经食道超声心动图在机器人辅助腹腔镜MayoⅢ～Ⅳ级下腔静脉瘤栓切除术中的临床价值

Clinical value of intraoperative transesophageal echocardiography for robotassisted laparoscopic Mayo Ⅲ-Ⅳ inferior vena cava thrombectomy

目的:探讨术中经食道超声心动图(TEE)在机器人辅助腹腔镜MayoⅢ~Ⅳ级下腔静脉瘤栓取出术中的临床应用价值。方法:回顾性分析2016年1月-2018年6月收治的11例肾肿瘤伴MayoⅢ~Ⅳ级下腔静脉瘤栓患者资料,肾脏肿瘤位于左侧3例,右侧8例。其中Ⅲ级瘤栓6例、Ⅳ级瘤栓5例,瘤栓平均长度为7.0~14.2 cm,平均(10.4±2.6)cm。11例患者均在术中TEE监测下完成机器人辅助腹腔镜下腔静脉瘤栓切除术。结果:麻醉诱导后,术中TEE发现1例术前诊断为Ⅳ瘤栓的患者,降为Ⅲ级,3例术前诊断为Ⅲ级瘤栓的患者,降为Ⅱ级,分别调整手术策略,前者避免体外循环,后者避免阻断第一肝门;术中TEE判断2例Ⅳ瘤栓侵犯心房壁,采取切开右心房取栓,3例Ⅳ瘤栓未侵犯心房壁,采取将瘤栓推纳至肝静脉以下下腔静脉取栓,缩短了体外循环的转机时间;术中TEE指导血管束带放置在下腔静脉瘤栓上极水平以上;5例Ⅳ瘤栓与6例Ⅲ级瘤栓手术切除瘤栓后TEE检查右心房及下腔静脉内均未发现残余瘤栓。结论:术中TEE是一种安全、无创的技术,其提供的信息可纠正、优化、指导外科决策,评估手术效果,具有重要的临床应用价值。

objective:To study the clinical value of intraoperative transesophageal echocardiography(TEE)in the robot-assisted laparoscopic MayoⅢ-Ⅳinferior vena cava thrombectomy.Methods:We performed a retrospective analysis on 11 cases of renal tumor with MayoⅢ-Ⅳinferior vena cava tumor thrombus between January 2016 and June 2018,including 3 cases of renal tumor on the left side and 8 cases on the right side.There were 6 cases of levelⅢand 5 cases of levelⅣtumor thrombus with average length of 10.4 cm(7.0-14.2 cm).All the 11 patients were treated with robot-assisted laparoscopic thrombectomy of inferior vena cava under intraoperative TEE monitoring.Results:After anesthesia induction,intraoperative TEE showed 1 case of preoperative diagnosis of levelⅣtumor thrombus,down to levelⅢ,3 cases of preoperative diagnosis of levelⅢtumor thrombus,down to levelⅡ.The former avoided cardiopulmonary bypass,and the latter avoided blocking the first hepatic hilum respectively,by adjusting the surgical strategy.Intraoperative TEE revealed that levelⅣtumor thrombus invaded the atrial wall in 3 cases who were given right atria opening and tumor thrombus removing,and levelⅣtumor thrombus did not invade the atrial wall in 3 cases whom tumor thrombus was pushed into inferior vena cava for thrombus removal,which shortened the turning time of cardiopulmonary bypass.Under the guidance of intraoperative TEE,vascular bundles were placed above the superior level of inferior vena cava tumor thrombus.After surgical removal of tumor thrombus in 5 cases ofⅣtumor thrombus and 6 cases of levelⅢtumor thrombus,TEE examination showed no residual tumor thrombus in right atrium and inferior vena cava.Conclusion:Intraoperative TEE is a safe and non-invasive technique,which can provide information to correct,optimize,guide surgical decisions,and evaluate surgical effects,and has important clinical application value.