參考文 英文參考文獻(xiàn)翻 參考文20142（11ParkJS,ChoiGS,LimKH,etal.RoboticassistedversueLaparoscopicsurgeryforlowrectalcancer:casematchedysisofshortterm es.AnnSurgOncol,2010,17(12):3195-3202.鄭民華.NOTES與單孔腹腔鏡技術(shù)的發(fā)展現(xiàn)狀與展望.中國微創(chuàng)外科雜志,PalaniveluC,RajanPS,RangarajanM.Transvaginalendoscopicappendectomyinhumans:auniqueapproachtoNOTES-world'sreport.SurgEndosc.2008;22:1343-1347.TanGY,GoelRK,KaoukJH,etal.Technologicaladvancesinroboticassistedlaparoscopicsurgery.UrologicClinicsofNorthAmerica.2009;36:237-249.PaHRH,LinaresA,JosephJV.Roboticandlaparoscopicsurgery:Costandtraining.SurgOncol.2009;18(3):242-246.Robotic-assistedlaparoscopicsurgery:recentadvancesinurology.AutorinoR,ZargarH,KaoukJH.FertilSteril.2014Oct;102(4):939-49.Retropubic,Laparoscopic,andRobot-AssistedRadicalProstatectomy:Surgical,Oncological,andFunctional es:ASystematicReview.DeCarloF,CelestinoF,VerriC,MaseduF,LiberatiE,DiStasiSM.UrolInt.2014;93(4):373-83.， 第1頁共4英文參考文獻(xiàn)翻[2]ParkJS,ChoiGS,LimKH,etal.RoboticassistedversueLaparoscopicsurgeryforlowrectalcancer:casematched ysisofshortterm es.AnnSurgOncol,2010,17(12):3195-3202.結(jié)果：168.0±49.3231.9±61.4分鐘(P<0.001)。時間的。接受手術(shù)的比例與修改后的自然孔技術(shù)(完全體內(nèi)手術(shù)與經(jīng)或經(jīng)的檢索的標(biāo)本)明顯高于機(jī)器人輔助組(48.8%8.8%，P0.001)。沒有組間標(biāo)本質(zhì)量的差異，包括遠(yuǎn)端切緣、淋清掃和環(huán)狀切緣。總體主要并發(fā)癥發(fā)生率相似(腹腔鏡9.8%比上機(jī)器人輔助9.8%，P=0.641)。PalaniveluC,RajanPS,RangarajanM.Transvaginalendoscopicappendectomyinhumans:auniqueapproachtoNOTES-world'sreport.SurgEndosc.2008;22:1343-1347.們描述的經(jīng)的方法內(nèi)鏡闌尾切除術(shù)對于人類來說,可能是世界上第一個報告。材料和方法：實(shí)現(xiàn)氣腹通腹針。常規(guī)12毫米內(nèi)窺鏡和常規(guī)儀器。到達(dá)腹膜是通過經(jīng)的方法獲得， 第2頁共4規(guī)腹腔鏡或腹腔鏡輔助。的平均是29.5歲。平均運(yùn)行時間為103.5分鐘,住院1-2天。跟進(jìn)安排在7天,30天,90天,6個月。傷口被婦科醫(yī)生檢查,發(fā)現(xiàn)完全愈合在第一次和第二次隨訪。：到目前為止在人類身上，經(jīng)胃的闌尾切除術(shù)，膽囊切除術(shù)，經(jīng)的膽囊切除術(shù)有相關(guān)。經(jīng)陰TanGY,GoelRK,KaoukJH,etal.TechnologicaladvancesinroboticassistedlaparoscopicUrologicClinicsofNorthAmerica.2009;36:237-局限性(IntuitiveSurgical公司)。然后檢查承諾縮減了的機(jī)器人平臺，創(chuàng)新早期經(jīng)驗(yàn)與體內(nèi)移動微型機(jī) HRH,LinaresA,JosephJV.Roboticandlaparoscopicsurgery:Costandtraining.Surg2009;18(3):242-列腺已被證明是一個,這項(xiàng)新技術(shù)有一個利基。當(dāng)交叉專業(yè)使用機(jī)器人雖然極其昂貴,可能是Robotic-assistedlaparoscopicsurgery:recentadvancesin域的機(jī)器人手術(shù)相關(guān)物及文獻(xiàn)的檢索，并對以為基礎(chǔ)的文獻(xiàn)進(jìn)行了性分析。使用達(dá)芬奇外科手術(shù)系種機(jī)器人手術(shù)系統(tǒng)）已應(yīng)用于摘除和重建腹腔鏡腎臟手術(shù)。用機(jī)器人進(jìn)行手術(shù)的方法可應(yīng)用， 第3頁共4表明，與開放式手術(shù)相比用機(jī)器人進(jìn)行切除手術(shù)量較少。除了癌，機(jī)器人還被用于對患有的良性增生的患者進(jìn)行簡單的切除手術(shù)。最近的研究表明，相較于開放手術(shù)，機(jī)器人手術(shù)可以已最不激進(jìn)的方式進(jìn)行切除術(shù)，這在腫瘤治療方面有鼓舞人心的成果。近年來，機(jī)器人手術(shù)的發(fā)展已使泌尿外科醫(yī)生可以進(jìn)行體內(nèi)改道手術(shù)。機(jī)器人復(fù)通手術(shù)以及其他用機(jī)器人進(jìn)行的男科相關(guān)術(shù)正在探索之中?？傊?，對于大多數(shù)泌尿外科手術(shù)而言，用機(jī)器人輔助手術(shù)是一項(xiàng)新興且安全的技術(shù)。在過去十年中人們對用機(jī)器人進(jìn)行切除手術(shù)的接受認(rèn)可為泌尿科醫(yī)生探索其他摘除和重建Retropubic,Laparoscopic,andRobot-AssistedRadicalProstatectomy:Surgical,Oncological,and es:ASystematicReview.方法：基于PubMed和Embase2013年12月之前的數(shù)據(jù)庫進(jìn)行系統(tǒng)性的查閱，通過檢索短語‘radical結(jié)果：44篇有參考價值的研究結(jié)果被挑選出來，在腹腔手術(shù)中，從圍手術(shù)期來看，LRPRALPRRP與此相反，成本比較方面，比較支持RRP。， 第4頁共4GynecolNov．2014Vol達(dá)芬奇機(jī)器人輔助婦科手術(shù)的臨床分析(市復(fù)旦大學(xué)附屬中山醫(yī)院婦產(chǎn)科

