机器人辅助腹腔镜手术治疗复杂肾上腺肿瘤的临床研究

Clinical study of robot-assisted laparoscopic surgery for complicated adrenal tumors that unfit for conventional laparoscopic adrenalectomy

目的 探讨达芬奇机器人辅助腹腔镜下肾上腺切除术（RALA）治疗不适合传统腹腔镜手术的复杂肾上腺肿瘤的可行性、安全性及疗效. 方法 2012年8月至2013年3月采用RALA治疗复杂肾上腺肿瘤患者14例,男5例,女9例.年龄34～73岁,平均52岁.B超、CT检查示肿瘤位于左侧10例,右侧4例；肿瘤直径2.5～10.0 cm,平均5.2 cm.选择RALA的主要原因：肿瘤体积较大（≥5 cm）9例；患者超重或肥胖（体质指数≥25 kg/m2）7例；因病情或患者要求需最大程度保留肿瘤旁肾上腺组织4例；肿瘤压迫腔静脉、主动脉等大血管或毗邻肝脏、肾门等脏器3例；转移性肿瘤1例.≥2个原因的患者6例.手术均在全麻下进行,采用健侧卧位经腹腔途径结肠旁沟入路,左侧肿瘤使用4个套管（3个达芬奇机器人专用套管,1个辅助孔）,右侧肿瘤使用5个套管（3个达芬奇机器人专用套管,2个辅助孔）. 结果 14例手术均获成功,无中转开放病例.机器人平均定位时间为10 min；手术时间30～120 min,平均73 min；术中出血量10～ 400 ml,平均111 ml,术中均未输血.术后住院时间4.0～ 10.0 d,平均5.7 d.术后病理诊断为嗜铬细胞瘤3例（含1例副神经节瘤）,大结节性增生1例,结节增生伴皮质腺瘤2例,单纯皮质腺瘤4例,髓样脂肪瘤1例,肺癌肾上腺转移肿瘤1例,复杂性肾上腺囊肿1例（支气管源性）,钙化囊肿1例.术后随访2～ 10个月,未见肿瘤复发.结论 对于传统腹腔镜手术治疗困难的复杂肾上腺肿瘤患者,可考虑选择机器人辅助腹腔镜手术.

Objective To discuss the feasibility, safety and efficacy of robot-assisted laparoscopic adrenalectomy（RALA） in the treatment of complicated adrenal tumors that unfit for conventional laparoscopic adrenalectomy. Methods Fourteen patients with complicated adrenal tumors underwent RALA from Au- gust 2012 to March 2013. Five patients were male and 9 patients were female. Preoperative ultrasound and CT scan indicated that tumors of 10 patients were in the left side, and 4 in the right. Images showed that the maximum diameters of the tumors were 2.5-10.0 cm, with an average of 5.2 cm. The reasons to choose RALA were as follows： large tumors （ ~〉5 cm） in 9 cases, patients＇ overweight or obesity in 7 cases, the need or the desire to save the normal adrenal tissue in a great extent in 4 cases, tumors compressing large vessels or important organs in 3 cases, the possibility that the tumor may be a metastasis in 1 case. Six cases had 2 or more reasons described above. All surgeries were performed by lateral transperitoneal approach star- ted with the paracolic gutter. General anesthesia was used in all cases. Four trocars （ 3 robotic arms and 1 as- sistant port） were used in the left-sided adrenalectomies and 5 trocars （3 robotic arms and 2 assistant ports） were used in the right-sided adrenalectomies. Results All the operations were successful without conver- sion to open surgery. The mean docking time of da Vinci surgical system was 10 min. The operative time was 30-120 min, with an average of 73 min. The estimated blood loss was 10-400 ml, with an average of 111 ml. No transfusion was needed during the surgeries. The length of postoperative hospital stay was 4.0-10.0 d, with an average of 5.7 d. Postoperative pathology showed pheochromocytoma in 3 cases （ including 1 para- ganglioma） , macronodular adrenal hyperplasia in 1 case, adenoma with hyperplasia in 2 cases, adenoma in 4 cases, myelolipoma in 1 case, metastatic tumor in 1 case, large cyst in 1 case, calcified cyst in 1 case. No recurrence was found during the follow-up of 2 to 10 months. Conclusion For patients with adrenal tumors that unfit for conventional laparoscopie surgery, RALA may provide an alternative option for the ad- vantage of delicate manipulation and three-dimensional magnifying image.