机器人辅助右半结肠切除术中标准化的耻骨上自下而上入路：完整结肠系膜切除（CME）的技术与肿瘤学进展
A standardized suprapubic bottom-to-up approach in robotic right colectomy: technical and oncological advances for complete mesocolic excision (CME).
作者信息
Schulte Am Esch Jan, Iosivan Sergio-I, Steinfurth Fabian, Mahdi Ammar, Förster Christine, Wilkens Ludwig, Nasser Alaa, Sarikaya Hülya, Benhidjeb Tahar, Krüger Martin
机构信息
Center of Visceral Medicine, Department of General and Visceral Surgery, Center of Visceral Medicine, Protestant Hospital of Bethel Foundation, Schildescher Str. 99, Bielefeld, Germany.
Institute of Pathology, KRH Clinic Nordstadt, Hannover, Germany.
出版信息
BMC Surg. 2019 Jul 1;19(1):72. doi: 10.1186/s12893-019-0544-2.
BACKROUND
Several studies have demonstrated a direct correlation between lymph node yield and survival after colectomy for cancer. Complete mesocolic excision (CME) in right colectomy (RC) reduces local recurrence but is technically demanding. Here we report our early single center experience with robotic right colectomy comparing our standardized bottom-to-up (BTU) approach of robotic RC with CME and central vessel ligation (CVL) facilitated by a suprapubic access with the "classical" medial-to-lateral (MTL) strategy.
METHODS
A 4-step BTU approach of robotic RC guided by embryonal planes in the process of retrocolic mobilization with suprapubic port placement was performed in the BTU-group (n = 24; all with intention to treat cancer). In step 1 CME was initiated with caudolateral mobilization of the right colon guided by the fascia of Toldt across the duodenum and up to the Trunk of Henle. Subsequently, dissection was performed BTU right of the middle supramesenteric vessels with central ileocolic vessel ligation in step 2. Subsequent to separation of the transverse retromesenteric space and completion of mobilization the hepatic flexure in step 3, the transverse mesocolon was then transected right of the middle colic vessels in step 4. An extracorporeal side to side anastomosis was performed. We compared the outcome of the BTU-group with a MTL-group (n = 7).
RESULTS
Patient characteristics like age, gender, BMI, comorbidity (ASA) and M-status were comparable among groups. There was no conversion. Overall complication rate was 35.5%. We experienced no anastomoses insufficiency, grade Dindo/Clavien III/IV complication or mortality in this study. Type I and II complications and surgical characteristics incl. OR-time, ICU- and hospital-stay were comparable between the two groups. However, the lymph node yield was superior in the BTU-group (mean 40.2 ± 17.1) when compared with the MTL-group (16,3 nodes ±8.5; p < 0,001).
CONCLUSIONS
Compared to the classical MTL approach, robotic suprapubic BTU RC changes from a search of the layers bordering the oncological dissection to a consequent utilization of the planes as a retro-mesocolic guide during CME. The BTU strategy could bear the potential to increase the lymph node yield. Robotic systems may provide the technical requirements to combine advantages of both open and minimally invasive RC.
背景
多项研究表明，结肠癌结肠切除术后淋巴结获取数量与生存率之间存在直接关联。右半结肠切除术（RC）中的完整结肠系膜切除术（CME）可降低局部复发率，但技术要求较高。在此，我们报告我们早期的单中心机器人辅助右半结肠切除术经验，比较我们标准化的自下而上（BTU）机器人辅助右半结肠切除术方法与CME以及通过耻骨上入路辅助的中央血管结扎术（CVL）与“经典”的由内侧向外侧（MTL）策略。
方法
在BTU组（n = 24；均为有治疗癌症意向者）中，采用在结肠后游离过程中以胚胎平面为导向的4步BTU机器人辅助右半结肠切除术，并放置耻骨上端口。在第1步中，以Toldt筋膜为导向，从十二指肠开始向尾外侧游离右半结肠直至Henle干，启动CME。随后，在第2步中，在肠系膜上动脉中部右侧进行由下而上的解剖，并结扎中央回结肠血管。在第3步分离横结肠系膜后间隙并完成肝曲游离后，在第4步中于结肠中动脉中部右侧横断横结肠系膜。进行体外侧侧吻合。我们将BTU组的结果与MTL组（n = 7）进行了比较。
结果
各组间患者的年龄、性别、体重指数、合并症（美国麻醉医师协会分级）和M分期等特征具有可比性。无中转开腹情况。总体并发症发生率为35.5%。本研究中未出现吻合口漏、Dindo/Clavien III/IV级并发症或死亡情况。两组间I型和II型并发症以及手术特征（包括手术时间、重症监护病房停留时间和住院时间）具有可比性。然而，与MTL组（16.3个淋巴结±8.5）相比，BTU组的淋巴结获取数量更优（平均40.2±17.1；p < 0.001）。
结论
与经典的MTL方法相比，机器人辅助耻骨上BTU右半结肠切除术在CME过程中从寻找肿瘤切除边界的层面转变为将这些平面作为结肠后系膜的引导加以充分利用。BTU策略可能具有增加淋巴结获取数量的潜力。机器人系统可能提供了结合开放和微创右半结肠切除术优势的技术条件。
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