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| 中国首例达芬奇机器人辅助全腔镜下右肾切除术 腔静脉Ⅱ级癌栓取出术 |
| 王林辉,叶华茂,吴震杰,李明敏,肖亮,吕晨,生晶,蔡晨,刘冰,杨庆,赵志青,盛夏,程欣,宋丽,曲乐,徐梦璐,申国君,孙颖浩 |
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| (第二军医大学长海医院泌尿外科;第二军医大学长海医院放射科;第二军医大学长海医院特需诊疗科;第二军医大学长海医院血管外科) |
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| 摘要: |
| 目的 探讨达芬奇机器人辅助全腔镜下右肾切除术 腔静脉Ⅱ级癌栓取出术的可行性、安全性,总结经验并分析临床疗效。方法 患者女性,73岁,体质指数 20.4 kg/m2。美国东部肿瘤协作组(ECOG)体力状况评分1分。Charlson全身合并症评分(Age-weighted) 2分。麻醉评分(ASA) 2分。因“右腰痛伴肉眼血尿4月”行 CT检查提示：右肾癌伴下腔静脉癌栓,肿瘤大小4.9×4.7cm,下腔静脉内癌栓长度4.6cm。术前行靶向药物治疗3月,肿瘤大小4.3×4.4cm,癌栓程度缩短为3.3cm。术前2天DSA下腔静脉癌栓近心端放置滤器。患者取左侧斜卧位,在右侧腹直肌外侧缘脐上2cm处经12mm套管置入镜头,直视下分别置入1、2号机械臂8mm套管及第1、2、3辅助孔套管,装配机械臂。将升结肠及十二指肠翻至左侧,暴露右肾周筋膜,打开下腔静脉鞘,沿下腔静脉表面充分游离。游离并夹闭右肾动脉后,使用血管吊带依次阻断癌栓尾侧下腔静脉、左肾静脉、癌栓头侧下腔静脉。于右肾静脉根部向上纵行切开下腔静脉5cm,完整取出下腔静脉内癌栓并切除部分与之粘连的右侧下腔静脉壁,关闭下腔静脉切口,开放血流。彻底止血,取出标本,放置引流后逐层关闭切口。结果 手术顺利完成,手术时间363min,下腔静脉共阻断47min,术中出血1200ml,术中输血1200m。术后因血色素偏低输血1000ml,无其他手术并发症发生,术后第3天肠道恢复通气,引流管留置时间3天,术后住院16天。术前及出院前血肌酐水平分别为68、88μmol/L。结论 达芬奇机器人辅助全腔镜下肾切除术 腔静脉Ⅱ级癌栓取出术安全、可行,微创效果好,但其肿瘤学疗效需进一步随访观察,临床应严格把握适应证,把手术安全放在第一位。 |
| 关键词: 机器人 肾癌 腔静脉癌栓 肾切除术 腹腔镜 |
| DOI：10.3724/SP.J.1008.2014.00763 |
| 投稿时间：2014-02-13修订日期：2014-06-10 |
| 基金项目:国家自然科学基金（81272817，81172447），上海市卫生系统优秀人才培养计划（XBR2011027），上海市科技人才计划（13XD1400100），上海市自然科学基金（11ZR1447800），上海市“领军人才”计划（2013046），长海医院“1255”学科建设计划（CH125520300），长海医院青年启动基金（201301） |
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| Robotic-assisted Laparoscopic Nephrectomy with Inferior Vena Caval Thrombectomy for Level II Tumor Thrombus: First Clinical Case in China |
| WANG Lin-hui,YE Hua-mao,WU Zhen-jie,LI Ming-min,XIAO Liang,LV Chen,SHENG Jing,CAI Chen,LIU Bing,YANG Qing,ZHAO Zhi-qing,SHENG Xia,CHENG Xin,SONG Li,QU Le,XU Meng-lu,SHEN Guo-jun,SHEN Guo-jun |
| (Changhai Hospital, Second Military Medical University) |
| Abstract: |
| Objective To report the first clinical case of robotic-assisted laparoscopic nephrectomy(right) combined with inferior vena caval thrombectomy for level Ⅱ tumor thrombus in China. Methods A 73-year-old female patient presented with "gross hematuria and flank discomfort for 4 months" was admitted to our hospital. Preoperative CT scans revealed a 4.9 cm×4.7 cm right renal cancer, grossly extending into the inferior vena cava (IVC, length of the IVC tumor thrombus: 4.6 cm). After three months of neoadjuvant targeted molecular therapies (TKIs), the tumor size reduced to 4.3 cm×4.4 cm on CT and the IVC tumor thrombus length reduced to 3.3 cm. IVC filter was placed cephalad 2 days before surgery under DSA intervention. The patient was placed in recumbent position during the operation; a 12-mm optical port was placed to the right of the rectus abdominis at 2 cm above the umbilicus. Two 8-mm robotic ports and three 12-mm assistant ports were placed percutaneously under direct visualization through a stab incision. The robotic system was then docked, with the colon reflected medially and the duodenum kocherized. The IVC sheath was opened, and the IVC was dissected circumferentially above and below the insertion of the right renal vein to the extent dictated by the length of the thrombus. With the right renal artery dissected and transected, the vessel loops were used to create modified-Rummel tourniquets. The vena cava below and above tumor thrombus, and the left renal vein were cross-clamped. With the vessel loops cinched down completely and secured by hem-o-lok clips, the wall of the IVC was then incised longitudinally for approximately 5 cm. The tumor thrombus was delivered intact along with the invaded IVC wall. The IVC was closed and tourniquet was loosened. After adequate hemostasis was achieved, the specimen was placed into an entrapment sac and incisions were closed by layers. Results The procedure was smoothly completed. The total operating time was 363 min and the total IVC cross-clamp time was 47 min. The estimated blood loss was 1 200 mL. The amount of intraoperative transfusion was 1 200 mL and 1 000 mL postoperative blood transfusion was required for a low level of hemoglobin. The bowel function recovered at day 3 after operation and drainage was maintained for 3 days. The patient was discharged 16 days after operation. Conclusion We successfully completed the first clinical case of robotic-assisted laparoscopic nephrectomy combined with inferior vena caval thrombectomy for level Ⅱ tumor thrombus in China; it is a safe and feasible procedure, but has great technical difficulty, so the patients should be chosen with great care. |
| Key words: Robotics Renal cancer Inferior vena cava thrombus Nephrectomy Laparoscopy. |
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