·短篇論著【】目的:研究運(yùn)用達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)進(jìn)行婦科手術(shù)的臨床效果探討機(jī)器人手術(shù)在婦科手術(shù)的應(yīng)用前景。方法:回顧分析2012年11月至2013年12月在復(fù)旦大學(xué)附屬中山醫(yī)院婦產(chǎn)科采用機(jī)器人手術(shù)系統(tǒng)行婦科手術(shù)的14例患者術(shù)時間術(shù)后住院天數(shù)術(shù)后短期并發(fā)癥和中轉(zhuǎn)開腹率。結(jié)果:我院成功將達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)應(yīng)用于宮肌瘤剝除術(shù)內(nèi)膜癌分期手術(shù)癌分期手術(shù)附件切除術(shù)及囊腫剝除術(shù)中。采用機(jī)器人手術(shù)系統(tǒng)手術(shù)術(shù)時間1．～7．5h術(shù)后住院天數(shù)3～5天無中轉(zhuǎn)開腹及、嚴(yán)重等短期并發(fā)癥。結(jié)論:達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)作為新興微創(chuàng)技術(shù)體現(xiàn)出并發(fā)癥少恢復(fù)快小的優(yōu)點(diǎn)但在技術(shù)應(yīng)用初始階段手術(shù)時間較長且費(fèi)用昂貴并未比以往術(shù)方式顯著優(yōu)越性。但隨著手術(shù)經(jīng)驗(yàn)積累及技術(shù)熟練完善后，手術(shù)時間可明顯縮短而且機(jī)器人手術(shù)醫(yī)師培訓(xùn)周期短術(shù)中對醫(yī)師的穩(wěn)定性常規(guī)內(nèi)鏡操作水平要求較低有助于技術(shù)普及。機(jī)器人手術(shù)系統(tǒng)的利弊評價需后續(xù)大樣本的臨床研究給予支持。【】手術(shù)機(jī)器人;達(dá)芬奇機(jī)器人手術(shù)系統(tǒng);婦號: 文獻(xiàn)標(biāo)志碼: 文章:1004－7379(2014):0．3/ ．．4．1．機(jī)器人腹腔鏡手術(shù)以其無與倫比的控制性和微創(chuàng)手術(shù)操作的精細(xì)性為普及提高外科醫(yī)師的顯微手術(shù)技術(shù)縮短外科醫(yī)師培訓(xùn)周期開辟了廣闊前景。機(jī)器人輔助手術(shù)具有使患者小疼痛輕住院時間短并發(fā)癥少的優(yōu)勢成為外科微創(chuàng)手術(shù)的又一發(fā)展趨勢。近年機(jī)器人手術(shù)系統(tǒng)在臨床婦科手術(shù)中同樣得到了應(yīng)用成為新一代的婦科微創(chuàng)手術(shù)技術(shù)。復(fù)旦大學(xué)附屬中山醫(yī)院婦產(chǎn)科自2012年11月開始應(yīng)用達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)本文通過回顧分析2012年11月至2013年12月我院采用達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)進(jìn)行婦科手術(shù)的臨床效果主要研究終點(diǎn)是手術(shù)時間術(shù)后住院時間術(shù)后并發(fā)癥及中轉(zhuǎn)開腹率以探討機(jī)器人手術(shù)在婦科的應(yīng)用前景。資料來源收集2012年11月至2013年12月期間芬奇機(jī)器人婦科手術(shù)病例14例其中肌瘤剝除術(shù)8例擴(kuò)大全雙附件切除加盆腔淋清掃3例腫瘤減滅術(shù)(全雙附件切除加大網(wǎng)膜闌尾切除加盆腔淋切除術(shù))1例囊腫剝除術(shù)1例附件切除術(shù)1例?；仡櫡治龌颊?/p>

手術(shù)患者的術(shù)前選擇主要基于以下幾個方面:(1)無常規(guī)腹腔鏡手術(shù)絕對如不適宜氣腹的嚴(yán)重心肺疾患急性或嚴(yán)重的肝腎功能損害急性腹壁皮膚疾病等;(2)病例的選擇包括婦科良性疾病和根據(jù)術(shù)前評估擬行全面分期手術(shù)的癌和臨床分期為I期的內(nèi)膜癌;(3)患者意愿經(jīng)濟(jì)狀況。手術(shù)醫(yī)師開展達(dá)芬奇機(jī)器人婦科手術(shù)前我院婦產(chǎn)科有兩位醫(yī)師(分別為副高屠蕊沁醫(yī)師高年主治肖洪洋醫(yī)師)專門到培訓(xùn)中心進(jìn)行為期1周的技術(shù)培訓(xùn)取得資格后組成達(dá)芬奇婦科手術(shù)組主要成員。統(tǒng)計(jì)期間的所有手術(shù)均由屠蕊沁醫(yī)師擔(dān)任主刀肖洪洋醫(yī)師擔(dān)任一助二助則根據(jù)手術(shù)情況由科內(nèi)其他主治以別醫(yī)師擔(dān)任。手術(shù)裝備手術(shù)裝備主要由兩部分組成主刀操作臺和裝載機(jī)器人 術(shù)車。達(dá)芬奇手術(shù)的機(jī)器人系統(tǒng)準(zhǔn)備包括各部件連接如術(shù)中所極鉗單極鉗等的組裝這些工作及機(jī)器人系統(tǒng)的日常機(jī)器人手術(shù)洗手護(hù)士由專門的達(dá)芬奇機(jī)器人手術(shù)護(hù)士小組負(fù)責(zé)?？股氐膽?yīng)用預(yù)防性抗生素僅在切口為II類以上的手術(shù)(如全切除)前30min靜脈使用手術(shù)時間超過3h 通訊作者:u．n@zs．．n

