机器人辅助肛门成形术治疗先天性肛门闭锁9例
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摘要
目的探讨机器人辅助肛门成形术治疗先天性肛门闭锁的可行性和近期疗效。方法 2016年10月~2017年10月,应用机器人辅助肛门成形术治疗男性中、高位肛门闭锁9例(2例直肠膀胱颈瘘,2例直肠前列腺部尿道瘘,5例直肠尿道球部瘘),平均年龄4.7月(3~9月)。仰卧位,三孔法,使用Si型da Vinci机器人手术系统,单极电凝游离松解直肠系膜,在直肠固有筋膜下游离盲端及瘘管,直至末端切断,机器臂缝扎瘘口。镜头直视下经横纹肌复合体中心建立盆底隧道,将直肠从中拖出,与会阴皮肤间断吻合。结果 9例均在机器人辅助下完成肛门成形术,平均手术时间116 min(105~130min),人机对接时间平均42 min(35~50 min),操作台手术时间平均31.4 min(26~38 min)。术中解剖层次清晰,几乎无出血,无术中并发症。术后住院时间平均10.2 d(7~14 d)。平均随访10个月(6~15个月),肛门功能评分优6例,良3例(污便)。2例肛门狭窄。经保守治疗,连续随访半年,污便与肛门狭窄逐渐好转。结论 da Vinci机器人手术系统解剖瘘管精细、清晰,瘘口缝合严密、可靠,完整保护盆底神经和外括约肌系统,近期疗效满意。
Objective To evaluate the feasibility and short-term outcome of robotic-assisted anorectal pull-through for anorectal malformations in infants.Methods From October 2016 to October 2017,9 male infants with anorectal malformations,including 2 cases of recto-bladder neck fistula,2 cases of recto-prostate fistula,and 5 cases of recto-bulbar fistula,were treated by robotic-assisted anorectal pull-through.Their mean age was 4.7 months( range,3-9 months).Three trocars were used.The patient was placed in supine position followed by insertion of trocars.The da Vinci Si robotic system was utilized.With the help of robotic hook,the rectum was mobilized by dividing the peritoneal folds on either side at the level of peritoneal reflection.Distal dissection was carried out under proper fascia of rectum until the end of fistula was identified.It was divided and repaired robotically.Guided by robotic visualization,an accurate pull-through canal was created with pelvic floor muscles surrounding it symmetrically.Then rectum was exteriorized to the perineum through this canal.Anorectal anastomosis was performed with interrupted suture.Results Nine patients underwent robotic-assisted anorectal pull-through successfully without intraoperative complications.The mean operative time was 116 min( range,105-130 min).The mean docking time was 42 min( range,35-50 min).The mean time at console was 31.4 min( range,26-38 min).Anatomical layers and details of tissue were clearly identified during the surgery,with little blood loss.No intraoperative complications occurred.The mean time of postoperative hospitalization was 10.2 days( range,7-14 d).During the follow-ups for a mean of 10 months( range,6-15 months),there were 6 cases of good anus function scores and 3 cases of fair( soiling).Two patients experienced stricture of anus,and their defecation functions showed favourable evolution during 6-month follow-ups after conservative treatment.Conclusions The da Vinci robotic system allows better dissection and easier closure of fistula.It minimizes side injury of pelvic nerves and external sphincter by dissection under the proper fascia of rectum and accurate creation of pull-through canal.Early outcomes are encouraging,though further evidences of larger trails and long-term follow-ups are needed.
