机器人肝胆胰手术Trocar布置方法的教学与实践

doi:10.3877/cma.j.issn.1674-6899.2018.03.015

目的

机器人手术是肝胆胰外科发展方向，目前绝大多数单位仍在开展早期，在Trocar布置方面缺乏经验，且无文献系统介绍。本研究基于大样本量机器人肝胆胰手术(robotic hepato－pancreato biliary surgery, RHPBS)经验，总结布孔原则、具体方法，希望对早期开展RHPBS医师有所帮助。

方法

2011年11月至2017年10月手术团队共完成1 600例RHPBS，其中胰腺1 048例、肝脏377例、胆道118例、其他57例。Trocar布置首先参考腹腔镜手术布孔方法，结合术中操作体验及所遇问题而不断优化，改善操作舒适度，多方兼顾，提高手术效率，减少中转率，总结经验，并针对常见RHPBS，制定模式化布孔和特殊布孔。

结果

总结四大布孔原则(脐周主操作侧置镜原则、主线对称原则、对侧牵引原则、平腹8 cm间距原则)，制定适用于肝胆胰常见手术的3种模式化布孔和3种特殊布孔。

结论

本方法经由大量临床实践形成和检验，简明易学，布孔时遵循基本原则，可确保不出现严重错误，术中巧用Trocar in Trocar技巧等改善操作。模式化布孔易重复，便于初学者借鉴，特殊手术应特殊布孔，简化操作。

关键词: 机器人手术, 微创手术, 胰腺, 肝脏, 胆道, 教学培训

Objective

Robotic surgery show enormous potential in Hepatopancreaticobiliary surgery during recent decades. However, the ports placements always be confused and related studies was deficiency. Therefore, our study aims to describe our experience with ports position in Robotic Hepato-Pancreato-Biliary Surgery (RHPBS) and to summarize the principle.

Methods

We retrospectively reviewed the medical records of 1 600 patients who underwent RHPBS by our surgery team between Nov. 2011 and Oct. 2017 at the PLA General Hospital in Beijing, China. It was included 1 048 cases of pancreatic surgery, 377 cases liver surgery, 118 cases biliary surgery and 57 cases other types of robotic surgery. In the early stage, we position the ports as traditional laparoscopy reference, then improve the ports position combine with intraoperative adjustment, thereby forming pattern of regular ports position for RHPBS.

Results

The four primary principles of RHPBS were concluded: Manipulation-oriented Peri-umbilicus Camera Port, Symmetry Operative-Arm Ports, Opposite Retractor-Arm Port, Eight centimeter Prots Rule, and the 3 patterns of perforation and 3 kinds of special perforation suitable for common and special hepatopancreaticobiliary surgery were formulated.

Conclusions

Ports position experience based on thousand cases was summarize and concluded and then it put forward follow the RHPBS ports position primary principle, that is easy to grasp the key points and facilitate the operation. Four primary principles of RHPBS well proven in safety, feasible and superiority. Standardization of regular robotic HPB surgery will improve the surgery accomplishment and patients′ prognosis.

Key words: Robotic surgery, Minimally invasive surgery, Pancreas, Liver, Biliary tract, Teaching and training

图1 机器人肝脏手术模式化布孔

图2 机器人近端胰腺和胆道手术模式化布孔

图3 机器人远端胰腺和脾脏手术模式化布孔

图4 机器人肝左外叶切除术特殊布孔

图5 机器人高位高段肝脏切除术特殊布孔

图6 机器人后腹腔镜胰腺手术特殊布孔

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Teaching and clinic application of trocar placement in the robotic hepatopancreaticobiliary surgery

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Teaching and clinic application of trocar placement in the robotic hepatopancreaticobiliary surgery