Name: robot-assisted radical antegrade modular pancreatosplenectomy including resection and reconstruction of the spleno-mesenteric junction
Uploaded: 2020-01-03T14:00:00
Duration: 12 min 34 s
Description: Watch this Scientific Journal Video about Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction at JoVE.com

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本文所述程序是按照比萨大学医院伦理委员会制定的机器人操作准则进行的，包括研究活动条例。
注：患者为70岁女性，胰腺导管腺腺癌位于胰腺靠近腺颈的体内。病人出现腹痛。她过去的病史表明动脉高血压和切除术。全身造影增强型计算机断层扫描（CT）显示，胰腺肿瘤在严格粘附于脾-肠结，与主胰腺导管的上游扩张相关扩张（图1）。没有发现遥远的转移，使肿瘤有可能具有治疗意图。
1. 实验预操作
<ol><li>患者选择<ol>
<li>通过活检或明确的成像发现确定胰腺癌的诊断。</li>
		<li>通过全身对比度增强CT扫描排除远距离转移。在手术14的4周内进行扫描。</li>
		<li>测定肿瘤标记物（CEA和Ca 19.9）。 注：高术前水平Ca 19.9有预后影响15，但低水平不叫怀疑手术16的指示。</li>
		<li>确保病人适合手术，并符合微创方法17，18。</li>
		<li>在学习曲线19期间不要执行 RAMPS。</li>
		<li>在达到标准 RAMPS 的熟练程度之前，不要接受明显涉及大型围网血管的肿瘤患者。</li>
	</ol>
</li>
	<li>患者准备<ol>
<li>提供标准的手术前准备。</li>
		<li>提供预防囊肿细菌（肺炎链球菌、脑膜炎奈斯奈菌、乙型流感嗜血杆菌）的疫苗接种，以防止出现压倒性的后脓毒症20。</li>
	</ol>
</li>
	<li>设备<ol>
<li>确保机器人系统的可用性。 注：到目前为止，只有一个机器人系统（材料表）被用于胰腺切片第18节。这里使用上一代机器人系统。停靠技术和定位过程是特定于此系统的。</li>
		<li>确保提供标准腹腔镜设备和以下机器人仪器：中小型下膝形夹式贴片、马里兰州双极钳、单极弯曲剪刀、谐波剪切器和大针驱动器。</li>
		<li>在静脉切除的情况下，确保提供以下仪器：机器人黑色钻石微钳和腹腔镜牛头犬夹。</li>
		<li>确保所有必要的缝合线和消耗品 （材料表） 可用.</li>
		<li>确保有腹腔镜订书机可用。</li>
	</ol>
</li>
</ol>2. 外科准备
<ol><li>麻醉17<ol>
<li>根据美国麻醉师协会（ASA）的身体健康分类，通过提供等级来评估操作风险。</li>
		<li>将至少一个大孔（14 G 或 16 G）静脉导管放入外周静脉。在周围静脉静脉凝固可能性有限的患者中放置一条中央静脉线。</li>
		<li>监测心电图、动脉压力（径向动脉的可分泌）、造影术、脉搏血氧仪、尿量和体温。</li>
		<li>提供通性麻醉。 注：吸入和静脉麻醉均可使用。</li>
		<li>提供深层神经肌肉封锁（溴化铬：0.075-0.1毫克/千克）。</li>
		<li>插入鼻胃管。</li>
		<li>在手术过程中，进行血气分析以验证血气和pH。</li>
		<li>在手术结束时，反向麻醉并取出鼻胃管。</li>
	</ol>
</li>
	<li>操作设置 注：图2提供了手术室设置的示意图视图。<ol>
<li>让主外科医生从机器人控制台操作。</li>
		<li>让腹腔镜外科医生（第一助理）站在病人的双腿之间。他或她操作吸力，引入和提取缝合线，帮助收回，并发射订书机。</li>
		<li>让助理外科医生站在病人的左边。他或她交换机器人仪器，并协助腹腔镜外科医生。</li>
		<li>让擦洗护士站在病人的右边。</li>
		<li>将患者的双腿分开（法国位置）放在装有热质毯的手术台上（图3A）。</li>
		<li>在腿部周围放置间歇性气动压缩袖口（图3B），以预防深静脉血栓形成。</li>
		<li>用宽带固定患者到手术台（图3C）。</li>
		<li>准备患者广泛暴露腹部 （图 3D）。包括超公共区域，允许用于标本提取的 Pfannenstiel 切口。 注：对于所有其他方面，病人必须准备与麻醉小组17合作进行主要的腹腔镜手术。</li>
	</ol>
</li>
</ol>3. 机器人系统的准备手术操作和对接
<ol><li>使用 Veres 针头或开放技术建立肺膜。将肺气膜保持在约10毫米汞柱。</li>
	<li>将 8 mm 机器人摄像机端口放在脐带正下方或正上方，具体取决于单独的腹部配置。 注：摄像机端口应距离目标解剖的最近边界约 10-15 厘米。</li>
	<li>插入机器人腹腔镜，探索腹部寻找隐匿转移沉积物。活检任何已确定的结核，并将其送去冷冻节性。如果未发现转移，则放置其他端口。</li>
	<li>沿横脐线放置所有端口。沿右侧参数线放置 12 mm 辅助端口。将剩余的机器人端口沿前一道线、两侧和左侧参数线放置（图4）。 注：理想的端口间距为 6~8 厘米。最低面积为4厘米。确保端口和骨突出之间的 2 厘米空间。</li>
	<li>在反向趋势伦堡位置（15±20°）调整手术台，并将其向患者右侧倾斜（5~8°）（图5）。将机器人塔放置在工作人员不会步行或站立的位置，以便最大限度地从床边进入患者通道。</li>
	<li>要开始停靠，将动臂的激光十字线对准摄像机端口（图 6A）。使用机械臂 2 作为相机。</li>
	<li>在机械臂底部的 FLEX 图标上将相机臂定向到 L 和 E 之间（图 6B）。</li>
