机器人辅助超精细被膜解剖技术在甲状腺癌手术中的应用:附1 045例报告
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中国人民解放军陆军军医大学第一附属医院 乳腺甲状腺外科,重庆 400038

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覃湘泉,中国人民解放军陆军军医大学第一附属医院住院医师,主要从事甲状腺及乳腺肿瘤相关的临床与基础方面的研究(

基金项目:

重庆市技术创新与应用发展专项基金资助项目(cstc2019jscx-msxmX0284);重庆市英才创新创业领军人才基金资助项目[CQYC202103078]。


The application of robot-assisted super-meticulous capsular dissection in thyroid cancer surgery: a report of 1 045 cases
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Department of Breast and Thyroid Surgery, the First Affiliated Hospital of the Army Military Medical University, Chongqing 400038, China

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    摘要:

    背景与目的 由于机器人手术设备的3D视野以及灵活的内关节器械,机器人手术系统在甲状腺外科的应用扩展了腔镜手术的适用范围。本研究对笔者单位应用机器人辅助超精细被膜解剖(SMCD)技术实施的甲状腺癌(TC)根治术进行总结分析,探讨应用机器人实施SMCD技术的疗效与安全性。方法 回顾性分析中国人民解放军陆军军医大学第一附属医院2018年6月—2022年5月应用机器人辅助SMCD技术完成TC根治手术的1 045例患者临床资料。结果 1 045例患者均顺利完成机器人手术,其中,214例(20.5%)行单侧腺叶切除+单侧中央区淋巴结清扫,342例(32.7%)行甲状腺全切+单侧中央区淋巴结清扫,317例(30.3%)行甲状腺全切+双侧中央区淋巴结清扫,157例(15.0%)行甲状腺全切+双侧中央区淋巴结+单侧侧方清扫,15例(1.4%)行甲状腺全切+双侧中央区淋巴结+双侧侧方清扫。除了进行侧方清扫的172例(16.5%)患者采用经双侧乳晕和腋窝(BABA)入路外,其余873例(83.5%)均采用经单侧腋窝双侧乳晕(UABA)入路完成,平均手术时间为(151.74±59.62)min。行甲状旁腺移植38例(3.6%),336例(32.2%)患者术后行131I治疗;术后发生了暂时性甲状旁腺功能减退245例(23.4%),永久性甲状旁腺功能减退7例(0.7%);术后发生了暂时性声音嘶哑4例(0.4%);术后发生局部复发3例(0.3%)。单因素与多因素分析均显示手术切除范围是发生暂时性甲状旁腺功能减退的影响因素(HR=1.51,95% CI=0.90~2.49,P<0.001;HR=1.20,95% CI=1.00~1.43,P=0.049)。结论 机器人TC手术安全彻底,UABA入路能够胜任机器人甲状腺全切+中央区清扫,而BABA则是行侧方淋巴结清扫更适合的选择。同时机器人辅助下SMCD的应用有助于保护甲状旁腺功能,减少永久性甲状旁腺功能低下的发生。

    Abstract:

    Background and Aims Due to the 3D visualization and flexible intra-articular elements of robotic surgical devices, the application of robotic surgical systems in thyroid surgery has expanded the scope of laparoscopic surgery. This study was designed to provide a summary and analysis of patients with thyroid cancer (TC) undergoing robot-assisted radical thyroidectomy with super-meticulous capsular dissection (SMCD) technique in the authors' hospital, to evaluate the efficacy and safety of implementing the SMCD technique with robotic assistance.Methods The clinical data of 1 045 TC patients who underwent robotic-assisted radical thyroidectomy with SMCD technique in the First Affiliated Hospital of the Army Military Medical University from June 2018 to May 2022 were retrospectively analyzed.Results All 1 045 patients successfully underwent robotic surgery. Among them, 214 cases (20.5%) underwent unilateral lobectomy with unilateral central lymph node dissection, 342 cases (32.7%) underwent total thyroidectomy with unilateral central lymph node dissection, 317 cases (30.3%) underwent total thyroidectomy with bilateral central lymph node dissection, 157 cases (15.0%) underwent unilateral lateral neck dissection and 15 cases (1.4%) underwent bilateral lateral neck dissection. Except for 172 cases (16.5%) who underwent lateral neck dissection via the bilateral axillo-breast approach (BABA), the remaining 873 cases (83.5%) were completed via the unilateral axilla-bilateral areola approach (UABA), with an average operative time of (151.74±59.62) min. Parathyroid transplantation was performed in 38 cases (3.6%), and 336 cases (32.2%) underwent postoperative 131I treatment. After operation, temporary hypoparathyroidism occurred in 245 cases (23.4%), and permanent hypoparathyroidism occurred in 7 cases (0.7%); temporary hoarseness occurred in 4 cases (0.4%); local recurrence occurred in 3 cases (0.3%). Both univariate and multivariate analyses showed that the extent of surgery was a factor for the occurrence of temporary hypoparathyroidism (HR=1.51, 95% CI=0.90-2.49, P<0.001; HR=1.20, 95% CI=1.00-1.43, P=0.049).Conclusion Robotic surgery for TC is safe and thorough, and the UABA approach is capable of performing robotic total thyroidectomy plus central compartment clearance, while the BABA approach is a more suitable choice for lateral lymph node dissection. The application of SMCD with robotic assistance helps preserve parathyroid function and reduces the occurrence of permanent hypoparathyroidism.

    表 2 术后复发转移患者的临床资料Table 2 Clinical data of patients with postoperative recurrence and metastasis
    图1 UABA入路 A:Trocar置入后;B:Da Vinci Xi®机械臂与Trocar相连接后,插入专用操作器械Fig.1 UABA approach A: View after Trocar placement; B: Insertion of specialized instruments after connection of the Da Vinci Xi® robotic arm with the Trocar
    图2 BABA入路 A:Trocar置入后;B:患者术后照Fig.2 BABA approach A: View after Trocar placement; B: Postoperative photograph of the patient
    图3 术中皮瓣游离完成后(皮瓣游离的层次位于颈阔肌深面,颈前静脉浅面)Fig.3 After completion of the intraoperative flap detachment (the detachment planes of the flap within the deep plane of the platysma and the superficial plan of to the anterior jugular vein)
    图4 右侧甲状腺叶切除过程中采用SMCD技术对右下甲状旁腺(电凝钩所指处)进行保留Fig.4 Preservation of the right inferior parathyroid gland (indicated by the electrosurgical hook) using the SMCD technique during the right thyroid lobotomy
    图5 UABA入路行右侧甲状腺切除+右中央区清扫后[右下甲状旁腺(黑色箭头)保存完好,右侧喉返神经(蓝色箭头)四周淋巴结已彻底清扫]Fig.5 After performing right thyroidectomy and central neck dissection via the UABA approach [well preservation of the right inferior parathyroid gland (indicated by the black arrow), and thorough clearance of the lymph nodes around the right recurrent laryngeal nerve (indicated by the blue arrow)]
    图6 BABA入路行右侧方淋巴结清扫后(电凝钩所指为副神经)Fig.6 After performing right lateral lymph node dissection through the BABA approach (the electrosurgical hook pointing to the accessory nerve)
    表 3 暂时性甲状旁腺功能减退影响因素分析Table 3 Analysis of factors for transient hypoparathyroidism
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覃湘泉,赵晶晶,罗佳,曾令娟,范林军.机器人辅助超精细被膜解剖技术在甲状腺癌手术中的应用:附1 045例报告[J].中国普通外科杂志,2023,32(11):1677-1686.
DOI:10.7659/j. issn.1005-6947.2023.11.006

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  • 收稿日期:2023-08-09
  • 最后修改日期:2023-11-03
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  • 在线发布日期: 2023-12-15