论著·外科天地|（附配文视频）第4代达芬奇设备人手术系统辅助六孔法直肠癌前切除术的临床疗效——王凯 符炜 付海啸等
<img src="https://mmbiz.qpic.cn/mmbiz_gif/cJFq46GOa3cMRK7vRs73M85IVy8HbWohnEUcpLPUnkxgrLiazn3A7ENnyDgtyuYRRib1b0Y3hsXOspxqwxIvhIQg/640?wx_fmt=gif&wxfrom=5&wx_lazy=1&tp=webp" style="width: 50%; margin-bottom: 20px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/cJFq46GOa3cMRK7vRs73M85IVy8HbWohqg8ovSExN5xKvTcmE2eRF5M9aATRwBX7ltFJL7VSMrDunhial5ll5kQ/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;"><span style="color: black;">引用本文</span></span><p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">王凯<span style="color: black;">,</span>符炜<span style="color: black;">,</span>付海啸<span style="color: black;">,</span>等<span style="color: black;">.</span>第<span style="color: black;">4</span>代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术的临床疗效<span style="color: black;">.</span>中华消化外科杂志<span style="color: black;">,2023,22(6):769-778. </span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">DOI:10.3760/cma.j.cn115610-20230403-00146.</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/cJFq46GOa3cywB7BuM5IH0dPyLlU8B8tRgOLp5kjNwDdk6L5Oic14jRzb3a4lTSNfjKXvHjVcpt1MR56Lg2M52g/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><span style="color: black;">张轩教授</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/cJFq46GOa3cywB7BuM5IH0dPyLlU8B8tTQresUUG2uPibyZr9FBgb6SKKxVYpuH485MiaFTkse6sWgsUS2oX4RyA/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">王凯教授</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_jpg/cJFq46GOa3cywB7BuM5IH0dPyLlU8B8tWicvzFwJp2xfzWrhmg8gFJ56FtKCTU1ianhgrBznuhHwkDmS9Tm2IsdQ/640?wx_fmt=jpeg&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">徐州医科大学<span style="color: black;">附庸</span>医院胃肠外科符炜教授团队</span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/cJFq46GOa3cywB7BuM5IH0dPyLlU8B8tEk2UAru1JibqIZbuiajunVCLAmeUicaT8LlajlhbAt6k625AUW3RdZ03A/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;">扫码观看手术视频</span></strong></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/cJFq46GOa3cywB7BuM5IH0dPyLlU8B8t1F5s9ToZzFoh06qmcn8ZhnkEIwyfb1yJSdAbAsz3qgCSmAXUq9wOvQ/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><strong style="color: blue;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">扫码观看团队介绍</span></strong></span></strong></p><span style="color: black;"><span style="color: black;">作者</span></span><span style="color: black;"><span style="color: black;">王凯</span><span style="color: black;">1</span><span style="color: black;"> <span style="color: black;">符炜</span></span><span style="color: black;">1</span><span style="color: black;"> <span style="color: black;">付海啸</span></span><span style="color: black;">1</span><span style="color: black;"> <span style="color: black;">李腾腾</span></span><span style="color: black;">1</span></span><span style="color: black;"><span style="color: black;"><span style="color: black;">刘浩</span></span><span style="color: black;">1</span><span style="color: black;"> <span style="color: black;">何京京</span></span><span style="color: black;">2</span><span style="color: black;"> <span style="color: black;">宋军</span></span><span style="color: black;">1</span><span style="color: black;"> <span style="color: black;">张轩</span></span><span style="color: black;">1</span></span><span style="color: black;"><span style="color: black;">通信作者：</span><span style="color: black;"><span style="color: black;">张轩</span></span></span><span style="color: black;"><span style="color: black;">作者单位</span></span><span style="color: black;"><span style="color: black;">1</span><span style="color: black;">徐州医科大学<span style="color: black;">附庸</span>医院普通外科，徐州</span></span><span style="color: black;"><span style="color: black;"><span style="color: black;">2</span></span></span><span style="color: black;"><span style="color: black;">东南大学公共卫生管理学院，南京</span></span><span style="color: black;"><strong style="color: blue;">摘 要</strong></span><strong style="color: blue;"><span style="color: black;"><span style="color: black;"><span style="color: black;">目的</span></span></span></strong><span style="color: black;"><span style="color: black;"><span style="color: black;">探讨第</span><span style="color: black;">4</span><span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术的临床疗效。</span><strong style="color: blue;"><span style="color: black;"><span style="color: black;">办法</span></span></strong><span style="color: black;">采用回顾性队列<span style="color: black;">科研</span><span style="color: black;">办法</span>。收集</span><span style="color: black;">2020</span><span style="color: black;">年</span><span style="color: black;">8</span><span style="color: black;">月至</span><span style="color: black;">2021</span><span style="color: black;">年</span><span style="color: black;">6</span><span style="color: black;">月徐州医科大学<span style="color: black;">附庸</span>医院收治的</span><span style="color: black;">102</span><span style="color: black;">例中低位直肠癌<span style="color: black;">病人</span>的临床病理资料；男</span><span style="color: black;">62</span><span style="color: black;">例，女</span><span style="color: black;">40</span><span style="color: black;">例；年龄为（</span><span style="color: black;">53±12</span><span style="color: black;">）岁。</span><span style="color: black;">102</span><span style="color: black;">例<span style="color: black;">病人</span>中，</span><span style="color: black;">51</span><span style="color: black;">例行第</span><span style="color: black;">4</span><span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术，设为<span style="color: black;">设备</span>人组；</span><span style="color: black;">51</span><span style="color: black;">例行腹腔镜直肠癌前切除术，设为腹腔镜组。观察指标：（</span><span style="color: black;">1</span><span style="color: black;">）治疗<span style="color: black;">状况</span>。（</span><span style="color: black;">2</span><span style="color: black;">）术后病理学<span style="color: black;">检测</span>结果。（</span><span style="color: black;">3</span><span style="color: black;">）随访<span style="color: black;">状况</span>。