Name: robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer
Uploaded: 2022-02-12T14:00:00
Description: Watch this Scientific Journal Video about Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer at JoVE.com

该项目由国家自然科学基金（第81870380号）和陕西省科学基金（2020ZDLSF01-03和2020KWZ-020）资助。

该协议符合西安交通大学第一附属医院伦理委员会（编号：2019ZD04）的指导方针。
1. 术前准备、患者体位、麻醉
<ol><li>确保在手术前进行适当的饮食管理。<ol>
<li>开具术前口服碳水化合物饮料，在睡前和手术前4小时食用。 注意：这是根据手术后增强恢复（ERAS）方案允许的。</li>
		<li>不要开任何额外的口服抗生素。 注：这些措施的实施应根据各中心的经验?...

<ol>
	<li>Fantus, R. J., 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=Facility-level+analysis+of+robot+utilization+across+disciplines+in+the+National+Cancer+Database.">Facility-level analysis of robot utilization across disciplines in the National Cancer Database.</a> Journal of Robotic Surgery. 13 (2), 293-299 (2019).</li><li>Akiyoshi, 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=Results+of+a+japanese+nationwide+multi-institutional+study+on+lateral+pelvic+lymph+node+metastasis+in+low+rectal+cancer+is+it+regional+or+distant+disease.">Results of a japanese nationwide multi-institutional study on lateral pelvic lymph node metastasis in low rectal cancer is it regional or distant disease.</a> Annals of Surgery. 255 (6), 1129-1134 (2012).</li><li>Fujita, S., 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=Mesorectal+excision+with+or+without+lateral+lymph+node+dissection+for+clinical+stage+II/III+lower+rectal+cancer+(JCOG0212):+A+multicenter,+randomized+controlled,+noninferiority+trial.">Mesorectal excision with or without lateral lymph node dissection for clinical stage II/III lower rectal cancer (JCOG0212): A multicenter, randomized controlled, noninferiority trial.</a> Annals of Surgery. 266 (2), 201-207 (2017).</li><li>Yamaguchi, T., Kinugasa, Y., Shiomi, A., Tomioka, H., Kagawa, H. <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+laparoscopic+versus+open+lateral+lymph+node+dissection+for+advanced+lower+rectal+cancer+(vol+30,+pg+721).">Robotic-assisted laparoscopic versus open lateral lymph node dissection for advanced lower rectal cancer (vol 30, pg 721).</a> Surgical Endoscopy and Other Interventional Techniques. 30 (2), 729 (2016).</li><li>Yamaguchi, 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=Oncological+outcomes+of+robotic-assisted+laparoscopic+versus+open+lateral+lymph+node+dissection+for+locally+advanced+low+rectal+cancer.">Oncological outcomes of robotic-assisted laparoscopic versus open lateral lymph node dissection for locally advanced low rectal cancer.</a> Surgical Endoscopy and Other Interventional Techniques. 32 (11), 4498-4505 (2018).</li><li>Gustafsson, U. O., 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=Guidelines+for+perioperative+care+in+elective+colorectal+surgery:+enhanced+recovery+after+surgery+(ERAS((R)))+society+recommendations:+2018.">Guidelines for perioperative care in elective colorectal surgery: enhanced recovery after surgery (ERAS((R))) society recommendations: 2018.</a> World Journal of Surgery. 43 (3), 659-695 (2019).</li><li>Brind'Amour, 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=Canadian+guidelines+on+the+management+of+colorectal+peritoneal+metastases.">Canadian guidelines on the management of colorectal peritoneal metastases.</a> Current Oncology. 27 (6), 621-631 (2020).</li><li>Watanabe, 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=Japanese+society+for+cancer+of+the+colon+and+rectum+(JSCCR)+guidelines+2016+for+the+treatment+of+colorectal+cancer.">Japanese society for cancer of the colon and rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer.</a> International Journal of Clinical Oncology. 23 (1), 1-34 (2018).</li><li>Professional Committee of Robotic Surgery, C.C.C.o.C.M.D.A. <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+Laparoscopic+Surgery+Committee+of+Chinese+Research+Hospital,+A.+[Chinese+expert+consensus+on+robotic+surgery+for+colorectal+cancer+(2020+edition)].">Robotic and Laparoscopic Surgery Committee of Chinese Research Hospital, A. [Chinese expert consensus on robotic surgery for colorectal cancer (2020 edition)].</a> Zhonghua Wei Chang Wai Ke Za Zhi. 24 (1), 14-22 (2021).