GynecolNov．2014Vol于術(shù)后4h內(nèi)追加一次同劑量抗生素抗生素選用I代頭孢菌素或克林霉素。不常規(guī)使用低分子肝素進(jìn)行預(yù)防性抗凝治療。手術(shù)采用氣管插管進(jìn)行全麻。緊貼軀體兩側(cè)手術(shù)單固定以擴(kuò)大一助工作空間及減少患者移動減少神經(jīng)損傷雙腿平移分開0到5度角形成剪刀位。這種可方便必要時二助放置舉宮器方便手術(shù)車放入雙腿之間更靠近腹部手術(shù)野且避免截石位腿部抬高后與機(jī)械臂碰撞。擺放完畢后按腹腔鏡婦科常規(guī)方法范圍進(jìn)行放置導(dǎo)尿管。除了卵巢癌分期手術(shù)預(yù)備行大網(wǎng)膜切除者需在劍突下與肚臍連線中點(diǎn)穿刺外其余手術(shù)均在臍輪上方開放性穿刺放置0mr作為鏡頭放置孔。充氣體至腹內(nèi)壓力達(dá)到約2g。雙側(cè)髂前上棘內(nèi)上1/3處分別穿刺放置5mor左側(cè)臍旁在臍輪上穿刺口一拳以外再穿刺放置0mr。先按照常規(guī)腹腔鏡手術(shù)步驟置入腹腔鏡檢查腹腔內(nèi)情況必要時分解粘連并取頭低足高約0度角使腸管退出盆腔術(shù)野。此后手術(shù)車由巡回護(hù)士推入患者雙腿內(nèi)3個機(jī)器分別與臍輪上兩側(cè)髂前上棘內(nèi)r錨接固定0度鏡頭與機(jī)器臂嵌接雙極鉗與左側(cè)機(jī)器臂嵌接用于抓提組織及電凝單極鉗與右側(cè)機(jī)器臂嵌接用于切斷及電凝。左側(cè)臍旁r可放入常規(guī)腹腔鏡手術(shù)器械以供一助必要時進(jìn)行輔助操作。肌瘤剝除全切除等手術(shù)中需要第二助手安裝舉宮杯操控方向時第二助手在手術(shù)車推入之前可在患者雙腿間按陰式全切除的方法放置舉宮杯手術(shù)車推入放置在第二助手身后。囊腫盆腔淋大網(wǎng)膜等體積較小的標(biāo)本在腹腔內(nèi)裝入標(biāo)本袋后可經(jīng)腹部穿刺口逐步取出肌瘤經(jīng)碎宮器切成細(xì)條狀后經(jīng)腹部切口取出經(jīng)取出。達(dá)芬奇機(jī)器人腹腔鏡下全切除術(shù)的殘端縫合也由主刀醫(yī)師操控達(dá)芬奇機(jī)器手術(shù)臂進(jìn)行一般用20薇喬線8字縫合2～3針。創(chuàng)面止血并檢查無后放置盆腔管接負(fù)壓球。檢查穿刺口無點(diǎn)后關(guān)閉氣腹撤出腹腔鏡頭0m穿刺口用10薇喬線縫合。手術(shù)時間是指麻醉成功至全部腹壁切口縫合完畢。 達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)在肌瘤剔除術(shù)中的應(yīng)用 8例患者采用達(dá)芬奇機(jī)器人系統(tǒng)行肌瘤剝除術(shù)平均手術(shù)時間3．53h平均術(shù)后住院天數(shù)3．5d，術(shù)中平均143．75l術(shù)后第一天血紅蛋白比入院評估平均下降22g/L;剝除肌瘤3～20個;術(shù)中無1例中轉(zhuǎn)開腹無1例因大量需輸血術(shù)后均無傷口盆腔氣胸縱隔氣腫等嚴(yán)重并發(fā)癥。其中1例還成功進(jìn)行了復(fù)雜腸粘連松解術(shù)手術(shù)時間7．5h。達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)在惡性婦科腫瘤手術(shù)中的應(yīng) 3例患者采用達(dá)芬奇手術(shù)系統(tǒng)完成擴(kuò)

