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中华结直肠疾病电子杂志 ›› 2024, Vol. 13 ›› Issue (01) : 45 -53. doi: 10.3877/cma.j.issn.2095-3224.2024.008

论著

"膜"解剖引导下的DaVinci机器人直肠癌手术与腹腔镜全直肠系膜切除术临床疗效的对照研究
马宁1, 刘威1, 陈志奇1, 陈旭1, 范宏伟1, 殷响1,()   
  1. 1. 163000 大庆油田总医院普通外科
  • 收稿日期:2023-11-12 出版日期:2024-02-25
  • 通信作者: 殷响
  • 基金资助:
    黑龙江省卫生健康委科研课题(No. 2020-013); 大庆市指导性科技计划项目(No. zdy-2021-81)

A comparative study on the clinical efficacy of DaVincin robot rectal cancer surgery guided by "membrane" anatomy and laparoscopic total mesorectal resection

Ning Ma1, Wei Liu1, Zhiqi Chen1, Xu Chen1, Hongwei Fan1, Xiang Yin1,()   

  1. 1. Department of General Surgery, Daqing Oilfifield General Hospital, Daqing, 163000, China
  • Received:2023-11-12 Published:2024-02-25
  • Corresponding author: Xiang Yin
引用本文:

马宁, 刘威, 陈志奇, 陈旭, 范宏伟, 殷响. "膜"解剖引导下的DaVinci机器人直肠癌手术与腹腔镜全直肠系膜切除术临床疗效的对照研究[J]. 中华结直肠疾病电子杂志, 2024, 13(01): 45-53.

Ning Ma, Wei Liu, Zhiqi Chen, Xu Chen, Hongwei Fan, Xiang Yin. A comparative study on the clinical efficacy of DaVincin robot rectal cancer surgery guided by "membrane" anatomy and laparoscopic total mesorectal resection[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2024, 13(01): 45-53.

目的

通过比较分析"膜"解剖引导下的DaVinci机器人直肠手术与腹腔镜全直肠系膜切除术(TME)的临床疗效,探讨"膜"解剖引导下的DaVinci机器人直肠手术应用开展的可能性及其价值。

方法

应用回顾性队列研究方法,依据纳入及排除标准收集大庆油田总医院普通外科2022年2月~2023年9月期间收治的60例直肠癌患者临床资料。按照手术方式分为两组,观察组为"膜"解剖引导下DaVinci机器人直肠癌手术组29例,对照组为腹腔镜下TME组31例。记录观察指标包括手术时间、术中出血量、切除标本质量、系膜完整性、淋巴结数目、阳性淋巴结数目、术后出现并发症情况及术后14天的生活自理能力、心理情况、术后三个月的排尿及性功能恢复等。

结果

两组所有患者均顺利完成手术,随访期内无死亡患者,两组在手术时间、术中出血量、保护性造口比例,肿瘤远切缘距离、TNM分期、淋巴结清扫数目及阳性数目,术后首次下床活动时间、术后首次肛门排气时间、术后恢复饮食时间、术后并发症总比例比较上差异均无统计学意义(P>0.05)。两组在切除标本质量评定达标总体上的差异无统计学意义(χ2=0.809,P=0.384),但从标本高质量完成上比较观察组(93.1%)明显优于对照组(71.0%),在住院时间、住院费用两组比较差异具有统计学意义(t=-5.133,12.700;均P<0.05),观察组住院时间(9.8±2.8)d短于对照组(11.8±4.3)d,但住院费用稍高于对照组(8.9±2.8 vs. 7.2±1.1)万元。术后14天日常活动自理能力及心理恢复评分两组存在差异,观察组均优于对照组(t=26.608,-12.207;均P<0.05)。术后并发症发生率观察组(13.8%)低于对照组(22.5%)。在距肛缘>5 cm患者中两组吻合口出血差异无统计学意义(χ2=0.850,P>0.05);但在距肛缘≤5 cm患者中,观察组低于对照组,差异具有统计学意义(χ2=9.253,P<0.05)。术后3个月排尿及生殖功能的比较,观察组优于对照组,差异具有统计学意义(χ2=11.818,59.342,61.653;均P<0.05),且观察组未出现Ⅲ~Ⅳ级排尿功能障碍及Ⅲ级勃起和射精功能障碍的情况发生。

