腹部无辅助切口机器人taTME术式治疗“困难骨盆”的低位直肠癌:附3例报告
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作者单位:

1.郑州大学第一附属医院 结直肠肛门外科,河南 郑州 450018;2.郑州大学第三附属医院 新生儿科,河南 郑州 450018

作者简介:

韩明宇,郑州大学第一附属医院住院医师,主要从事结直肠肿瘤微创手术方面的研究。

基金项目:

国家自然科学基金资助项目(U2004112);河南省医学科技攻关计划基金资助项目(SBGJ202102121)。


Safety and efficacy of atural orifice robot-assisted transanal total mesorectal excision for low rectal cancer in "difficult pelvic" conditions: a report of 3 cases
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Affiliation:

1.Department of Colorectal Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450018, China;2.Department of Neonates, the Third Affiliated Hospital of Zhengzhou University, Zhengzhou 450018, China

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    摘要:

    背景与目的 目前,腹部无辅助切口机器人经肛全直肠系膜切除术(NOSES R-taTME)治疗“困难骨盆”低位直肠癌的临床经验尚缺乏。因此,本研究对3例行该术式的患者临床资料进行总结分析,评估短期结果,以期为临床实践提供初步经验。方法 回顾性分析2022年2月—2022年5月3例在郑州大学第一附属医院行NOSES R-taTME治疗“困难骨盆”低位直肠癌患者的围手术期资料及短期预后。结果 3例患者均为男性,年龄54~59岁;BMI为24~34 kg/m2;坐骨结节间距离为8.0~9.5 cm;肿瘤距肛缘距离为4~5 cm;直肠系膜脂肪面积为23.1~30.7 cm2。3例中有1例行新辅助化疗;2例肿瘤位于直肠前壁。机器人对接时间为9~20 min,经肛门操作时间为40~70 min,总手术时间为200~290 min,估计出血量为50~100 mL,淋巴结检出总数为15~20枚。3例均为R0切除,切除直肠系膜分级均为完整。术后病理I期2例,Ⅲ期1例。术后住院时间为7~11 d。手术均顺利完成,无中转开腹、术后并发症及死亡发生,无术后30 d内非计划再次住院。随访3个月,未见吻合口相关并发症,未见肿瘤复发或转移。结论 NOSES R-taTME治疗“困难骨盆”低位直肠癌安全可行。然而,该结论仍需要更大样本量的前瞻性研究进一步证实。

    Abstract:

    Background and Aims There is currently a lack of clinical experience in using the natural orifice robot-assisted transanal total mesorectal excision (NOSES R-taTME) approach to treat "difficult pelvic" low rectal cancer. Therefore, this study summarizes and analyzes the clinical data of three patients who underwent this procedure, evaluates short-term results, and aims to provide preliminary experience for clinical practice.Methods The perioperative data and short-term outcomes of three patients with "difficult pelvic" low rectal cancer who underwent NOSES R-taTME treatment at the First Affiliated Hospital of Zhengzhou University from February to May 2022 were retrospectively analyzed.Results All three patients were male, aged 54-59 years, and the BMI was 24-34 kg/m2. The distance between the ischial tuberosities was 8.0-9.5 cm, the distance from the tumor to the anal verge was 4-5 cm, and a mesorectal fat area of 23.1-30.7 cm2. One patient received neoadjuvant chemotherapy, and two patients had tumors located on the anterior wall of the rectum. The robot docking time was 9-20 min, the transanal operation time was 40-70 min, the total operation time was 200-290 min, the estimated blood loss was 50-100 mL, and the total number of lymph nodes retrieved was 15-20. All three cases achieved R0 resection, and complete total mesorectal excision grade. Postoperative pathology showed stage I in two cases and stage Ⅲ in one case. The length of postoperative hospital stay was 7-11 d All operations were completed successfully without conversion to open surgery, postoperative complications, or deaths, and there were no unplanned readmissions within 30 d after surgery. During follow-up for 3 months, no anastomotic-related complications were observed, and there was no evidence of tumor recurrence or metastasis.Conclusion The NOSES R-taTME approach is safe and feasible for the treatment of "difficult pelvic" low rectal cancer. However, this conclusion still requires further confirmation through larger prospective studies.

    图1 术中照片 A:保留左结肠动脉的第253组淋巴结清扫;B:荧光模式下第253组及第252组绿染的淋巴结;C:R-taTME手术操作平台;D:完成达芬奇机器人Xi机械臂与经肛操作平台的对接;E:预切线标记(在预定切开肠壁处,电剪电灼环形标记肠壁1周);F:依次切开黏膜、黏膜下层、环形肌、纵行肌,进入直肠前间隙;G:经肛与经腹“holy plane”平面贯通;H:游离直肠系膜右侧,保护自主神经;I:置入扩肛器后观察结肠-肛管吻合满意Fig.1 Intraoperative photos A: Dissection of No. 253 lymph nodes with preservation of the left colonic artery; B: Green-stained No. 253 and 252 lymph nodes in fluorescence mode; C: Surgical operating platform of R-taTME; D: Completion of the docking of the robotic arm of Da Vinci robot Xi to the transanal operating platform; E: Pre-incision marking (marking a circular line around the bowel wall 1 circle on the planned incision site using an electric scissors); F: Sequentially incising the mucosa, submucosal layer, cricoid muscle, and longitudinal muscle, to enter the anterior rectal space; G: The communication of holy plane through transanal and transabdominal access; H: Dissecting the rectal mesentery on the right side to protect the autonomous nerves; I: Satisfactory colon-anal canal anastomosis after the placement of anal dilator
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韩明宇,王文秀,王玉行,段小飞,张海容,周全博,张晴晴,孙伟鹏,袁维堂,胡军红,连玉贵.腹部无辅助切口机器人taTME术式治疗“困难骨盆”的低位直肠癌:附3例报告[J].中国普通外科杂志,2023,32(4):506-513.
DOI:10.7659/j. issn.1005-6947.2023.04.004

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  • 收稿日期:2022-08-08
  • 最后修改日期:2022-09-09
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  • 在线发布日期: 2023-04-28