	<li>离合器并指向摄像机以瞄准操作解剖结构 （图 6C）。按下摄像机头上的专用按钮，执行定位。 注：定位可自动调整头顶动臂的高度、平移和旋转，以最大化机械臂的运动范围。其余手臂对接（图6D），机器人仪器在视觉下插入。</li>
</ol>4. 造素切除术
<ol><li>通过分割结肠和阴野的反射来打开较小的囊。不要通过胃痛韧带，因为这可能导致心肌梗死21。</li>
	<li>沿着横贯中位开始解剖，并向右延伸，直到达到结肠的肝弯曲，并向左，直到结肠的脾柔弯曲完全动员。一旦较小的囊完全打开，胰腺体和尾巴变得清晰可见。</li>
	<li>开始沿着胰腺的低边缘解剖围气，以便调动胰腺的车身尾部。</li>
	<li>识别上司的静脉。 注： 优越的静脉是一个关键的里程碑，以安全地进行进一步解剖。</li>
	<li>在准备创建胰腺颈部后面的隧道时，识别胰腺颈部上方的普通肝动脉和入口静脉。切除淋巴节点号8A，使共同的肝动脉清晰可见。</li>
	<li>使用下交道夹或连字密封尽可能多的淋巴血管。一旦明确了普通肝动脉的疗程，解剖动脉和胰腺颈部上边缘之间的淋巴组织，使入口静脉清晰可见。</li>
	<li>用容器回路标记普通肝动脉，以提高可见性，并方便在手术过程中处理容器。</li>
	<li>使用冷剪刀对主要动脉进行解剖，因为使用能量装置可能导致血管壁的热损伤，从而可能增加延迟出血的风险22。通过周围的淋巴神经组织剥离常见的肝动脉、腹腔躯干和脾动脉的第一部分，以清晰了解血管解剖学。 注：在随附的视频中，背胰腺动脉发生损伤。出血用5/0聚丙烯缝合线固定。背胰腺动脉的连体和分裂无论如何都是必须的，因为这个马瑙尔改善了脾动脉起源的暴露，并为这个大动脉的安全结扎提供了更大的空间。</li>
	<li>在连字或夹子之间划分脾动脉。直接应用两个连字，并将容器分到两个下交线夹。只要有可能，在分割脾静脉之前，先分割脾动脉，这样可以防止中氏性门户高血压的发生，从而减少脾脏中的血合血和向后出血量。<ol>
<li>或者，使用装有血管盒的订书机。 注：在此阶段，胰腺颈部后面的隧道被开发出来。然而，正如术前成像的嫌疑人，肿瘤严格地粘附在血管-粘膜结上，因此最好在进行静脉之前进一步动员标本，以实现对所有血管血管的更广泛的控制。切除和重建。</li>
	</ol></li>
	<li>识别上流的动脉，在上流的静脉左侧。剥去上流的动脉 180° 在其左侧。</li>
	<li>识别劣质的肠动脉，并保存在静脉重建时用作血管贴片。在血管外检期间，夹住大淋巴，以减少淋巴泄漏量。</li>
	<li>开始在后平面中进行中侧解剖，以去除与标本一起的大量反前体软组织。在此阶段识别左肾上腺。再往左，取出用标本覆盖左肾上极的Gerota筋膜，从而发现上肾杆的前表面。左肾静脉和左肾上腺静脉被清楚地识别。</li>
	<li>在剪辑之间划分劣质的静脉。抽出一段静脉进行血管重建。解剖脾静脉自由接近肿瘤的部位粘附，实现上游血管控制。</li>
	<li>在腺体的下边缘放置一个转修复缝合线，以遮挡横向胰腺动脉。分割胰腺的脖子。当有足够的空间时，请使用腹腔镜或机器人订书机。或者，使用谐波剪刀分割颈部。 注：对于视频中显示的患者，由于可用空间有限，使用谐波剪切器对胰腺进行分割。</li>
	<li>识别、解剖和分离主胰腺导管。使用 4/0 膨胀聚四氟乙烯 （e-PTFE） 的中断缝合线，在鱼嘴配置中关闭分段表面。</li>
	<li>如果可能，发送冷冻节性学的胰腺边缘。如果认为缘位非常接近肿瘤，则延迟在标本提取后冻结胰腺边缘部分，以因体内取样似乎很麻烦。 注：在这个患者中，由于肿瘤靠近胰腺颈部，在取出标本后评估分段裕量。</li>
	<li>分割脾静脉。 注：如果肿瘤接近胸膜-肠子连接引起对手术的激进性的担忧，现在不应分割静脉。在这些情况下，需要静脉切除和重建来实现 R0 切除。</li>
</ol>5. 静脉切除和重建
<ol><li>规划最合适的静脉切除类型，并相应地为重建做好准备。如果需要，确定适合重建的血管段。</li>
	<li>实现控制所有血管的足刺。</li>
	<li>交叉夹住脾脉上游到肿瘤介入部位。</li>
	<li>交叉夹紧上流的动脉，以减少静脉交叉夹钳过程中肠道中血合的量。</li>
	<li>交叉夹住上流的静脉和门静脉。</li>
	<li>用标本切除所涉及的静脉段。对门户-肠子连接进行侧壁切除。收获劣质的肠外静脉。在劣质静脉移植物和静脉缺陷的上角之间放置e-PTFE缝合线。</li>
	<li>如果需要血管贴片来封闭血管缺陷，请使用两个半程缝合 6/0 e-PTFE 缝合血管贴片。</li>
	<li>在松开夹子之前，使用连接到注射器的输尿管用含有肝素钠的盐水溶液冲洗静脉。 注：腹腔镜外科医生进行血管冲洗。</li>
	<li>拆下牛头犬夹。首先取出门户静脉上的牛头犬，以检查在较低压力下出血部位。</li>
</ol>6. 完成解剖
<ol><li>完全清除反光容器。沿着上流的动脉的围周平面，以头颅方向解剖。</li>
	<li>骨架的右侧的上流道动脉和删除右腹腔结节，如果肿瘤位于靠近胰腺的颈部，由于淋巴排水23和路径神经入侵24。</li>
	<li>到达右侧主动脉后，在左侧执行相同的解剖。</li>
	<li>完成后解剖。取出带有标本的左腹腔结组。使用谐波剪切时，请注意与动脉相对的有源刀片。当需要更精细的解剖时，使用冷剪刀。</li>
	<li>沿着后表面和胰腺的上边缘分割短胃血管。</li>
	<li>调动脾脏。</li>
</ol>7. 保护逆行器
<ol><li>调动圆形和假体韧带。</li>
	<li>用圆形和假体韧带覆盖裸行性血管。</li>
</ol>8. 标本提取和伤口封闭
<ol><li>做一个Pfannenstiel切口（+5厘米）。</li>
	<li>提取试样并装入内窥镜袋中。</li>
	<li>合上层切口，将腹部塞住，进行最终探索。</li>
	<li>关闭 12 mm 辅助端口的筋膜。</li>
	<li>将 14 Fr 辫尾导管靠近胰腺树桩。</li>
	<li>使肺气膜消瘦。</li>
	<li>关闭所有切口。</li>
</ol>