正态分布的计量资料以</span></span><span style="color: black;">x±s</span><span style="color: black;"><span style="color: black;">暗示</span>，组间比较采用独立样本</span><span style="color: black;">t</span><span style="color: black;">检验；偏态分布的计量资料以</span><span style="color: black;">M</span><span style="color: black;"><span style="color: black;">（范围）<span style="color: black;">暗示</span>，组间比较采用</span><span style="color: black;">Mann‑Whitney </span></span><span style="color: black;">U</span><span style="color: black;">检验。计数资料以绝对数<span style="color: black;">暗示</span>，组间比较采用</span><span style="color: black;">χ</span><span style="color: black;">²<span style="color: black;">检验或</span><span style="color: black;">Fisher</span><span style="color: black;">确切概率法。重复<span style="color: black;">测绘</span>数据采用重复<span style="color: black;">测绘</span>方差分析。</span><strong style="color: blue;"><span style="color: black;">结果</span></strong><span style="color: black;">（</span><span style="color: black;">1</span><span style="color: black;">）治疗<span style="color: black;">状况</span>。两组<span style="color: black;">病人</span>均顺利施行直肠癌根治术，术中均<span style="color: black;">没</span>输血、中转开腹手术、术后</span><span style="color: black;">30d</span><span style="color: black;">内死亡。<span style="color: black;">设备</span>人组<span style="color: black;">病人</span>手术时间，术中<span style="color: black;">流血</span>量，淋巴结清扫数目，术后首次肛门排气时间，术后首次<span style="color: black;">摄食</span>流质<span style="color: black;">食品</span>时间，术后导尿管拔除时间，术后<span style="color: black;">病痛</span>分级（</span><span style="color: black;">1</span><span style="color: black;">级、</span><span style="color: black;">2</span><span style="color: black;">级、</span><span style="color: black;">3</span><span style="color: black;">级、</span><span style="color: black;">4</span><span style="color: black;">级），治疗<span style="color: black;">花费</span>分别为（</span><span style="color: black;">170±12</span><span style="color: black;">）</span><span style="color: black;">min</span><span style="color: black;">，（</span><span style="color: black;">73±50</span><span style="color: black;">）</span><span style="color: black;">mL</span><span style="color: black;">，（</span><span style="color: black;">23±6</span><span style="color: black;">）枚，（</span><span style="color: black;">35.1±9.4</span><span style="color: black;">）</span><span style="color: black;">h</span><span style="color: black;">，（</span><span style="color: black;">2.1±0.8</span><span style="color: black;">）</span><span style="color: black;">d</span><span style="color: black;">，（</span><span style="color: black;">2.9±2.7</span><span style="color: black;">）</span><span style="color: black;">d</span><span style="color: black;">，</span><span style="color: black;">13</span><span style="color: black;">、</span><span style="color: black;">15</span><span style="color: black;">、</span><span style="color: black;">17</span><span style="color: black;">、</span><span style="color: black;">6</span><span style="color: black;">例，（</span><span style="color: black;">7.1±4.5</span><span style="color: black;">）万元；腹腔镜组<span style="color: black;">以上</span>指标分别为（</span><span style="color: black;">153±22</span><span style="color: black;">）</span><span style="color: black;">min</span><span style="color: black;">，（</span><span style="color: black;">119±66</span><span style="color: black;">）</span><span style="color: black;">mL</span><span style="color: black;">，（</span><span style="color: black;">15±4</span><span style="color: black;">）枚，（</span><span style="color: black;">40.7±1.9</span><span style="color: black;">）</span><span style="color: black;">h</span><span style="color: black;">，（</span><span style="color: black;">2.9±0.4</span><span style="color: black;">）</span><span style="color: black;">d</span><span style="color: black;">，（</span><span style="color: black;">5.3±2.1</span><span style="color: black;">）</span><span style="color: black;">d</span><span style="color: black;">，</span><span style="color: black;">6</span><span style="color: black;">、</span><span style="color: black;">7</span><span style="color: black;">、</span><span style="color: black;">26</span><span style="color: black;">、</span><span style="color: black;">12</span><span style="color: black;">例，（</span><span style="color: black;">6.7±1.6</span><span style="color: black;">）万元；两组<span style="color: black;">病人</span><span style="color: black;">以上</span>指标比较，差异均有统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">t</span><span style="color: black;">=6.79<span style="color: black;">、</span><span style="color: black;">-4.46</span><span style="color: black;">、</span><span style="color: black;">20.09</span><span style="color: black;">、</span><span style="color: black;">-3.01</span><span style="color: black;">、</span><span style="color: black;">-5.54</span><span style="color: black;">、</span><span style="color: black;">-16.69</span><span style="color: black;">，</span></span><span style="color: black;">Z</span><span style="color: black;">=-2.87<span style="color: black;">，</span></span><span style="color: black;">t</span><span style="color: black;">=4.22<span style="color: black;">，</span></span><span style="color: black;">P</span><span style="color: black;"><0.05<span style="color: black;">）。（</span><span style="color: black;">2</span><span style="color: black;">）术后病理学<span style="color: black;">检测</span>结果。