结论

"膜"解剖引导下DaVinci机器人直肠癌手术与腹腔镜下TME相比,其手术根治性与安全性疗效相当,但在距肛缘≤5 cm患者中,观察组术后并发症发生率更低,且在术后排尿、性功能保护方面,观察组比对照组更具有优势。初步研究得出"膜"解剖引导下DaVinci机器人直肠癌手术是一种可重复性的高质量的手术,值得应用推广。

Objective

By comparing and analyzing the clinical effects of DaVinci robot rectal surgery guided by "membrane" anatomy and laparoscopic total mesorectal resection(TME), the possibility and value of DaVinci robot assisted rectal surgery under the guidance of "membrane" anatomy were discussed.

Methods

Retrospective cohort study was used. The clinical data of 60 patients with rectal cancer treated in the Department of General surgery of Daqing Oilfield General Hospital from February 2022 to September 2023 were collected according to the inclusion and exclusion criteria. According to the mode of operation, the patients were divided into two groups: observation group (n=29) and control group (n=31). The observation group was assisted by DaVinci robot under the guidance of membrane anatomy, and the control group was treated with laparoscopic TME. The observation indexes were recorded, such as operation time, intraoperative blood loss, quality of resected specimens, mesangial integrity, number of lymph nodes, number of positive lymph nodes, postoperative complications and self-care ability, psychological condition, voiding and sexual function recovery three months after operation.

Results

All patients in the two groups completed the operation successfully, and there was no death during the follow-up period, there was no significant difference between the two groups in terms of operation time, intraoperative blood loss, proportion of protective stoma, distance of distant cutting edge of tumor, TNM stage, number of lymph node dissection and positive number, first time of getting out of bed after operation, time of first anal exsufflation after operation, time of recovery of postoperative diet and total proportion of postoperative complications. There was no statistical significance (P>0.05). There was no significant difference in the quality evaluation of resected specimens between the two groups (χ2=0.809, P=0.384), but in terms of high quality, the observation group (93.1%) was significantly better than the control group (71.0%). There were significant differences in hospitalization time and hospitalization expenses between the two groups (t=-5.133, 12.700; P<0.05). The hospitalization time in the robot group (9.8 ±2.8)d was shorter than that in the laparoscopy group (11.8±4.3)d. However, the cost of hospitalization in the laparoscopy group was slightly higher than that in the laparoscopy group (8.9±2.8vs.7.2±1.1). There were differences in daily self-care ability and psychological recovery scores between the two groups 14 days after operation, and the robot observation group was better than the control group(t=26.608, -12.207; P<0.05). The incidence of postoperative complications in the robot group (13.8%) was lower than that in the laparoscopic group (22.5%). There was no significant difference in the comprehensive index of anastomotic bleeding complications between the two groups in the patients with anal margin>5 cm(χ2=0.850, P<0.05), but in the patients with anal margin≤5 cm(χ2=9.253, P<0.05), the incidence in the observation group was significantly lower than that in the control group. Three months after operation, the comparison of micturition and reproductive function in the observation group was better than that in the control group, and the difference was statistically significant(χ2=11.818, 59.342, 61.653; P<0.05).There was no Ⅲ~Ⅳ grade voiding dysfunction and Ⅲ grade erectile and ejaculatory dysfunction in the observation group.

Conclusion

Compared with laparoscopic TME, DaVinci robot assisted rectal cancer surgery under the guidance of membrane anatomy has the same radical effect and safety effect, but in patients with anal margin≤5 cm, the incidence of postoperative complications in robot group is lower, and the robot group has more advantages than laparoscopy in the protection of postoperative urination and sexual function. The preliminary study shows that rectal cancer surgery assisted by DaVinci robot under the guidance of "membrane" anatomy is a repeatable and high-quality operation, which is worth popularizing.