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C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Refining+the+care+of+patients+with+pancreatic+cancer:+the+AGITG+Pancreatic+Cancer+Workshop+consensus.">Refining the care of patients with pancreatic cancer: the AGITG Pancreatic Cancer Workshop consensus.</a> The Medical Journal of Australia. 204 (11), 419-422 (2016).</li><li>Boeck, S., Stieber, P., Holdenrieder, S., Wilkowski, R., Heinemann, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prognostic+and+therapeutic+significance+of+carbohydrate+antigen+19-9+as+tumor+marker+in+patients+with+pancreatic+cancer.">Prognostic and therapeutic significance of carbohydrate antigen 19-9 as tumor marker in patients with pancreatic cancer.</a> Oncology. 70 (4), 255-264 (2006).</li><li>Hayman, A. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CA+19-9+nonproduction+is+associated+with+poor+survival+after+resection+of+pancreatic+adenocarcinoma.">CA 19-9 nonproduction is associated with poor survival after resection of pancreatic adenocarcinoma.</a> American Journal of Clinical Oncology. 37 (6), 550-554 (2014).</li><li>Amorese, G., Boggi, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Properative+evaluation+and+anesthesia+in+minimally+invasive+surgery+of+the+pancreas.">Properative evaluation and anesthesia in minimally invasive surgery of the pancreas.</a> Minimally Invasive Surgery of the Pancreas. , 49-63 (2018).</li><li>Boggi, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+pancreatic+resections.">Robotic-assisted pancreatic resections.</a> World Journal of Surgery. 40 (10), 2497-2506 (2016).</li><li>Napoli, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+learning+curve+in+robotic+distal+pancreatectomy.">The learning curve in robotic distal pancreatectomy.</a> Updates in Surgery. 67 (3), 257-264 (2015).</li><li>Hammerquist, R. J., Messerschmidt, K. A., Pottebaum, A. A., Hellwig, T. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vaccinations+in+asplenic+adults.">Vaccinations in asplenic adults.</a> American Journal of Health-System Pharmacy. 73 (9), e220-e228 (2016).</li><li>Javed, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postoperative+omental+infarct+after+distal+pancreatectomy:+appearance,+etiology+management,+and+review+of+literature.">Postoperative omental infarct after distal pancreatectomy: appearance, etiology management, and review of literature.</a> Journal of Gastrointestinal Surgery. 19 (11), 2028-2037 (2015).</li><li>Emam, T. A., Cuschieri, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+safe+is+high-power+ultrasonic+dissection?.">How safe is high-power ultrasonic dissection?.</a> Annals of Surgery. 237 (2), 186-191 (2003).</li><li>Cesmebasi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+surgical+anatomy+of+the+lymphatic+system+of+the+pancreas.">The surgical anatomy of the lymphatic system of the pancreas.</a> Clinical Anatomy. 28 (4), 527-537 (2015).</li><li>Tsuchikawa, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detailed+analysis+of+extra-pancreatic+nerve+plexus+invasion+in+pancreatic+body+carcinoma+analyzed+by+50+consecutive+series+of+distal+pancreatectomy+with+en-bloc+celiac+axis+resection.">Detailed analysis of extra-pancreatic nerve plexus invasion in pancreatic body carcinoma analyzed by 50 consecutive series of distal pancreatectomy with en-bloc celiac axis resection.</a> Hepatogastroenterology. 62 (138), 455-458 (2015).</li><li>Dindo, D., Demartines, N., Clavien, P. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Classification+of+surgical+complications:+a+new+proposal+with+evaluation+in+a+cohort+of+6336+patients+and+results+of+a+survey.">Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.</a> Annals of Surgery. 240 (2), 205-213 (2004).</li><li>Bassi, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+2016+update+of+the+International+Study+Group+(ISGPS)+definition+and+grading+of+postoperative+pancreatic+fistula:+11+Years+After.">The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After.</a> Surgery. 161 (3), 584-591 (2017).</li><li>Strasberg, S. M., Linehan, D. C., Hawkins, W. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radical+antegrade+modular+pancreatosplenectomy+procedure+for+adenocarcinoma+of+the+body+and+tail+of+the+pancreas:+ability+to+obtain+negative+tangential+margins.">Radical antegrade modular pancreatosplenectomy procedure for adenocarcinoma of the body and tail of the pancreas: ability to obtain negative tangential margins.</a> Journal of the American College of Surgeons. 204 (2), 244-249 (2007).</li><li>Sunagawa, H., Harumatsu, T., Kinjo, S., Oshiro, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ligament+of+Treitz+approach+in+laparoscopic+modified+radical+antegrade+modular+pancreatosplenectomy:+report+of+three+cases.">Ligament of Treitz approach in laparoscopic modified radical antegrade modular pancreatosplenectomy: report of three cases.</a> Asian Journal of Endoscopic Surgery. 7 (2), 172-174 (2014).</li><li>Ishikawa, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+dexterity:+evaluation+of+three-dimensional+monitoring+system+and+non-dominant+hand+maneuverability+in+robotic+surgery.">Robotic dexterity: evaluation of three-dimensional monitoring system and non-dominant hand maneuverability in robotic surgery.</a> Journal of Robotic Surgery. 1 (3), 231-233 (2007).</li><li>Ocuin, L. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+and+open+distal+pancreatectomy+with+celiac+axis+resection+for+locally+advanced+pancreatic+body+tumors:+a+single+institutional+assessment+of+perioperative+outcomes+and+survival.">Robotic and open distal pancreatectomy with celiac axis resection for locally advanced pancreatic body tumors: a single institutional assessment of perioperative outcomes and survival.</a> HPB. 18 (10), 835-842 (2016).</li><li>Napoli, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Indications,+technique,+and+results+of+robotic+pancreatoduodenectomy.">Indications, technique, and results of robotic pancreatoduodenectomy.</a> Updates in Surgery. 68 (3), 295-305 (2016).</li><li>Kauffmann, E. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+pancreatoduodenectomy+with+vascular+resection.">Robotic pancreatoduodenectomy with vascular resection.</a> Langenbeck's Archives of Surgery. 401 (8), 1111-1122 (2016).</li><li>Boggi, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+robot-assisted+pancreas+transplantation:+First+world+experience.">Laparoscopic robot-assisted pancreas transplantation: First world experience.</a> Transplantation. 93 (2), 201-206 (2012).</li><li>Boggi, U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+renal+transplantation:+First+European+case.">Robotic renal transplantation: First European case.</a> Transplant International. 24 (2), 213-218 (2011).</li><li>Tempero, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+adenocarcinoma,+version+2.2017,+NCCN+Clinical+Practice+Guidelines+in+Oncology.">Pancreatic adenocarcinoma, version 2.2017, NCCN Clinical Practice Guidelines in Oncology.</a> Journal of the National Comprehensive Cancer Network. 15 (8), 1028-1061 (2017).</li><li>Tienhoven, G. V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+chemoradiotherapy+versus+immediate+surgery+for+resectable+and+borderline+resectable+pancreatic+cancer+(PREOPANC-1):+A+randomized,+controlled,+multicenter+phase+III+trial.">Preoperative chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC-1): A randomized, controlled, multicenter phase III trial.</a> Journal of Clinical Oncolology. 36 (18), LBA4002 (2018).</li><li>Motoi, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+phase+II/III+trial+of+neoadjuvant+chemotherapy+with+gemcitabine+and+S-1+versus+upfront+surgery+for+resectable+pancreatic+cancer+(Prep-02/JSAP05).">Randomized phase II/III trial of neoadjuvant chemotherapy with gemcitabine and S-1 versus upfront surgery for resectable pancreatic cancer (Prep-02/JSAP05).</a> Japanese Journal of Clinical Oncology. 49 (2), 190-194 (2019).</li></ol>

