全机器人心脏不停跳下房间隔缺损修补术

目的 总结使用"达芬奇S"(da Vinci S)机器人手术系统,心脏不停跳下房间隔缺损修补或房间隔缺损修补+三尖瓣成形术的经验体会.方法 2009年3月至2010年12月,使用da Vinic S机器人系统,心脏不停跳下完成继发孔型房间隔缺损修补或房间隔缺损修补+三尖瓣成形术40例.患者女23例,男17例;年龄平均(38±13)岁.房间隔缺损直径为1.5～3.5 cm,平均(2.8±1.3)cm,无右向左分流,伴有或不伴有三尖瓣重度关闭不全.手术经股动、静脉及右侧颈内静脉插管建立体外循环.于右侧胸壁打直径为0.8 cm的器械臂孔3个,直径为2 cm工作孔1个,术中不阻断升主动脉,经内窥镜套管持续给予二氧化碳,心脏跳动下,术者于操作台前遥控机器人进行房间隔缺损修补,三尖瓣重度关闭不全患者同期行三尖瓣成形术.其中直接缝合房间隔缺损22例,心包补片修补房间隔缺损18例,同期三尖瓣成形9例.术中食管超声评估修补及三尖瓣成形效果.对比不停跳与心脏停跳下全机器人房间隔缺损修补术的手术时间及体外循环时间.结果 所有患者均成功接受全机器人心脏不停跳下房间隔缺损修补术或房间隔缺损修补+三尖瓣成形术,无体循环气体栓子及残余分流等并发症.不停跳组的手术时间、机器人使用时间或体外循环时间少于停跳组.结论 机器人心脏不停跳下房间隔缺损修补术无需阻断升主动脉,简化了全机器人手术过程,手术效果安全可靠.

Abstract：

Objective To Summary the first 40 cases underwent robotic atrial septal defect (ASD) closure or atrial septal defect closure combined bicuspid valve plasty (TVP) using "da Vinci S" surgical System on beating heart. Methods 40 cases of atrial septal defect or combined sever tricuspid valve regurgitation were repaired using "da Vinic S" surgical system on beating heart from March 2009 to December 2010 in cardiovascular department of PLA general hospital. The average age was (38 ± 13) yeas old. 23 cases were female and 17 cases were male. All patients were ostium atrial septal defect with or without pulmonary hypertension. The atrial defect diameter was 1.5 -3.5 cm, and the mean diameter was(2. 8 ±1.3)cm. 9 patients had sever tricuspid valve regurgitation. Without sternotomy, the extracorporeal circulation was established through groin artery,groin vein and internal jugular vein cannulation with the guidance of transeophageal echocardiography. 3 ports of 8 mm and 1 working port of 2 cm were made in the right chest wall. After "da Vinci S" syetem was set up, with the assistant of bed-side surgeon, the surgeon completed the atrial septal defect closure or combined tricuspid valve plasty in the surgeon console with three dimensions visualization. During the operation, without cardioplegia administrated and aortic occlusion, the procedure was completed through right atriotomy. The pleural space was insufflated with carbon dioxide to avoid the air embolism. The direct suturing was used in 22 cases and pericardial patch were used in 18 cases. 9 patients accepted concurrent De Vega tricuspid valve plasty. The transesophageal echocardiography were used to evaluate the result of atrial defect closure or tricuspid valve repair. The operation time, robotic using time and cardiopulmonary time were compared with totally robotic atrial defect repair in arrested heart. Results All cases were accomplished successfully without complication. There was no residual shunt and air embolism. The operation time, robotic using time and cardiopulmonary time were less than the arrested group. Conclusion Robotic atrial septal defect closure or combined tricuspid valve repair on beating heart can avoid aortic ocllusion and can be utilized effectively and safely.     

