Robot-assisteret Total Mesorectal Excision og Lateral Bækken lymfeknude Dissektion for lokalt avanceret mellemlav endetarmskræft
Summary
Den robotteknik, der er beskrevet heri, har til formål at beskrive en trinvis tilgang til robotassisteret total mesorrektal excision og lateral bækkenlymfeknude dissektion for lokalt avanceret (T3/T4) endetarmskræft placeret under peritoneal refleksion.
Abstract
Siden deres godkendelse til klinisk brug har da Vinci kirurgiske robotter vist store fordele i gastrointestinale kirurgiske operationer, især i komplekse procedurer. Den højkvalitets 3D visuelle, flerøje arm og naturlige tremor filtrering gør det muligt for kirurgen at eksponere og dissekere mere præcist med minimal invasion. Total mesorectal excision er standard kirurgisk teknik til behandling af resectable endetarmskræft. For at reducere den laterale gentagelseshastighed kan lateral bækkenlymfeknude dissektion udføres, da det er en sikker og mulig procedure for lokalt avanceret mellemlav endetarmskræft med en høj mulighed for metastaser til de laterale lymfeknuder. Kompleksiteten af de anatomiske strukturer og den høje postoperative komplikationshastighed begrænser imidlertid dens anvendelse. For nylig har flere kirurger i stigende grad brugt robotteknikker til total mesorektal excision og lateral bækken lymfeknude dissektion. Sammenlignet med åben og laparoskopisk kirurgi har robotteknikken flere fordele, såsom mindre blodtab, færre blodtransfusioner, minimale traumer, kortere postoperativ hospitalsindlæggelse og hurtigere genopretning. En robot tilgang er generelt betragtes som et rimeligt alternativ til komplicerede procedurer såsom lateral bækken lymfeknude dissektion, selv om der er et begrænset antal af høj kvalitet potentielle randomiserede kontrollerede undersøgelser rapportering direkte beviser. Her giver vi de detaljerede trin i robot-assisteret total mesorektal excision og lateral bækken lymfeknude dissektion udført på first affiliated hospital i Xi’an Jiaotong University.
Introduction
Siden deres godkendelse til klinisk brug af USA Food and Drug Administration i 2000, da Vinci kirurgiske robotter er i stigende grad blevet udnyttet på tværs af forskellige kirurgiske specialiteter1. Robot kirurgisk system har fordelene ved at bruge fleksible flerøje arme, en høj kvalitet tre-dimensionelle kamera, tremor filtrering, og stærkt forbedret ergonomi, som kan minimere invasivitet af operationen og dermed gøre den ideel til komplekse procedurer.
I årtier har total mesorectal excision (TME) været standarden for behandling af gensectable endetarmskræft. Men for avanceret (T3/T4) endetarmskræft placeret under peritoneal refleksion, lateral bækken lymfeknude (LPLN) metastaser er en væsentlig årsag til lokal gentagelse efter operation2. Kliniske beviser viser tydeligt, at lateral bækken lymfeknude dissektion (LPLND) kunne reducere den lokale gentagelseshastighed3. Sammenlignet med den åbne procedure har robotassisteret TME og LPLND været forbundet med mindre blodtab, færre blodtransfusioner og færre postoperative komplikationer4. Desuden er de langsigtede resultater ikke signifikant forskellige mellem de to procedurer5. Resultaterne af disse rapporter viser, at robot-assisteret LPLND kan være en mulig modalitet for lokalt avanceret endetarmskræft. Det skal dog bemærkes, at robotassisteret TME og LPLND er komplekse procedurer og bør udføres af en erfaren kirurg.
Heri beskrives en standard systematisk tilgang til robotassisteret TME og LPLND trin for trin. Denne procedure blev udviklet i centrum med erfaring med at udføre mere end tre tusinde robotprocedurer6. Derudover var denne tilgang baseret på normale anatomiske egenskaber; sjældne anatomiske variationer skal bemærkes.
Vi præsenterer sagen om en 64-årig mandlig patient, der havde periodisk hæmatochezia i ca. 3 måneder. Digital rektal undersøgelse viste, at en masse var placeret på den forreste og højre sidevæg af endetarmen, 5 cm fra anus. En forbedret computertomografi (CT) scanning og endoskopisk ultralyd (EUS) afslørede lavere endetarmskræft med intern iliac lymfeknude metastaser. Koloskopisk biopsi bekræftede tilstedeværelsen af moderat differentieret adenocarcinom. Den præoperative evaluering tydede på, at det kliniske stadium var cT3N+M0. Derfor besluttede vi at udføre robotassisteret TME og LPLND. Patientens samtykke blev indhentet, før disse procedurer blev udført.
Protocol
Representative Results
Discussion
Kolorektal cancer (CRC) er en af de mest almindelige kræftformer på verdensplan13. Blandt dem er mere end en tredjedel end endetarmskræft. På grund af den højere postoperative funktionelle krav og den sofistikerede neuro- og fascial anatomi af bækkenet og mellemkødet, den bedste kirurgiske tilgang til endetarmskræft, især lav eller ultralav endetarmskræft, er stadig under stor debat. Siden sin første rapport i 1979, samlede mesorectal excision (TME) har været standard kirurgisk teknik …
Disclosures
The authors have nothing to disclose.
Acknowledgements
Dette projekt blev støttet af National Natural Science Foundation of China (No. 81870380) og Shaanxi Province Science Foundation (2020ZDLSF01-03 og 2020KWZ-020).
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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