机器人辅助腹腔镜下应用第三臂经腹膜外途径保留肾单位手术治疗复杂性肾肿瘤的可行性

Utility of the third arm in robot-assisted laparoscopic partial nephrectomy for complex renal tumor

目的探讨应用机器人第三臂完成经腹膜外途径保留肾单位手术治疗复杂性肾肿瘤的安全性与可行性。 方法2015年11月至2017年1月收治的36例复杂性肾肿瘤患者。年龄19～71岁，平均（53.2±12.9）岁。体重指数21.1～32.0 kg/m2，平均（25.8±5.6）kg/m2。肾门肿瘤12例，中央型肾肿瘤11例，完全内生型肾肿瘤7例，多发性肾肿瘤6例。肿瘤位于左肾15例，右肾21例。肿瘤直径为4～14 cm，平均（3.7±6.1）cm。36例均行经腹膜外途径机器人辅助肾部分切除术，手术均由同一术者完成。于腋中线髂嵴上2横指处置入镜头孔套管，分别于与镜头孔同一平面的腋后线和腋前线处置入2个8 mm套管，保持与镜头孔8 cm的工作间隙。助手直视下沿腹壁肌肉后鞘向腹中线方向推开腹膜，避免损伤腹膜，并在腹直肌旁镜头孔平面置入第三臂8 mm套管。术中应用第三臂配合完成各项操作。 结果36例均顺利建立第三臂及腹膜外空间并顺利完成手术，无中转开放或改行其他术式。控制台时间98～357 min，平均（127±21）min。热缺血时间为12～38 min，平均（25.5±8.3）min。术中估计失血量50～510 ml，平均（198.0±201.5）ml。术后1例因出血予输血治疗并急诊行数字减影血管造影高选择性动脉栓塞。术后病理检查诊断为肾透明细胞癌12例，血管平滑肌脂肪瘤16例，嫌色细胞癌6例，嗜酸细胞癌2例。无切缘阳性病例。术后随访3个月，eGFR平均降低4.3 ml/（min·1.73m2），无复发或转移病例。 结论机器人第三臂的应用在经腹膜外途径复杂性肾肿瘤保留肾单位手术中最大程度增加了术者的自主性。机器人第三臂在复杂位置肿瘤的暴露牵拉、畸形血管的钳夹阻断、狭小空间内肾动脉夹的释放与回收、残肾重建等方面能克服经腹膜外途径空间有限的缺点，最大限度发挥经腹膜外途径对腹腔脏器影响小、安全可靠、术后并发症少的特点。

ObjectiveTo assess the safety and feasibility of utility of the third arm in robotic partial nephrectomy（RPN） through retroperitoneal approach for complex renal tumor. Methods36 robotic-assisted partial nephrectomy were performed by one surgeon between November 2015 and January 2017, including hilar tumors in 12 cases, central tumors in 11 cases, endophytic tumors in 7 cases and multiple tumors in 6 cases. A 12 mm camera port is placed 2 fingerbreadth above iliac crest. The lateral and medial robotic trocars are placed in the posterior axillary line and anterior axillary plane respectively parallel to the cameraport trocar. Under direct visualization, the peritoneum is swept medially towards the paramedianplane.The fourth arm trocar is placed in the most medial and inferior aspect of the field approximately 7 cm to 8 cm across and parallel to the medial robotic trocar. Descriptive statistics on patient characteristics, operative parameters, and oncologic outcomes are analyzed. ResultThe 4-arms retroperitoneal approach was used in all patients without any conversion. Mean console time was 127±21（98-357）min. Mean ischemia time was 25.5±8.3（12-38）min, Mean estimated blood lost was 198±201.5（50-510）ml. No patients required blood transfusion, except one case underwent selective intra-arterial embolization with DSA（digital subtraction angiography） and blood transfusion post-operatively. Pathology revealed renal cell carcinoma in 12 patients, angiomyolipoma in 16 patients, chromophobe renal cell carcinoma in 6 cases, oncocytoma in 2 cases and all had negative surgical margins. Under 3 months follow-up, Mean decrease in eGFR was 4.3 ml/（min·1.73m2）. No patients found recurrence or metastasis. ConclusionsThe third robotic arm provides the console surgeon maximal independence from the surgical assistant when performing kidney retraction, ligation or clamping of renal hilar vessels in complex renal morbidities. It would be beneficial for patient with merits of retroperitoneal approach and overcomes limited space during RPN.