Objective To evaluate the feasibility and short-term outcome of robotic-assisted anorectal pull-through for anorectal malformations in infants.Methods From October 2016 to October 2017,9 male infants with anorectal malformations,including 2 cases of recto-bladder neck fistula,2 cases of recto-prostate fistula,and 5 cases of recto-bulbar fistula,were treated by robotic-assisted anorectal pull-through.Their mean age was 4.7 months( range,3-9 months).Three trocars were used.The patient was placed in supine position followed by insertion of trocars.The da Vinci Si robotic system was utilized.With the help of robotic hook,the rectum was mobilized by dividing the peritoneal folds on either side at the level of peritoneal reflection.Distal dissection was carried out under proper fascia of rectum until the end of fistula was identified.It was divided and repaired robotically.Guided by robotic visualization,an accurate pull-through canal was created with pelvic floor muscles surrounding it symmetrically.Then rectum was exteriorized to the perineum through this canal.Anorectal anastomosis was performed with interrupted suture.Results Nine patients underwent robotic-assisted anorectal pull-through successfully without intraoperative complications.The mean operative time was 116 min( range,105-130 min).The mean docking time was 42 min( range,35-50 min).The mean time at console was 31.4 min( range,26-38 min).Anatomical layers and details of tissue were clearly identified during the surgery,with little blood loss.No intraoperative complications occurred.The mean time of postoperative hospitalization was 10.2 days( range,7-14 d).During the follow-ups for a mean of 10 months( range,6-15 months),there were 6 cases of good anus function scores and 3 cases of fair( soiling).Two patients experienced stricture of anus,and their defecation functions showed favourable evolution during 6-month follow-ups after conservative treatment.Conclusions The da Vinci robotic system allows better dissection and easier closure of fistula.It minimizes side injury of pelvic nerves and external sphincter by dissection under the proper fascia of rectum and accurate creation of pull-through canal.Early outcomes are encouraging,though further evidences of larger trails and long-term follow-ups are needed.
引文
1 de Vries PA,Pena A.Posterior sagittal anorectoplasty.J Pediatr Surg,1982,17(5):638-643.
2 Georgeson KE,Inge TH,Albanese CT.Laparoscopically assisted anorectal pull-through for high imperforate anus:a new technique.J Pediatr Surg,2000,35(6):927-930.
3 汤绍涛,曹国庆,童强松,等.腹腔镜下高位肛门闭锁肛门成形术及中期临床评估.中华小儿外科杂志,2011,32(7):509-514.
4 汤绍涛.腹腔镜辅助手术治疗先天性肛门直肠畸形.中华小儿外科杂志,2014,35(6):466-469.
5 Meehan JJ,Sandler A.Pediatric robotic surgery:a single-institutional review of the first 100 consecutive cases.Surg Endosc,2008,22(1):177-182.
6 Sinha CK,Haddad M.Robot-assisted surgery in children:current status.J Robot Surg,2008,1(4):243-246.
7 Holschneider A,Hutson J,Pe1a A,et al.Preliminary report on the international conference for the development of standards for the treatment of anorectal malformations.J Pediatr Surg,2005,40(10):1521-1526.
8 Stephens FD,Smith ED.Classification,identification,and assessment of surgical treatment of anorectal anomalies.Pediatr Surg Int,1986,1(1):200-205.
9 李正,王练英,王维林,等.先天性无肛术后远期排便功能综合评定.中华小儿外科杂志,1990,11(5):283-285.
10 De Vos C,Arnold M,Sidler D,et al.A comparison of laparoscopicassisted(LAARP)and posterior sagittal(PSARP)anorectoplasty in the outcome of intermediate and high anorectal malformations.S Afr J Surg,2011,49(1):39-43.
11 Kimura O,Iwai N,Sasaki Y,et al.Laparoscopic versus open abdominoperineal rectoplasty for infants with high-type anorectal malformation.J Pediatr Surg,2010,45(12):2390-2393.
12 Diao M,Li L,Ye M,et al.Congenital anomaly rectified at birth:onestage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula.Surg Endosc,2016,30(11):5156-5164.
13 Yang J,Zhang W,Feng J,et al.Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through.J Pediatr Surg,2009,44(12):2380-2383.
14 Ming AX,Li L,Diao M,et al.Long term outcomes of laparoscopicassisted anorectoplasty:a comparison study with posterior sagittal anorectoplasty.J Pediatr Surg,2014,49(4):560-563.
