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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2026, Vol. 19 ›› Issue (04) : 225 -232. doi: 10.3877/cma.j.issn.1674-6899.2026.04.006

论著

基于倾向性评分匹配的机器人手术与腹腔镜手术治疗肝细胞癌的疗效及预后研究
朱宜灿1,2, 胡君2, 黎兵华1, 余德才1,†()   
  1. 1210008　南京医科大学鼓楼临床医学院南京鼓楼医院肝胆与肝移植外科
    2210001　南京，中国人民解放军东部战区空军医院普外科
  • 收稿日期:2026-05-21 出版日期:2026-08-30
  • 通信作者: 余德才
  • 基金资助:
    国家自然科学基金项目(82372834)

Study on the efficacy and prognosis of robotic surgery versus laparoscopic surgery for hepatocellular carcinoma based on propensity score matching

Yican Zhu1,2, Jun Hu2, Binghua Li1, Decai Yu1,†()   

  1. 1Department of Hepatobiliary Surgery and Liver Transplantation, Nanjing Drum Tower Hospital, Gulou Clinical Medical College, Nanjing Medical University, Nanjing, 210008, China
    2General Surgery Department, Air Force Hospital of the Eastern Theater Command, Chinese People′s Liberation Army, Nanjing 210001, China
  • Received:2026-05-21 Published:2026-08-30
  • Corresponding author: Decai Yu
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引用本文：

朱宜灿, 胡君, 黎兵华, 余德才. 基于倾向性评分匹配的机器人手术与腹腔镜手术治疗肝细胞癌的疗效及预后研究[J/OL]. 中华腔镜外科杂志(电子版), 2026, 19(04): 225-232.

Yican Zhu, Jun Hu, Binghua Li, Decai Yu. Study on the efficacy and prognosis of robotic surgery versus laparoscopic surgery for hepatocellular carcinoma based on propensity score matching[J/OL]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2026, 19(04): 225-232.

目的

对比机器人辅助肝切除术与腹腔镜辅助肝切除术在治疗肝细胞癌的短期疗效及远期预后情况。

方法

本研究回顾性分析了南京医科大学附属鼓楼医院肝胆与肝移植外科在2021年至2023年期间接受机器人辅助肝切除及腹腔镜辅助肝切除治疗的肝细胞癌患者，经过纳入和排除标准，最终221例患者被纳入分析，其中机器人组51例，腹腔镜组170例。采用倾向评分匹配(propensity score matching，PSM)法建立机器人组与腹腔镜组1∶1的匹配关系，观察分析各组患者肝门阻断时间、手术时间、术中出血量、术中输血量、中转开腹情况、30天再入院、术后并发症、住院时间等围手术期疗效间差异。采用Kaplan-Meier法估算两组无进展生存期(progression-free survival，PFS)结果并进行对比分析。

结果

PSM前两组之间提示机器人肝切除组中PT时间更短(P＝0.022)、肝硬化发生率更低(P＝0.009)、所切除的肝癌肿瘤标本直径显著更大(P＝0.007)，在传统大范围肝切除中优势更明显(P<0.001)，在Iwate评分高的手术中具有更强的选择性(P<0.001)。围手术期疗效提示机器人组手术时间明显长于腹腔镜组(200 min vs. 180 min ，P＝0.006)且具有更高的Clavien-Dindo并发症分级(Ⅰ＋Ⅱ＋Ⅲ，21.6% vs. 7.6%，P＝0.020)。经PSM后两组在围手术期预后(手术时间、肝门阻断、术中失血、术中输血、术后住院日、中转开腹、30 d再入院、Clavien-Dindo并发症分级)均无显著差异(P>0.05)。PSM前后的机器人组与腹腔镜组之间长期预后对比均显示组间无统计学差异(P>0.05)。

结论

机器人辅助肝切除术是腹腔镜肝切除术治疗HCC的可接受替代方案，两者整体安全性无统计学差异。值得注意的是，机器人组在复杂肝切除及远期预后(PFS)中具有潜在优势。

关键词: 机器人肝切除, 腹腔镜肝切除, 肝细胞癌, 肿瘤预后
Objective

To compare the short-term efficacy and long-term prognosis of robot-assisted hepatectomy versus laparoscopic hepatectomy in the treatment of hepatocellular carcinoma (HCC).