<span style="color: black;">设备</span>人组<span style="color: black;">病人</span>肿瘤长径，标本切除长度，肿瘤上切缘距离，肿瘤下切缘距离，全直肠系膜切除完整性分级（完整、大部分完整），肿瘤分化程度（高分化、中分化、低分化），术后</span><span style="color: black;">TNM</span><span style="color: black;">分期（</span><span style="color: black;">Ⅰ</span><span style="color: black;">期、</span><span style="color: black;">Ⅱ</span><span style="color: black;">期、</span><span style="color: black;">Ⅲ</span><span style="color: black;">期）分别为（</span><span style="color: black;">3.8±1.1</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，（</span><span style="color: black;">18.7±3.2</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，（</span><span style="color: black;">11.8±3.6</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，（</span><span style="color: black;">2.7±0.8</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，</span><span style="color: black;">48</span><span style="color: black;">、</span><span style="color: black;">3</span><span style="color: black;">例，</span><span style="color: black;">4</span><span style="color: black;">、</span><span style="color: black;">41</span><span style="color: black;">、</span><span style="color: black;">6</span><span style="color: black;">例，</span><span style="color: black;">6</span><span style="color: black;">、</span><span style="color: black;">17</span><span style="color: black;">、</span><span style="color: black;">28</span><span style="color: black;">例；腹腔镜组<span style="color: black;">病人</span><span style="color: black;">以上</span>指标分别为（</span><span style="color: black;">3.7±1.0</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，（</span><span style="color: black;">18.3±2.8</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，（</span><span style="color: black;">10.2±2.7</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，（</span><span style="color: black;">2.5±0.6</span><span style="color: black;">）</span><span style="color: black;">cm</span><span style="color: black;">，</span><span style="color: black;">46</span><span style="color: black;">、</span><span style="color: black;">5</span><span style="color: black;">例，</span><span style="color: black;">6</span><span style="color: black;">、</span><span style="color: black;">39</span><span style="color: black;">、</span><span style="color: black;">6</span><span style="color: black;">例，</span><span style="color: black;">5</span><span style="color: black;">、</span><span style="color: black;">20</span><span style="color: black;">、</span><span style="color: black;">26</span><span style="color: black;">例；两组<span style="color: black;">病人</span><span style="color: black;">以上</span>指标比较，差异均<span style="color: black;">没</span>统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">t</span><span style="color: black;">=1.72<span style="color: black;">、</span><span style="color: black;">1.29</span><span style="color: black;">、</span><span style="color: black;">1.64</span><span style="color: black;">、</span><span style="color: black;">1.11</span><span style="color: black;">，</span></span><span style="color: black;">χ</span><span style="color: black;">²=0.14<span style="color: black;">，</span></span><span style="color: black;">Z</span><span style="color: black;">=-0.42<span style="color: black;">，</span><span style="color: black;">-0.26</span><span style="color: black;">，</span></span><span style="color: black;">P</span><span style="color: black;">>0.05<span style="color: black;">）。<span style="color: black;">设备</span>人组<span style="color: black;">病人</span><span style="color: black;">没</span>环周切缘阳性和肠系膜破坏，腹腔镜组<span style="color: black;">病人</span><span style="color: black;">以上</span>指标均为</span><span style="color: black;">1</span><span style="color: black;">例，两组<span style="color: black;">病人</span><span style="color: black;">以上</span>指标比较，差异均<span style="color: black;">没</span>统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;">>0.05<span style="color: black;">）。（</span><span style="color: black;">3</span><span style="color: black;">）随访<span style="color: black;">状况</span>。两组<span style="color: black;">病人</span>均<span style="color: black;">得到</span>术后</span><span style="color: black;">12</span><span style="color: black;">个月随访。两组<span style="color: black;">病人</span>术后均<span style="color: black;">没</span>肿瘤局部复发和远处转移。<span style="color: black;">设备</span>人组<span style="color: black;">病人</span>大便失禁严重程度评分、低前切除<span style="color: black;">综合症</span>评分、国际前列腺功能评分、夜间排尿评分、国际勃起功能指数问卷评分、女性性功能指数评分分别由术前的</span><span style="color: black;">0</span><span style="color: black;">、（</span><span style="color: black;">12.25±1.08</span><span style="color: black;">）分、（</span><span style="color: black;">4.43±0.33</span><span style="color: black;">）分、（</span><span style="color: black;">0.49±0.09</span><span style="color: black;">）分、（</span><span style="color: black;">24.07±2.75</span><span style="color: black;">）分、（</span><span style="color: black;">65.84±1.79</span><span style="color: black;">）分，变化为术后</span><span style="color: black;">12</span><span style="color: black;">个月的（</span><span style="color: black;">1.34±0.11</span><span style="color: black;">）分、（</span><span style="color: black;">18.11±3.54</span><span style="color: black;">）分、（</span><span style="color: black;">4.03±0.26</span><span style="color: black;">）分、（</span><span style="color: black;">1.08±0.28</span><span style="color: black;">）分、（</span><span style="color: black;">22.63±2.03</span><span style="color: black;">）分、（</span><span style="color: black;">38.57±6.13</span><span style="color: black;">）分；腹腔镜组<span style="color: black;">以上</span>指标分别由术前</span><span style="color: black;">0</span><span style="color: black;">、（</span><span style="color: black;">12.60±1.11</span><span style="color: black;">）分、（</span><span style="color: black;">4.56±0.36</span><span style="color: black;">）分、（</span><span style="color: black;">0.46±0.07</span><span style="color: black;">）分、（</span><span style="color: black;">23.11±2.77</span><span style="color: black;">）分、（</span><span style="color: black;">66.31±1.73</span><span style="color: black;">）分，变化为术后</span><span style="color: black;">12</span><span style="color: black;">个月的（</span><span style="color: black;">1.99±1.33</span><span style="color: black;">）分、（</span><span style="color: black;">20.85±6.19</span><span style="color: black;">）分、（</span><span style="color: black;">6.43±1.78</span><span style="color: black;">）分、（</span><span style="color: black;">2.27±0.23</span><span style="color: black;">）分、（</span><span style="color: black;">21.00±2.73</span><span style="color: black;">）分、（</span><span style="color: black;">27.62±8.20</span><span style="color: black;">）分；两组<span style="color: black;">病人</span><span style="color: black;">以上</span>指标比较，差异均有统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;"><0.05<span style="color: black;">）。