作者没有什么可透露的。

根前体胰腺切除术旨在提高胰腺体和尾部肿瘤的彻底切除率，并实现彻底的淋巴切除术。根据再生膜肿瘤的生长程度，左肾上腺可以幸免（前原体前体胰腺切除术）或随标本切除（后原体前体模块化胰腺切除术）。在所有程序中，必须切除覆盖左肾上极的Gerota筋膜，以及围绕普通肝动脉、腹腔躯干和上部肾动脉11、27的左侧的所有淋巴神经组织。
整体激进的前体模块化胰腺切除术是一个复杂的过程，即使使用开放的方法。虽然激进的前体模块化胰腺切除术也使用纯腹腔镜技术12，28，使用机器人系统被认为是促进程序，由于机器人援助提供的增强的灵巧29。事实上，Duoadi等人发现，机器人辅助降低了转换到开放手术的速度，同时增加了切除的淋巴结的数量和边缘负切除率13。
当肿瘤位于靠近胰腺颈部时，可能会出现上等肠静脉和/或腹腔干，使手术更加复杂。动脉和静脉切除术在激进的前体胰腺切除术30期间都使用机器人辅助进行，但这些手术的安全性和肿瘤学功效仍有待确定。
在此介绍的情况下，我们执行了波托森特基轴的侧壁切除。该缺陷使用静脉贴片关闭。我们仍然认为公开血管介入是机器人接近18，31的禁忌。然而，我们已经进行了一些机器人胰腺切片与相关的血管程序，当血管介入有限，手术条件允许程序安全地完成机器人援助32。我们已经进行了超过500个这样的程序开放，我们有经验与胰腺33和肾脏34机器人移植。
并非所有位于胰腺尾部的胰腺肿瘤都可以使用微创技术（包括机器人辅助）进行切除。虽然机器人切除的禁忌症预计将随中心和外科医生的经验而变化，但可以合理地接受，患有真正本地晚期癌症的患者，其门户高血压次要于优越的肠胃静脉狭窄/阻塞，严重中央肥胖，和/或需要多体切除的患者不太可能被安全地进行机器人切除，而不是开放。
虽然目前的指南建议对不符合"边缘可伸张"或"本地先进"35标准标准的胰腺癌进行前期复审，但新佐剂治疗对立即可切除肿瘤36、37的患者也是有益的。目前没有证据表明新的辅助疗法对微创胰腺切片的可行性和安全性的影响。这个问题可能值得探讨。