15 Yazaki Y,Koga H,Ochi T,et al.Surgical management of rectoprostatic and recto-bulbar anorectal malformations.Pediatr Surg Int,2016,32(10):939-944.
16 Srimurthy KR,Ramesh S,Shankar G,et al.Technical modifications of laparoscopically assisted anorectal pull-through for anorectal malformations.J Laparoendosc Adv Surg Tech A,2008,18(2):340-343.
17 Diao M,Li L,Guan KP,et al.A novel laparoscopic technique for anorectal malformation with low recto-bulbar fistulae.Surg Endosc,2017,31(10):4326-4330.
18 Albassam A,Gado A,Mallick MS,et al.Robotic-assisted anorectal pull-through for anorectal malformations.J Pediatr Surg,2011,46(9):1794-1797.
19 Ruiz MR,Kalfa N,Allal H.Advantages of robot-assisted surgery in anorectal malformations:report of a case.J Minim Access Surg,2016,12(2):176-178.
20 张茜,汤绍涛,曹国庆,等.da Vinci机器人辅助腹腔镜Soave拖出术治疗先天性巨结肠症.中国微创外科杂志,2016,16(2):165-167,184.
21 张金山,李龙,刁美,等.经脐单切口腹腔镜辅助肛门成形术治疗小儿中高位肛门闭锁.中国微创外科杂志,2016,16(5):424-427.
22 侯文英,李龙,刘树立,等.腹腔镜辅助中位肛门闭锁成形术11 例报告.中国微创外科杂志,2007,7(5):439-441.
23 Muraoka K,Takenaka A.New findings of clinical anatomy in pelvis.Nihon Rinsho,2016,74(1):66-71.
24 高炜,张雪宁,郭志,等.Denonvilliers筋膜的应用解剖学研究进展.中国临床解剖学杂志,2016,34(1):111-114.
25 Wei HB,Fang JF,Zheng ZH,et al.Effect of preservation of Denonvilliers’fascia during laparoscopic resection for mid-low rectal cancer on protection of male urinary and sexual functions.Medicine(Baltimore),2016,95(24):e3925.
26 苏松盛,何进达,曾凡英.腹腔镜直肠癌术中保留Denonvilliers筋膜对中青年男性排尿及性功能影响.中华普外科手术学杂志(电子版),2017,11(2):140-143.
27 Ozben V,Cengiz TB,Atasoy D,et al.Is da Vinci Xi better than da Vinci Si in robotic rectal cancer surgery?Comparison of the 2generations of da Vinci Systems.Surg Laparosc Endosc Percutan Tech,2016,26(5):417-423.
28 Morelli L,Di Franco G,Guadagni S,et al.Robot-assisted total mesorectal excision for rectal cancer:case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si.Surg Endosc,2018,32(2):589-600.
2 Georgeson KE,Inge TH,Albanese CT.Laparoscopically assisted anorectal pull-through for high imperforate anus:a new technique.J Pediatr Surg,2000,35(6):927-930.
3 汤绍涛,曹国庆,童强松,等.腹腔镜下高位肛门闭锁肛门成形术及中期临床评估.中华小儿外科杂志,2011,32(7):509-514.
4 汤绍涛.腹腔镜辅助手术治疗先天性肛门直肠畸形.中华小儿外科杂志,2014,35(6):466-469.
5 Meehan JJ,Sandler A.Pediatric robotic surgery:a single-institutional review of the first 100 consecutive cases.Surg Endosc,2008,22(1):177-182.
6 Sinha CK,Haddad M.Robot-assisted surgery in children:current status.J Robot Surg,2008,1(4):243-246.
7 Holschneider A,Hutson J,Pe1a A,et al.Preliminary report on the international conference for the development of standards for the treatment of anorectal malformations.J Pediatr Surg,2005,40(10):1521-1526.
8 Stephens FD,Smith ED.Classification,identification,and assessment of surgical treatment of anorectal anomalies.Pediatr Surg Int,1986,1(1):200-205.