Methods

This retrospective study analyzed patients with hepatocellular carcinoma who underwent robot-assisted hepatectomy or laparoscopic hepatectomy in the Department of Hepatobiliary and Liver Transplantation Surgery, Gulou Hospital affiliated to Nanjing Medical University between 2021 and 2023. After applying the inclusion and exclusion criteria, a total of 221 patients were included, including 51 patients in the robotic group and 170 patients in the laparoscopic group. Propensity score matching (PSM) was performed at a 1∶1 ratio between the two groups. Perioperative outcomes, including hepatic inflow occlusion time, operative time, intraoperative blood loss, intraoperative transfusion volume, conversion to open surgery, 30-day readmission, postoperative complications, and length of hospital stay, were compared between the groups. Kaplan-Meier analysis was used to estimate and compare progression-free survival (PFS) between the two groups.

Results

Before PSM, the robotic liver resection group exhibited shorter PT duration (P=0.022) and a lower incidence of cirrhosis (P=0.009). Patients in the robotic hepatectomy group had significantly larger tumor diameters in the resected specimens compared with those in the laparoscopic group (P=0.007). The robotic approach demonstrated a more pronounced advantage in conventional major hepatectomy (P<0.001) and showed stronger selectivity in surgeries with high Iwate difficulty scores (P<0.001). Perioperative outcomes before matching indicated that the robotic group had a significantly longer operative time than the laparoscopic group (200 min vs. 180 min, P=0.006) and a higher rate of Clavien-Dindo complications (Grade Ⅰ+ Ⅱ+ Ⅲ: 21.6% vs. 7.6%, P=0.020). After PSM, no significant differences were observed between the two groups in perioperative outcomes, including operative time, hepatic inflow occlusion time, intraoperative blood loss, intraoperative transfusion, postoperative hospital stay, conversion to open surgery, 30-day readmission, or Clavien-Dindo complication grade (all P>0.05). Long-term prognosis before and after PSM also showed no statistically significant difference in PFS between the robotic and laparoscopic groups (P>0.05).

Conclusion

Robot-assisted hepatectomy is an acceptable alternative to laparoscopic hepatectomy for the treatment of HCC, with no statistically significant difference in overall safety between the two approaches. Notably, the robotic approach may offer potential advantages in complex hepatectomy procedures and long-term prognosis (PFS).