胰腺癌的发病率和死亡率都在上升，而且该病将很快成为西方国家癌症相关死亡的第二大原因。胰腺癌的高致死率主要与该肿瘤类型的生物学攻击性有关，早期和快速转移传播2.因此，只有大约20%的患者被诊断为看似局部的疾病。在这些患者中，根肿瘤切除，与新佐剂3，4或辅助化疗5，提供了治愈的唯一希望。
胰腺癌的诊断位于胰腺的体尾，往往是当肿瘤已经广泛生长或转移明显6，7。少数患者似乎局部疾病是那些谁可以从手术中受益，特别是如果负切除幅度达到8和足够的淋巴结被检索9。符合这些标准的患者实际上可以获得长期生存，因为与胰腺头癌10相比，左侧胰腺癌与攻击性较低的恶性表型有关。
由Strasberg等人11号首先描述的根前型模块化胰腺切除术（RAMPS），是专门为身体尾部胰腺癌提供彻底切除而构思的一种程序。虽然腹腔镜RAMPS在精心挑选的患者中是可行的，但这个程序的复杂性和机器人程序13后报告的利润率阴性切除率表明，机器人辅助在这项手术中可能是有益的。我们在此介绍机器人辅助 RAMPS 技术，该技术是在一个中心开发的，该中心在数千个机器人程序以及超过 350 个机器人胰腺切片方面拥有丰富的经验。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0 ethylene terephthalate sutures, straight needle</td>
			<td>Ethicon</td>
			<td>PE6624</td>
			<td>Polyethylene terephthalate is a braided non absorbable suture. 0 refers to suture size.</td>
		</tr>
		<tr>
			<td>0 linen ligatures</td>
			<td>LORCA MARIN</td>
			<td>63055</td>
			<td>Linen is a sterile, non-absorbable, spun surgical suture material made of flax fibers of linen. Linen gives excellent knot security. 0 refers to suture size.</td>
		</tr>
		<tr>
			<td>0 Polysorb sutures</td>
			<td>Ethicon</td>
			<td>CL-5-M</td>
			<td>Polysorb is a braided absorbable suture armed with a single needle. 0 refers to suture size.</td>
		</tr>
		<tr>
			<td>12mm port</td>
			<td>Kii</td>
			<td>CTB73</td>
			<td>Conventional laparoscopic port, used by the laparoscopic surgeon. The 12 mm size is required to accept a laparoscopic stapler, if required.</td>
		</tr>
		<tr>
			<td>2/0 linen ligatures</td>
			<td>LORCA MARIN</td>
			<td>63254</td>
			<td>Linen is a sterile, non-absorbable, spun surgical suture material made of flax fibers of linen. Linen gives excellent knot security. 2/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>2/0 Polysorb sutures</td>
			<td>Ethicon</td>
			<td>GL-323</td>
			<td>Polysorb is a braided absorbable suture armed with a single needle. 2/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>3/0 linen ligatures</td>
			<td>LORCA MARIN</td>
			<td>63515</td>
			<td>Linen is a sterile, non-absorbable, spun surgical suture material made of flax fibers of linen. Linen gives excellent knot security. 3/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>3/0 linen sutures</td>
			<td>LORCA MARIN</td>
			<td>63146</td>
			<td>Linen is a sterile, non-absorbable, spun surgical suture material made of flax fibers of linen. Linen gives excellent knot security. Linen sutures are armed with a single needle. 3/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>3/0 Polysorb sutures</td>
			<td>Ethicon</td>
			<td>GL-322</td>
			<td>Polysorb is a braided absorbable suture armed with a single needle. 3/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>4 robotic 8mm ports</td>
			<td>Intuitive Surgical</td>
			<td>470359</td>
			<td>Robotic ports are the specific type of cannulas that are docked to the robotic system and are used to introduce robotic instruments in the human body.</td>
		</tr>
		<tr>
			<td>4/0 e-PTFE sutures</td>
			<td>GORE</td>
			<td>4N04</td>
			<td>Expanded polytetrafluoroethylene (e-PTFE) is non absorbable, microporous, monofilament material typically used for vascular sutures. Other properties of e-PTFE inculde low-friction and comprexibility. 4/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>4/0 SH polypropylene sutures</td>
			<td>Ethicon</td>
			<td>8521</td>
			<td>Nonabsorbable, monofilament (polypropylene), suture typically used for vascular sutures and/or to fix bleeding sites. 4/0 refers to suture size. SH refers to the range fo curvature of the needle (26 mm)</td>
		</tr>
		<tr>
			<td>4/0 SH1 polypropylene sutures</td>
			<td>Ethicon</td>
			<td>EH7585</td>
			<td>Nonabsorbable, monofilament (polypropylene), suture typically used for vascular sutures and/or to fix bleeding sites. 4/0 refers to suture size. SH1 refers to the range fo curvature of the needle 22 mm)</td>
		</tr>
		<tr>
			<td>5/0 C1 polypropylene sutures</td>
			<td>Ethicon</td>
			<td>8720</td>
			<td>Nonabsorbable, monofilament (polypropylene), suture typically used for vascular sutures and/or to fix bleeding sites. 5/0 refers to suture size. C1 refers to the range fo curvature of the needle (12 mm)</td>
		</tr>
		<tr>
			<td>5/0 e-PTFE sutures</td>
			<td>GORE</td>
			<td>5N04</td>
			<td>Expanded polytetrafluoroethylene (e-PTFE) is non absorbable, microporous, monofilament material typically used for vascular sutures. Other properties of e-PTFE inculde low-friction and comprexibility. 5/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>5/0 SH1 polypropylene sutures</td>
			<td>Ethicon</td>
			<td>PEE5692</td>
			<td>Nonabsorbable, monofilament (polypropylene), suture typically used for vascular sutures and/or to fix bleeding sites. 5/0 refers to suture size. SH1refers to the range fo curvature of the needle (22 mm)</td>
		</tr>
		<tr>
			<td>6/0 e-PTFE sutures</td>
			<td>GORE</td>
			<td>6M12</td>
			<td>Expanded polytetrafluoroethylene (e-PTFE) is non absorbable, microporous, monofilament material typically used for vascular sutures. Other properties of e-PTFE inculde low-friction and comprexibility. 6/0 refers to suture size.</td>
		</tr>
		<tr>
			<td>6/0 polypropylene sutures</td>
			<td>Ethicon</td>
			<td>8706</td>
			<td>Nonabsorbable, monofilament (polypropylene), suture typically used for vascular sutures and/or to fix bleeding sites. 6/0 refers to suture size. 6/0 polypropylene comes with just one needle size.</td>
		</tr>
		<tr>
			<td>Belt for legs</td>
			<td>Eswell</td>
			<td>249100</td>
			<td>This device is used to prevent pressure injuries during surgical procudures.</td>
		</tr>
		<tr>
			<td>Bioabsorbable staple line reinforcement</td>
			<td>GORE SEAMGUARD</td>
			<td>12BSGTRI45P</td>
			<td>The reinforcement consists ofa synthetic buttressing material meant to distribute the jaw closure stress on a larger surface.</td>
		</tr>
		<tr>
			<td>Black diamond micro forceps</td>
			<td>Intuitive Surgical</td>
			<td>470033</td>
			<td>Small needle driver suitable for fine sutures.</td>
		</tr>
		<tr>
			<td>Bracci ureteral catheter 8Fr</td>
			<td>Coloplast</td>
			<td>AC4108</td>
			<td>A Bracci catheter is a straight rubber hose with 6 side holes located close to an open distal tip. It has also with a radiopaque line. Bracci catheters have been designed for use in urology but can be used also to flush vessels during laparoscopic procedures. 8 Fr refers to the size of the catheter in French.</td>
		</tr>
		<tr>
			<td>Cadiere forceps</td>
			<td>Intuitive Surgical</td>
			<td>470049</td>
			<td></td>
		</tr>
		<tr>
			<td>da Vinci Xi Surgical System</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td>The da Vinci Surgical System is a telemanipulator that increases surgical dexterity during minimally invasive procedures. The system consists of three components: a patient side cart, a console, and a vision cart.</td>
		</tr>
		<tr>
			<td>Endo GIA articulating reload with tri-staple technology 60mm</td>
			<td>Covidien</td>
			<td>EGIA60AMT</td>
			<td>Cartridge for stapler reload</td>
		</tr>
		<tr>
			<td>Endocatch II 15mm</td>
			<td>Covidien</td>
			<td>173049</td>
			<td>Bag for specimen extraction.</td>
		</tr>
		<tr>
			<td>Endoscope with 8mm camera 30&#176;</td>
			<td>Intuitive Surgical</td>
			<td>470027</td>
			<td>The robotic endoscope is a vision system providing HD and steroscopic vision to the surgeon working form the console.</td>
		</tr>
		<tr>
			<td>Harmonic shears</td>
			<td>Intuitive Surgical</td>
			<td>480275</td>
			<td></td>
		</tr>
		<tr>
			<td>Hug-u-vac</td>
			<td>Allen Medical</td>
			<td>A-60001</td>
			<td>This device is used to safely anchor the patient to the operating bed</td>
		</tr>
		<tr>
			<td>Ioban</td>
			<td>3M</td>
			<td>6650EZ</td>
			<td>3M is an incise drap that adheres securely to the skin thus reducing the risk of drape lift. It also provides wound protection, when placed to cover the entire lenght of the surgical incision.</td>
		</tr>
		<tr>
			<td>Kendall SCD sequential compression comfort sleeves</td>
			<td>Cardinal Health</td>
			<td>74012</td>
			<td>This device provides sequential, gradient, circumferential compression (to the leg, foot or both simultaneously) to help prevent deep vein thrombosis and pulmonary embolism.</td>
		</tr>
		<tr>
			<td>Laparoscopic stapler (Signia power handle)</td>
			<td>Covidien</td>
			<td>SIGSBCHGR</td>
			<td>Signia is a laparoscopic, robotized stapler suturing and dividing tissues between three rows of titanium staples applied on each suture side.</td>
		</tr>
		<tr>
			<td>Large needle driver (n=2)</td>
			<td>Intuitive Surgical</td>
			<td>470006</td>
			<td></td>
		</tr>
		<tr>
			<td>Maryland bipolar forceps</td>
			<td>Intuitive Surgical</td>
			<td>470172</td>
			<td></td>
		</tr>
		<tr>
			<td>Medium hem-o-lok clip applier</td>
			<td>Intuitive Surgical</td>
			<td>470327</td>
			<td></td>
		</tr>
		<tr>
			<td>Monopolar curved scissors</td>
			<td>Intuitive Surgical</td>
			<td>400180</td>
			<td></td>
		</tr>
		<tr>
			<td>Pig-tail drain 14Fr</td>
			<td>Cook</td>
			<td>ULT14.0-38-25-P-6S-CLM-RH</td>
			<td>A pig drain catheter is a rubber hose used to drain fluids from deep spaces in the human body. As compared with other catheters, the pigtail ends with a curl, similar to the tail of a pig, that is thought to facilitare the anchoring of the catheter. 14 Fr refers to the size of the catheter in French.</td>
		</tr>
		<tr>
			<td>Potts scissors</td>
			<td>Intuitive Surgical</td>
			<td>470001</td>
			<td>Non-electrified scissors used mainly to incise, or unroof, vessels.</td>
		</tr>
		<tr>
			<td>Set of laparoscopic bulldogs clamps</td>
			<td>Aesculap</td>
			<td></td>
			<td>This set consists of several bulldog clamps (of different shape and size) with dedicated laparoscopic instruments to be used to apply and remove the clamps</td>
		</tr>
		<tr>
			<td>Signia power shell for signia power handle</td>
			<td>Covidien</td>
			<td>SIGPSSHELL</td>
			<td>Sterile cover for Signia power handle</td>
		</tr>
		<tr>
			<td>Small hem-o-lok clip applier</td>
			<td>Intuitive Surgical</td>
			<td>470401</td>
			<td></td>
		</tr>
		<tr>
			<td>Veress needle</td>
			<td>Aesculap</td>
			<td>EJ995</td>
			<td>A Verres needle is a particular type of needle that is used to puncture the abdominal wall in order to create a pneumoperitoneum. It consists of an outer cannula, with a sharp tip, and an inner stylet, with a dull tip. The inner stylet is spring-loaded in order to protect viscera at the time of needle insertion, that occurs blindly.</td>
		</tr>
		<tr>
			<td>Vessel loops</td>
			<td>Omnia Drains</td>
			<td>NVMR61</td>
			<td>Disposable silicon rubber stripes, typically used to tag relevant anatomical structures</td>
		</tr>
	</tbody>
</table>

