从穿刺孔转移思考腹腔镜机器人胆道肿瘤外科

穿刺孔转移是腹腔镜或机器人肿瘤外科的少见事件,在腹腔镜结直肠癌或泌尿系肿瘤根治术后的发生率约为0.09％～ 0.73％,这和传统开放手术的切口转移率相当.但意外胆囊癌等胆道肿瘤实施腹腔镜或机器人手术后PSM发生率高达6.7％～30.0％,很可能和胆道肿瘤特殊的生物学行为、手术操作违反无瘤原则以及术中胆汁溢漏入腹腔污染切口直接相关.目前对腹腔镜和机器人胆道肿瘤外科技术的早期探索阶段,应在筛选合适的早期病例、提高外科经验、避免术中胆汁溢漏和严格遵守外科肿瘤原则操作等方面严格把关,从而降低PSM的发生率、提高肿瘤学效果.此外,应开展临床对照研究以获得开放手术和腹腔镜/机器人手术治疗胆道肿瘤的远期疗效的证据,明确胆道肿瘤是否可作为腹腔镜机器人技术的适应证.

Port-site metastasis triggers a consideration of laparoscopic and robotic surgery for biliary malignancies

Port-site metastasis （PSM） is a rare phenomenon following laparoscopic and robotic oncologic surgery, and the incidence of PSM is about 0.09%-0.73% after laparoscopic surgery for colorectal and urological malignancies, which is similar to the incidence of wound metastases rates after conventional open operation. However, the extremely high occurrence rate of PSMs reaches up to 6.7%-30% after laparoscopic cholecytectomy for incidental gallbladder cancer or robotic surgery for biliary malignancies. The pathogenesis probably links to the unique biologic behaviors of cholangiocarcinoma, surgical technique with a violation of oncologic principle, and direct wound implantation of tumor cells from bile spillage. At the early exploratory phase to investigate the feasibility and safety of laparoscopic and robotic surgery for biliary malignancies, we need to adhere to some issues such as proper patient selection, improvement of surgical techniques, avoidance of bile spillage and strict abidance to the principles of oneologic surgery, so as to reduce the occurrence rate of PSMs and improve oncologic outcomes. In addition, a controlled clinical trial about long-term outcomes of open surgery or laparoscopic robotic surgery for biliary malignancies to validate its indication should be performed.