机器人手术在困难子宫切除术中的应用

doi:10.3877/cma.j.issn.1674-6899.2023.05.006

目的

探讨机器人手术在困难子宫切除术中的应用价值与手术技巧。

方法

回顾性分析2021年4月至2023年6月于解放军总医院第七医学中心由同一术者实施的困难子宫切除术病例资料，描述患者的人口统计学特征、切除子宫参数、术中术后情况等临床数据。

结果

纳入的24例患者平均年龄为47.50岁，平均体质量指数(body mass index，BMI)为24.62 kg/m²，11例有腹部手术史，5例有肌瘤剔除史。术前评估子宫大小超出孕16周的患者占66.67%，术后测量子宫平均重量为752.58 g，最重者达2650 g。全部患者中位手术时间136.50 min，中位出血量150 ml, 1例患者中转开腹，患者术后均1～2 d排气，术后平均住院5.63 d。4例患者出现术后并发症，分别为阴道残端出血、气胸、下肢肌间血栓和残余卵巢综合征，无泌尿系和肠道损伤。

结论

机器人手术具有清晰放大的3D视野、灵活有力的机械臂和滤过震颤功能，在视野放大效果、操作的灵活性和稳定性上带来了革新，有助于降低出血量、减少并发症、加速术后恢复，因此在困难子宫切除中具有一定优势。

关键词: 机器人手术, 微创手术, 子宫切除术, 子宫腺肌症, 子宫肌瘤

Objective

To discuss the application value of robotic-assisted surgery in difficult hysterectomy and summarize the surgical technique.

Methods

We retrospectively analyzed the hysterectomy cases performed by the same surgeon in the Seventh Medical Center of Chinese PLA General Hospital from Apr. 2021 to Jun. 2023. Clinical data such as demographic characteristics, parameters of uteri, and intraoperative and postoperative details was described.

Results

The average age of 24 patients was 47.50 years and the average BMI value was 24.62 kg/m². 11 patients had a history of abdominal surgery and 5 had a history of myomectomy. 66.67% of the patients were found uterine size exceeding 16 weeks of pregnancy before surgery, and the average weight of the uteri measured after surgery was 752.58 g, with the maximum weight reaching 2650 g. The median operation time of all patients was 136.50 min, and the median bleeding volume was 150 ml. Only 1 patient was converted to laparotomy. The postoperative venting time was 1-2 days, and the mean length of postoperative hospital stay was 5.63 days. The complications in 4 patients included vaginal stump bleeding, pneumothorax, lower limb intermuscular thrombosis and residual ovarian syndrome. No patient had urinary and intestinal injuries.

Conclusions

Surgical robot has a clear and enlarged 3D field of view, a flexible and powerful robotic arm with the function of filtering tremors, which brings innovations in field of view amplification, operational flexibility and stability. It could help to decrease blood loss, reduce complications and accelerate postoperative recovery, so it has certain advantages in difficult hysterectomy.

Key words: Robotic-assisted surgery, Minimally invasive surgery, Hysterectomy, Adenomyosis, Uterine leiomyoma

表1 人口统计学特征

	平均值/例数	范围/占比
年龄(岁)	47.50±4.13	38～55
身高(cm)	161.04±4.01	155～174
体重(kg)	63.92±9.26	51～82
BMI(kg/m²)	24.62±3.25	19.92～31.65
腹部手术史	11	45.83%
肌瘤剔除手术史	5	20.83%

表1 人口统计学特征

	平均值/例数	范围/占比
年龄(岁)	47.50±4.13	38～55
身高(cm)	161.04±4.01	155～174
体重(kg)	63.92±9.26	51～82
BMI(kg/m²)	24.62±3.25	19.92～31.65
腹部手术史	11	45.83%
肌瘤剔除手术史	5	20.83%

表2 切除子宫参数

	平均值/例数	范围/占比
子宫大小
<孕16周	8	33.33%
≥孕16周	16	66.67%
子宫重量(g)	752.58±506.49	410～2650
超声最大径(cm)	11.11±3.52	6.9～19.7
病理最大径(cm)	16.61±6.44	8.0～35.0
最终诊断
多发子宫肌瘤	11	45.83%
子宫腺肌症	3	12.50%
多发子宫肌瘤＋子宫腺肌症	10	41.67%

表2 切除子宫参数

	平均值/例数	范围/占比
子宫大小
<孕16周	8	33.33%
≥孕16周	16	66.67%
子宫重量(g)	752.58±506.49	410～2650
超声最大径(cm)	11.11±3.52	6.9～19.7
病理最大径(cm)	16.61±6.44	8.0～35.0
最终诊断
多发子宫肌瘤	11	45.83%
子宫腺肌症	3	12.50%
多发子宫肌瘤＋子宫腺肌症	10	41.67%

图1 手术关键步骤注：A.暴露术野，探查子宫；B．凝断右侧圆韧带；C.下推膀胱反折腹膜；D.凝闭左侧子宫血管；E.环形切开阴道壁；F.缝合阴道断端；G.3号臂下压子宫；H.削苹果法缩小子宫体积。

表3 术中术后相关指标

	平均值/中位数/例数	范围/占比
手术方式
全子宫双输卵管切除	18	75.00%
全子宫双输卵管切除＋盆腔粘连松解	3	12.50%
全子宫双附件切除	3	12.50%
手术时间(median，min)	136.50	62～223
出血量(median，ml)	150	30～1500
输血情况
无	17	70.83%
有，术前纠正贫血	4	16.67%
有，术后纠正贫血	3	12.50%
是否中转开腹
否	23	95.83%
是	1	4.17%
术后排气天数(d)	1.67±0.48	1～2
术后住院天数(d)	5.63±1.25	3～7
并发症	4	16.67%
阴道残端出血	1	4.17%
气胸	1	4.17%
下肢肌间血栓	1	4.17%
残余卵巢综合征	1	4.17%
感染	0	0
泌尿损伤	0	0
肠道损伤	0	0

表3 术中术后相关指标

	平均值/中位数/例数	范围/占比
手术方式
全子宫双输卵管切除	18	75.00%
全子宫双输卵管切除＋盆腔粘连松解	3	12.50%
全子宫双附件切除	3	12.50%
手术时间(median，min)	136.50	62～223
出血量(median，ml)	150	30～1500
输血情况
无	17	70.83%
有，术前纠正贫血	4	16.67%
有，术后纠正贫血	3	12.50%
是否中转开腹
否	23	95.83%
是	1	4.17%
术后排气天数(d)	1.67±0.48	1～2
术后住院天数(d)	5.63±1.25	3～7
并发症	4	16.67%
阴道残端出血	1	4.17%
气胸	1	4.17%
下肢肌间血栓	1	4.17%
残余卵巢综合征	1	4.17%
感染	0	0
泌尿损伤	0	0
肠道损伤	0	0

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Application of robotic-assisted surgery in difficult hysterectomy

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Application of robotic-assisted surgery in difficult hysterectomy