全切除加雙附件切除加盆腔淋切除術(shù)其中2例為內(nèi)膜癌I期1例為CII累及腺體;其中1例為52歲合并高血壓患者，1例為85歲合并高血壓患者;手術(shù)時間分別為4h6h3．h;術(shù)后住院時間分別為4天3天5天;術(shù)中分別為100ml300ml200ml。癌分期手術(shù)1例，62歲合并高血壓腦梗塞手術(shù)時間33h住院時間11天術(shù)中100ml達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)在良性病變手術(shù)中的應(yīng)用1例采用達(dá)芬奇機(jī)器人完成1例囊腫剝除術(shù)和1例附件切除術(shù)其中附件切除術(shù)中同時進(jìn)行復(fù)雜腸粘連松解手術(shù)時間分別為108h、．h 手術(shù)體會 機(jī)器人手術(shù)系統(tǒng)下剝除肌瘤突破了腹腔鏡下某些視野盲角操作死角的局限縫扎、止血更得心應(yīng)手對多發(fā)性肌瘤巨大肌瘤有嚴(yán)重盆腹腔粘連的操作較傳統(tǒng)腹腔鏡有優(yōu)］大大擴(kuò)展了肌瘤剝除微創(chuàng)手術(shù)的使用范圍與經(jīng)腹手術(shù)相比更適應(yīng)患者保留功能減少的要求。機(jī)器人手術(shù)施行于肥胖患者可解決開腹手術(shù)手術(shù)切口脂肪液化傷口愈合不良及傳統(tǒng)腹腔鏡氣腹視野不清的問題與文獻(xiàn)一2－］。并且還發(fā)現(xiàn)在機(jī)器人系統(tǒng)下進(jìn)行盆腔淋的切除或活檢術(shù)視野比經(jīng)腹手術(shù)更清楚操作更穩(wěn)定而且可節(jié)省經(jīng)腹手術(shù)需2～3名助手術(shù)野而耗費(fèi)的人力尤其在進(jìn)行腹主動脈旁淋活檢時達(dá)芬奇機(jī)器人的三維視野及位置轉(zhuǎn)換更具優(yōu)9－］。從目前完成的病例來看內(nèi)科合并癥都不是達(dá)芬奇機(jī)器人系統(tǒng)婦科分期手術(shù)的證而手術(shù)時間也可通過技術(shù)水平的不斷提高和熟練程度的加強(qiáng)而縮短如在內(nèi)膜癌分期手術(shù)從第1例耗時6h到最近1例手術(shù)時間3．15h。機(jī)器人系統(tǒng)在婦科手術(shù)的應(yīng)用范圍 目前機(jī)器人系統(tǒng)在良性病變手術(shù)應(yīng)用領(lǐng)域與傳統(tǒng)腹腔鏡手術(shù)的比較優(yōu)勢主要體現(xiàn)在盆腔粘連嚴(yán)重需進(jìn)行精細(xì)松解的方］。顯4－］機(jī)器人輔助的腹腔鏡手術(shù)與常規(guī)腹腔鏡手術(shù)比較能更好地完成粘連分離縫合和打結(jié)等具有一定難度的動作。多數(shù)認(rèn)為機(jī)器人手術(shù)對有盆腔手術(shù)史術(shù)中需進(jìn)行盆腔粘連松解的患者具有優(yōu)勢。我院腹腔鏡輔助全切除術(shù)發(fā)展較成熟達(dá)芬奇機(jī)器人系統(tǒng)的引入有望拓展全腹腔鏡切除術(shù)的應(yīng)用范圍。 GynecolNov．2014Vol達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)的優(yōu)點(diǎn)和不足 通過復(fù)習(xí)文獻(xiàn)及總結(jié)的應(yīng)用經(jīng)驗(yàn)達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)的優(yōu)點(diǎn)有:操作者坐著完成手術(shù)不易疲乏，可更輕松的完成長時間高難度手術(shù);避免了因長期手術(shù)導(dǎo)致的疲倦和手腕顫抖;通過濾除了人手震顫減少粗糙操作造成的損傷;避免了心情情感因素對手術(shù)的影響;三維成像系統(tǒng)從而使手術(shù)變得容易縮短學(xué)習(xí)曲線;其內(nèi)腕系統(tǒng)靈活度接近并在某些方面超過人手可完成腹腔鏡所不能完成的動作，甚至可完成人手所不能到達(dá)的生理曲度;可連續(xù)完成精密動作而不會產(chǎn)生;可完成人類無法完成的超精密動作;手術(shù)時間縮短術(shù)后幾率小;結(jié)合影像學(xué)三維重建技術(shù)可對復(fù)雜手術(shù)在術(shù)前進(jìn)行模擬手術(shù)保證手術(shù)的成功率;可通過預(yù)設(shè)定手術(shù)區(qū)域預(yù)防手術(shù)誤損傷;可通過準(zhǔn)確返回上次操作區(qū)域和手術(shù)位置;可通過網(wǎng)絡(luò)實(shí)現(xiàn)手術(shù)。但該系統(tǒng)也有存在不足:如費(fèi)用昂貴推廣普及難度大機(jī)器人手術(shù)的適應(yīng)證和操作尚未規(guī)范化。同時達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)技術(shù)上也還有一定的不足如壓力和觸覺的喪失術(shù)者只能看到器械鉗住了組織卻無法感覺鉗夾的力量;在進(jìn)行縫合或打結(jié)時不能感知打結(jié)力量．過緊易造成打結(jié)過緊，導(dǎo)致組織缺血壞死;手術(shù)中機(jī)器人位置固定后移動較繁瑣需要助手更換機(jī)械臂;控制臺與機(jī)械臂之間的無線通訊易受到干擾。而且就目前技術(shù)而言還不可能由機(jī)器人獨(dú)立完成手術(shù)機(jī)器人僅起到一種輔助的作用。未來達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)的改進(jìn)方向:在技術(shù)層面可加入精細(xì)動作的動力回饋通過設(shè)置和對張力數(shù)據(jù)的計(jì)算機(jī)分析在術(shù)中為醫(yī)生提供警示還可在機(jī)械手上整合影像學(xué)系統(tǒng)加入圖像分析功能幫助醫(yī)生判斷組織血管判讀內(nèi)鏡下解剖結(jié)構(gòu)加快手術(shù)進(jìn)程并使機(jī)械臂能自動更換減少更換機(jī)械臂花費(fèi)的時間和人力。價格層面可通過系統(tǒng)小型化降低價格大力發(fā)展指揮機(jī)器人手術(shù)系統(tǒng)拓展手術(shù)方向?qū)崿F(xiàn)手術(shù)系統(tǒng)的效能最大化提高性價比。