</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=Robot-Assisted+Radical+Antegrade+Modular+Pancreatosplenectomy+Including+Resection+and+Reconstruction+of+the+Spleno-Mesenteric+Junction.">Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction.</a> Journal of Visualized Experiments. (155), e60370 (2020).</li><li>Shi, 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=Clinical+feasibility+and+safety+of+third+space+robotic+and+endoscopic+cooperative+surgery+for+gastric+gastrointestinal+stromal+tumors+dissection+:+A+new+surgical+technique+for+treating+gastric+GISTs.">Clinical feasibility and safety of third space robotic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumors dissection : A new surgical technique for treating gastric GISTs.</a> Surgical Endoscopy and Other Interventional Techniques. 33 (12), 4192-4200 (2019).</li><li>Sung, H., 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=Global+cancer+statistics+2020:+GLOBOCAN+estimates+of+incidence+and+mortality+worldwide+for+36+cancers+in+185+countries.">Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.</a> CA Cancer Journal for Clinicians. 71 (3), 209-249 (2021).</li><li>Heald, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+approach+to+rectal+cancer.">A new approach to rectal cancer.</a> British Journal of Hospital Medication. 22 (3), 277-281 (1979).</li><li>Jiang, T. Y., Ma, J. J., Zheng, M. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Controversies+and+consensus+in+transanal+total+mesorectal+excision+(taTME):+Is+it+a+valid+choice+for+rectal+cancer.">Controversies and consensus in transanal total mesorectal excision (taTME): Is it a valid choice for rectal cancer.</a> Journal of Surgical Oncology. 123, 59-64 (2021).</li><li>Di Saverio, S., Stupalkowska, W., Hussein, A., Fearnhead, N., Wheeler, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+ultralow+anterior+resection+with+intracorporeal+coloanal+stapled+anastomosis+for+low+rectal+cancer+-+is+robotic+surgery+or+transanal+total+mesorectal+excision+always+needed+to+achieve+a+good+oncological+and+sphincter-sparing+dissection+-+a+video+vignette.">Laparoscopic ultralow anterior resection with intracorporeal coloanal stapled anastomosis for low rectal cancer - is robotic surgery or transanal total mesorectal excision always needed to achieve a good oncological and sphincter-sparing dissection - a video vignette.</a> Colorectal Diseases. 21 (7), 848-849 (2019).</li><li>Sylla, P., Rattner, D. W., Delgado, S., Lacy, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=NOTES+transanal+rectal+cancer+resection+using+transanal+endoscopic+microsurgery+and+laparoscopic+assistance.">NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.</a> Surgical Endoscopy and Other Interventional Techniques. 24 (5), 1205-1210 (2010).</li><li>Larsen, S. G., Pfeffer, F., Korner, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Norwegian+moratorium+on+transanal+total+mesorectal+excision.">Norwegian moratorium on transanal total mesorectal excision.</a> British Journal of Surgery. 106 (9), 1120-1121 (2019).</li><li>Koedam, T. W., 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=Transanal+total+mesorectal+excision+(TaTME)+for+rectal+cancer:+effects+on+patient-reported+quality+of+life+and+functional+outcome.">Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported quality of life and functional outcome.</a> Techniques in Coloproctology. 21 (1), 25-33 (2017).</li><li>Baik, S. H., 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+total+mesorectal+excision+for+the+treatment+of+rectal+cancer.">Robotic total mesorectal excision for the treatment of rectal cancer.</a> Journal of Robotic Surgery. 1 (1), 99-102 (2007).</li><li>Gavriilidis, P., 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+vs+laparoscopic+total+mesorectal+excision+for+rectal+cancers:+has+a+paradigm+change+occurred?+A+systematic+review+by+updated+meta-analysis.">Robotic vs laparoscopic total mesorectal excision for rectal cancers: has a paradigm change occurred? A systematic review by updated meta-analysis.</a> Colorectal Diseases. 22 (11), 1506-1517 (2020).