</span><strong style="color: blue;"><span style="color: black;">结论</span></strong><span style="color: black;">第</span><span style="color: black;">4</span><span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术和腹腔镜直肠癌前切除术的肿瘤学疗效相当；但前者在术中<span style="color: black;">流血</span>量、淋巴结清扫、胃肠功能恢复和盆腔自主神经<span style="color: black;">守护</span>方面更优。</span></span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">关 键 词</strong></span></p><span style="color: black;">直肠肿瘤；<span style="color: black;"><span style="color: black;">设备</span>人手术系统；腹腔镜<span style="color: black;">检测</span>；六孔法；并发症；疗效</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">随着微创外科理念的深入和腔镜技术的<span style="color: black;">持续</span><span style="color: black;">加强</span>，达芬奇<span style="color: black;">设备</span>人手术系统以其独特的<span style="color: black;">优良</span>在结直肠癌的临床治疗中迅猛发展，<span style="color: black;">加强</span>了全直肠系膜切除术（<span style="color: black;">total mesorectal excision</span>，<span style="color: black;">TME</span>）质量</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">1‑7</span>］</span></span><span style="color: black;">。第<span style="color: black;">4</span>代达芬奇<span style="color: black;">设备</span>人<span style="color: black;">Xi</span>手术系统<span style="color: black;">拥有</span>革命性的手术通路，易学易用的操作方式，强大的影像系统。<span style="color: black;">Firefly</span>荧光<span style="color: black;">影像</span>技术、<span style="color: black;">Vein Viewer</span>技术和光纤<span style="color: black;">CO</span></span><span style="color: black;"><span style="color: black;">2</span></span><span style="color: black;">激光技术等先进技术的运用，更有助于精细手术操作，且为狭窄骨盆的<span style="color: black;">肥壮</span>症<span style="color: black;">病人</span>在窄小空间内操作和低位保肛<span style="color: black;">供给</span>可能</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">8‑15</span>］</span></span><span style="color: black;">。本<span style="color: black;">科研</span>回顾性分析<span style="color: black;">2020</span>年<span style="color: black;">8</span>月至<span style="color: black;">2021</span>年<span style="color: black;">6</span>月我科收治的<span style="color: black;">102</span>例中低位直肠癌<span style="color: black;">病人</span>的临床病理资料，探讨第<span style="color: black;">4</span><span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术的临床疗效。</span></span></p><strong style="color: blue;"><span style="color: black;">资料与<span style="color: black;">办法</span></span></strong><strong style="color: blue;"><span style="color: black;"><span style="color: black;">1、</span><span style="color: black;">通常</span>资料</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;">采用回顾性队列<span style="color: black;">科研</span><span style="color: black;">办法</span>。收集</span><span style="color: black;">102</span><span style="color: black;">例中低位直肠癌<span style="color: black;">病人</span>的临床病理资料；男</span><span style="color: black;">62</span><span style="color: black;">例，女</span><span style="color: black;">40</span><span style="color: black;">例；年龄为（</span><span style="color: black;">53±12</span><span style="color: black;">）岁。</span><span style="color: black;">102</span><span style="color: black;">例<span style="color: black;">病人</span>中，</span><span style="color: black;">51</span><span style="color: black;">例行第</span><span style="color: black;">4</span><span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术，设为<span style="color: black;">设备</span>人组；</span><span style="color: black;">51</span><span style="color: black;">例行腹腔镜直肠癌前切除术，设为腹腔镜组。两组<span style="color: black;">病人</span>性别、年龄、</span><span style="color: black;">BMI</span><span style="color: black;">、腹部手术史、</span><span style="color: black;">ASA</span><span style="color: black;">分级、体力<span style="color: black;">情况</span>评分、肿瘤组织学类型、</span><span style="color: black;">CEA</span><span style="color: black;">、</span><span style="color: black;">CA19‑9</span><span style="color: black;">、肿瘤距肛缘距离、</span><span style="color: black;">TNM</span><span style="color: black;">分期、新辅助化疗比较，差异均<span style="color: black;">没</span>统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;">>0.05<span style="color: black;">），<span style="color: black;">拥有</span>可比性。见表</span><span style="color: black;">1</span><span style="color: black;">。本<span style="color: black;">科研</span><span style="color: black;">经过</span>我院医学伦理委员会审批，批号为</span><span style="color: black;">XYFY2020‑JS003‑03</span><span style="color: black;">。<span style="color: black;">病人</span>及家属均签署知情同意书。</span></span></span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/cJFq46GOa3c8bT0w7xmG2icAXYjRBTFpyZrg4sDHBGhPnsxBOKlwvYQyTibHHa5ibrgAxxdBXolicF0Lv30uwnV9uw/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">2、</span>纳入标准和排除标准</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">纳入标准：（</span>1<span style="color: black;">）年龄</span>>18<span style="color: black;">岁。（</span>2<span style="color: black;">）组织病理学<span style="color: black;">检测</span>证实为直肠腺癌。（</span>3<span style="color: black;">）肿瘤距肛缘距离</span>≤10cm<span style="color: black;">。（</span>4<span style="color: black;">）</span>B<span style="color: black;">超、</span>CT<span style="color: black;">等<span style="color: black;">检测</span><span style="color: black;">没</span>远处转移。（</span>5<span style="color: black;">）直肠</span>MRI<span style="color: black;"><span style="color: black;">检测</span>诊断为临床</span>T1~3N0~1<span style="color: black;">期。（</span>6<span style="color: black;">）<span style="color: black;">没</span>其他恶性肿瘤病史。（</span>7<span style="color: black;">）<span style="color: black;">拥有</span>腹腔镜和<span style="color: black;">设备</span>人手术适应证。