訪。機(jī)器人手術(shù)系統(tǒng)將首先在廣泛性切除術(shù)、盆腹腔淋巴清掃術(shù)肌瘤剔除術(shù)等需要精確分離和縫合技術(shù)術(shù)中顯示出優(yōu)勢并在控制手術(shù)中得到遠(yuǎn)大的應(yīng)用前景。參考文獻(xiàn)．scopicmyomectomycomparedwithstandardlaparoscopicmyomectomy:aretrospectivematchedcontrolstudyJ．FertilSteril，2009，91(2):556［2］DuboisF，BerthelotG，LevardH．ceholecystectomy:experieneewith2006ease．WorldJSurg，1995，19(5):748752［3］PerissatJ，ColletDＲ，BelliardＲ．Gallstones:Laparoscopictreatmentintracorporeallithotripsyfollowedbycholecystostomyorcholecystectomyrsonaltechniqu．Endoscopy，1989，1(suppll):373374．workingwiththeaidofaroboticassistant(thevoicecontrolledopticholderAESOP)ingynaecologiealendoscopicsurger．HumＲeprod，1999，13(1):27482750［5］沈周俊王先進(jìn)．達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)在泌尿外科領(lǐng)域的應(yīng)用現(xiàn)狀J．中華醫(yī)學(xué)雜志，2012，928)［6］BoceaS，StadtmauerL，OehningerS．UncoroplieatedfulltermpregnancyafterdaVinciassistedlaparoscopicmyomectom．ＲeprodBioroedOnline，2007，14(2):246．a(chǎn)roscopicmyomectoroyversusabdominalroyomeetomy:acomparisonofshorttermsurgical esandimmediatecoast．．malminimallyinvasivesurgiealprocedureforendometrialcallcerstagingintheobeseandmorbidlyobese．Gynecol［9］SertMAbelerM．Ｒoboticassistedlaparoscopicradicalhysterectomy(PivertypeⅢ)withnodedissectioncaserepor．EurJGynecolOncol，2006，27(5):531533．chysterectomy:Comparisonwithlaparoscopyandlapamtomy．．robotsssistedlaparoscopicstagingofgynecologicmalignancie．JSLS，2005，9(4):149158．calparametrectomyandlymphadenectoroyinpatientscance．111(3):1821［13］．達(dá)芬奇機(jī)器人輔助內(nèi)8例臨床分析J．中國婦產(chǎn)科臨床雜志，2010，11(6):44744819年前開始嘗試機(jī)器人輔助的婦科手術(shù)［2－3］，［14］DiazArrastieC，JumalovC，GomezG，etl．chysterectomyusingacomputerenhancedsurgical近7年才在歐家獲得較廣泛的應(yīng)用我國2006年引進(jìn)達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)］到目前逐漸為臨床醫(yī)師所認(rèn)識為患者所接收。初步的應(yīng)用顯示了這一新技術(shù)的優(yōu)勢也提示了待改善的方面。機(jī)器人輔助的婦科手術(shù)仍需更長時間的應(yīng)用更廣手術(shù)領(lǐng)域的探索經(jīng)驗(yàn)的積累及大樣本多中心前瞻性隨機(jī)對照的研究和臨床病例近遠(yuǎn)期隨

．Surg［15］PayneTN，Dauterive．comparisonoftotallaparoscopichysterectomytoroboticallyassistedhysterectomy:sur esinacommunitypractic．JMinimInvasiveGynecol，2008，15(3):286291(收稿日期201406第一作者簡介:(1983)，女復(fù)旦大學(xué)附屬中山醫(yī)院主治醫(yī)師。主要研究方向:婦科腫瘤。 AnnSurgOncol(2010)17:319510.1245/s1043401011625ORIGINALORIGINALARTICLE COLORECTALCANCERCancer:Case-MatchedysisofShort-Term JunSeokPark,MD,Gyu-SeogChoi,MD,KyoungHoonLim,MD,YouSeokJang,MD,andSooHanJun,DepartmentofSurgery,KyungpookNationalUniversityHospital,SchoolofMedicine,KyungpookNationalUniversity,Daegu,KoreaPurpose.Theaimofthisstudyistocompareshort-termesandsurgicalqualityofrobot-assisted(RAP)andlaparoscopic(LAP)totalmesorectalexcision(TME)patientswithlowrectalMethods.FromDecember2007toJune2009,41con-secutivepatientswithlowrectalcancerunderwentTMEbyrobot-assistedprocedures.Thelowesttumormarginswerebelowperitonealreflectionand1.08.0cmabovetheverge.Thesepatientswerematched1:2byage,gender,bodymassindex,dateofsurgery,AmericanSocietyofAnesthesiologistsscore,andtumorstage,with82patientswhounderwentconventionalLAP.Macroscopicqualityofthespecimensandoperativeandpostoperative werecompared.Results.Meanoperationtimewas168.0±49.3minforLAPgroupand231.9±61.4minforRAPgroup(P\0.001).Timetoregulardiet(RAP,6.7daysvs.LAP,6.6days)andlengthofstay(RAP,9.9daysvs.LAP,9.4days)weresimilar.Theproportionofsurgeriesper-formedwiththemodifiednaturalorificetechniques(totallyintracorporealprocedureswithtransortransvaginalretrievalofspecimens)wassignificantlyhigherintheRAPgroup(RAP,48.8%vs.LAP,13.4%;P\0.001).Therewerenobetween-groupdifferencesinspecimenquality,includingdistalresectionmargins,harvestedlymphnodes,andcircumferentialmargins.Theoverallmajorcomplica-tionratesweresimilar(RAP,9.8%vs.LAP,7.3%;P=0.641).Conclusions.RAPwassafeandeffectiveforpatientswithlowrectalcancer.Furthermore,thetechnicaladvantagesof?SocietyofSurgicalOncology2010Received:3January2010;PublishedOnline:30JuneG.S.Choi,:

