机器人辅助肛门成形术治疗先天性肛门闭锁9例

Robotic-assisted Anorectal Pull-through for Anorectal Malformations in 9 Infants

目的探讨机器人辅助肛门成形术治疗先天性肛门闭锁的可行性和近期疗效。方法 2016年10月~2017年10月,应用机器人辅助肛门成形术治疗男性中、高位肛门闭锁9例(2例直肠膀胱颈瘘,2例直肠前列腺部尿道瘘,5例直肠尿道球部瘘),平均年龄4.7月(3~9月)。仰卧位,三孔法,使用Si型da Vinci机器人手术系统,单极电凝游离松解直肠系膜,在直肠固有筋膜下游离盲端及瘘管,直至末端切断,机器臂缝扎瘘口。镜头直视下经横纹肌复合体中心建立盆底隧道,将直肠从中拖出,与会阴皮肤间断吻合。结果 9例均在机器人辅助下完成肛门成形术,平均手术时间116 min(105~130min),人机对接时间平均42 min(35~50 min),操作台手术时间平均31.4 min(26~38 min)。术中解剖层次清晰,几乎无出血,无术中并发症。术后住院时间平均10.2 d(7~14 d)。平均随访10个月(6~15个月),肛门功能评分优6例,良3例(污便)。2例肛门狭窄。经保守治疗,连续随访半年,污便与肛门狭窄逐渐好转。结论 da Vinci机器人手术系统解剖瘘管精细、清晰,瘘口缝合严密、可靠,完整保护盆底神经和外括约肌系统,近期疗效满意。

Objective To evaluate the feasibility and short-term outcome of robotic-assisted anorectal pull-through for anorectal malformations in infants. Methods From October 2016 to October 2017, 9 male infants with anorectal malformations, including 2 cases of recto-bladder neck fistula, 2 cases of recto-prostate fistula, and 5 cases of recto-bulbar fistula, were treated by robotic-assisted anorectal pull-through. Their mean age was 4.7 months （range, 3-9 months）. Three trocars were used. The patient was placed in supine position followed by insertion of trocars. The da Vinci Si robotic system was utilized. With the help of robotic hook, the rectum was mobilized by dividing the peritoneal folds on either side at the level of peritoneal reflection. Distal dissection was carried out under proper fascia of rectum until the end of fistula was identified. It was divided and repaired robotically. Guided by robotic visualization, an accurate pull-through canal was created with pelvic floor muscles surrounding it symmetrically. Then rectum was exteriorized to the perineum through this canal. Anorectal anastomosis was performed with interrupted suture. Results Nine patients underwent robotic-assisted anorectal pull-through successfully without intraoperative complications. The mean operative time was 116 min （range, 105-130 min）. The mean docking time was 42 min （range, 35-50 min）. The mean time at console was 31.4 min （range, 26-38 min）. Anatomical layers and details of tissue were clearly identified during the surgery, with little blood loss. No intraoperative complications occurred. The mean time of postoperative hospitalization was 10.2 days （range, 7-14 d）. During the follow-ups for a mean of 10 months （range, 6-15 months）, there were 6 cases of good anus function scores and 3 cases of fair （soiling）. Two patients experienced stricture of anus, and their defecation functions showed favourable evolution during 6-month follow-ups after conservative treatment.Conclusions The da Vinci robotic system allows better dissection and easier closure of fistula. It minimizes side injury of pelvic nerves and external sphincter by dissection under the proper fascia of rectum and accurate creation of pull-through canal. Early outcomes are encouraging, though further evidences of larger trails and long-term follow-ups are need