（</span>8<span style="color: black;">）</span>ASA<span style="color: black;">分级</span>≤Ⅲ<span style="color: black;">级。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">排除标准：（</span>1<span style="color: black;">）临床</span>T1N0<span style="color: black;">期适合局部切除术。（</span>2<span style="color: black;">）因急性肠梗阻、<span style="color: black;">流血</span>、穿孔等<span style="color: black;">原由</span>行急诊手术。（</span>3<span style="color: black;">）多原发结直肠恶性肿瘤。（</span>4<span style="color: black;">）家族性腺瘤性息肉病、</span>Lynch<span style="color: black;"><span style="color: black;">综合症</span>、炎症性肠病。（</span>5<span style="color: black;">）需<span style="color: black;">同期</span>行结肠切除术。（</span>6<span style="color: black;">）</span>ASA<span style="color: black;">分级</span>>Ⅲ<span style="color: black;">级。（</span>7<span style="color: black;">）妊娠和哺乳期。（</span>8<span style="color: black;">）非直肠腺癌。（</span>9<span style="color: black;">）行新辅助放化疗以外的术前治疗。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">3、</span>手术<span style="color: black;">办法</span></span></strong><span style="color: black;"><span style="color: black;">（一）<span style="color: black;">设备</span>人组<span style="color: black;">病人</span>行第</span>4<span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术</span></span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1.<span style="color: black;">程序化六孔法</span>Trocar<span style="color: black;">布局和装机</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">取脐上方</span>1<span style="color: black;">横指偏右</span>1~2cm<span style="color: black;">为</span>3<span style="color: black;">号臂镜头孔，水平向左</span>7~8cm<span style="color: black;">为</span>2<span style="color: black;">号臂孔，</span>2<span style="color: black;">号臂孔水平向左</span>7~8cm<span style="color: black;">为</span>1<span style="color: black;">号臂孔，</span>3<span style="color: black;">号臂孔水平向右向尾侧</span>7~8cm<span style="color: black;">为</span>4<span style="color: black;">号臂孔，</span>1~4<span style="color: black;">号臂孔均为</span>8mm<span style="color: black;">，</span>3<span style="color: black;">号和</span>4<span style="color: black;">号向头侧等边三角形顶点为辅助孔</span>1<span style="color: black;">（</span>12mm<span style="color: black;">），耻骨联合上方</span>2<span style="color: black;">横指为辅助孔</span>2<span style="color: black;">（</span>5mm<span style="color: black;">），各孔间距个体化<span style="color: black;">调节</span>。如图</span>1<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2.<span style="color: black;">乙状结肠外侧游离，直线化与内外贯通</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">分离乙状结肠外侧粘连，</span>1<span style="color: black;">号臂向外侧轻推左腹壁，</span>2<span style="color: black;">号臂和助手向右侧牵拉乙状结肠，呈三角牵拉。</span>4<span style="color: black;">号臂沿髂结肠韧带生理融合处约</span>1mm<span style="color: black;">分离肠系膜，进入外侧</span>Toldts<span style="color: black;">间隙，向内侧和头侧游离至乙状结肠隐窝部、左侧输尿管内侧、左髂总动脉外侧缘，充分游离乙状结肠，便于直肠直线化牵拉以及与内侧直肠后间隙贯通，标记内侧游离汇合点。见图</span>2<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3.<span style="color: black;">内侧入路及直肠后间隙上段游离</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1<span style="color: black;">号臂抓持腹膜返折上方约</span>5cm<span style="color: black;">直肠系膜向</span>11<span style="color: black;">点方向牵拉，</span>2<span style="color: black;">号臂抓持骶岬高度系膜向</span>9<span style="color: black;">点方向牵拉。在骶岬稍下方肠系膜附着点凹陷处（腹侧</span>5~10mm<span style="color: black;">处）切开腹膜，向尾侧切开右侧腹膜至骶骨生殖襞内侧，向左侧拓展至左侧腹下神经，离断细小结肠支。<span style="color: black;">调节</span>牵拉位置，</span>1<span style="color: black;">号臂向腹侧牵拉右侧骶骨生殖襞，</span>2<span style="color: black;">号臂向前推开直肠后壁，助手越过骶岬，向下压挡腹下神经前筋膜，形成三角牵拉，在直肠固有筋膜与腹下神经前筋膜间游离（</span>A<span style="color: black;">层面），向下游离至两者融合筋膜</span>‑<span style="color: black;">直肠骶骨筋膜。见图</span>3<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">4.<span style="color: black;">以直肠上动脉和神经为导向的肠系膜下动脉根部游离，与外侧贯通</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">在骶岬水平定位并沿直肠上动脉走行方向，在其外侧</span>5~10mm<span style="color: black;">肠系膜切开系膜后方间隙，游离至左侧髂总动脉上方与外侧贯通。沿固有筋膜向头侧游离至肠系膜下动脉根部背侧，左侧腰内脏神经与肠系膜下动脉交汇处为背侧游离止点。在肠系膜下动脉前方，向头侧切开结肠系膜和小肠系膜的融合腹膜，分离十二指肠与腹膜粘连，确定头侧游离的内侧界。</span>1<span style="color: black;">号臂牵拉肠系膜下血管，</span>2<span style="color: black;">号臂抓持头侧系膜，呈三角展开，离断右侧腰内脏神经结肠支。游离内侧界为肠系膜下动脉系膜根部，外侧界为肠系膜下静脉内侧缘，上界至十二指肠。清扫第</span>253<span style="color: black;">组淋巴结，打开肠系膜下动脉血管鞘，根部离断。沿肠系膜下静脉背侧充分游离进入</span>Toldts<span style="color: black;">间隙，离断左侧腰内脏神经结肠支，爬坡式游离疏松组织，与头侧游离相通。见图</span>4<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">5.Toldts<span style="color: black;">间隙游离后，离断肠系膜下静脉和左结肠动脉</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1<span style="color: black;">号臂提拉远端系膜断端，</span>2<span style="color: black;">号臂提拉肠系膜下端断端，助手按压肾前筋膜，拓展</span>Toldts<span style="color: black;">间隙，使肠系膜形成圆顶状张力，扩大左结肠系膜后间隙。向头侧拓展空间，外侧至降结肠与腹壁的交界线，上方至胰腺下缘，下方至髂总动脉外侧。<span style="color: black;">调节</span></span>1<span style="color: black;">号臂牵拉肠系膜下静脉外侧的<span style="color: black;">没</span>血管系膜向腹侧外侧展开，向右季肋区</span>4<span style="color: black;">点方向牵拉肠系膜下动脉残端，离断肠系膜下静脉和左结肠动脉。见图</span>5<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">6.<span style="color: black;">降结肠外侧及直肠上段左侧游离</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1<span style="color: black;">号臂向外侧轻推腹壁，</span>2<span style="color: black;">号臂向右侧牵拉结肠系膜，助手于</span>2<span style="color: black;">号臂近端结肠</span>10cm<span style="color: black;">处向右侧呈三角牵拉乙状结肠，沿黄白交界线游离外侧腹膜，并与后方的</span>Toldts<span style="color: black;">间隙汇合至结肠脾曲。游离直肠上段左侧，</span>1<span style="color: black;">号臂向尾侧推顶腹膜返折，助手向右侧</span>4<span style="color: black;">点方向牵拉直肠系膜，使直肠后腔可视化，</span>2<span style="color: black;">号臂向左牵拉外侧腹膜，暴露左侧骶骨生殖襞，以左侧肠系膜附着点</span>5~10mm<span style="color: black;">偏向肠系膜侧为起点，紧贴直肠固有筋膜向尾侧游离至第</span>4<span style="color: black;">骶椎水平。见图</span>6<span style="color: black;">。</span></span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/cJFq46GOa3c8bT0w7xmG2icAXYjRBTFpy7QP1rUMDazz4u64ObiaWHp5Kic2qb8lwfGrThvBOqBm4icb1bcrPK90MQ/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">7.