robot-assisted radical antegrade modular pancreatosplenectomy including resection and reconstruction of the spleno-mesenteric junction

本文介绍了机器人辅助的激进前体式胰腺切除术的技术，包括切除和重建胰腺体尾癌的脾-肠结。患者被放置在双腿分开的上摆，并建立并保持在10毫米汞柱肺气膜。要使用手术系统，需要四个 8 mm 端口和一个 12 mm 端口。光端口位于脐带。其他端口位于两侧，沿参数线和前辅助线放置在脐线水平处。辅助端口（12 mm）沿右侧参数线放置。解剖开始分离胃部韧带，从而打开较小的囊，并通过结肠的脾弯曲的广泛动员。上流的静脉是沿着胰腺的劣等边界识别的。淋巴节点编号 8a 被移除，以允许公共肝动脉的明确可视化。然后，在胰腺的颈部后面创建一个隧道。为了安全切除和重建脾科结，在分割胰腺颈部之前，需要进一步先发制人地解剖，以便清晰地查看所有相关的血管血管。其次，脾动脉被连接和分割，胰腺颈部被分割，胰腺导管有选择性的结扎。静脉切除和重建后，解剖继续进行，以完成从所有淋巴神经组织剥离的胰腺动脉的清除。两个腹腔神经带都与标本一起被移除。覆盖左肾上极的Gerota筋膜也随标本一起被切除。短胃血管和脾切除术的分部完成程序。在胰腺树桩附近留有排水沟。肝脏的圆韧带被动员起来保护血管。