全机器人不开胸心脏手术4例

目的总结一组全机器人不开胸心脏手术情况，观察其安全性及手术效果。方法2007年1月15日至18日，使用da Vinie S机器人系统，不开胸连续完成房间隔缺损修补3例、微创冠状动脉旁路移植术（加卫cAB）1例。结果病人手术均成功，术后出血明显减小，恢复快，无并发症发生。结论全机器人不开胸心脏手术安全可靠，效果确实、是微创心脏外科的发展方向。     

机器人辅助与全胸腔镜下不停跳房间隔缺损修补术的疗效观察

目的观察采用机器人手术系统(Da Vinci Si)辅助或全胸腔镜进行体外循环心脏不停跳下房间隔缺损(atrial septal defects,ASD)修补手术的近期临床效果。方法回顾性分析安徽医科大学第一附属医院2015年1月至2018年12月行机器人辅助下或全胸腔镜下ASD修补手术50例患者的临床资料。依据手术方式不同将患者分为机器人组和全胸腔镜组。机器人组35例,男11例、女24例,平均年龄(42.1±16.8)岁;全胸腔镜组15例,男8例、女7例,平均年龄(38.4±10.9)岁。随访期间,通过心脏多普勒超声心动图记录左心室射血分数、左心房直径、右心房直径、右心室舒张末期内径。记录并比较手术时间、体外循环时间、呼吸机使用时间、术后ICU滞留时间、术后住院时间、围手术期胸腔引流量、早期并发症。结果围手术期机器人组手术时间[(3.8±0.3)h vs.(6.1±1.4)h]、体外循环时间[(72.3±10.4)min vs.(139.1±32.8)min]、呼吸机使用时间[(5.5±1.2)h vs.(9.5±2.1)h]、术后住院时间[(6.7±0.5)d vs.(9.8±0.6)d]及胸腔引流量[(253.4±26.8)mL vs.(289.3±29.5)mL]均短于或少于全胸腔镜组,差异均有统计学意义(P<0.05),而术后并发症发生率等方面差异无统计学意义(P>0.05)。全部患者术后1个月复查心脏彩超,扩张的右心房、右心室及左心房较术前缩小。结论对于ASD修补手术的患者,机器人辅助及全胸腔镜下均可取得良好效果,但在手术时间、体外循环时间、呼吸机使用时间、术后住院时间及胸腔引流量方面,机器人组更有优势。     

成人房间隔缺损的手术治疗

成人房间隔缺损的手术治疗杨国泰张杰春许志方我院自１９７４年１月～１９９３年１１月在体外循环下手术治疗２０岁以上成人房间隔缺损患者８９例，占同期房缺手术患者（８９／３９７）的２２．０４％，手术疗效好，无手术死亡，现报道如下。１临床资料男２３例，女６６例...     

右胸小切口封堵缺乏边缘的Ⅱ孔型房间隔缺损

目的 评估右胸小切El封堵缺乏边缘房间隔缺损的可行性和安全性.方法 2005年11月至2007年11月.25例1-2个边缘完全缺乏的病人行右胸小切口房间隔缺损封堵手术,女15例,男lO例;年龄5.64岁,平均28.8岁.其中单纯前边缘缺乏11例,前边缘合并下边缘缺乏3例,前边缘合并后边缘缺乏4例,后边缘缺乏l例,前边缘合并上边缘缺乏l例.单纯上边缘缺乏4例,静脉窦型房间隔缺损1例.后边缘和下边缘缺乏者使用4-o pmlene线在心脏外面贯穿缝合固定封堵器;后边缘缺乏在房间沟偏右房侧缝合2针固定;下边缘缺乏者在右心房靠下腔静脉和右下肺静脉处缝合l针固定;静脉窦型房间隔缺损在左心房顶以4-o prolene线作2针间断缝合,在上腔静脉后壁作1针间断缝合,释放封堵器后,推拉试验检查是否牢固.以5-4例Ⅱ孔型房间隔缺损有充分边缘者(>5衄)行右胸小切El房间隔缺损封堵治疗者作为对照组,其中女36例.男18例,平均年龄31.9岁(5-72岁).结果 无边缘组房间隔缺损直径10-38衄,平均(23.3±8.5)mm.封堵器大小为(27.9±7.8)mm(14-42衄).对照组房间隔缺损直径9.38衄,平均(23.6±7.0)mm,封堵器大小为(29.4-I-7.3)r唧(12-42m).两组房间隔缺损直径和所用封堵器大小差别无统计学意义(P>O.05).平均手术时间分别为(30±7)min和(15 4-4)rain.差别有统计学意义(P<0.c15).25例缺乏边缘者100%(25,25例)封堵成功,对照组96%(52,54例)封堵成功,2例存在轻度残余分流.随访6个月,两组封堵成功率均为100%,均无严重并发症.结论 右胸小切口可以成功封堵边缘缺乏的房间隔缺损,但需要更长期的随访评估长期的安全性和有效性.     

