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中华胸部外科电子杂志 ›› 2020, Vol. 07 ›› Issue (03) : 146 -151. doi: 10.3877/cma.j.issn.2095-8773.2020.03.04

所属专题: 机器人专题 机器人手术 文献

论著

胃-食管预制机器人胸内手工分层吻合——一种胃-食管胸内吻合的新策略
卓泽国1, 李刚2, 林一丹1,()   
  1. 1. 610041 成都,四川大学华西医院胸外科
    2. 610041 成都,四川大学华西医院胸外科;610041 成都,西藏自治区人民政府驻成都办事处医院/华西医院西藏成办分院胸外科
  • 收稿日期:2020-08-04 修回日期:2020-08-25 接受日期:2020-08-26 出版日期:2020-08-28
  • 通信作者: 林一丹

Pretreatment-facilitated robot intrathoracic layered anastomosis—a novel strategy for robotic intrathoracic anastomosis between the esophagus and gastric conduit

Zeguo Zhuo1, Gang Li2, Yidan Lin1,()   

  1. 1. Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
    2. Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China; Department of Thoracic Surgery, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region, Chengdu 610041, China
  • Received:2020-08-04 Revised:2020-08-25 Accepted:2020-08-26 Published:2020-08-28
  • Corresponding author: Yidan Lin
  • About author:
    Corresponding author: Lin Yidan, Email:
引用本文:

卓泽国, 李刚, 林一丹. 胃-食管预制机器人胸内手工分层吻合——一种胃-食管胸内吻合的新策略[J/OL]. 中华胸部外科电子杂志, 2020, 07(03): 146-151.

Zeguo Zhuo, Gang Li, Yidan Lin. Pretreatment-facilitated robot intrathoracic layered anastomosis—a novel strategy for robotic intrathoracic anastomosis between the esophagus and gastric conduit[J/OL]. Chinese Journal of Thoracic Surgery(Electronic Edition), 2020, 07(03): 146-151.

目的

报告胃-食管预制机器人胸内手工分层吻合(PRILA)的技术特点。

方法

术前活检确诊为食管癌并愿意接受机器人辅助微创食管切除术(RAMIE)的患者为本研究纳入对象。胃食管吻合前预处理措施主要包括以下四方面:以胸骨角为标志在体外完成管状胃的预制;吻合前采用冷造口的方法在胃前壁造口;采取保护性胃包裹及传动法拖曳管状胃进入胸腔的方式;采用腔内阻断的方法夹闭食管近端,以减少吻合时食管端出血。术后每半年随访一次以追踪患者转归。

结果

2018年9月至2019年7月,12名食管癌患者采用PRILA术式顺利完成了肿瘤切除及消化道重建,均未发生中转开胸。所有患者取得R0切除,术后均未发生吻合口瘘。术后住院时间平均9.9天,出院时所有患者可耐受半流质饮食,术后随访1年均未发生肿瘤复发或转移。

结论

胃-食管PRILA在食管癌的外科治疗中安全可行。该术式通过对食管及管状胃的预处理,为术者提供了一个清晰的术野,保证了手术的流畅性和分层吻合的精确性。该方法为胸外科医师应对胃-食管胸内吻合的挑战提供了一条新策略。

Objective

To report the experience of pretreatment-facilitated robot intrathoracic layered anastomosis (PRILA) .

Methods

Patients with esophageal cancer proved by biopsy and willing to accept robot-assisted minimally invasive esophagectomy (RAMIE) were included in this study. The pretreatments before anastomosis included the following procedures. Firstly, we used the sternal angle as a marker to confirm the length of the gastric conduit so that we could construct the conduit outside the body. Secondly, cold scissors, rather than the electrocoagulation equipment, were used in making the gastrostomy. Thirdly, the gastric conduit was carefully packaged with single-layered gauze before we move it into the thoracic cavity. Lastly, an intrathoracic clamp was placed on the proximal esophageal stump to reduce the bleeding of the stump. An interview was performed every half-year after the surgery to track the postoperative outcomes.

Results

Between September 2018 and July 2019, 12 patients with esophageal cancer received PRILA for tumor resection and digestive tract reconstruction. All the patients achieved R0 resection, and no patient suffered from an anastomotic leakage. The mean length of postoperative stay was 9.9 day. All patients could receive semiliquid diet when discharged. No relapse or metastasis happened in the first year after the surgery.

Conclusion

PRILA is a safe and feasible procedure with favorable surgical outcomes. The pretreatment procedures provide us a clean surgical field so that the anastomosis could be performed fluently and accurately. It provides surgeons a new strategy to handle the challenges of the intrathoracic robotic anastomosis.

图1 胃-食管预制机器人胸内手工分层吻合胸部手术阶段镜孔分布图。镜孔位于腋中线第8肋间,1号机械臂放置于镜孔右前方,2号、3号机械臂则位于镜孔左前方。以上4个孔位呈弧形排列,彼此之间相隔距离至少8 cm。助手孔则位于腋前线前方第4肋间,长度约为3.5 cm
图2 切除胸骨角以远胃底组织,完成管状胃的剪裁。将管状胃沿患者身体的前正中线在胸部摆开,于胸骨角水平使用直线切割缝合器切除胸骨角以远胃底组织
图3 缝扎胃部吻合区黏膜下血管,冷造口法完成胃部吻合区预制。在管状胃前壁选取胃部吻合口,尖刀片切开浆肌层暴露黏膜下层,缝扎通过吻合区的黏膜下血管以减少胃部吻合区出血(图中4个椭圆处为缝扎点),接着再继续向下切开黏膜下层及黏膜层,完成胃部吻合口的预制
图4 纱布保护性包裹管状胃,拖曳纱布带动管状胃进入胸腔。A.单层纱布稍加压包裹管状胃,线结标记胃网膜右动脉以供拖曳过程中管状胃方位辨别,防止管状胃扭转。B.机械手抓持纱布,通过纱布与管状胃间的摩擦力带动管状胃进入胸腔,避免对管状胃的直接抓持。C.移去纱布,暴露胃部吻合口
图5 食管近端放置一腔内阻断钳,完成食管端吻合前的预处理。距食管断端以近3~4 cm处放置一腔内阻断钳,以减少吻合时食管近端的出血
表1 机器人PRILA患者基线资料与术后转归
1
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