所有患者均顺利出院。随访时间2～14个月[(5.9±2.7)个月],无复发、转移。结论应用达芬奇机器人手术系统治疗肺小结节病变安全、可行,尤其在肺癌根治手术中具有优势,可推荐用于早期非小细胞肺癌的手术治疗。

Objective To evaluate the usage of Da Vinci Surgical System in the diagnosis and treatment of pulmonary nodule. Methods A total of 29 patients with pulmonary nodule less than 3 cm in diameter was treated with Da Vinci Surgical System （ Intuitive Surgical, California） in our department from November 2011 to October 2012. This group of patients included 19 males and 10 females, and the mean age was 58. 5 years （range：39-80 years）. Wedge-shaped resection or lobectomy was performed depending on the result of rapid pathology and systemic lymph node dissection was done for malignant leision. We used general anesthesis with double lumens trachea cannula. We set the patients in lateral decubitus position with jackknife. The patient cart enter from top of the patient. The position of trocars would be set according to the position of lesion. A 12 mm incision was positioned at the 8th intercostal space in the posterior axillary line as vision port, and two 8 mm incisions were positioned at the 5th intercostal space between the anterior axillary line and midclavicular line, and the 8th infrascapular line as robotic instrument ports about 10 cm apart from the vision port. One additional auxiliary small incision for instrument without retracting ribs was set at the 7th intercostal space in the middle axillary line. Results There were 10 benign leisions and 19 malignancies identified. Wedge-shaped resection was performed for 9 patients and lobectomy for 20 patients （including 5 right upper lobectomies, 8 right lower lobectomies, 1 right middle lobectomy and 6 left lower lobectomies）. All of the 29 cases were completed with total robotic procedure without conversion. The pathological results included 4 inflammatory pseudotumors,5 tuberculosis, 1 hamartoma, 15 adenocarciaomas, 2 squamous cell carcinomas, 1 mucoepidermoid carcinoma and 1 adenosquamous carcinomas. The median intraoperative blood loss was 50 ml and no blood transfusion was needed. All patients were successfully extubated after operation. The mean drainage time was （ 8.7 ± 3.5 ） days. All of the 29 patients were discharged smoothly. The patients were followed up for 2-14 months [ （5. 9 ± 2. 7）months ] without recurrence or metastasis. Conclusion Da Vinci Surgical System can besafely used for the diagnosis and treatment of pulmonary nodule, especially for the the treatment of early non-small cell lung cancer.