全胸腔镜房间隔室间隔缺损修补手术学习曲线

目的 总结全胸腔镜下心脏手术的学习曲线.方法 回顾性收集2004年10月至2010年1月由同一术者连续完成的125例全胸腔镜下房间隔缺损、室间隔缺损修补手术病例资料,按手术先后顺序分为A、B、C、D、E5组,每组25例,从各组手术时间、体外循环时间、主动脉阻断时间、中转开胸率及手术并发症等指标比较手术效果.结果 各组病例年龄、性别、体重、病种及手术方式差异无统计学意义(P＞0.05).手术时间、体外循环时间、主动脉阻断时间3项指标A、B组明显长于C、D、E组(P＜0.05),A、B两组间差异无统计学意义(P＞0.05),C、D、E3组之间差异亦无统计学意义(P＞0.05).各组中转开胸率及手术并发症发生率比较差异均无统计学意义(P＞0.05).结论 全胸腔镜房间隔、室间隔缺损修补术的学习曲线约为50例.     

复合技术治疗低龄低体重病儿房间隔缺损

目的 介绍一种房间隔缺损(ASD)"复合"技术介入封堵方法,并探讨该手术方法的优缺点.方法 2007年6月至2008年3月,27例婴幼儿房间隔缺损者接受新"复合"技术治疗.其中男15例,女12例.年龄3个月-4岁,平均(2.00±O.22)岁.采用浅镇静加局部麻醉,非气管插管单纯面罩吸氧或喉罩下辅助通气支持,胸骨旁第4肋间小切口,保留胸膜,经胸膜外进入心包腔显露右心房壁,切开右房壁置入ASD封堵器及输送器.心前区或剑突下超声引导进行ASD介入封堵术.结果 全部病儿3d后康复出院,随访0.5-9.5个月,平均(5.9±0.5)个月,仅l例病儿因心包压塞行心包穿刺引流术,余无异常.超声检查没有残余分流或其它并发症.结论 该手术方法创伤小、疗效好,费用低,是婴幼儿ASD病例一种较为理想手术方法.     

机器人与经胸骨正中切开入路行房间隔缺损修补术的疗效对比

目的 比较机器人(da Vinci Si)辅助与经胸骨正中切开入路行房间隔缺损(atrial septal defect,ASD)修补术的短期疗效.方法 回顾性分析2016年1月至2020年5月于安徽医科大学第一附属医院心脏大血管外科接受ASD修补术140例患者的临床资料.根据手术方式将所有患者分为机器人组和正中开胸组...     

非体外循环下闭式房间隔缺损修补术

<正> 房间隔缺损是常见的失天性心脏畸形,手术治疗一般采用体外循环、心内直视下进行。1998年5月～2000年5月,我们不用体外循环进行闭式房缺修补术,取得满意效果。 1 临床资料 1.1 一般资料:本组病人12例,男5例,女7例。年龄3～52岁(平均15岁)。术前心功能Ⅰ级7例,Ⅱ级3例,Ⅲ级2例。2例有严重肺动脉高压,有咯血史,心脏杂音不明显,肺动脉第二音亢进,余10例有典型的心脏杂音。8例心脏X线示     

Anesthesia management of totally endoscopic atrial septal defect repair with a robotic surgical system

Study Objective

To investigate anesthetic techniques for robot-assisted endoscopic atrial septal defect (ASD) repair.

Design

Clinical observational study.

Setting

Operating room of a general military hospital.

