全机器人妇科手术11例

目的:总结全机器人妇科手术情况,观察其安全性及手术效果.方法:2009年2月10日至4月21日使用da Vinic(3S HD)机器人手术系统完成卵巢子宫内膜异位囊肿剥除术6例、卵巢肿瘤切除术2例、子宫肌瘤剔除术2例、子宫全切术1例,分析其临床效果.结果:11例手术均成功,平均手术时间97分钟,术中出血量40～150 ml,平均出血量80 ml,术后平均28小时肛门排气,无一例发生并发症,平均住院日6天,术后1、3个月所有患者随访均无特殊.结论:全机器人妇科手术具有良好的安全性、临床效果好,是妇科微创手术发展的方向.     

达芬奇机器人辅助妇科手术的临床分析

目的:研究运用达芬奇机器人手术系统进行妇科手术的临床效果,探讨机器人手术在妇科手术的应用前景。方法:回顾分析2012年11月至2013年12月在复旦大学附属中山医院妇产科采用机器人手术系统行妇科手术的14例患者的手术时间、术后住院天数、术后短期并发症和中转开腹率。结果:我院成功将达芬奇机器人手术系统应用于子宫肌瘤剥除术、子宫内膜癌分期手术、卵巢癌分期手术、附件切除术及卵巢囊肿剥除术中。采用机器人手术系统手术的手术时间1.08~7.5h,术后住院天数3~5天,无中转开腹及感染、严重出血等短期并发症。结论:达芬奇机器人手术系统作为新兴微创技术,体现出并发症少、恢复快、创伤小的优点,但在技术应用初始阶段,手术时间较长,且费用昂贵,并未比以往的手术方式表现出显著优越性。但随着手术经验积累及技术熟练完善后,手术时间可明显缩短,而且机器人手术医师培训周期短,术中对医师的稳定性、常规内镜操作水平要求较低,有助于技术普及。机器人手术系统的利弊评价需后续大样本的临床研究给予支持。     

计算机辅助下的腹腔镜手术在妇科的应用进展

计算机辅助下的腹腔镜手术(也称达芬奇机器人手术系统)的出现将微创化技术带入了机器人手术时代.目前已经有大量的将机器人手术成功应用于妇科良性和恶性疾病的报道,包括子宫切除术、子宫肌瘤剥除术、输卵管吻合术、卵巢移位术、盆底重建术,以及子宫内膜癌、宫颈癌和卵巢癌的手术治疗.机器人手术系统比较普通的腹腔镜手术具有更大的精确性和灵活性以及清晰的三维视野等独特优点,但是缺乏触觉反馈和费用高昂的缺点也是其推广过程中的限制因素.     

机器人手术系统在妇科良性疾病中的应用及价值

<正>腹腔镜微创技术是现代外科领域的重要发展方向，2005年美国食品药品监督管理局(Food and Drug Administration, FDA)批准达芬奇手术机器人用于妇科微创手术，使妇科腹腔镜技术进入新的发展阶段。机器人手术广泛应用于妇科良性疾病中，包括子宫切除术、子宫肌瘤切除术、子宫内膜异位症手术、输卵管吻合术、骶骨阴道固定术等。本文将阐述近二十年内机器人手术系统在妇科良性疾病中的应用情况及其优缺点，对机器人手术系统的未来发展进行展望。     

机器人辅助的腹腔镜手术在妇科领域中的应用

近年来，机器人辅助的腹腔镜手术正在逐渐引入妇科领域，在子宫切除、输卵管吻合、肿瘤切除及阴道壁膨出修补等手术中，显示了一定的优越性。本文就目前机器人辅助的腹腔镜手术的种类、系统组成、手术特点及此项技术在妇科领域的临床应用等综述如下。     

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段.在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多.目前,机器人手术多是回顾性病例报告,...     

机器人手术系统在妇科恶性肿瘤中的应用及优势

<正>机器人手术在全球已广泛应用于各外科系统如泌尿外科、妇科、普通外科、胸外科和头颈部手术等。机器人手术系统在妇科恶性肿瘤领域同样发展迅速，凭借清晰的三维视野、灵活的操作臂以及滤过震颤等优势为妇科恶性肿瘤手术提供了良好的设备背景。机器人手术提高了妇科手术的精准度和技巧，可以达到精准的解剖及精细的缝合，逐渐在国内外妇科肿瘤治疗中占据了重要的地位。子宫颈癌、子宫内膜癌和卵巢癌是妇科3大恶性肿瘤，下面就机器人手术系统在妇科主要肿瘤中的应用分别阐述。     

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段。在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多。目前,机器人手术多是回顾性病例报告,缺乏随机对照、大样本比较性研究,其适应证和手术效果还需要大量临床探索,以作出全面的评价。     

