机器人保留脾血管胰体尾切除术治疗儿童胰岛素瘤报道

First report of robotic spleen-preserving distal pancreatectomy for children suffered from insulinoma

目的报道国内外首例儿童机器人保留脾血管胰体尾切除术,探讨该方法治疗儿童胰腺良性疾病的可行性和安全性。方法 2016年7月收治1例儿童胰体尾胰岛素瘤病例,患儿女性,9岁,体质量24 kg,身高1.20 m。行机器人保留脾血管的胰体尾切除术。机器人操作时采用4孔法:自脐下缘微小切口置入气腹针建立气腹后缝合该切口,观察孔位于下腹正中脐下5 cm(10 mm),1臂位于左侧平脐水平与腋前线的交点(8 mm),2臂位于右侧脐水平下2 cm与腋前线交点(8 mm),辅助孔位于左侧锁骨中线脐水平下3 cm(12 mm)。用超声刀切开胃结肠韧带,显露胰腺,腹腔镜超声探查证实病灶位于胰尾,直径约2 cm;切断脾结肠韧带,结肠脾曲向下游离;用电凝沿胰腺下缘分离胰后间隙,向脾门进行,将胰尾与脾脏之间的粘连分开,于胰腺后方分离出脾静脉,胰腺上缘分离出脾动脉,逐一分离夹闭或缝合动静脉与胰腺之间的分支,使胰尾完全游离,距离肿瘤右侧约1 cm以直线切割闭合器蓝色钉仓切断胰体尾,胰腺断端以4-0 Prolene线连续缝合。标本装入一次性标本袋自辅助孔取出,胰腺断端放置乳胶引流管1根自腹壁右侧孔引出。结果手术时间155 min,气腹时间120 min,术中出血量约10 ml,围手术期恢复顺利,无胰瘘、出血及腹腔感染等并发症。术后血糖恢复正常,空腹胰岛素及血糖比值小于0.4,胰腺MRI平扫及增强扫描显示胰腺无肿瘤残留。结论机器人与传统腹腔镜相比,具有三维视野、操作灵活等优点,该病例的成功经验初步显示机器人保留脾血管的胰体尾切除术治疗儿童胰岛素瘤是安全、可行的。

Objective To report the first case of robotic-assisted splenic vascular preserving distal pancreatectomy for child patient in China,and to investigate the feasibility and safety of this surgical method in the treatment of children＇s benign pancreatic diseases. Methods A 9-year-old female patient（ 24 kg in weight and 1. 20 m in height） diagnosed with insulinoma in the tail of pancreas was hospitalized in Jul. 2016 and was treated with robotic-assisted splenic vascular preserving distal pancreatectomy. The pneumoperitoneum was established with Veress needle through a minor incision in the inferior edge of umbilicus and the incision was closed whereafter. The robotic-assisted procedure was performed with four ports： a 10 mm optical port in the ventral midline 5 cm blow the umbilicus,an 8 mm port for the first robotic arm in the left anterior axillary line at the level of umbilicus,an 8 mm port for the second robotic arm in the right anterior axillary line 2 cm below the level of umbilicus,a 12 mm assistant port in the left midclavicular line 3 cm below the level of umbilicus. The gastrocolic ligament was divided by ultrasonic scalpel to expose the pancreas. The tumor was identified in the tail of pancreas using laparoscopic ultrasound,with a diameter of 2 cm. Then the splenocolic ligament was divided and splenic flexure was dissected downwards. The pancreas was separated from the retroperitoneal tissues with robotic hook cautery along the inferior border of pancreas towards the splenic hilum. After division of adhesion between the tail of pancreas and spleen,the splenic vein and artery were dissected off the posterior of pancreas and superior edge of pancreas,respectively. The branches of splenic vessels into the pancreas were progressively ligated or sutured to free the tail of pancreas completely. Subsequently,the distal pancreas was transected using laparoscopic linear stapler（ Echelon 60,blue cartridge,Ethicon Endo-Surgery,Cincinnati,OH,United States） 1 cm from the right side of the tumor. The cut edge was continuously sutured using 4-0 Prolene. The resected specimen was transferred into the endo-bag and removed through the assistant port. A rubber drainage tube along the cut edge of pancreas was brought out through a stab incision on the right side of abdominal wall. Results The operative time was 155 minutes and the pneumoperitoneum time was 120 minutes. The estimated blood loss was 10 ml. The postoperative recovery was smoothly,without complications like pancreatic fistula,bleeding and infection,etc. The blood glucose was restored normal with a fasting insulin to glucose ratio less than0. 4. Unenhanced and contrast-enhanced MRI showed no sign of tumor residue. Conclusions Compared with traditional laparoscopic procedure,robotic-assisted surgery has advantages including three-dimensional vision and flexible manipulation,etc. The successful operation of this case initially ascertained the safety and feasibility of robotic-assisted spleen-preserving distal pancreatectomy in the treatment of insulinomas in children.