手术时间是6小时15分钟，估计失血量为150 mL。完成贴片的血管缝合所需的时间为11分钟。术后课程不周。病理学显示胰腺（G2/3）的中度分化导管腺腺癌（G2/3），具有围神经入侵和sperno-mesenteric结的介入。所有56个切除的淋巴结都是阴性的。圆周肿瘤边缘，评估在1毫米，也是负，使切除激进。该肿瘤的最终病理阶段是T3 N0 R0。在30个月最长的随访中，病人还活着，很好，没有疾病。
在我们的机构，在20名患者中进行了机器人辅助的激进前坡模块化胰腺切除术。无可否认，在同一时期，其他适合微创方法的患者在无需机器人协助的情况下，使用腹腔镜技术接受了相同的程序。这并不是因为病人的选择或外科医生的偏好，而是因为机器人在计划手术时并不总是及时可用的，因为与我们小组执行的其他程序（例如胰腺切除术）的竞争，或其他组执行的程序（例如泌尿外科）。
简单地说，所有程序都是在机器人协助下完成的，没有转为开放手术，尽管有三个病人需要相关的血管手术（表1）。即，两名患者需要切除和重建的脾科-肠子结，和一个患者需要切除腹腔躯干（修改的Appleby程序）。平均手术时间是325分钟~88.6分钟，12例患者出现术后并发症（60%），根据Clavien-Dindo分类25，3例患者（3a =2;3b = 1）（15%）严重。没有90天或住院死亡。B级术后胰腺瘘26在5例患者中发展（35%）。术后胰腺瘘没有C级。病理学在14例患者中发现导管腺癌，5例患者发现恶性内皮粘体肿瘤，1例患者胰腺神经内分泌癌。在平均肿瘤直径为34毫米~13毫米的患者群体中，圆周肿瘤边缘（评估为1毫米）在17例患者中为阴性（85%）。检查淋巴结的平均数量为39± 16.6。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60370/60370fig1.jpg"> 图1：术前计算机断层扫描。（A） 巴萨尔;（B） 动脉阶段;（C） 静脉相;（D） 帕伦奇马尔阶段.胰腺导管的上游扩张，在胰腺体的近端部分被注意到。<a href="https://www.jove.com/files/ftp_upload/60370/60370fig1large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/60370/60370fig2.jpg"> 图2：手术室设置。<a href="https://www.jove.com/files/ftp_upload/60370/60370fig2large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/60370/60370fig3.jpg"> 图 3：操作设置。（A） 病人双腿分开， 被放在苏普林.（B） 间歇性气动压缩袖口放在腿部周围。（C） 病人使用宽带固定在手术台上。（D） 腹部准备广泛.<a href="https://www.jove.com/files/ftp_upload/60370/60370fig3large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/60370/60370fig4.jpg"> 图 4：端口放置和提取站点。（A） 腹部地标.1：右前一线;2：右参数线;3：中线;4 左参数线;5：左前一线;6：横向脐带线;7： 超量萃取点。（B） 使用韦雷斯针技术诱导肺膜。（C） 紧放在脐带下方的光学端口。（D） 端口.I： 臂 1 的机械端口;二：辅助端口;III：臂2的机械端口（光学）;四：臂3的机械端口;V：臂 4 的机械端口。<a href="https://www.jove.com/files/ftp_upload/60370/60370fig4large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/60370/60370fig5.jpg"> 图 5：操作表方向。如左下角方格所强调的那样，手术台方向为 15–20°，反倒为 Trendelenburg，向患者右侧倾斜 5–8°。<a href="https://www.jove.com/files/ftp_upload/60370/60370fig5large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/60370/60370fig6.jpg"> 图6：远端造影切除术的手术系统对接。（A） 在初始摄像机端口上对齐动臂的激光十字线。（B） 位于机械臂底部的 FLEX 图标上的 L 和 E 之间的摄像机臂（数字 2）的方向。（C） 机械臂 2 的对接和机器人摄像头的插入。（D） 完成瞄准后，剩余武器对接。<a href="https://www.jove.com/files/ftp_upload/60370/60370fig6large.jpg" target="_blank">请点击此处查看此图的较大版本。</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always"><tbody>
<tr>
<td></td>
			<td>均值或数</td>
			<td>标准偏差或百分比</td>
		</tr>
<tr>
<td>操作时间（分钟）</td>
			<td>325</td>
			<td>≤ 88.6</td>
		</tr>
<tr>
<td>相关的血管程序</td>
			<td>3</td>
			<td>15%</td>
		</tr>
<tr>
<td>静脉切除和重建</td>
			<td>2</td>
			<td>10%</td>
		</tr>
<tr>
<td>动脉切除（修改的 Appleby 程序）</td>
			<td>1</td>
			<td>5%</td>
		</tr>
<tr>
<td>术后并发症25
</td>
			<td>12</td>
			<td>60%</td>
		</tr>
<tr>
<td>严重的术后并发症（+3级）</td>
			<td>3</td>
			<td>15%</td>
		</tr>
<tr>
<td>临床相关术后胰腺瘘26
</td>
			<td>5</td>
			<td>25%</td>
		</tr>
<tr>
<td>B级术后胰腺瘘</td>
			<td>5</td>
			<td>25%</td>
		</tr>
<tr>
<td>C级术后胰腺瘘</td>
			<td>0</td>
			<td>-</td>
		</tr>
<tr>
<td>90天或住院死亡率</td>
			<td>0</td>
			<td>-</td>
		</tr>
<tr>
<td>肿瘤类型</td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>腺腺癌</td>
			<td>14</td>
			<td>70%</td>
		</tr>
<tr>
<td>恶性粘内肠内皮质肿瘤</td>
			<td>5</td>
			<td>25%</td>
		</tr>
<tr>
<td>神经多克林癌</td>
			<td>1</td>
			<td>5%</td>
		</tr>
<tr>
<td>肿瘤直径（毫米）</td>
			<td>34</td>
			<td>≤ 13</td>
		</tr>
<tr>
<td>肿瘤边缘（评估为 1 毫米）</td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>负数 （R0）</td>
			<td>17</td>
			<td>85%</td>
		</tr>
<tr>
<td>检查淋巴结</td>
			<td>39</td>
			<td>≤ 16.6</td>
		</tr>
</tbody></table>表1：连续20个机器人辅助的激进前级模块化胰腺切除术的结果。

Watch this Scientific Journal Video about Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction at JoVE.com