妇科腹腔镜手术454例临床分析

目的:探讨腹腔镜技术在基层医院妇科手术中的应用价值。方法:回顾性分析近5年的454例行妇科腹腔镜手术的临床资料。结果:454例患者中在镜下顺利完成手术450例,其中异位妊娠手术176例,卵巢修补术15例,卵巢肿瘤剔除术61例,子宫肌瘤剥除术55例,子宫次全切除术81例,腹腔镜辅助阴式子宫切除术7例,盆腔粘连松解术55例。术后24h拔除导尿管,1～2d可下床活动,并发症发生率为0.89%。结论:腹腔镜技术在基层医院妇科手术中具有较大的应用价值。     

剖宫产术对再次妇科手术的影响

随着剖宫产术率升高 ,剖宫产术后再次手术人数增加。剖宫产术对再次妇科手术无疑增加了难度和风险。目前 ,绝大多数医院采用新式剖宫产术[1] ,它具有操作简单、手术时间短、术后恢复快、美观等优点。但新式剖宫产术对再次妇科手术的影响尚未见报道。本文比较有剖宫产术史与无妇产科手术史全子宫切除患者术中、术后情况 ,以探讨剖宫产术对再次妇科手术的影响。1　资料与方法1 1　一般资料　以本院 1998年 2月至 2 0 0 0年 5月有剖宫产术史患子宫良性疾病行全子宫切除术者共 5 1例作为研究组 ,其中 2 4例行子宫下段剖宫产术 ,均为腹壁纵切口 ,…     

腹腔镜技术在妇科应用的热点问题

腹腔镜技术作为微创的代表因具有视野清晰、切口小、损伤小、出血少、粘连轻和术后恢复快等优点广为接受,其在妇科领域的应用日益广泛和深入。随着手术操作的熟练、手术技巧经验的积累、新的手术设备和机器以及能源的引用,手术指征已经扩展到包含深部浸润型子宫内膜异位症、盆底手术和早期恶性肿瘤等绝大部分的开腹手术,更出现了机器人腹腔镜、单孔腹腔镜以及经自然孔道内镜等更加微创精细的新技术。新手术指征和新技术的应用带来了新的挑战和争议,腹腔镜技术不断向前发展。     

Dual-console robotic surgery compared to laparoscopic surgery with respect to surgical outcomes in a gynecologic oncology fellowship program

Objective

Minimally invasive surgical techniques decrease surgical morbidity and recovery time. Studies demonstrate similar surgical outcomes comparing robotic to laparoscopic surgery. These studies have not accounted for the incorporation of fellow education. With the dual-console da Vinci Si Surgical System®, a two surgeon approach could be performed. We sought to compare surgical outcomes at a gynecologic oncology fellowship program of traditional laparoscopic to robotic surgeries using the dual-console system.

Methods

We identified patients who underwent laparoscopic or robotic surgery performed by a gynecologic oncologist from November 2009-November 2010. Robotic surgeries were conducted using the dual-console, utilizing a two surgeon approach. Surgeries involved a staff physician with a gynecologic oncology fellow. Statistical analysis was performed using student t-test and chi-squared analysis.

Results

A total of 222 cases were identified. Cases were analyzed in groups: all cases identified, all cancer cases, and endometrial cancer cases only. When analyzing all cases, no statistical difference was noted in total operating room time (172 vs. 175 min; p = 0.6), pelvic lymph nodes removed (10.1 vs. 9.6; p = 0.69), para-aortic lymph nodes dissected (3.7 vs. 3.8; p = 0.91), or length of stay (1.5 vs. 1.3 days; p = 0.3). There was a significant difference in total surgical time (131 vs.110 min; p < 0.0001) and EBL (157 vs.94 ml; p < 0.0001), favoring robotic surgery. When analyzing all cancer cases, the advantage in total surgical time for robotic surgery was lost. Complications were similar between cohorts.

Conclusion

Incorporating fellow education into robotic surgery does not adversely affect outcomes when compared to traditional laparoscopic surgery.     

从妇科肿瘤医生角度看子宫颈癌腹腔镜手术

广泛性子宫切除术+盆腔淋巴结清扫术是早期子宫颈癌的标准治疗方式。由于腹腔镜手术在围手术期结局上的优势,且肿瘤治疗结局与开腹手术相似,逐渐成为早期子宫颈癌的主要手术方式之一。直到2018年11月,《新英格兰医学杂志》发表了2项临床研究结果显示,与开腹手术相比,微创手术的复发率更高、生存期更短。这使得子宫颈癌的微创手术受到了前所未有的打击。而2019年12月《妇科肿瘤学杂志》发表的一项大数据回顾性分析研究结果无疑对于子宫颈癌微创手术是雪上加霜的考验,该研究结果显示,与开腹组相比,腹腔镜组的手术相关并发症发生率更高。文章将从妇科肿瘤医生视角就无瘤原则、无瘤技术及腹腔镜操作细节等方面进行分析及建议。     