Patients

56 adult, ASA physical status 1 and 2 patients undergoing elective general anesthesia.

Interventions

After induction of general anesthesia, a left-sided, double-lumen endotracheal tube was positioned to allow single left-lung ventilation and contralateral CO₂ pneumothorax (capnothorax). With ultrasound guidance, peripheral cardiopulmonary bypass (CPB) catheters were placed.

Measurements and Main Results

All patients tolerated single left-lung ventilation before CPB; however, hypoxia (oxygen saturation < 90%) occurred in 11 (19.6%) patients post-CPB, which required treatment with continuous positive airway pressure. Fifteen (26.8%) patients had hypotension secondary to capnothorax, which was treated with transfusion and vasopressors. Aortic cross-clamp time was 43.6 ± 11.2 minutes, and CPB time was 106.7 ± 12.4 minutes. The median intensive care unit stay was 21 hours and postoperative hospital stay was 4 to 7 days.

Conclusions

The key issue for anesthetic management of robot-assisted totally endoscopic ASD repair is maintaining stable hemodynamics and oxygenation, especially during one-lung ventilation and capnothorax.     

改良机器人手术方式行房间隔缺损修补术22例

目的 总结使用“达芬奇”（da Vinci S）机器人手术系统行体外循环下房间隔缺损修补或房间隔缺损修补＋三尖瓣成形术的经验体会.方法 2013年7月至2013年10月回顾性研究,使用da Vinic S机器人系统,体外循环下完成继发孔型房间隔缺损修补或房间隔缺损修补＋三尖瓣成形术22例.患者女16例,男6例;年龄平均（36.5±5.8）岁.房间隔缺损直径为2.5～4.1 cm,平均（3.8±1.3）cm,左向右分流,2例伴有三尖瓣中度关闭不全,2例伴有右侧胸膜腔部分粘连.手术经股动、静脉插管,于右侧胸壁打3个孔,采用我院成熟全腔镜心脏手术技术建立体外循环,阻断升主动脉,切开右心房后,再连接机器人手术系统,术者于操作台前遥控机器臂进行房间隔缺损修补,三尖瓣中度关闭不全患者同期行三尖瓣成形术.其中直接缝合房间隔缺损20例,补片修补房间隔缺损2例,同期三尖瓣成形及胸膜粘连松解各2例.结果 22例均成功接受机器人房间隔缺损修补术或房间隔缺损修补＋三尖瓣成形术,手术时间1.5 ～ 3.5 h,平均（2.3±0.6）h;后10例手术时间体外循环（58.6±18.3） min,升主动脉阻断（26.8±8.6） min,术后呼吸机辅助（5.8±1.6）h.胸液引流量50 ～ 300 ml,平均（150±32） ml,平均1～2d拔除胸腔闭式引流管.术后住院时间（5.6±1.4）d.均无中转开胸、院内死亡及术后并发症发生.全组术后3～5d超声心动图示手术效果满意,患者均顺利出院.随访1个月～3个月,无残余分流,下肢静脉血栓形成,心功能均为Ⅰ级,超声心动图检查结果满意.结论 改良达芬奇S机器人手术方式体外循环下房缺修补术安全可靠,疗效满意,且进一步缩短手术时间,创伤小、恢复快,具有良好的发展前景.     

机器人辅助下房间隔缺损修补术学习曲线与临床结果的相关性

目的 明确单中心的机器人辅助下房间隔缺损修补术的学习曲线及临床结果.方法 回顾性分析2007年1月至2010年12月完成的94例机器人房间隔缺损修补术,按术式不同分成心脏停搏组(54例,Ⅰ组)和心脏搏动组(40例,Ⅱ组).记录每组手术、体外循环、主动脉阻断、术后呼吸机辅助、住ICU和住院时间等指标,采用对数曲线回归分析建立学习曲线,并分析上述指标与临床结果的相关性.结果 两组均无手术死亡或严重并发症发生,术中及术后超声复查未见残余分流.Ⅰ组方法学习曲线为:y(min)=68.741 -8.283(n)(x) (r2 =0.489,P＜0.01);Ⅱ组方法学习曲线为:y(min)=355.51 -56.29(n)(x)(r2 =0.581,P＜0.01).手术、体外循环和主动脉阻断时间与术后呼吸机辅助、住ICU和住院时间无相关性.结论 机器人辅助下房间隔缺损修补术安全、可靠,学习曲线显著,手术时间延长不影响患者恢复.     

