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目的总结“达芬奇”机器人手术系统在治疗胆管恶性肿瘤的临床经验。方法我院在2009年1月至2010年10月期间应用“达芬奇”机器人手术系统进行了180例肝胆胰及胃肠手术,其中涉及胆管恶性肿瘤58例,对其病例分布、手术过程和术后恢复情况进行分析、总结。结果 58例包括肝内胆管囊腺癌3例,均行肝脏楔形切除术;肝门部胆管癌36例,行解剖性左半肝切除术3例,肝外胆管切除+胆囊桥式胆道重建术3例,肝外胆管切除+胆肠Roux-en-Y吻合术14例,肿瘤切除+肝门部胆管重建术1例,姑息性肝内胆管外引流术5例和肝门T管“Y”式内引流术10例;胆囊癌10例,2例行胆囊及肝外胆管切除+胆肠Roux-en-Y吻合术,3例行胆囊切除术,1例行胆囊切除+肝内胆管外引流术,4例行胆囊切除+T管“Y’式肝门胆管支撑胆汁内引流术;胆总管中段癌1例,行根治性肝外胆管切除+胆肠Roux-en-Y吻合术;胆总管下段癌8例,均行胰十二指肠切除术。58例患者中2例中转开腹手助完成,中转率为3.4%。手术时间为(6.18±1.71)h,术中出血量为(116.66±56.06)ml,输血量为(85.55±38.28)ml,术后下床活动时间为(9.10±2.91)h,进食时间为(14.95±4.35)h,住院时间为(12.81±4.29)d。术后发生漏胆3例,肝创面出血1例,胰肠吻合口漏2例,肺部感染1例和肾功能衰竭1例,总并发症率为13.8%;经止血、充分引流及抗感染治疗,6例恢复顺利,2例分别因严重肺部感染、肾功能衰竭分别于术后3周及4周死亡,总死亡率为3.4%。36例肝门胆管癌患者中,19例死亡(术后2个月4例,6个月5例,10个月8例,12个月2例),11例生存良好(>26个月4例,>22个月3例,>19个月4例),6例需住院治疗。10例胆囊癌患者中7例死亡(术后3个月1例,5个月1例,8个月1例,11个月3例,12个月1例),3例目前仍存活(>17个月2例,>13个月1例)。8例行胰十二指肠切除患者中5例死亡(包括中转开腹者,4个月2例,6个月2例,10个月1例),余3例患者术后生存已超过2年,且目前状态良好。3例肝内胆管囊腺癌术后生存时间均超过1年。结论 应用”达芬奇“机器人手术系统可以完成涉及胆管恶性肿瘤各种类型手术,对于部位深在、结构复杂的肝门部手术,其优势尤为突出,突破了腹腔镜在肝胆恶性肿瘤中的禁区。
Objective To summarize the clinical experience of ”Da Vinci“ robotic surgery system in the treatment of biliary malignancies. Methods 180 cases of hepatobiliary and pancreatic and gastrointestinal surgery were performed in our hospital from January 2009 to October 2010 with ”Da Vinci“ robotic surgery system. Among them, 58 cases were involved in the malignant tumor of the bile duct. The distribution of the cases, operation Process and postoperative recovery analysis, summary. Results of 58 cases including intrahepatic cholangiocarcinoma in 3 cases, underwent liver wedge resection; hilar cholangiocarcinoma in 36 cases, anatomical left hemihepatectomy in 3 cases, extrahepatic bile duct resection + cholecystic bridge biliary reconstruction 3 cases, extrahepatic bile duct resection + cholecystolithiasis Roux-en-Y anastomosis in 14 cases, tumor resection + hilar bile duct reconstruction in 1 case, palliative intrahepatic biliary drainage in 5 cases and hepatic portal T tube ”Y 10 cases of gallbladder carcinoma, 10 cases of gallbladder carcinoma, 2 cases of gallbladder and extrahepatic bile duct resection plus Roux-en-Y cholangiojejunostomy, 3 cases of cholecystectomy, 1 cases of cholecystectomy + intrahepatic bile duct External drainage, 4 cases of cholecystectomy + T tube “Y ’hilar biliary drainage biliary drainage; 1 case of common bile duct cancer, radical resection of extrahepatic bile duct + Roux-en-Y choledochojejunostomy ; Common bile duct cancer in 8 cases, all underwent pancreatoduodenectomy .58 cases of patients in 2 cases of laparotomy assisted transfer completed, the conversion rate was 3.4% .The operation time was (6.18 ± 1.71) h, intraoperative bleeding The amount of blood transfusion was (85.55 ± 38.28) ml, the time of bed ambulation after operation was (9.10 ± 2.91) h, the time of eating was (14.95 ± 4.35) h and the length of hospital stay was (12.81 ± 4.29) ) d. 3 cases of postoperative leakage of gallbladder, liver wound bleeding in 1 case, 2 cases of pancreaticojejunostomy leakage, 1 case of pulmonary infection and 1 case of renal failure, the total complication rate was 13.8%. After hemostasis, full drainage and anti-infection treatment, 6 cases recovered smoothly, 2 cases were severe lung Infection and renal failure died after 3 weeks and 4 weeks respectively, with a total mortality rate of 3.4%. Of the 36 patients with hilar cholangiocarcinoma, 19 died (4 cases 2 months and 5 cases 6 months after operation, (8 in 10 months and 2 in 12 months), 11 survived well (4> 26 months, 3> 22 months, 4> 19 months), and 6 were hospitalized. Of the patients, 7 died (1 in 3 months, 1 in 5 months, 1 in 8 months, 3 in 11 months, and 1 in 12 months) and 3 survived (> 17 months 2 (> 13 months, 1 case) .8 Of the 8 patients who underwent pancreatoduodenectomy, 5 died (including those who underwent an open surgery, 2 at 4 months, 2 at 6 months, and 1 at 10 months) The remaining 3 patients survived for more than 2 years and were in good condition at present.The survival time of all the 3 cases with intrahepatic cholangiocarcinoma was over 1 year.Conclusion The application of ”Da Vinci" robotic surgery system can complete the operation involving the bile duct Various types of malignant tumor surgery, the site deep in the complex structure of the hilar surgery, the advantages are particularly prominent, breakthrough In the area of laparoscopic gallbladder malignant tumor.