The expanding spectrum of robotic gynecologic surgery: A review

Minimally invasive surgical approaches in gynecology have evolved considerably in the last 30 years. The integration of robotic technology represents significant progression along the continuum of minimally invasive operative techniques in gynecology utilized to treat both benign and malignant conditions. Robotic systems have the potential to convert surgical procedures that we presently perform by laparotomy to laparoscopy and are currently utilized in the fields of reproductive endocrinology and fertility, gynecologic oncology and female pelvic medicine/reconstructive surgery. Robotic-assisted procedures may help overcome some of the cited limitations associated with standard laparoscopy, including longer operative times, counterintuitive and limited instrument maneuverability, and lack of formal training and/or a steep learning curve. However, a critical appraisal of robotic systems is essential due to technological limitations. These limitations include a system that is bulky and costly to maintain and does not give haptic feedback, uncertainty about the long-term outcomes following robotic surgery, and the need for a greater number of larger incisions when compared to standard laparoscopy.     

Risque opératoire lié au tabac en gynécologie

If tobacco has been recognized for many years as a major risk factor for cardiovascular, lung diseases and cancer in the general population, women are insufficiently aware of the consequences and the specific gynecological operative risks related to this intoxication. Thus, a regular tobacco consumption increases the risk for many gynecological conditions may require surgical treatment with in addition a significant negative impact on the healing process and the risk of postoperative complications. The operative risk must be explained by surgeons in daily practice gynecological, pelvic surgery or breast screening. The issue of smoking cessation should precede surgery has been established by a consensus conference of experts on perioperative smoking held in 2005. The implementation of these recommendations during the preoperative period requires improvement of staff training and better practices to allow smoking cessation effective and sustainable. It is lawful in this context to delay scheduled surgery of 6 to 8 weeks to allow an optimal smoking cessation and to continue smoking cessation for the time necessary for healing to reduce the excess operative risk associated with smoking.     

妇科手术中泌尿系损伤的预防

泌尿系损伤是一种少见但后果却可能极为严重的盆腹腔手术并发症,其中50%医源性泌尿系损伤由妇科手术操作所致。开腹、腹腔镜、阴式手术3种术式中泌尿系损伤原因和特点各异,了解盆腔手术不同手术路径的特点,选择合适的手术方式,进行良好的术前评估,熟悉手术区域解剖,正确使用各种电器械,熟练掌握手术操作技巧,术中时刻警惕泌尿系损伤的发生,能有效地预防妇科手术导致的泌尿系损伤。     

机器人辅助广泛性子宫切除术和盆腔淋巴结切除术的初步研究

目的 探讨将机器人手术系统应用于宫颈癌的广泛性子宫切除+盆腔淋巴结切除术的可行性.方法 2008年12月-2009年8月,采用da Vinci机器人手术系统,对5例Ⅰb1～Ⅱ a期宫颈癌患者行机器人辅助广泛性子宫切除+盆腔淋巴结切除术.记录手术时间、术中出血量、术中及术后并发症的发生情况、手术前后血红蛋白含量变化、术后体温及排气时间、术后恢复自主排尿时间、术后住院时间、病理检查结果、盆腔淋巴结切除数等.结果 5例患者全部顺利完成手术,无中转开腹,无术中或术后并发症出现.5例患者的手术时间分别为305、365、275、240和245 min,平均为286 min;术中出血量分别约为200、400、650、300和400 ml,平均为390 ml.5例患者术后最高体温均未超过37.5℃,术后36 h均排气.5例患者术后住院时间分别为11、13、9、12和12 d,平均为11.4 d.5例患者的病理检查结果均为鳞状细胞癌,阴道残端和宫旁切缘均无残留病灶.盆腔淋巴结切除数分别为14、22、16、21和18个,平均为18.2个,淋巴结无转移.结论 机器人手术系统可以应用于宫颈癌的广泛性子宫切除+盆腔淋巴结切除术,这一新方法为宫颈癌的手术治疗提供了一个新的选择.     

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery.     

Robotic surgery in gynecologic oncology

The goal of this paper is to review the current data documenting the advantages of robotic surgery over open or laparoscopic surgery. The aim of this study is to compare the complications and perioperative outcome of robotic surgery with open and laparocopic surgery, in gynecologic oncology. The terms radical robotic or robot- assisted hysterectomy in PubMed search lead to 41 references. We excluded one review of literature, ten studies with benign and malignant cases, eight cases reports, one letter to the editor. We kept the prospective studies and comparative studies (total abdominal hysterectomy (TAH) vs. total robotic hysterectomy (TRH), total laparoscopic hysterectomy (TLH) vs. TRH or TAH vs. TRH vs. TLH). The results are separated for endometrial cancers, early cervical cancers, pelvic and paraaortic lymph node dissections, radical parametrectomy and trachelectomy, and pelvic exenteration. The literature on robotic-assisted radical hysterectomy supports its safety and feasibility for the surgical management of early cervical cancer and endometrial cancer. However, the results of a phase III randomized clinical trial testing the equivalence of outcomes after laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy are expected.     

Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared With Laparoscopy and Laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.