<span style="color: black;">悬吊直肠、游离直肠下段后间隙</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">悬吊直肠，<span style="color: black;">经过</span>耻骨上孔，向头侧和腹侧呈圆锥体式牵拉直肠，暴露直肠后间隙，紧贴直肠固有筋膜游离至第</span>4<span style="color: black;">骶椎水平，切开直肠骶骨筋膜，两侧不超越腹下神经与盆丛汇入处，游离至肛提肌上间隙，向盆底游离至</span>Hiatal<span style="color: black;">韧带。见图</span>7<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">8.<span style="color: black;">直肠前间隙游离</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">于腹膜返折最低点上方</span>1cm<span style="color: black;">切开腹膜，沿邓氏筋膜前方游离，并向两侧拓展间隙，显露精囊腺或阴道后壁，至精囊腺底部下方</span>0.5cm<span style="color: black;">或女性腹膜返折下方</span>5cm<span style="color: black;">，呈倒</span>U<span style="color: black;">形离断邓氏筋膜，并自上而下向两侧扩展。见图</span>8<span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">9.<span style="color: black;">直肠两侧游离</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">依次完成直肠后、前间隙游离，向头侧和对侧牵拉直肠，沿直肠固有筋膜和腹下神经前筋膜间疏松组织自上而下游离直肠两侧。分离直肠侧韧带并离断直肠支和直肠中动脉，在精囊腺水平形成弧形内拐，与邓氏筋膜前间隙汇合，充分显露盆底内筋膜至肛管上缘。见图</span>9<span style="color: black;">。</span></span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/cJFq46GOa3c8bT0w7xmG2icAXYjRBTFpylic38eP7SmI5XYFyabf5ZRJ6t1uR70Ondh3sINm8FKLVv64Ticj5yzmQ/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;">
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">10.<span style="color: black;">离断直肠末端前壁及后壁</span>Hiatal<span style="color: black;">韧带</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">以</span>Hiatal<span style="color: black;">韧带<span style="color: black;">上下</span>两侧的肛提肌上间隙游离面为参照线，螺旋式游离切断</span>Hiatal<span style="color: black;">韧带至肛管上缘，到达</span>TME<span style="color: black;">终点线</span>‑<span style="color: black;">肛提肌裂孔。术中肠镜<span style="color: black;">检测</span>准确判断肿瘤下切缘后，远端直肠灌洗后离断。肚脐下方切口取出标本，<span style="color: black;">安置</span>砥钉座。重建气腹、吲哚菁绿荧光显影确认血供良好，采用吻合器经肛吻合，全层间断加固缝合</span>6~8<span style="color: black;">针，吻合钉交汇处浆肌层包埋。<span style="color: black;">检测</span>吻合口<span style="color: black;">没</span>漏后，<span style="color: black;">安置</span>引流管，结束手术。</span></span></p><span style="color: black;">（二）腹腔镜直肠癌前切除术</span>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">腹腔镜组<span style="color: black;">病人</span>采用文献［</span>16<span style="color: black;">］的<span style="color: black;">办法</span>施行手术。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">4、</span>观察指标和<span style="color: black;">评估</span>标准</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">观察指标：（</span>1<span style="color: black;">）治疗<span style="color: black;">状况</span><span style="color: black;">包含</span>两组<span style="color: black;">病人</span>手术施行<span style="color: black;">状况</span>、术中输血、中转开腹、术后</span>30d<span style="color: black;">内死亡、手术方式、<span style="color: black;">守护</span>性回肠造口、手术时间、术中<span style="color: black;">流血</span>量、淋巴结清扫数目、术后首次肛门排气时间、术后首次<span style="color: black;">摄食</span>流质<span style="color: black;">食品</span>时间、术后导尿管拔除时间、术后下床时间、术后并发症、术后<span style="color: black;">病痛</span>分级、术后保肛、造口还纳、术后辅助化疗、术后住院时间、治疗<span style="color: black;">花费</span>。（</span>2<span style="color: black;">）术后病理学<span style="color: black;">检测</span>结果：肿瘤长径、标本切除长度、肿瘤上缘距离、肿瘤下缘距离、全直肠系膜切除完整性分级、肿瘤分化程度、环周切缘阳性、肠系膜破坏、术后</span>TNM<span style="color: black;">分期。（</span>3<span style="color: black;">）随访<span style="color: black;">状况</span>：<span style="color: black;">得到</span>随访的<span style="color: black;">病人</span>例数、随访时间、肿瘤局部复发和转移、大便失禁严重程度评分（</span>Wexner<span style="color: black;">评分）、低位前切除<span style="color: black;">综合症</span>（</span>low anterior resection syndrome<span style="color: black;">，</span>LARS<span style="color: black;">）评分、国际前列腺功能评分（</span>international prostate symptom score<span style="color: black;">，</span>IPSS<span style="color: black;">）、夜间排尿评分、国际勃起功能指数问卷（</span>international index of erectile<span style="color: black;">，</span>IIEF<span style="color: black;">）评分、女性性功能指数（</span>female sexual function index<span style="color: black;">，</span>FIFS<span style="color: black;">）评分比较。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;">评估</span>标准：</span><span style="color: black;">采用</span>Wexner<span style="color: black;">评分和</span>LARS<span style="color: black;">评分<span style="color: black;">评估</span>排便功能，</span>IPSS<span style="color: black;">评分<span style="color: black;">评估</span>排尿功能，</span>IIEF<span style="color: black;">评分和</span>FIFS<span style="color: black;">评分分别<span style="color: black;">评估</span>男性和女性<span style="color: black;">病人</span>性功能。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">5、</span>随访</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">采用门诊或<span style="color: black;">tel</span>方式随访，每</span>3<span style="color: black;">个月随访</span>1<span style="color: black;">次，<span style="color: black;">认识</span><span style="color: black;">病人</span>术后并发症和盆腔自主神经<span style="color: black;">状况</span>。随访时间<span style="color: black;">截止</span></span>2022<span style="color: black;">年</span>7<span style="color: black;">月。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">6、</span>统计学分析</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;">应用</span><span style="color: black;">SPSS 24.0</span><span style="color: black;">统计软件进行分析。正态分布的计量资料以</span></span><span style="color: black;">x±s</span><span style="color: black;"><span style="color: black;">暗示</span>，组间比较采用独立样本</span><span style="color: black;">t</span><span style="color: black;">检验；偏态分布的计量资料以</span><span style="color: black;">M</span><span style="color: black;"><span style="color: black;">（范围）<span style="color: black;">暗示</span>，组间比较采用</span><span style="color: black;">Mann‑Whitney </span></span><span style="color: black;">U</span><span style="color: black;">检验。计数资料以绝对数<span style="color: black;">暗示</span>，组间比较采用</span><span style="color: black;">χ</span><span style="color: black;">²<span style="color: black;">检验或</span><span style="color: black;">Fisher</span><span style="color: black;">确切概率法。重复<span style="color: black;">测绘</span>数据采用重复<span style="color: black;">测绘</span>方差分析。