三孔法腹腔镜直肠前切除术操作难度的影响因素

Factors affecting the difficulty of laparoscopy-assisted triple-port anterior resection

目的探讨影响三孔法腹腔镜（TLS）直肠前切除术手术操作难度的因素。方法采用回顾性病例对照研究的方法，分析2013—2016年间在上海交通大学医学院附属瑞金医院结直肠外科病区行TLS结直肠手术治疗的106例结直肠癌患者临床及MRI影像资料。纳入标准：（1）TLS根治性直肠前切除（Dixon）手术患者；（2）肿瘤分期为Ⅰ-Ⅲ期的恶性肿瘤；（3）肿瘤下缘距肛缘5-15 cm；（4）能够获取术前直肠MRI检查图像。排除标准：（1）术前辅助治疗者；（2）低位直肠肿瘤者；（3）肿瘤周围侵犯者。利用术前直肠磁共振（MRI）图像行骨盆测量（MRI矢状位上选取第1骶椎上缘、第3骶椎上缘、尾骨尖、耻骨联合上缘连线形成五边形，5条径线分别标记为N、O、P、Q、R，5个夹角分别标记为角1、2、3、4、5）、脏器测量（子宫和前列腺）和肿瘤测量（横径、纵径、切面积、病灶长度以及环周切缘距离）；以手术时间作为衡量手术难度的标准，根据手术时间中位数进行分组，比较不同手术时间患者的一般情况（年龄、性别、体质指数、肿瘤距肛缘距离、既往手术史和肿瘤长径）、术前肿瘤TNM分期、MRI测量（骨盆、肿瘤、子宫及前列腺）等，多因素logistic分析影响TLS直肠前切除术手术难度的因素。结果全组男73例，女33例，年龄（59.8±12.2）岁，体质指数（22.8±3.3）kg/m^2，既往有腹部手术史25例，肿瘤距肛缘距离（7.4±2.0）cm，肿瘤长径（3.7±1.4）cm；肿瘤TNM分期：Ⅰ期24例，Ⅱ期36例，Ⅲ期46例。全组患者均顺利完成TLS手术，中位淋巴结清扫数13（11-16）枚，中位远切端长度2.5（2.0-3.1）cm，中位手术时间2.0（1.5-2.6）h，中位术中出血量50（0-100）ml，中位术后进食流质时间4（3-5）d，中位住院时间7（6-10）d，短期并发症10例（9.4%）。根据患者手术时间中位数（2 h）为分组标准，分为手术时间≤2 h组和〉 2 h组，每组均为53例。与手术时间≤2 h组比较，手术时间〉2 h组者的肿瘤距肛缘距离更短[（6.8±1.5）cm比（8.0±2.4）cm，t=3.174，P=0.004]、骨盆测量的（R＋N）/（O＋P）更小（1.61±0.27比1.73±0.19，t=2.494，P= 0.014）、肿瘤横径更大[（3.45±0.72）cm比（3.05±0.89）cm，t=0.224，P=0.027]。多因素logistic回归分析显示，肿瘤距肛缘距离是手术难度的独立影响因素（OR=0.584，95%CI：0.429-0.796，P=0.001）。结论肿瘤距肛缘距离长的患者行TLS手术难度相对较小，术前应综合评估手术难度，以肿瘤距肛缘距离作为主要衡量难度依据，以（R＋N）/（O＋P）和肿瘤最大横径作为重要参考因素，为不同阶段TLS术者选择不同难度的病例，以顺利渡过TLS手术学习曲线。

Objective To explore the factors affecting the operative difficulty of triple-port laparoscopic surgery （TLS） in anterior resection. Methods A retrospective case-control study was carried out. Clinical and MRI imaging data of 106 colorectal cancer cases undergoing TLS anterior resection at Department of Colorectal Surgery of Ruijin Hospital between 2013 and 2016 were retrospectively analyzed. Inclusion criteria： （1） patients receiving TLS anterior resection （Dixon operation）; （2） preoperative stage I to Ill malignant tumor; （3） distance of 5-15 cm from inferior margin of tumor to anal verge; and （4） available preoperative rectal MRI. Exclusion criteria： （1） patients receiving preoperative adjuvant therapy; （2） patients with low rectal cancer or with local advanced disease; （3） T4b tumor. Rectal MRI was introduced to measure the structure of pelvis. In sagittal view, superior margin of the first sacral vertebrae, superior margin of the third sacral vertebrae, apex of coccyx, and the line of superior margin of pubic symphysis were used to form a pentagon. The 5 lines were marked as N, O, P, Q, R, and the 5 included angles were marked as angle 1, 2, 3, 4, 5. Organs （uterus and prostate） and tumor （transverse diameter, longitudinal diameter, section area, lesion length, distance to circumference cutting edge） were also measured on MRI. The operative time was applied to be the indicator of operative difficulty and patients were divided into 2 groups according to median operative time. Baseline information （age, gender, BMI, distance from inferior margin of tumor to anal verge, operative history, length of tumor）, preoperative tumor staging, and MRI measurements （pelvis, tumor, uterus, prostate）, etc were compared between two groups. Factors affecting operative difficulty of TLS were analyzed with logistic regression model. Results Of 106 enrolled patients, 73 were male and 33 female with mean age of （59.8±12.2） years and mean BMI of （22.8±3.3） kg/m^2; 25 patients had previous abdominal surgery; distance from inferior margin of tumor to anal verge was （7.4±2.0） cm and the tumor diameter was （3.7±1.4） cm; 24, 36 and 46 patients were in stage Ⅰ, Ⅱ and Ⅲ respectively. All operations were completed successfully. The median number of harvested lymph node was 13 （11-16）; the median length of distal resection margin was 2.5（2.0-3.1） cm; the median operative time was 2.0（1.5-2.6） hours; the median intraoperative blood loss was 50（0-100） ml; the median time to liquid diet was 4（3-5） days; the median hospital stay was 7 （6-10） days. Ten cases （9.4%） developed complications within 30 days after surgery. Patients were divided into ≤ 2 h group and 〉 2 h group according to median operative time, and both groups had 53 patients. As compared to ≤ 2 h group, 〉2 h group had shorter distance from inferior margin of tumor to anal verge [（6.8 ± 1.5） cm vs. （8.0 ± 2.4） cm, t= 3.174, P= 0.004], lower ratio of （R±N）/（O＋P） （ 1.61±0.27 vs. 1.73±0.19, t = 2.494, P = 0.014）, larger transverse distance of tumor [ （3.45±0.72） cm vs. （3.05±0.89） cm, t = 0.224, P= 0.027]. Multivariate logistic regression analysis showed the distance from inferior margin of tumor to anal verge was the independent factor affecting operative difficulty （OR =0.584, 95%CI：0.429-0.796, P = 0.001）. Conclusions Surgeons may have less difficuhy in performing TLS anterior resection for patients with longer distance from inferior margin of tumor to anal verge. In preoperative assessment of operative difficulty of TLS, comprehensive evaluation should be performed. Distance from inferior margin of tumor to anal verge should be regarded as the main factor, and MRI （R＋N）/（O＋P） and transverse diameter of tumor should be used as important reference, leading to reasonable choice of cases for TLS and smooth pass of study curve.