表1 两组患者一般资料比较[x±s,例(%)]
图1 戳卡布局;图2 切开膜桥;图3 进入直肠后间隙;图4 Denonvilliers筋膜前间隙;图5 Denonvilliers筋膜后间隙;图6 离断直肠侧韧带
表2 切除标本质量
表3 观察组与对照组手术情况[x±s,例(%)]
表4 两组手术后病理反馈[x±s,例(%)]
表5 两组术后情况比较[x±s,例(%)]
表6 两组术后3个月泌尿及性生殖功能情况比较[例(%)]
表7 两组术后随访情况[例(%)]
[1]
Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014[J]. CA Cancer J Clin, 2014, 64(2): 104-117.
[2]
Fleshman J, Branda M, Sargent DJ, et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial[J]. JAMA, 2015, 314(13): 1346-1355.
[3]
郑民华,马君俊.微创外科在结直肠肿瘤手术的新进展[J/CD].中华结直肠疾病电子杂志, 2015, 4(5): 460-464.
[4]
龚建平.外科膜解剖——新的外科学基础?[J].中华实验外科杂志, 2015, 32(2): 225-226.
[5]
龚建平.膜解剖的兴起与混淆[J].中华胃肠外科杂志, 2019, 22(5): 401-405.
[6]
中国医师协会结直肠肿瘤专业委员会机器人手术专业委员会,中国研究型医院学会机器人与腹腔镜外科专业委员会.机器人结直肠癌手术中国专家共识(2020版)[J].中国实用外科杂志, 2021, 41(1): 12-19.
[7]
池畔.基于膜解剖的腹腔镜与机器人结直肠肿瘤手术学[M].北京:人民卫生出版社, 2019.
[8]
龚建平.外科解剖中的第三元素及其影响[J].中华胃肠外科杂志, 2016, 19(10): 1081-1083.
[9]
池畔,王枭杰,官国先,等.全直肠系膜切除术中直肠系膜分离终点线的发现和解剖及其临床意义[J].中华胃肠外科杂志, 2017, 20(10): 1145-1150.
[10]
中华医学会外科学分会腹腔镜与内镜外科学组,中华医学会外科学分会结直肠外科学组,中国医师协会外科医师分会结直肠外科医师委员会,等.腹腔镜结直肠癌根治术操作指南(2018版) [J].中华消化外科杂志, 2018,17(9): 877-885.
[11]
池畔.腹腔镜直肠癌全直肠系膜切除术中保护盆自主神经的手术技巧[J].中华消化外科杂志, 2011, 10(3): 168-169.
[12]
Nagtegaal ID, van de Velde CJ, van der Worp E, et al. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control[J]. J Clin Oncol, 2002, 20(7): 1729-1734.
[13]
李苗苗,代永静. Barthel指数评分量表在康复护理中的应用进展[J].护士进修杂志, 2018, 33(6): 508-510.
[14]
王焕利,李庆.基于行为转变理论的护理模式对直肠癌造口患者心理情绪障碍和生活质量的影响[J].中国肿瘤临床与康复, 2019, 26(5): 629-633.
[15]
王裕玲,顾巧丽,袁吕荣. Snyder希望理论的护理干预在直肠癌术后结肠造口患者中的应用观察[J].现代中西医结合杂志, 2019, 28(15): 1681-1685.
[16]
Saito N, Sarashina H, Nunomura M, et al. Clinical evaluation of nerve-sparing surgery combined with preoperative radiotherapy in advanced rectal cancer patients[J]. Am J Surg, 1998, 175(4): 277-282.
[17]
Nagpal K, Bennett N. Colorectal surgery and its impact on male sexual function [J]. Curr Urol Rep, 2013, 14(4): 279-284.
[18]
Yucel S, Erdogru T, Baykara M, et al. Recent neuroanatomical studies on the neurovascular bundle of the prostate and cavernosal nerves: clinical reflections on radical prostatectomy [J]. Asian J Androl, 2005, 7(4): 339-349.
[19]
Bonjer HJ, Deijen CL, Abis GA, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer[J]. N Engl J Med, 2015, 372(14): 1324-1332.
[20]
Stevenson AR, Solomon MJ, Lumley JW, et al. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial[J]. JAMA, 2015, 314(13): 1356-1363.
[21]
Sajid MS, Ahamd A, Miles WF, et al. Systematic review of oncological outcomes following laparoscopic vs open total mesorectal excision[J]. World J Gastrointest Endosc, 2014, 6(5): 209-219.