9 李正,王练英,王维林,等.先天性无肛术后远期排便功能综合评定.中华小儿外科杂志,1990,11(5):283-285.
10 De Vos C,Arnold M,Sidler D,et al.A comparison of laparoscopicassisted(LAARP)and posterior sagittal(PSARP)anorectoplasty in the outcome of intermediate and high anorectal malformations.S Afr J Surg,2011,49(1):39-43.
11 Kimura O,Iwai N,Sasaki Y,et al.Laparoscopic versus open abdominoperineal rectoplasty for infants with high-type anorectal malformation.J Pediatr Surg,2010,45(12):2390-2393.
12 Diao M,Li L,Ye M,et al.Congenital anomaly rectified at birth:onestage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula.Surg Endosc,2016,30(11):5156-5164.
13 Yang J,Zhang W,Feng J,et al.Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through.J Pediatr Surg,2009,44(12):2380-2383.
14 Ming AX,Li L,Diao M,et al.Long term outcomes of laparoscopicassisted anorectoplasty:a comparison study with posterior sagittal anorectoplasty.J Pediatr Surg,2014,49(4):560-563.
15 Yazaki Y,Koga H,Ochi T,et al.Surgical management of rectoprostatic and recto-bulbar anorectal malformations.Pediatr Surg Int,2016,32(10):939-944.
16 Srimurthy KR,Ramesh S,Shankar G,et al.Technical modifications of laparoscopically assisted anorectal pull-through for anorectal malformations.J Laparoendosc Adv Surg Tech A,2008,18(2):340-343.
17 Diao M,Li L,Guan KP,et al.A novel laparoscopic technique for anorectal malformation with low recto-bulbar fistulae.Surg Endosc,2017,31(10):4326-4330.
18 Albassam A,Gado A,Mallick MS,et al.Robotic-assisted anorectal pull-through for anorectal malformations.J Pediatr Surg,2011,46(9):1794-1797.
19 Ruiz MR,Kalfa N,Allal H.Advantages of robot-assisted surgery in anorectal malformations:report of a case.J Minim Access Surg,2016,12(2):176-178.
20 张茜,汤绍涛,曹国庆,等.da Vinci机器人辅助腹腔镜Soave拖出术治疗先天性巨结肠症.中国微创外科杂志,2016,16(2):165-167,184.
21 张金山,李龙,刁美,等.经脐单切口腹腔镜辅助肛门成形术治疗小儿中高位肛门闭锁.中国微创外科杂志,2016,16(5):424-427.
22 侯文英,李龙,刘树立,等.腹腔镜辅助中位肛门闭锁成形术11 例报告.中国微创外科杂志,2007,7(5):439-441.
23 Muraoka K,Takenaka A.New findings of clinical anatomy in pelvis.Nihon Rinsho,2016,74(1):66-71.
24 高炜,张雪宁,郭志,等.Denonvilliers筋膜的应用解剖学研究进展.中国临床解剖学杂志,2016,34(1):111-114.
25 Wei HB,Fang JF,Zheng ZH,et al.Effect of preservation of Denonvilliers’fascia during laparoscopic resection for mid-low rectal cancer on protection of male urinary and sexual functions.Medicine(Baltimore),2016,95(24):e3925.
26 苏松盛,何进达,曾凡英.腹腔镜直肠癌术中保留Denonvilliers筋膜对中青年男性排尿及性功能影响.中华普外科手术学杂志(电子版),2017,11(2):140-143.
27 Ozben V,Cengiz TB,Atasoy D,et al.Is da Vinci Xi better than da Vinci Si in robotic rectal cancer surgery?Comparison of the 2generations of da Vinci Systems.Surg Laparosc Endosc Percutan Tech,2016,26(5):417-423.
28 Morelli L,Di Franco G,Guadagni S,et al.Robot-assisted total mesorectal excision for rectal cancer:case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si.Surg Endosc,2018,32(2):589-600.