robotsurgicalsystemsmayallowanovelapproachusinghybridnaturalorificesurgery.Minimallyinvasivetechniqueshaveallowedtheuseoflaparoscopicapproachesinthetreatmentofpatientswithcoloncancer.Severalrandomizedtrialshaveshownthatlaparoscopiccolectomyisassociatedwiththesamemor-bidityrate,lesssurgicaltrauma,andimprovedimmediate es,withshorterrecoverytimesandhospitalays1–5Earlyconcernsoveroncological eshavealsobeenaddressedbysomeofthesetrialsreportingequivalentoncologic esbetweenthetwoapproaches.1,2,6,7However,alaparoscopicapproachforpatientswithrectalcancerisquitedifferentandmoredifficultthanlaparoscopicproceduresinpatientswithcoloncancer.Proceduressuchasdissectiondeepintothepelvisto plishatotalmesorectalexcision(TME)andobtainaspecimenwithintactmargins,aswellasfash-ioningasafeanastomosis,aretechnicallydemanding.Consequently,theclinicaltrialsCOSTandCOLORyiel-dedonlyacceptableresultsforcoloncancer.3,5Moreover,theBritishCLASICCtrialindicatedthatrectalexcisionbytrendtowardhighercircumferentialmarginpositivity,althoughthesamegroupreportedsimilarratesoflocalrecurrencesbetweenlaparoscopicandconventionalTherecentintroductionofroboticsurgicalsystemhasrevolutionizedthefieldofminimallyinvasivesurgery.Thissystemprovideshigh-definitionthree-dimensionalvision,eliminatesphysiologictremor,usesroboticcameracontrol,thuseliminatingrelianceonasurgicalassistant,andpro-videsbetterergonomics,resultingindecreasedsurgeonfatigue.8,9Thus,adoptionofaroboticsurgicalsystemforpatientswithextrritonealrectalcancerseemsappealing,becausethisnewtechnologymaybeevenmorebeneficial J.S.Parketwhenoperationsareperformedwithinaconfinedspacesuchasthepelvis.10Itisdifficult,however,todrawanyconclusionsregardingtheabilityofroboticassistancetoprovidelowrectalcancercontrol.Roboticrectalexcisionhasbeenreportedtobefeasibleandsafe,butthesecon-clusionswerebasedonheterogeneousinterventionsinvolvinganteriorresectionoftheupperrectumorsmallnumbersoftt.1113Althoughrandomizedcontrolledtrialsarenecessarytoidentifythebestprocedure,thisapproachisdifficultforanizationalorindividualreasons,becauseroboticequipmentneedstobeusedatumcapacityandpaymentforsurgerydiffersforthetwomethods.Indeed,itisthepolicyofourinstitutiontousethedaVinci?surgicalsystem(IntuitiveSurgical,Sunnyvale,CA,USA)selec-tivelyinpatientswithirradiatedrectumorverylowrectalcancers,thusizingtheclinicalbenefitsofrobotAfterrandomizedcontrolledtrials,thenextbeststrategytocomparetheseproceduresisamatchedpairstudythatincludesalargeprospectivelycollecteddatabase.In2002,weinitiatedalargeprospectivedatabaseofpatientsundergoinglaparoscopicsurgeryforcolorectalcancer,andin2007weinitiatedadatabaseofpatientsundergoingrobotic-assistedprocedures.13,14Ouraim,therefore,isto esinpatientsundergoingrobotictotalmesorectalexcision(RAP)forlowrectalcancerandacase-matchedcohortofpatientsundergoingconventionallaparoscopicprocedures(LAP).Furthermore,weevaluatedtheimpactofrobot-assistedsurgeryonourstandardpro-ceduresfortreatmentoflowrectalcancer.PATIENTSANDFromDecember2005toJune2009,theprospectivelycollectedrecordsofallpatientsatKyungpookUniversityHospitalwithrectalcancerslocatedwithin8cmofthevergewerereviewedretrospectively.Weidentifiedagroupof41patientswhounderwentroboticproceduresforlowrectalcancer;thisgroupwasmatched1:2withagroupof82laparoscopicTMEpatientsundergoinglaparoscopicTME.Matchingcriteriaincludedpatientage(±3years),gender,bodymassindex(BMI),dateofsurgery(±2years),AmericanSocietyofAnesthesiologists(ASA)score,andclinicaltumor(T)stage.Patientswhohadtumorwithintestinalobstructionorperforation,localtumorresectablewithtransaccess,adjacentaninvasionrequiringenblocmulti-anresections,anddistantmetastasiswerenotconsideredsuitableforlaparoscopyorroboticsurgery.Thechoicebetweenthetwodifferentsurgicalapproacheswasbasedonajointdecisionbythepatientsandphysicians,andthecriteriaforpatientselec-tionwerenotmodifiedbytheuseofrobot.Thisstudywas

