两种通道布局对儿童机器人辅助腹腔镜左侧肾盂成形术影响的对比分析

Effects of two channel layouts on left robot-assisted laparoscopic pyeloplasty in children

目的:分析两种通道布局对儿童机器人辅助腹腔镜左侧肾盂成形术的影响,探讨改良通道布局在该术式中的可行性与安全性。方法:我院2018年3月—2020年3月接受机器人辅助腹腔镜左侧肾盂成形术的肾盂输尿管连接部梗阻患儿共143例。其中传统组(采用传统通道布局)患儿103例,改良组(采用改良通道布局)40例。传统组通道布局于脐部建立8.5 mm镜头通道,脐下正中Pfannenstie线上建立8 mm 1号机械臂通道,以脐为中心正中线上1号机械臂对称点处建立8 mm 2号机械臂通道,在Pfannenstie线上于1号机械臂通道健侧3 cm处建立3 mm辅助通道;改良组通道布局于脐窝下缘建立8.5 cm套管作为镜头通道,于脐窝上缘建立8 mm 2号机械臂通道,于Pfannenstie线处建立8 mm的1号机械臂通道。1号机械臂操作通道健侧3 cm Pfannenstie线上建立3 mm辅助通道。比较两组患儿手术时间、术中出血量、机械臂干扰次数、术后并发症及术后6个月随访情况。结果:传统组与改良组手术均顺利完成,无中转开放手术。传统组术中无增加辅助通道,改良组3例患儿增加1个3 mm辅助通道。传统组Docking时间(9.2±2.6)min,改良组(14.7±3.1)min;传统组机械臂操作时间(108.0±10.2)min,改良组(123.5±14.1)min;传统组机械臂干扰次数(3.7±1.2)次,改良组(7.6±1.2)次。术后外观满意度评分传统组(1.3±0.4)分,改良组(2.3±0.4)分。两组Docking时间、机械臂操作时间、机械臂干扰次数以及术后外观满意度比较均差异有统计学意义(均P<0.05)。传统组出血量(9.5±2.5)mL,改良组(9.9±2.4)mL。两组患儿术后均未发生吻合口狭窄、再梗阻等ClavienⅢ~Ⅳ级并发症。传统组术后ClavienⅠ~Ⅱ级并发症发生率为22.6%,改良组为23.4%,经过内科保守治疗后均可治愈。传统组术后住院时间(6.2±1.5)d,改良组(7.1±1.5)d;两组患儿术中出血量、术后并发症发生率及术后住院时间比较均差异无统计学意义。两组患儿术后随访泌尿系超声肾盂前后径均较术前明显减小(均P<0.05),利尿性肾核素扫描均较术前改善(均P<0.05)。结论:改良通道法可以在儿童机器人辅助腹腔镜左侧肾盂成形术中安全开展,可取得与传统通道布局相当的治疗效果,术后患儿外观满意度高;该技术将镜头通道及2号机械臂操作通道集中于脐缘,可作为以后开展单孔机器人辅助腹腔镜肾盂成形术的技术过度。

Objective To analyze the effects of two different channel layouts on robot-assisted laparoscopic left pyeloplasty in children,and to explore the feasibility and safety of modified channel layout in this operation.Methods From March 2018 to March 2020,143 children with ureteropelvic junction obstruction underwent robot-assisted laparoscopic left pyeloplasty.Among them,there were 103 children in the traditional group(using traditional channel layout),and 40 children in the modified group.In the traditional group,an 8.5 mm lens channel was established at the umbilical region,an 8 mm No.1 robotic arm channel was established at the median Pfannenstie line below the umbilical region,and an 8 mm No.2 robotic arm channel was established at the symmetry point of No.1 robotic arm on the median line with the umbilical region as the center,an auxiliary channel of 3 mm was established on the Pfannenstie line at 3 cm from the healthy side of the channel of the first robotic arm.In the modified group,an 8.5 cm cannula was established at the lower edge of the umbilicus as the lens channel,an 8 mm No.2 robotic arm channel was established at the upper edge of the umbilicus,and an 8 mm No.1 robotic arm channel was established at the Pfannenstie line.A 3 mm auxiliary channel was established on the 3 cm Pfannenstie line on the healthy side of the manipulator arm 1.The operation time,intraoperative blood loss,interference times of mechanical arm,postoperative complications and follow-up at 6 months after operation were compared between the two groups.Results The operations of the traditional group and the modified group were successfully completed without conversion to open surgery.No auxiliary channel was added in the traditional group,and an auxiliary channel of 3 mm was added in 3 children in the modified group.The Docking time was(9.2±2.6)min in the traditional group and(14.7±3.1)min in the modified group.The operation time of the robotic arm was(108.0±10.2)min in the traditional group and(123.5±14.1)min in the modified group.The interference frequency of the traditional group was(3.7±1.2)times,and the modified group was(7.6±1.2)times.The postoperative appearance satisfaction score was(1.3±0.4)in the traditional group and(2.3±0.4)in the modified group.There were significant differences in Docking time,robotic arm operation time,robotic arm interference times,and postoperative appearance satisfaction between the two groups(all P<0.05).The blood loss was(9.5±2.5)mL in the traditional group and(9.9±2.4)mL in the modified group.There were no ClavienⅢ-Ⅳcomplications such as anastomotic stenosis or re-obstruction in the two groups.The incidence of postoperative ClavienⅠ-Ⅱcomplications was 22.6%in the traditional group and 23.4%in the modified group,which were cured by conservative medical treatment.The postoperative hospital stay was(6.2±1.5)days in the traditional group and(7.1±1.5)days in the modified group.There were no significant differences in intraoperative blood loss,postoperative complications,or postoperative hospital stay between the two groups.The anteroposterior diameter of the renal pelvis in the two groups were significantly reduced(both P<0.05),and the diuretic renal radionuclide scan were improved(both P<0.05).Conclusion The modified channel method can be safely carried out in robot-assisted laparoscopic left pyeloplasty in children,it can achieve the same therapeutic effect as the work transfer channel layout.This technique concentrates the lens channel and the No.2 robotic arm operation channel at the umbilical margin,which can be used as a technical transition for single-port robot-assisted laparoscopic pyeloplasty in the future.