62例机器人心脏手术的麻醉管理

目的 对达芬奇(da Vinci)手术系统完成的机器人心脏手术的麻醉方法进行总结.方法 实施机器人心脏手术62例,其中房间隔修补32例、冠状动脉搭桥22例、二尖瓣成形5例和左房黏液瘤摘除3例.全麻诱导后插入双腔支气管导管,术中单肺通气.监测经食管超声心动图(TEE)、血气和血流动力学变化.结果 多数病人在CPB前能够耐受单肺通气.但CPB前有1例肺功能差的病人和CPB后有17例(27%)病人单肺通气时SpO2降至90%而使用持续气道正压装置(CPAP)治疗.CO2气胸引起的血压下降通过输入羟乙基淀粉130/0.4氯化钠注射液和升压药予以纠正.升主动脉阻断时间(56.2±19.6)min,CPB时间(103.7±43.1)min,平均ICU停留时间1.3d,术后平均住院时间6.5 d.无住院死亡发生.结论 机器人心脏手术的麻醉所需要的复杂设备和监护,以及CO2气胸并单肺通气是对麻醉医师的新挑战,麻醉医师与术者和灌注师之间的团队配合对保证手术成功非常重要.     

Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience

Background In the last few years, robotics has been applied in clinical practice for a variety of laparoscopic procedures. This study reports our preliminary experience using robotics in the field of general surgery to evaluate the advantages and limitations of robot-assisted laparoscopy.Methods Thirty-two consecutive patients were scheduled to undergo robot-assisted laparoscopic surgery in our units from March 2002 to July 2003. The indications were cholecystectomy, 20 patients; right adrenalectomy, two points; bilateral varicocelectomy, two points; Hellers cardiomyotomy, two points; Nissens fundoplication, two points; total splenectomy, one point; right colectomy, one point; left colectomy, 1 point; and bilateral inguinal hernia repair, one point. In all cases, we used the da Vinci surgical system, with the surgeon at the robotic work station and an assistant by the operating table.Results Twenty-nine of 32 procedures (90.6%) were completed robotically, whereas three were converted to laparoscopic surgery. Conversion to laparoscopy was due in two patients to minor bleeding that could not be managed robotically and to robot malfunction in the third patient. There were no deaths. Median hospital stay was 2.2 days (range, 2–8).Conclusions The main advantages of robot-assisted laparoscopic surgery are the availability of three-dimensional vision and easier instrument manipulation than can be obtain with standard laparoscopy. The learning curve to master the robot was 10 robotic procedures. The main limitations are the large diameter of the instruments (8 mm) and the limited number of robotic arms (maximum, three). We consider these technical shortcomings to be the cause for our conversions, because it is difficult to manage bleeding episodes with only two operating instruments. The benefit to the patient must be evaluated carefully and proven before this technology can become widely accepted in general surgery.     

膜周部室间隔缺损的微创封堵术

目的 探讨经胸壁微创室间隔缺损(VSD)封堵术对膜周部室间隔缺损(PVSD)的治疗效果及安全性.方法 2011年1月至12月,治疗129例PVSD患者(儿),男60例,女69例;年龄9个月～57岁.PVSD直径1.4～9.0 mm,均经胸骨中下1/3段3～5 cm正中小切口行微创VSD封堵术.术后密切随访观察,定期复查超声心动图和心电图.结果 114例封堵成功,15例术中转体外循环下行VSD修补术.其中应用等边封堵伞96枚,偏心封堵伞20枚.术后随访期间均无严重并发症发生.结论 经胸壁微创VSD封堵术治疗PVSD的近期治疗效果满意,具有良好的应用前景.目前尚缺乏长期的随访资料,有待进一步的随访观察.