达芬奇机器人辅助直肠癌手术的流程化:单中心经验

Process of Leonardo da Vinci robot-assisted rectal cancer surgery:single center experience

目的探讨第四代达芬奇机器人Xi系统在直肠癌手术中的应用,以期程序化其手术操作。方法针对以往腹腔镜手术和机器人手术中的要点和难点,总结2020年10月至2021年12月我科收治的100例直肠癌患者的临床经验,术中采取各种技术手段进行调整和改进:从操作孔的设计、机械臂的摆放、不同术野的显露方法、层面张力的维持、筋膜组织的辨识、正确的筋膜间隙分离手法等方面进行分析和总结,制定了“流程化”的手术操作过程。结果机器人手术术中平均出血量(55.2±29.8)mL,术后胃肠功能恢复时间(38.8±11.2)h,饮食恢复时间(2.6±0.8)d,拔除尿管时间(3.3±1.4)d,淋巴结清扫数目(22.9±6.2)枚,手术时间(170.1±11.8)min,住院费用(8.1±1.3)万元。术后6、9和12个月随访Wexner、LARS评分、IPSS评分,患者对排便功能、排尿功能的满意度较高。术后平均随访18个月,均未见局部复发、远处转移及患者死亡。结论对机器人直肠癌手术的操作方法进行程序化、流程化有利于手术层面的解剖和游离,可实现高质量的TME手术,操作简单易行,并且利于缩短机器人手术学习曲线,促进团队配合。

Objective To explore the application and experience of the fourth generation da Vinci surgical robot Xi system in rectal cancer surgery,and to programmed and standardized the surgical procedure.Methods In view of the key points and difficulties in previous laparoscopic surgery and robotic surgery,100 rectal cancer patients treated in our department from October 2020 to December 2021 were summarized.Various technical means were adopted to adjust and improve,including the design of operating hole,the placement of the robot arm,the exposure methods of different surgical fields,the maintenance of plane tension,the identification of fascia tissue,the correct dissection technique of fascia space,etc.The programmed procedure of robotic rectal cancer surgery was established based on the surgical operating improvements mentioned above.Results The average intra-operative blood loss,post-operative gastrointestinal function recovery time,diet recovery time and catheter removal time were 55.2±29.8 mL,38.8±11.2 h,2.6±0.8 d and 3.3±1.4 d,respectively.The number of lymph node dissection was 22.9±6.2,the operation time was 170.1±11.8 min,and the average hospitalization cost was 81±13 thousand yuan in the robot cases.The Wexner,LARS and IPSS scores were followed up at 6,9 and 12 months after the operation,and the patients appeared high satisfaction with defecation function and urination function.During average 18 months follow-up,there was no local recurrence,distant metastasis and death.Conclusion The programmed and standardized procedure of robotic rectal cancer surgery is conductive to dissection and dissociation at the surgical level,achieve high-quality of TME surgery,easy to operating,shorten the robot learning curve and promote team cooperation.