approvedbytheinstitutionalreviewboard.Allpatientsreceivedanextensiveexplanationoftheprocedureandprovidedinformedconsent.Preoperativepatientworkupconsistedofphysicalexamination,completebloodcount,electrolyteandliverfunctiontests,serumcarcinoembryonicantigen(CEA),chestX-ray,andelectrocardiogram.Colonoscopy,abdominopelviccomputedtomography,andpelvicmag-neticresonanceimagingwereperformedroutinelytoassessdistantmetastases,localdiseaseinfiltration,andtumorcharacteristics.Tumorlocationwasmeasuredusingrigidsigmoidoscopyorrectalclinicalexamination.Patientswerestagedusingtheclinicaltumornodemetastasis(TNM)classification.PatientswithT3,T4ornode-positive(N?)diseaseselectivelyreceivedlong-coursepreoperativeradiochemotherapy(50Gyin25fractionsfor5weeks).Surgerywasperformed6or7weeksafterradiotherapy.SurgicalAllprocedures,laparoscopicandroboticsurgery,wereperformedorsupervisedbyasinglesurgeon(G.-S.C.).RoboticApproachreferredtouseamixedtechnique,consistingofconventionallaparoscopyforvesselligationandsplenicflexuremobilizationandrobotic-assistedproctectomywithtotalmesorectalexcision.15One12-mmsupraumbilicalportforthecamera,three8-mmroboticinasemicircularlineconnectingbothanteriorsuperioriliacspinesandtheumbilicuswereintroducedfortractionandfortheoperation.Highligationoftheinferiormesentericvesselandmobilizationoftheleftcolonandsplenicflexurewereperformedlaparoscopically.Thereafter,theroboticsystemwaspositionedbetweenthepatient’slegs;theroboticarmwasengagedattherightlowertrocarandthesecondandthirdarmsattheleftupperandlowertrocar,respectively.Theassistantwasplacedontherightsideofthepatientandusedoneortwoportsforsuctioningandadditionalretraction.Thetwoworkingarms,dockedtotheleftmedialandrightlateraltrocar,usuallycarriedCardiereforcepsandscissorswithamonopolarcauteryforfineretractionanddissection.Thethirdroboticarmonthepatient’sleftlateraltrocarcarrieddoublefenestratedCardiereforcepsandwasusedasanadditionaltoolforsuspensionoftherectum.Therectumwasroboticallymobilizedusingmonopolarcauteryscissorsbydissectingthroughtheavascularplaneandbetweentheendopelvicfasciatokeeptheautonomicnervesintact.Althoughallsurgerieswereperformedthroughthisstep,twoapproacheswereusedsubsequently.Intheconventionalapproach,therectumwastransectedusinganendoscopiclinearstapleraftertheroboticsystemShort esofRoboticRectal wasdisengaged.Thespecimenwasextractedthrougha4-to6-cmminilaparotomy,andatraditionalend-to-endanastomosiswascreatedusingamechanicalcircularsta-pler.Patientswithverylowtumorsunderwentintersphinctericresectionsandhandsewncoloansto-moses.If,however,thetumorwasnotlargeorifintracorporealsuturingwasfeasible,wemodifiedpartsoftheconventionalapproachandperformedacompleteintracorporealresectionandanastomosisofthecolonorrectum,withremovalofthespecimenthroughatrans-vaginalortransapproach,asdescribedpreviously.15Briefly,theproximalcolonandtherectumdistaltothetumorweredividedbymonopolarcauterytothepreviousligature.Forbothmaleandfemalepatients,aplasticbagwasintroducedthroughtheanus,thespecimenwascol-lected,andthebagwasremovedthroughtheanus(Fig.1a,b).Forsomefemalepatients,analternativeprocedureconsistedofinsertionofaplasticbagthroughatransversecolpotomy,removalofthespecimen,andclosurebyroboticintracorporealsuturing.Ananvilofacircularsta-plerwastransferredthroughtherectal(orvaginal)openingandplacedattheendoftheproximalcolon.Finally,wecompletedanend-to-endanastomosisusingintracorporealpurse-stringsuturesatbothends(Fig.1c).LaparoscopicApproachTheLAPtechniqueweusehasbeendescribedpreviously.16Thesamestandardizedprincipleandsurgicalstepswereusedinboththelaparoscopicandrobotprocedures:ligatureofthemesentericbloodvesselsclosetotheorigin,mobilization

ofthesigmoidcolonandrectumusingtotalmesorectalexcisionwithnerve-sparingtechnique,clambelowthetumor,andwashingoftherectalstumpwith10%povidone-iodinebeforerectalsectioning.Anastomosiswasthenperformedmanuallyorbymechanicalcircularstapling.Specimenextractionandreconstructionwerethesameinthelaparoscopicandroboticgroups,withahybridtechniqueusingnaturalorificesalsousedinselectedpatients.Inselectedpatients,atemporaryileostomywasconstructedtoprotecttheanastomosis,withre-establishmentofdigestivecontinuityperformed2or3monthsaftertheprimaryprocedure.e esincludedskin-to-skinoperationtime,timetopassingflatus,lengthofhospitalstay,morbidity,andconversiontoanopenprocedure.Typeofspecimenextraction(conventionalminilaparotomyorthroughanaturalorifice)andhistologicalresultswerealsoyzed.Conversiontoanopenoperationwasdefinedastheneedforaconventionalmidlinelaparotomy,andindi-cationsforconversionwererecorded.Morbiditywasstratifiedas mended.17MinorsurgicalmorbiditywasassessedasgradeIorII,andmajormorbidityasgradeIII,IVorV.Symptomaticanastomoticleakagewasdefinedclinicallyorradiologicallyasapparentleakageofgas,pus,orfecaldischargefromthedrain,orasperitonitis.After1or2daysoftoleratingasoliddietwithno fortorcomplications,thepatientsweredischarged.FIG.1Anovelapproachforroboticassistedlowanteriorresection:totallyintracorporealresectionandanastomosis,withtransortransvaginalspecimenextraction.aTherectumdistaltothetumorwasdividedusingroboticcautery12cmdistaltothepreviousrectalligature.bTopreventintraoperativespillage,aplasticbagwasintroducedthroughtheanusorvaginaandusedtocollectthespecimen.cDoublepursestringsutureswereappliedtotheproximalcolonicanddistalrectalsides.dAbdomenofthepatientshowingonlytrocarincisionscarsaftersurgery J.S.ParketassessmentincludedtumorinfiltrationthroughtheAgeatsurgery61.263.0assessmentincludedtumorinfiltrationthroughtheAgeatsurgery61.263.0wall(pT),numberoflymphnodesharvested,presenceSex,no.positivelymphnodes,anddistaland2449resectionmargins.Distanceofcircumferentialmargins1733

