机器人辅助全直肠系膜切除术和盆腔外侧淋巴结清扫术治疗局部晚期中低直肠癌
Summary
本文描述的机器人技术旨在详细说明机器人辅助全直肠系膜切除和盆腔外侧淋巴结清扫的逐步方法，用于位于腹膜反射下方的局部晚期（T3 / T4）直肠癌。
Abstract
自批准用于临床以来，达芬奇手术机器人在胃肠道外科手术中显示出巨大的优势，特别是在复杂的程序中。高质量的3-D视觉，多关节臂和自然震颤过滤使外科医生能够以最小的侵入更准确地暴露和解剖。全直肠系膜切除术是治疗可切除直肠癌的标准手术技术。为了降低侧向复发率，可以进行盆腔外侧淋巴结清扫术，因为它是局部晚期中低直肠癌的安全可行的手术，转移至侧淋巴结的可能性很高。然而，解剖结构的复杂性和术后并发症的高率限制了其应用。最近，一些外科医生越来越多地使用机器人技术进行全直肠系膜切除术和盆腔外侧淋巴结清扫术。与开放和腹腔镜手术相比，机器人技术具有几个优点，例如失血量少，输血量少，创伤最小，术后住院时间短，恢复更快。机器人方法通常被认为是复杂手术（如盆腔外侧淋巴结清扫术）的合理替代方案，尽管报告直接证据的高质量前瞻性随机对照研究数量有限。在这里，我们提供了在西安交通大学第一附属医院进行的机器人辅助全直肠系膜切除术和侧向盆腔淋巴结清扫术的详细步骤。
Introduction
自 2000 年美国食品和药物管理局批准用于临床以来，达芬奇手术机器人已越来越多地用于不同的外科专业1。机器人手术系统具有使用灵活的多关节臂，高质量的三维相机，震颤过滤以及大大改进的人体工程学的优点，可以最大限度地减少手术的侵入性，从而使其成为复杂手术的理想选择。
几十年来，全直肠系膜切除术（TME）一直是治疗可切除直肠癌的标准。然而，对于位于腹膜反射下方的晚期（T3/T4）直肠癌，盆腔外侧淋巴结（LPLN）转移是术后局部复发的主要原因2。临床证据明确表明，盆腔外侧淋巴结清扫术（LPLND）可显著降低局部复发率3。与开放式手术相比，机器人辅助 TME 和 LPLND 的失血量更少，输血次数更少，术后并发症更少4。此外，两种手术之间的长期结果没有显著差异5。这些报告的结果表明，机器人辅助的LPLND可能是局部晚期直肠癌的可行方法。但是，应该注意的是，机器人辅助的TME和LPLND是复杂的程序，应由经验丰富的外科医生执行。
本文逐步描述了机器人辅助TME和LPLND的标准系统方法。该程序是在该中心开发的，该中心具有执行三千多个机器人程序的经验6。此外，这种方法基于正常的解剖学特征;应注意罕见的解剖学变异。
我们以一名 64 岁男性患者为例，该患者间歇性便血发作约 3 个月。直肠指检显示，直肠前壁和右外侧壁上有一个肿块，距离肛门5厘米。增强型计算机断层扫描（CT）和内镜超声（EUS）显示下直肠癌伴髂内淋巴结转移。结肠镜活检证实存在中度分化性腺癌。术前评估提示临床分期为cT3N+M0。因此，我们决定执行机器人辅助TME和LPLND。在执行这些程序之前已获得患者的同意。
Protocol
该协议符合西安交通大学第一附属医院伦理委员会（编号：2019ZD04）的指导方针。 1. 术前准备、患者体位、麻醉 确保在手术前进行适当的饮食管理。 开具术前口服碳水化合物饮料，在睡前和手术前4小时食用。注意：这是根据手术后增强恢复（ERAS）方案允许的。 不要开任何额外的口服抗生素。注：这些措施的实施应根据各中心的经验?…
Representative Results
视频中所示病例的详细围手术期信息如 表1 和 图3所示。该程序由通讯作者于2019年4月使用达芬奇Si机器人系统执行。手术期间估计失血量为90毫升，不需要输血。术后管理遵循ERAS的原则。手术后第6天第一次排便后，我们给予葡甲胺二氮酸盐灌肠，并进行X射线照相，以确定是否发生吻合口渗漏。然后，在确认没有泄漏证据后，我们移除了排水管。患者在随访期间…
Discussion
结直肠癌（CRC）是全球最常见的癌症之一13。其中，超过三分之一是直肠癌。由于术后功能要求较高，骨盆和会阴的神经和筋膜解剖结构复杂，直肠癌，特别是低直肠癌或超低直肠癌的最佳手术方法仍在争论中。自 1979 年首次报告以来，全直肠系膜切除术 （TME） 一直是治疗可切除直肠癌的标准手术技术14。随着肠系膜的完全切除，局部复发率显着降低。然而，?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
该项目由国家自然科学基金（第81870380号）和陕西省科学基金（2020ZDLSF01-03和2020KWZ-020）资助。
Materials
| 0 Silk suture | N/A | N/A | Secure the anvil |
| 12mm Trocar | Medtronic (Minneapolis, MN) | NONB12STF | Assistant port 1 |
| 19 Fr drain | N/A | N/A | Pelvic drain |
| 2-0 Silk suture | N/A | N/A | Close skin incisions |
| 2-0 V-Loc sutures | Covidien (Dublin, Ireland) | VLOCL0315 | Barbed Absorable Suture |
| 4-0 PDS | Ethicon (Somerville, NJ) | SXPP1A400 | Synthetic Absorbable Suture |
| 8mm Trocar | Medtronic (Minneapolis, MN) | NONB8STF | Assistant port 2 |
| Bipolar forceps | Intuitive (Sunnyvale, CA) | 470172 | Operation |
| Cadiere grasping forceps | Intuitive (Sunnyvale, CA) | 470049 | Operation |
| Circular stapler | EzisurgMed (Shanghai, China) | CS2535 | Laparoscopic Surgical Stapler |
| Da Vinci Si | Intuitive (Sunnyvale, CA) | N/A | Surgical Robot |
| Da Vinci Xi | Intuitive (Sunnyvale, CA) | N/A | Surgical Robot |
| Hem-o-lok ligation clip | Weck (Morrisville, NC) | 544995 | Ligation of vessel |
| Laparoscopic single use linear cutting stapler | EzisurgMed (Shanghai, China) | U12M45 | Laparoscopic Surgical Stapler |
| Large needle driver | Intuitive (Sunnyvale, CA) | 470006 | Operation |
| Monopolar scissors | Intuitive (Sunnyvale, CA) | 470179 | Operation |
| Ribbon retractor | N/A | N/A | Control movement of rectum |
| Specimen Bags | N/A | N/A | Extract specimen |
| Veress needle | N/A | N/A | Saline drop test |
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Cite This Article
Hu, C., Zhang, Z., Zhang, L., Liu, R., Yan, J., Sun, Q., Wang, G., She, J. Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer. J. Vis. Exp. (180), e62919, doi:10.3791/62919 (2022).