Key words: Robotic liver resection, Laparoscopic liver resection, Hepatocellular carcinoma, Tumor prognosis
图1 患者筛选、倾向评分匹配及随访流程图
表1 倾向性匹配前后的机器人组和腹腔镜组肝癌患者基线资料表
指标 倾向性评分前 倾向性评分后
机器人(n＝51) 腹腔镜(n＝170) 统计量 P值 机器人(n＝41) 腹腔镜(n＝41) 统计量 P值
年龄(岁) 60.5±11.9 59.5±10.6 0.582 0.561 61.3±12.1 59.0±9.6 0.977 0.335
性别[例(%)]     0.049 0.825     0.100 0.754
男 41.0(80.4) 139.0(81.8)     35.0(85.4) 37.0(90.2)    
女 10.0(19.6) 31.0(18.2)     6.0(14.6) 4.0(9.8)    
BMI(kg/m2) 23.2(20.8，25.6) 23.4(21.7，25.8) －1.147 0.251 23.2(21.2，25.6) 23.4(20.3，25.9) －0.706 0.480
血红蛋白(g/L) 139.0(125.5，150.3) 143.0(130.0，152.5) －1.312 0.189 142.0(127.5，151.0) 141.0(129.5，153.5) －0.680 0.497
血小板计数(109/L) 162.5(116.5，204.5) 142.0(111.0，186.0) －0.940 0.347 157.0(97.5，202.5) 148.0(96.5，178.0) －0.823 0.411
凝血酶原时间(s) 11.4(10.9，11.8) 11.6(11.1，12.1) －2.286 0.022 11.4(10.8，11.9) 11.4(11.0，11.9) －0.251 0.802
肿瘤最大直径(mm) 47.5(25.0，70.0) 32.0(20.5，50.0) －2.695 0.007 40.0(25.0，67.5) 38.0(25.5，71.0) －0.668 0.504
AFP>40[例(%)] 24.0(47.1) 63.0(37.1) 1.644 0.200 18.0(43.8) 15.0(36.4) 0.211 0.648
肝硬化[例(%)] 26.0(51.0) 120.0(70.6) 6.728 0.009 24.0(58.5) 28.0(65.9) 0.444 0.508
既往腹部手术史[例(%)] 9.0(17.6) 53.0(31.2) 3.558 0.059 7.0(17.1) 14.0(34.1) 2.118 0.143
合并胆囊切除[例(%)] 29.0(56.9) 78.0(45.9) 1.894 0.169 20.0(53.7) 24.0(58.5) 0.050 0.824
Child-Pugh评分     0.217 0.641     0.000 1.000
A 50.0(98.0) 162.0(95.3)     40.0(97.6) 39.0(95.1)    
B 1.0(2.0) 8.0(4.7)     1.0(2.4) 2.0(4.9)    
切除范围[例(%)]     19.128 <0.001     0.000 1.000
≥3肝段 23.0(45.1) 27.0(15.9)     13.0(31.7) 14.0(34.1)    
<3肝段 28.0(54.9) 143.0(84.1)     28.0(68.3) 27.0(65.9)    
ASA麻醉分级[例(%)]     2.905 0.200     －0.333 0.739
Ⅱ 4.0(7.8) 6.0(3.5)     4.0(9.8) 1.0(2.4)    
Ⅲ 42.0(82.4) 155.0(91.2)     34.0(82.9) 39.0(95.2)    
Ⅳ 5.0(9.8) 9.0(5.3)     3.0(7.3) 1.0(2.4)    
Iwate难度分级[例(%)]     19.525 <0.001     －0.211 0.833
Ⅰ 5.0(9.8) 15.0(8.8)     5.0(12.2) 4.0(9.8)    
Ⅱ 5.0(9.8) 51.0(46.5)     5.0(12.2) 5.0(12.2)    
Ⅲ 20.0(39.2) 79.0(46.5)     18.0(43.9) 20.0(48.8)    
Ⅳ 21.0(41.2) 25.0(14.7)     13.0(31.7) 12.0(29.2)    
IMM难度分级[例(%)]     4.763 0.092     －0.404 0.686
Ⅰ 8.0(15.7) 38.0(22.4)     8.0(19.5) 6.0(14.6)    
Ⅱ 17.0(33.3) 74.0(43.5)     14.0(34.1) 16.0(39.0)    
Ⅲ 26.0(51.0) 58.0(34.1)     19.0(46.4) 19.0(46.4)    
表2 倾向性匹配前后的机器人组和腹腔镜组肝癌患者围术期结局比较
指标 倾向性评分前 倾向性评分后
机器人(n＝51) 腹腔镜(n＝170) 统计量 P值 机器人(n＝41) 腹腔镜(n＝41) 统计量 P值
肝门阻断时间(min) 45(30，60) 45(30，60) －0.774 0.439 45(35，60) 60(38，60) －0.706 0.480
手术时间(min) 220(175，280) 180(139，250) －2.755 0.006 215(175，255) 240(168，308) －0.840 0.401
术中失血量(cc/ml) 200(100，300) 100(100，300) －0.782 0.434 200(100，300) 200(100，450) －1.243 0.214
术中输血(cc/ml) 0(0，0) 0(0，0) －1.544 0.123 0(0，0) 0(0，0) －1.572 0.116
术后住院日(d) 9(7，12) 8(7，12) －1.389 0.165 9(7.5，12) 9(7，15) －1.423 0.155
Clavien Dindo分级[例(%)]     8.611 0.020     －0.272 0.785
0级 40(78.4) 157(92.4)     34(82.9) 34(82.9)    
Ⅰ级 3(5.9) 2(1.2)     1(2.4) 1(2.4)    
Ⅱ级 6(11.8) 9(5.3)     5(12.3) 4(9.8)    
Ⅲ级及以上 2(3.9) 2(1.2)     1(2.4) 2(4.9)    
中转开腹[例(%)] 0(0) 6(3.5) 0.755 0.385 0(0.0) 0(0.0) 0.000 1.000
30 d再入院[例(%)] 0(0) 4(2.4) 0.257 0.612 0(0.0) 0(0.0) 0.000 1.000
图2 倾向性匹配前后机器人组和腹腔镜组肝癌患者无进展生存期比较(A.PSM前，B.PSM后)
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[8] 中国研究型医院学会放射学专业委员会, 上海抗癌协会实体肿瘤聚焦诊疗专业委员会. 血管包裹肿瘤簇在肝细胞癌影像诊疗中的临床应用专家共识（2026年版）[J/OL]. 中华消化病与影像杂志(电子版), 2026, 16(03): 193-198.
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