机器人辅助腹腔镜前列腺癌根治术经腹膜途径和腹膜外途径术后肺不张观察

Transperitoneal versus extraperitoneal robot-assisted laparoscopic radical prostatectomy： a prospective study of perioperative atelectasis by lung ultrasound

应用肺部超声技术比较经腹膜途径机器人辅助腹腔镜前列腺癌根治术（transperitoneal robot-assisted laparoscopic radical prostatectomy, T-RLRP）和腹膜外途径机器人辅助腹腔镜前列腺癌根治术（extraperitoneal robot-assisted laparoscopic radical prostatectomy, E-RLRP）术后肺不张情况。 方法 采用随机数字表法将40例患者分为T-RLRP组和E-RLRP组，每组20例。两组患者分别于麻醉前（T0），建立气腹和Trenderlenburg体位后60 min（T1）、120 min（T2）和气管拔管后（T3），抽取桡动脉血，观察PaO2/FiO2和PaCO2；记录气腹和Trenderlenburg体位后120 min内的平均气道压；术毕拔管前，肺部超声下观察患者肺不张程度。 结果 术中T-RLRP组的平均气道压高于E-RLRP组（P＜0.05）。T-RLRP组PaO2/FiO2水平T1和T2时点明显低于T0水平（P＜0.05，P＜0.01），T2时点低于T1时点水平（P＜0.05）。E-RLRP组在T2时PaO2/FiO2水平低于T0（P＜0.05），T1、T2和T3时点PaO2/FiO2水平均明显高于T-RLRP组（P＜0.01，P＜0.05，P＜0.05）。两组T1和T2时点PaCO2明显高于T0（P＜0.01），T-RLRP组T1和T2时点PaCO2均高于E-RLRP组（P＜0.05）。术毕肺部超声显示肺不张1级、2级和3级，T-RLRP组比例均明显高于E-RLRP组（P＜0.01）。 结论 相比T-RLRP组，E-RLRP对患者术中和术后氧合影响更小，术后肺不张发生程度更轻。

Objective To compare perioperative atelectasis occurs during transperitoneal robot-assisted laparoscopic radical prostatectomy（T-RALRP） with extraperitoneal robot-assisted laparoscopic radical prostatectomy（E-RALRP） detected by lung ultrasound. Methods Forty patients without pulmonary comorbidities who were scheduled for Robot-assisted laparoscopic radical prostatectomy were enrolled in the study and underwent either transperitoneal or extraperitoneal robot-assisted laparoscopic radical prostatectomy. For all the patients, the MAP was recorded. Arterial blood gas was monitored and recorded before anesthesia （T0）, 60 min （T1） and 120 min （T2） after pneumoperitoneum and Trendelenberg position was achieved, and after extubation （T3）. Before extubation, a total of 240 pairs of lung ultrasound clips were ultimately analyzed to determine the presence and classification of atelectasis in 12 prescribed lung regions. Results No significant difference was found for age, body mass index, blood loss, total operation time, PaCO2 and PaO2/FiO2 before anesthesia. T-RALRP had higher MAP （P〈0.05）. Compared with T0, T-RALRP, PaO2/FiO2 decreased at T1 and T2 after pneumoperitoneum and Trendelenberg position （ P〈0.05, P〈0.01）. Whereas, PaO2/FiO2 for E-RALRP decreased at T2（P〈0.05）. PaO2/FiO2 values for T-RALRP at T1, T2 and T3 were all lower than value in E-RALRP （P〈0.01, P〈0.05, P〈0.05）. PaCO2 showed significant increase at T1 and T2 in both group （P〈0.01）, but the value of PaCO2 in T-RALRP at T1 and T2 were all higher than the value of E-RALRP （P〈0.05）. The degrees of 1, 2, 3 of atelectasis detected by lung ultrasound showed significant difference between T-RALRP and E-RALRP （42% vs 28%, 14% vs 5%, 4% vs 2%, P〈0.01）. Conclusions Extraperitoneal robot-assisted laparoscopic radical prostatectomy seems to be less impact on perioperative PaO2/FiO2 and the severity of postoperative atelectasis.