机器人辅助腹腔镜小儿上尿路手术的体位、操作通道设计和机械臂安装应用体会

Patient positioning, port placements setting and robot cart docking in pediatric robot-assisted laparoscopic upper urinary tract operation

【摘要】目的总结机器人辅助腹腔镜小儿上尿路手术的体位、操作通道设计和机械臂安装应用体会。方法回顾性分析2017年3—12月解放军陆军总医院附属八一儿童医院140例行机器人辅助腹腔镜上尿路手术患儿的临床资料。男103例，女37例；年龄1个月至18岁，中位年龄2岁。肾盂输尿管连接处梗阻110例，重复肾输尿管畸形15例，多囊性肾囊肿8例，肾萎缩4例，肾上腺肿瘤3例。采用助手与器械护士相邻的手术布局方式，患侧垫高60。～80。足低健侧卧位，操作通道的建立采用分散式的半隐藏切口法：即经脐置人镜头孔操作通道，其余两器械臂操作通道分别置于剑突下和耻骨联合上腹横纹处，两操作通道距镜头孔的距离基本相等，辅助孔操作通道置于健侧腹横纹线上距正中线约3cm处。结果本组140例中，肾盂成形术110例，重复肾输尿管全长切除术15例，单纯肾切除术12例，肾上腺切除术3例。手术从切皮到机器人器械臂对接完成时间为（11．5±3．2）min（10．5～16．5min），手术时间（146．9±48．7）min（78—259min）。所有手术均顺利完成，无中转开放手术，1例外院行开放肾盂成形术后再次梗阻者术中粘连严重，于健侧上腹部增加1个辅助通道后完成手术。无胃肠道及其他脏器损伤等并发症发生。140例术后住院时间（5．7±1．4）d（4—10d）。术后6周体表基本无可视瘢痕，所有家长均对术后外观满意。术后随访1—9个月，中位时间6个月。110例行肾盂成形术患者术后积水明显减轻，15例重复肾输尿管切除和12例肾切除患者术后症状均消失，3例肾上腺肿物切除患者术后未见复发。结论良好的手术布局与体位摆放有利于手术团队术中协作、交流与配合，半隐藏切口法操作通道的设计充分发挥了机器人手术优势，有利于主刀医生灵活操作及其与助手有效配合，使手术更加安全、有效，有利于患者术后快速康复。

Objective To summarize the experience of patient positing, port placements setting and robot cart docking in pediatric robot-assisted laparoscopic upper urinary tract operations. Methods From March 2017 to December 2017, 140 robot-assisted laparoscopic upper urinary tract procedures were performed in our institution, including 110 cases of pyeloplasty, 15 upper pole heminephroureterectomy, 12 simple nephreetomy and 3 adrenaleetomy. There were 103 males and 37 females with a range age from 1 month to 18 years. The assistant surgeon was adjacent to the instrument nurse, and patients were placed in a supine posilion with 60° - 80° inelinalion and keep the legs low Io the body. Room setup and patienl positioning were similar to the traditional laparoseopie surgery. Semi-hidden incision technique was used in 140 palients： the camera port was placed umbilicus, two additional arm ports （one 5 mm and one 8 mm） were placed under direel vision, lhe 8, mm arm port was placed on the line tff a Pfannenstiel incision and the 5 mm arm port was placed helow the Xiphoid along the midline. Finally, a 3 or 5 mm assistant port was placed approximately 3 cm lateral to the interior arnl port, the line of a Pfannensliel incision. Results The average time was （ 11.5 ±3.2 ） min （ 10.5 - 16.5 min） from skin incision to robot cart docking eompleted. All surgeries wore successfully completed wilhoul open conversion. One palient required an additional assist port lot severe adhesion after the previously open surgery, there was no injury to other viscera. Average pera/ive time was （ 146.9 ± 48.7 ） rain （ 78 - 259 min） and average post-operative hospilalizalion time was （5.7 ±1.4） d（4 - 10 d）, respectively. There was no visual sear on abdominal 6 weeks postoperalively, trod all parents made comments about their satisfaction with the eosmelie appearance. All opera, lions gol complete success at a mean tbllow up of 6 （1 -9 ）months. Conclusions A good room setup, patie,patient posilioning and the semi-hidden incision technique port placements are maintaining the safety of the patient, avoiding compression injuries, allowing maximum mobility of the rohotie arms, and facilitating a smooth and effieient surgery, and improving posl-operative reeovery.