</span></span><span style="color: black;">P</span><span style="color: black;"><0.05<span style="color: black;">为差异有统计学<span style="color: black;">道理</span>。</span></span></span></p><strong style="color: blue;"><span style="color: black;">结果</span></strong><strong style="color: blue;"><span style="color: black;"><span style="color: black;">1、</span>治疗<span style="color: black;">状况</span></span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;">两组<span style="color: black;">病人</span>均顺利施行直肠癌根治术，术中均<span style="color: black;">没</span>输血、中转开腹手术、术后</span><span style="color: black;">30 d</span><span style="color: black;">内死亡。两组<span style="color: black;">病人</span>手术时间、术中<span style="color: black;">流血</span>量、淋巴结清扫数目、术后首次肛门排气时间、术后首次<span style="color: black;">摄食</span>流质<span style="color: black;">食品</span>时间、术后导尿管拔除时间、术后<span style="color: black;">病痛</span>分级、治疗<span style="color: black;">花费</span>比较，差异均有统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;"><0.05<span style="color: black;">）；手术方式、<span style="color: black;">守护</span>性肠造口、术后下床时间、术后并发症、术后保肛、造口还纳、术后辅助化疗、术后住院时间比较，差异均<span style="color: black;">没</span>统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;">>0.05<span style="color: black;">）。见表</span><span style="color: black;">2</span><span style="color: black;">。<span style="color: black;">设备</span>人组<span style="color: black;">病人</span>术后吻合口漏</span><span style="color: black;">2</span><span style="color: black;">例、肺部感染</span><span style="color: black;">2</span><span style="color: black;">例、骶前感染</span><span style="color: black;">1</span><span style="color: black;">例、肠粘连与梗阻</span><span style="color: black;">1</span><span style="color: black;">例，术后并发症</span><span style="color: black;">Clavien⁃Dindo</span><span style="color: black;">分级为</span><span style="color: black;">Ⅰ</span><span style="color: black;">级和</span><span style="color: black;">Ⅱ</span><span style="color: black;">级各</span><span style="color: black;">3</span><span style="color: black;">例；腹腔镜组患者术后吻合口漏</span><span style="color: black;">2</span><span style="color: black;">例、肺部感染</span><span style="color: black;">2</span><span style="color: black;">例、骶前感染</span><span style="color: black;">1</span><span style="color: black;">例、肠粘连与梗阻</span><span style="color: black;">1</span><span style="color: black;">例、尿潴留</span><span style="color: black;">1</span><span style="color: black;">例，术后并发症</span><span style="color: black;">Clavien⁃Dindo</span><span style="color: black;">分级</span><span style="color: black;">Ⅰ</span><span style="color: black;">级和</span><span style="color: black;">Ⅱ</span><span style="color: black;">级分别为</span><span style="color: black;">4</span><span style="color: black;">例和</span><span style="color: black;">3</span><span style="color: black;">例。</span></span></span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/cJFq46GOa3c8bT0w7xmG2icAXYjRBTFpyNtjE2dzr1zbxt4Aj1Kriaa9zdVqEaROQueQGqaEzKiagpS6mPMHsCS8A/640?wx_fmt=png&tp=webp&wxfrom=5&wx_lazy=1&wx_co=1" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">2、</span>术后病理学<span style="color: black;">检测</span>结果</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;">两组<span style="color: black;">病人</span>肿瘤长径、标本切除长度、肿瘤上切缘距离、肿瘤下切缘距离、全直肠系膜切除完整性分级、肿瘤分化程度、环周切缘、肠系膜破坏、术后</span><span style="color: black;">TNM</span><span style="color: black;">分期比较，差异均<span style="color: black;">没</span>统计学有<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;">>0.05<span style="color: black;">）。见表</span><span style="color: black;">3</span><span style="color: black;">。</span></span></span></p><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;"><span style="color: black;">3、</span>随访<span style="color: black;">状况</span></span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;">两组<span style="color: black;">病人</span>均<span style="color: black;">得到</span>术后</span><span style="color: black;">12</span><span style="color: black;">个月随访。两组<span style="color: black;">病人</span>术后均<span style="color: black;">没</span>肿瘤局部复发和远处转移。两组<span style="color: black;">病人</span></span><span style="color: black;">Wexner</span><span style="color: black;">评分、</span><span style="color: black;">LARS</span><span style="color: black;">评分、</span><span style="color: black;">IPSS</span><span style="color: black;">评分、夜间排尿评分、</span><span style="color: black;">FIFS</span><span style="color: black;">评分、</span><span style="color: black;">IIEF</span><span style="color: black;">评分比较，差异均有统计学<span style="color: black;">道理</span>（</span></span><span style="color: black;">P</span><span style="color: black;"><0.05<span style="color: black;">）。见表</span><span style="color: black;">4</span><span style="color: black;">。</span></span></span></p><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"><strong style="color: blue;"><span style="color: black;">讨论</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">设备</span>人直肠癌根治术于<span style="color: black;">2006</span>年首次开展<span style="color: black;">败兴</span>广泛运用临床</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">17-19</span>］</span></span><span style="color: black;">。第<span style="color: black;">4</span>代达芬奇<span style="color: black;">设备</span>人手术系统<span style="color: black;">拥有</span>更高的稳定性、准确性、灵活性、清晰性，其在术中<span style="color: black;">流血</span>量、排尿功能和性功能以及术后<span style="color: black;">恢复</span>等方面优于腹腔镜手术</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">20‑25</span>］</span></span><span style="color: black;">。笔者团队总结简单易行的程序化六孔法<span style="color: black;">设备</span>人直肠手术流程，可<span style="color: black;">加强</span>手术安全性和可重复性，缩短学习曲线，以期达到膜解剖和层面游离，实现高质量<span style="color: black;">TME</span>。已有的<span style="color: black;">科研</span>结果<span style="color: black;">表示</span>：<span style="color: black;">设备</span>人中低位直肠癌手术并发症<span style="color: black;">出现</span>率为<span style="color: black;">15.0%~19.1%</span>，腹腔镜手术并发症<span style="color: black;">出现</span>率为<span style="color: black;">18.4%~26.2%</span></span><span style="color: black;"><span style="color: black;">［<span style="color: black;">26</span>］</span></span><span style="color: black;"><span style="color: black;">。