TABLE1Patient

RAPgroupLAPgroup BMI23.423.4ASAscore,no,I1734224226BMI23.423.4ASAscore,no,I1734224226Meandistance5.75.9Distanceverge1.04.014264.08.0Preoperative274.3564.5Previousabdominalsurgery914PreoperativeCCRT1417No.clinicalTstage331430StatisticalAllstatisticalyseswereperformedusingtheSPSSsoftwarepackage(SPSS75.1,Chicago,IL,USA)forWindows.Nonparametricvariablesareexpressedasmed-ianandrange,andparametricvariablesasmean±standarddeviation.Variablesexpressedasproportionswerecom-paredusingthev2testorFisher’sexacttest,whereappropriate.Between-groupdifferencesinparametricandnonparametricvariableswerecomparedusingtheStudentt-testortheMannWhitneyU-testforindependentvalues,asappropriate.DifferencesinoperationtimewerecomparedusingSpearman’srankcorrelationtestandthepowerregressiontest.Groupswerecomparedonanintention-to-treatbasis.DifferenceswereconsideredsignificantifPvalueswere\0.05.PreoperativeclinicaldataforthetwogroupsofpatientsarepresentedinTable1.Groupsweresimilarintermsofage,dateofoperation,gender,BMI,ASA,anddistributionofclinicalT-stage.PreoperativeserumCEAconcentration,tumorsize,previousoperativehistory,andproportionundergoingpreoperativeradiochemotherapywerealsosimilarinthetwogroups.Intraoperativeandperioperative esarepresentedinTable2.Nopatientsrequiredconversiontoopensur-gery.ThetimefromthestartoftheoperationuntilclosureofthewoundwassignificantlylongerintheRAPthanintheLAPgroup[231.9min(range155360min)vs.168.9min(range,90400min),P\0.001].Themeantimefordockingtherobotarmwas5.5min(range420min).Figure2showstheoperationtimeforeachpatient.ysisoftheRAPshowedthatoperationtimedecreasedwithincreasedexperience(Spearman’srankcorrelationcoefficient,q-0.42;P=0.007).Theindivid-ualdatapointswerealsoplottedonascattergram,and

RT3surr98Anoembryonicantigen,ASAAmericanSocietyofBMIbodymassindex,CCRTconcurrentaValuesinparenthesesaremean(standardtrendlinesbasedonapowerregressionequationweregenerated(Fig.2).The10RAPoperationswereeachlongerthan260min;theoperationtimethengraduallydecreasedandreachedaplateauof220minafter23operations(Fig.2).ThefrequencyofconstructionofaprotectivestomawasthesameintheRAPandLAPgroups(4.9%vs.4.9%,P=1.000).Earlypostoperativerecoveryparameters,includingmeandaystopassingflatusandmeandaystoregulardiet,didnotdiffersignificantlybetweenthetwogroups.Meanlengthofhospitalstaywas9.9±4.2daysintheRAPgroupand9.4±2.9daysintheLAPgroup(P=0.527).Ahybridnaturalorificeapproach,whichinvolvedatotallyintracorporealanastomosisfollowedbyextractionofthespecimenviatheanusorvagina,wasperformedin11patients(13.4%)intheLAPgroupand20patients(48.8%)intheRAPgroup(P\0.001).Of31casesusingnaturalorificeaccess,postoperativecomplicationsoccur-redinsevenpatients(22.5%).Thesecomplicationsincludedanastomoticleakinthreepatients,deepveinthrombosisinonepatient,hemorrhagerequiringtransfu-sionintwopatients,andrespiration-relatedcomplicationinonepatient.NoneofthepatientsinthisgroupencounteredShort esofRoboticRectal RAPgroup LAPgroupRAPgroup LAPgroup POperationtime231.9168.6Intraoperativetransfusion11Conversiontoopensurgery00Sphincterpreservationrate4181Protectivestoma24TypeofresectionLowanterior2963 1218RAProboticassisted

AbdominoperinealresectionSpecimenremovalapproach(%)

0 1

LAPlaparoscopicaValuesaremean(standardTimeTimetoresumeregulardiet6.7 6.6Lengthofstay9.9 9.4TABLE3Pathologic PTumorsize 3.83.9Proximalmargin 17.218.5Distalmargin 2.12.3Circumferentialmargin 7.08.3involvement(%)1 3879B1 23RetrievedLN,n 17.314.2PositiveLN,n 1.00.9Histologicdifferentiation

21 71Natural 20 11Flatuspassage 2.9 2.7 Transortransvaginalhandsewnanastomosis)FIG.2Changesinoperatingtimeforroboticresectioninlowrectalcancer.Theplateauwasobservedafter22patientshadundergonetheoperationcomplicationassociatedwiththeextractionsite,suchasperinealpain,vaginalcuffdehiscenceorincontinence.Ingeneral,morbiditywasequivalentbetweengroups(naturalorificegroup,n=31,22.5%;vs.traditionalapproachgroup,n=92,26.0%).TheresultsofmacroscopicevaluationofspecimensarepresentedinTable3.MeandistalresectionmarginsintheRAPandLAPgroupswere2.1±1.4cmand2.3±1.5cm,respectively(P=0.438),andmeancircumferen-tialresectionmarginswere7.0±3.9mmand8.3±5.6mm,respectively(P=0.242).ThecircumferentialmarginwasinvadedintwoRAPandthreeLAPpatients(4.9%vs.3.7%,P=0.542).Themeannumberofhar-vestedlymphnodeswas17.3±7.7intheRAPgroup14.2±8.9intheLAPgroup(P=0.060).The

6 4306925Other34Stage 13 21 14 3