第四代达芬奇机器人经双侧腋窝乳晕入路甲状腺手术疗效单中心649例分析

Efficacy of bilateral axillo-breast approach thyroidectomy using the 4th-generation Da Vinci surgical robot:a single-center analysis of 649 cases

背景与目的:机器人系统在甲状腺外科的应用已逐渐扩展,但目前国内外针对第四代达芬奇机器人经双侧腋窝乳晕入路(BABA)的甲状腺手术大样本报道尚不多见。因此,笔者对所在中心所完成的第四代达芬奇机器人BABA甲状腺手术病例的治疗结果与经验进行总结,以期为临床提供参考信息。方法:回顾性收集吉林大学中日联谊医院甲状腺外科2020年4月—2023年8月开展第四代达芬奇机器人辅助下行BABA甲状腺手术649例的临床资料,总结分析相关临床指标。结果:649例患者中,男性79例,女性570例;年龄13~64岁,平均(35.1±9.2)岁;单侧恶性464例、双侧恶性107例、单侧良性64例、双侧良性14例。所有患者手术均顺利完成,无中转开放手术,中位手术时间130(110~150)min。571例恶性病变患者中央区淋巴结(CLN)清扫总数2628枚,平均(4.60±3.59)枚;CLN阳性总数489枚(18.6%),平均(0.86±1.65)枚。术后第3天无痛及轻、中、重度疼痛比例分别为52.2%、30.5%、17.3%、0。术后中位住院时间3(3~3)d,中位住院费用为5.05(4.81~5.67)万元。术中出现喉返神经(RLN)肌电信号降低71例。术后出现暂时性RLN损伤17例;暂时性饮水呛咳4例,暂时性音调降低10例;暂时性低钙血症145例。术后中位随访期6个月,整体满意度94.6%,无永久性并发症。学习曲线分析显示,曲线于第26例时出现明显降低,随后趋于稳定,不同术式间学习曲线相似。结论:第四代达芬奇机器人BABA甲状腺手术安全有效,且微创美容效果较好。应用过程中需遵循相应的学习曲线,对机器人手术操作系统的熟练掌握程度是制约手术进程的关键。

Background and Aims:The application of robotic systems in thyroid surgery has gradually expanded,but there is limited large-sample reports on bilateral axillo-breast approach(BABA)thyroidectomy using the 4th-generation da Vinci surgical robot both locally and abroad.Therefore,this study was performed to summarize the treatment outcomes and experiences of BABA thyroidectomy cases completed at the authors'center using the 4th-generation da Vinci surgical robot,so as to provide reference information for clinical practice.Methods:The clinical data of 649 patients undergoing the 4th-generation da Vinci robot-assisted BABA thyroidectomy at the Department of Thyroid Surgery of China-Japan Union Hospital of Jilin University from April 2020 to August 2023 were retrospectively collected.Relevant clinical variables were summarized and analyzed.Results:Of the 649 patients,79 were males and 570 were females,with an age range of 13 to 64 years and an average age of(35.1±9.2)years.There were 464 cases of unilateral malignancy,107 cases of bilateral malignancy,64 cases of unilateral benign tumors,and 14 cases of bilateral benign tumors.All surgeries were successfully completed without conversion to open surgery,with a median operative time of 130(110-150)min.In 571 cases of malignant lesions,the total number of central lymph nodes(CLNs)dissected was 2628,with an average of number of 4.60±3.59;the total number of positive CLNs was 489(18.6%),with an average of number of 0.86±1.65.On the third postoperative day,the proportions of painless and mild,moderate,and severe pain were 52.2%,30.5%,17.3%,and 0,respectively.The median postoperative hospital stay was 3(3-3)d,and the median hospitalization cost was 50500(48100-56700)yuan.During operation,EMG signal degradation of the recurrent laryngeal nerve(RLN)occurred in 71 cases.After operation,temporary RLN injury occurred in 17 cases;temporary coughing during drinking occurred in 4 cases,and temporary reduction of vocal range occurred in 10 cases;temporary hypocalcemia occurred in 145 cases.During a median follow-up of 6 months,the overall satisfaction rate was 94.6%,with no permanent complications.Learning curve analysis showed a significant decrease in the curve at the 26th case,followed by stabilization,and similar learning curves were observed between different surgical procedures.Conclusion:The 4th-generation da Vinci robot-assisted BABA thyroidectomy is safe,effective,and offers good minimally invasive cosmetic results.Adherence to a learning curve is necessary during the application process,and the mastery of the robotic surgical operating system is a key factor influencing the surgical process.