本<span style="color: black;">科研</span>结果与之<span style="color: black;">类似</span>。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">1、</span><span style="color: black;">设备</span>人手术系统布孔策略</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">本<span style="color: black;">科研</span>中第</span>4<span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统采用横向直线化布孔<span style="color: black;">方法</span>，呈等腰三角形或扇形直指病灶中心。戳卡<span style="color: black;">根据</span>程序化六孔法在肚脐上方布孔，各孔间距为</span>7~8cm<span style="color: black;">（气腹前），气腹后间距还会<span style="color: black;">增多</span>，有效防止各机械臂交叉碰撞，如<span style="color: black;">病人</span>瘦小可<span style="color: black;">按照</span>其腹部横径缩短间距。本<span style="color: black;">科研</span><span style="color: black;">增多</span>耻骨上孔<span style="color: black;">做为</span>二助辅助孔，<span style="color: black;">重点</span>用于游离直肠中下段（直肠上段至腹膜返折上</span>2~3cm<span style="color: black;">）时牵拉直肠，以保持良好张力，较好显露直肠<span style="color: black;">周边</span>间隙，尤其在肿瘤<span style="color: black;">很强</span>、骨盆狭窄、<span style="color: black;">肥壮</span>症<span style="color: black;">病人</span>中实用价值更<span style="color: black;">明显</span>。可在肿瘤下缘</span>1cm<span style="color: black;">处二次悬吊，利于直肠末端间隙的显露和游离。该操作未闲置机械臂充当辅助孔，不会降低机械效率。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">2、</span>张力牵拉和游离<span style="color: black;">办法</span>的<span style="color: black;">要紧</span><span style="color: black;">功效</span></span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">手术视野的显露，<span style="color: black;">尤其</span>是牵拉的力度、方向、抓持组织的量在达芬奇<span style="color: black;">设备</span>人手术系统游离中非常<span style="color: black;">要紧</span></span><span style="color: black;"><span style="color: black;">［<span style="color: black;">27‑29</span>］</span></span><span style="color: black;">。笔者团队多采用三角牵拉，与机械臂的两把抓钳形成对抗牵引，在三角范围内解剖游离。术中可实时变换牵拉位置，以实现直肠<span style="color: black;">周边</span>各间隙游离均保持三角牵拉，从而<span style="color: black;">得到</span>最大限度手术层面暴露</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">13</span>］</span></span><span style="color: black;"><span style="color: black;">。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">游离</span>Toldts<span style="color: black;">间隙的经验：笔者运用锐钝结合分离<span style="color: black;">办法</span>并遵循不同层面微血管走行判断间隙，层面拓展时避免打洞式点状游离，需<span style="color: black;">根据</span>平面式协同推进。</span></span></p><strong style="color: blue;"><span style="color: black;"><span style="color: black;">3、</span>神经和筋膜组织解剖的辨识</span></strong>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">本<span style="color: black;">科研</span><span style="color: black;">经过</span>第<span style="color: black;">4</span>代达芬奇双摄像头构建三维立体手术视野，结合程序化六孔法手术<span style="color: black;">过程</span>，可<span style="color: black;">加强</span>微血管、神经、筋膜组织结构的辨识度，并且将其<span style="color: black;">做为</span>标识指引游离方向，可呈现清晰的游离层面</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">30‑31</span>］</span></span><span style="color: black;">。这与直肠后方、前方和两侧均有相互连续和贯通的膜解剖观点一致</span><span style="color: black;"><span style="color: black;">［<span style="color: black;">32‑33</span>］</span></span><span style="color: black;">。且本<span style="color: black;">科研</span><span style="color: black;">办法</span>还可扩大盆腔操作空间，显露直肠<span style="color: black;">周边</span>筋膜结构，<span style="color: black;">守护</span>盆自主神经，<span style="color: black;">处理</span>系膜肥厚和狭窄困难骨盆的游离难点。这与文献<span style="color: black;"><span style="color: black;">［34‑38］</span></span><span style="color: black;">的观点一致。基于<span style="color: black;">设备</span>人手术系统<span style="color: black;">以上</span><span style="color: black;">优良</span>，本<span style="color: black;">科研</span>结果<span style="color: black;">表示</span>：<span style="color: black;">设备</span>人组<span style="color: black;">病人</span>术中<span style="color: black;">流血</span>量、淋巴结清扫数目、自主神经功能恢复优于腹腔镜组。</span></span></p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">综上，第</span>4<span style="color: black;">代达芬奇<span style="color: black;">设备</span>人手术系统辅助六孔法直肠癌前切除术和腹腔镜直肠癌前切除术的肿瘤学疗效相当；但前者在术中<span style="color: black;">流血</span>量、淋巴结清扫、胃肠功能恢复和盆腔自主神经<span style="color: black;">守护</span>方面更优。</span></span></p><span style="color: black;"><strong style="color: blue;"><span style="color: black;">利益冲突 </span></strong><span style="color: black;">所有作者均声明不存在利益冲突</span></span><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">作者贡献声明 </span></strong><span style="color: black;">王凯、张轩：<span style="color: black;">文案</span>整体设计和撰写，数据审核和文稿审核；刘浩、何京京、付海啸、李腾腾：数据整理、分析；张轩：制作示意图，数据登记；符炜、宋军：文稿审核</span></span></span><span style="color: black;"><strong style="color: blue;">参考文献</strong></span><span style="color: black;">详见本刊官方<span style="color: black;">网</span> http://www.zhxhwk.com</span><span style="color: black;"><strong style="color: blue;">版权声明</strong></span><span style="color: black;">本文为《中华消化外科杂志》原创<span style="color: black;">文案</span>，版权归中华医学会所有。其他<span style="color: black;">媒介</span>、<span style="color: black;">网</span>、公众号等如需转载本文，请联系本刊编辑委员会<span style="color: black;">得到</span>授权，并在文题下醒目位置注明“原文刊发于《中华消化外科杂志》，卷（期）：起止页码”。谢</span><span style="color: black;">谢合作！</span><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"><a style="color: black;"><span style="color: black;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></span></a><span style="color: black;"><img src="data:image/svg+xml,%3C%3Fxml version=1.0 encoding=UTF-8%3F%3E%3Csvg width=1px height=1px viewBox=0 0 1 1 version=1.1 xmlns=http://www.w3.org/2000/svg xmlns:xlink=http://www.w3.org/1999/xlink%3E%3Ctitle%3E%3C/title%3E%3Cg stroke=none stroke-width=1 fill=none fill-rule=evenodd fill-opacity=0%3E%3Cg transform=translate(-249.000000, -126.000000) fill=%23FFFFFF%3E%3Crect x=249 y=126 width=1 height=1%3E%3C/rect%3E%3C/g%3E%3C/g%3E%3C/svg%3E" style="width: 50%; margin-bottom: 20px;"></span>
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