[22]
Lim RS, Yang TX, Chua TC. Postoperative bladder and sexual function in patients undergoing surgery for rectal cancer: a systematic review and meta-analysis of laparoscopic versus open resection of rectal cancer[J]. Tech Coloproctol, 2014, 18(11): 993-1002.
[23]
刘海龙,常毅,林谋斌.科学解读膜解剖理论规范应用膜解剖名词[J].中华胃肠外科杂志, 2020, 23(7): 634-642.
[24]
邓祥兵,孟文建,张元川,等.直肠前间隙Denovilliers筋膜分层结构及与前列腺血管分支的关系[J].中华胃肠外科杂志, 2013, 16(5): 489-493.
[25]
池畔.膜解剖指导下的腹腔镜全直肠系膜切除术[J].中华胃肠外科杂志, 2016, 19(10): 1088-1091.
[26]
池畔,王枭杰.膜解剖——推动精准腔镜与机器人结直肠外科的动力[J].中华胃肠外科杂志, 2019, 22(5): 406-412.
[27]
Yoo BE, Cho JS, Shin JW, et al. Robotic versus laparoscopic intersphincteric resection for low rectal cancer: comparison of the operative, oncological, and functional outcomes[J]. Ann Surg Oncol, 2015, 22(4): 1219-1225.
[28]
Prete FP, Pezzolla A, Prete F, et al. Robotic versus laparoscopic minimally invasive surgery for rectal cancer: a systematic review and meta-analysis of randomized controlled trials[J]. Ann Surg, 2018, 267(6): 1034-1046.
[29]
Allemann P, Duvoisin C, Di Mare L, et al. Robotic-assisted surgery improves the quality of total mesorectal excision for rectal cancer compared to laparoscopy: results of a case-controlled analysis[J].World J Surg, 2016, 40(4): 1010-1016.
[30]
Aselmann H, Kersebaum JN, Bernsmeier A, et al. Robotic-assisted total mesorectal excision (TME) for rectal cancer results in a signify cantly higher quality of TME specimen compared to the laparoscopic approach-report of a single-center experience[J]. Int J Colorectal Dis, 2018, 33(11): 1575-1581.
[31]
Liao G, Zhao Z, Deng H, et al. Comparison of pathological outcomes between robotic rectal cancer surgery and laparoscopic rectal cancer surgery: a meta-analysis based on seven randomized controlled trials [J]. Int J Med Robot, 2019, 15(5): e2027.
[32]
李干斌,韩加刚,王振军.结直肠术后吻合口出血的预防与诊治探讨[J].中华胃肠外科杂志, 2020, 23(12): 1149-1154.
[33]
Baek SJ. Kim J. Kwak J. et al. Can trans- anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy?[J]. World J Gastroenterol, 2013, 19(32): 5309-5313.
[34]
Maeda K, Nagahara H, Shibutani M, et al. Efficacy of intracorporeal reinforcing sutures for anastomotic leakage after laparoscopic surgery for rectal cancer[J]. Surg Endosc, 2015, 29(12): 3535-3542.
[35]
王国慧,易波,刘勇,等.国产手术机器人临床Ⅰ期研究(附103例报告)[J].中国实用外科杂志, 2019, 39(8): 840-843.
[36]
郑民华,马君俊.腹腔镜直肠癌根治术的难点与争议[J].中华消化外科杂志, 2017, 16(8): 782-786.
[37]
梁小波,王毅,马国龙."膜"引导保护盆腔植物神经技术在直肠癌手术中的应用[J].中华胃肠外科杂志, 2017, 20(6): 614-617.
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