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

本文所示的机器人技术旨在忠实地再现胰腺体尾癌的激进治疗开放程序。该协议还证明了在不转换为开放手术的情况下掌握主要围网血管参与的能力。

机器人辅助基质前体模块化胰腺切除术，包括切除和重建的斯普尔诺-梅森特克结

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

这段视频展示了一个机器人辅助的激进前科模块化胰腺切除术，包括切除和重建的斯普列诺-内肠结。手术被执行，以去除位于胰腺体内的癌症。本视频中显示的程序是按照比萨大学医院伦理委员会为机器人操作制定准则进行的，包括关于研究活动的条例。CT扫描显示胰腺肿瘤功能低，主导管上游扩张。肿瘤位于胰腺身体的近位部分，似乎严格粘附在静脉上，靠近血栓-内肠结。机器人患者侧推车可以从两侧到达患者。机器人视觉车方便地放置在患者的一侧，以便让医生在餐桌上清晰地看到屏幕。机器人控制台放置在患者的脚部。桌旁的外科医生站在病人的双腿之间，而手术外科医生则坐在控制台前。全身麻醉后，患者被放置与腿分离开。间歇性气动压缩袖口被放置在腿部周围，用于预防深静脉血栓形成。病人被安全地固定在手术台上，腹部也得到广泛准备。其次，建立并维持约10毫米汞的肺气管。需要四个机器人端口和一个腹腔镜端口。腹腔镜端口的大小必须为 12 mm，由餐桌上的助手使用。其中一个机器人端口用于内窥镜，而其余三个端口用于机器人仪器。光学端口放置在脐带上。内窥镜被引入，并探索腹部，寻找神秘的肿瘤沉积。此后，其他端口沿横向脐带两侧、前轴线级别放置。辅助端口沿右直线放置。在对接机器人系统之前，患者将处于逆行位置，桌子向右侧倾斜。到达所需位置后，来自头顶动臂的激光指向光学端口的站点。接下来，将适当的臂停靠到光学端口上，并引入内窥镜。示波器面向手术现场，允许通过按下相机头上的专用按钮触发定位过程。目标自动调整架空动臂。机器人仪器插入视觉。手术从从结肠分离上开始，而不分裂胃部韧带。解剖沿横向中异子龙开始中途，一直延伸到右侧，直到到达结肠的肝弯曲，向左，直到结肠的松性弯曲被完全调动。一旦较小的囊完全打开，胰腺体和尾巴变得清晰可见。解剖从调动胰腺的劣质边缘开始。早期识别优越的肠胃静脉，为安全进行进一步解剖提供了一个关键里程碑。在准备创建胰腺颈部后面的隧道时，必须清楚地识别胰腺颈部上方的普通肝动脉和入口静脉。淋巴结8a被重新连接，使常见的肝动脉进入清晰的视野。淋巴血管用血红球夹或连结密封。一旦共同的肝动脉过程被明确界定，位于动脉和胰腺颈部上边缘之间的淋巴组织的解剖使入口静脉清晰可见。常见的肝动脉循环，以提高能见度，方便在手术过程中处理船只。主要动脉周围的解剖是优先使用冷剪刀进行，因为使用这种水平的能量装置可能会导致血管壁的内部损伤，从而可能增加延迟出血的风险。沿着腹腔静脉进行，从下到上，腹腔躯干在周围的组织中是赤裸裸的。在确定腹腔躯干后，解剖沿腹腔动脉的起源进行。在这一阶段，后静脉动脉受伤。用5-0聚丙烯缝合固定出血点。无论如何，需要连结和分裂后静脉动脉，因为这种策略改善了静脉动脉起源的暴露，并提供了更多的空间，以安全连结这个大动脉。在光清的动脉下，容器现在可以安全地连接和分割。两个连字被近侧应用，容器最终被分成两个血红球夹。只要有可能，脾动脉的分裂应在脾脏静脉分裂之前发生，因为这种策略可以防止鼻血性门户高血压的发生，从而减少脾脏的血液汇集和后出血量。胰腺颈部后面的隧道在这个阶段发展，但是，正如在术前成像中所怀疑的，肿瘤被严格粘附在血栓-内肠结，因此最好进一步调动标本，以便在进行静脉切除和重建之前，实现对所有血管皮囊的更广泛控制。因此，上位肠动脉的主干干被识别到上位肠静脉的左侧。在静脉重建时，低劣的肠胃静脉也被识别并用作血管贴片。在血管周围解剖期间，大淋巴被剪裁，以减少淋巴泄漏量。解剖现在继续中侧到横向在后平面删除与标本大量的逆骨软组织。在此阶段识别左肾上腺。再向左走，在左肾上极上盘旋的格罗塔筋膜与标本一起切除，从而揭开上肾极的前部表面。左肾静脉和左肾上腺静脉也明确识别。下级肠静脉在夹子之间分裂。静脉的一部分可以幸免于血管重建。静脉解剖释放近到肿瘤粘附的位点，实现上游血管控制。在分割胰腺颈部之前，将一个固定的缝合线放置在腺体的下边缘，以遮挡横向胰腺动脉。胰腺的分部通常使用内窥镜订书机进行，但在这个患者中，由于可用空间有限，腺体使用谐波剪分。胰管被识别，解剖，并选择性地连接。转口完成后，胰腺颈部被中断的4-0 ePTFE缝合线闭合。如果可能，颈部边缘立即被发送到冷冻部分组织学。在这个患者中，由于肿瘤接近胰腺颈部，在切除标本后评估了转切边缘。进行静脉切除，血管皮囊被交叉截。首先，静脉被夹在肿瘤介入的位点上游。其次，将优越的肠动脉交叉截，以减少静脉闭塞期间的肠道充血。第三，上位肠静脉和门户静脉交叉采样。对入口中间结进行侧壁切除。劣质的肠胃静脉被收获。ePTFE缝合线被放置在低劣的肠胃静脉移植和静脉缺陷的上角之间。移植物纵向被分直，用作血管贴片。在静脉缺陷的右边缘放置留缝合线，以改善暴露。使用两个半运行的缝合线。在松开夹子之前，静脉用含有肝素钠的盐水溶液冲洗。解剖现在沿着上一个肠动脉的周围平面在头孢子。由于这个肿瘤的中心位置，也优越的肠动脉的右侧骨架与切除右腹腔结节。到达平面后，在左侧执行相同的解剖。使用谐波剪切时，注意主动出血与动脉相反。当需要更精细的解剖时，首选使用冷剪刀。此外，左腹腔结节被删除与标本集团。解剖现在沿着后表面和胰腺的上边缘完成。脾脏也是被调动的。最后，上肠静脉、上肠动脉、左肾上腺静脉、左肾静脉清晰可见。在完成手术之前，将调动圆形韧带，并放置以保护裸背血管。标本现在被放置在内窥镜袋中，并通过一个超公开的横向切口取回。手术在635分钟内完成，估计失血150 mL，无需输血。最终病理学证明G2导管腺癌的胰腺，与内膜入侵和参与的斯普列诺-内肠结。所有56个被切除的淋巴结都是阴性。周长肿瘤边缘也是负数。此肿瘤的病理阶段为 T3 N0 R0。在最长的30个月的随去，病人是活的，好，和无病。在这段视频中，我们展示了机器人辅助的激进前科模块化胰腺切除术的可行性。还显示了对斯列诺-中肠结的带段切除和重建。机器人辅助允许在开放过程中遵循的同一平面上执行肿瘤学正确的解剖。我们要强调，机器人辅助提供的增强的灵巧性不能替代手术能力。我们还认为，需要先进的腹腔镜技能，以充分利用机器人辅助在复杂的胰腺切除手术的潜力。

Research

JoVE Journal

Medicine

The Influence of Liver Resection on Intrahepatic Tumor Growth

肝切除肝内肿瘤生长的影响

The high incidence of tumor recurrence after resection of metastatic liver lesions remains an unsolved problem. Small tumor cell deposits, which are not ...

科研

医学

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

猪作为头颈部微血管重建训练模块

Live models that resemble surgical conditions of humans are needed for training free-flap harvesting and anastomosis. Animal models for training purposes ...

Updated Technique for Reliable, Easy, and Tolerated Transcranial Electrical Stimulation Including Transcranial Direct Current Stimulation

用于可靠、简单和耐受的颅内电刺激（包括颅内直流刺激）的更新技术

Transcranial direct current stimulation (tDCS) is a noninvasive method of neuromodulation using low-intensity direct electrical currents. This method of ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

经腋窝第一肋骨切除术治疗胸廓出口综合征

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

Technical Detail for Robot Assisted Pancreaticoduodenectomy

机器人辅助胰腺切除术的技术细节

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible

可读机辅助重建术后评估指南

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging ...

Blood Circuit Reconstruction in an Abdominal Mouse Heart Transplantation Model

腹部小鼠心脏移植模型中的血液回路重建

The surgical technique of heterotopic abdominal heart transplantation in mice is a standard model for research in transplantation immunology. Here, the ...

Robot-Assisted Kidney Transplantation

机器人辅助肾移植

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

机器人辅助全直肠系膜切除术和盆腔外侧淋巴结清扫术治疗局部晚期中低直肠癌

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

保留 retzius 机器人辅助根治性前列腺切除术

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...