机器人、腹腔镜以及开腹肝切除术治疗肝内胆管结石的对比研究

A comparative study of robotic,laparoscopic or open hepatectomy for hepatolithiasis

目的:探讨比较机器人、腹腔镜、开腹肝切除术治疗肝内胆管结石的安全性和有效性。方法:回顾性分析2019年5月—2020年4月在南京大学医学院附属鼓楼医院肝胆外科接受达芬奇机器人辅助肝段切除手术治疗的肝内胆管结石患者23例,同时纳入腹腔镜手术(20例)、开腹手术(25例)治疗的肝内胆管结石患者作为对照,比较3组患者基本临床信息、手术时间、失血量、输血情况、肝门阻断情况、术后住院时间、术后肛门排气时间、术后进食时间、下床活动时间、视觉模拟评分(visual analogue scale,VAS)、肝功能、并发症等情况。结果:机器人组手术时间与腹腔镜组相近,均长于开腹组;由于机器人装机消耗一定时间,去除装机时间以后,机器人组实际手术操作时间与开腹组相近。术中出血方面,机器人组出血量最少,腹腔镜组次之,开腹组最多。全肝门阻断方面,机器人组和腹腔镜组的肝门阻断比例明显低于开腹组。此外,机器人与腹腔镜在促进术后恢复方面整体优于开腹手术,包括术后住院时间更短、肛门通气更快、术后进食更早、下床活动更快以及VAS更低。3组患者的术后肝功能以及并发症发生率没有统计学差异。结论:机器人手术以及腹腔镜手术能够有效减少肝内胆管结石肝切除手术出血量,降低全肝门阻断率,促进术后恢复。尤其在缩短手术操作时间、降低出血量、加快术后出院方面,机器人手术明显优于腹腔镜手术。

Objective:To explore and compare the safety and effectiveness of robotic,laparoscopic,and open hepatectomy for hepatolithiasis. Methods:A retrospective analysis of 23 patients with hepatolithiasis who underwent Da Vinci robot-assisted hepatectomy at the Department of Hepatobiliary Surgery,Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School from May 2019 to April 2020,was conducted. At the same time,patients who underwent laparoscopic(20 cases)or open hepatectomy(25 cases)for hepatolithiasis were included as controls,in order to make a comparison on the basic clinical information,operation time,blood loss,blood transfusion rate,hepatic port occlusion rate,postoperative hospital stay,postoperative anal exhaust time,postoperative oral intake time,off-bed activity time,visual analogue scale(VAS),liver function,complications,etc.Results:The operation time of the robot group was similar to that of the laparoscopy group,and both were longer than the laparotomy group. There was a long setup time in robot group. When the setup time was excluded,the operative time of the robot group was similar to that of the laparotomy group. As to intraoperative blood loss,the robot group was the least,followed by the laparoscopic group,and the laparotomy group was the most. In terms of total hilar occlusion,the rate of hilar occlusion in the robot group and laparoscopic group was significantly lower than that in the laparotomy group. In addition,robot and laparoscopy hepatectomy were overall superior to open surgery in promoting postoperative recovery,including shorter postoperative hospital stay,faster anal ventilation,earlier oral intake,faster get-out-of-bed,and lower VAS. There was no statistical difference in postoperative liver function and complication rate among the three groups. Conclusion:Robotic and laparoscopic hepatectomies were significantly associated with less intraoperative blood loss,lower rate of total hepatic port occlusion,and better postoperative recovery. Compared with laparoscopic hepatectomy,robotic hepatectomy was associated with significantly less intraoperative blood loss,a shorter operative time,and a shorter postoperative hospital stay.