</li><li>Prete, F. P., 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+versus+laparoscopic+minimally+invasive+surgery+for+rectal+cancer:+A+Systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Robotic versus laparoscopic minimally invasive surgery for rectal cancer: A Systematic review and meta-analysis of randomized controlled trials.</a> Annals of Surgery. 267 (6), 1034-1046 (2018).</li><li>Qiu, H., 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=Long-term+oncological+outcomes+in+robotic+versus+laparoscopic+approach+for+rectal+cancer:+A+systematic+review+and+meta-analysis.">Long-term oncological outcomes in robotic versus laparoscopic approach for rectal cancer: A systematic review and meta-analysis.</a> International Journal of Surgery. 80, 225-230 (2020).</li><li>Kapiteijn, E., 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+radiotherapy+combined+with+total+mesorectal+excision+for+resectable+rectal+cancer.">Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.</a> New England Journal of Medicine. 345 (9), 638-646 (2001).</li><li>Ogura, 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=Neoadjuvant+(Chemo)radiotherapy+with+total+mesorectal+excision+only+is+not+sufficient+to+prevent+lateral+local+recurrence+in+enlarged+nodes:+Results+of+the+multicenter+lateral+node+study+of+patients+with+low+cT3/4+rectal+cancer.">Neoadjuvant (Chemo)radiotherapy with total mesorectal excision only is not sufficient to prevent lateral local recurrence in enlarged nodes: Results of the multicenter lateral node study of patients with low cT3/4 rectal cancer.</a> Journal of Clinical Oncology. 37 (1), 33-43 (2019).</li><li>Emile, S. H., Elfeki, H., Shalaby, M., Sakr, A., Kim, N. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcome+of+lateral+pelvic+lymph+node+dissection+with+total+mesorectal+excision+in+treatment+of+rectal+cancer:+A+systematic+review+and+meta-analysis.">Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis.</a> Surgery. 169 (5), 1005-1015 (2021).</li><li>Hajibandeh, S., Hajibandeh, S., Matthews, J., Palmer, L., Maw, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+survival+and+functional+outcomes+after+total+mesorectal+excision+with+or+without+lateral+pelvic+lymph+node+dissection+in+rectal+cancer+surgery.">Meta-analysis of survival and functional outcomes after total mesorectal excision with or without lateral pelvic lymph node dissection in rectal cancer surgery.</a> Surgery. 168 (3), 486-496 (2020).</li><li>Laparoscopic surgery committee of the endoscopist branch in the chinese medical doctor, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+surgery+committee+of+colorectal+cancer+committee+of+chinese+medical+doctor,+A.+and+Colorectal+surgery+group+of+the+surgery+branch+in+the+chinese+medical,+A.+[Chinese+expert+consensus+on+the+diagnosis+and+treatment+for+lateral+lymph+node+metastasis+of+rectal+cancer+(2019+edition)].">Laparoscopic surgery committee of colorectal cancer committee of chinese medical doctor, A. and Colorectal surgery group of the surgery branch in the chinese medical, A. [Chinese expert consensus on the diagnosis and treatment for lateral lymph node metastasis of rectal cancer (2019 edition)].</a> Zhonghua Wei Chang Wai Ke Za Zhi. 22 (10), 901-912 (2019).</li><li>Podda, 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=Multidisciplinary+management+of+elderly+patients+with+rectal+cancer:+recommendations+from+the+SICG+(Italian+Society+of+Geriatric+Surgery),+SIFIPAC+(Italian+Society+of+Surgical+Pathophysiology),+SICE+(Italian+Society+of+Endoscopic+Surgery+and+new+technologies),+and+the+WSES+(World+Society+of+Emergency+Surgery)+International+Consensus+Project.">Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project.</a> World Journal of Emergency Surgery. 16 (1), 35 (2021).</li><li>Fung, T. L. D., Tsukada, Y., Ito, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Essential+anatomy+for+total+mesorectal+excision+and+lateral+lymph+node+dissection,+in+both+trans-abdominal+and+trans-anal+perspective.">Essential anatomy for total mesorectal excision and lateral lymph node dissection, in both trans-abdominal and trans-anal perspective.</a> Surgeon. , (2020).</li></ol>

结直肠癌（CRC）是全球最常见的癌症之一13。其中，超过三分之一是直肠癌。由于术后功能要求较高，骨盆和会阴的神经和筋膜解剖结构复杂，直肠癌，特别是低直肠癌或超低直肠癌的最佳手术方法仍在争论中。自 1979 年首次报告以来，全直肠系膜切除术 （TME） 一直是治疗可切除直肠癌的标准手术技术14。随着肠系膜的完全切除，局部复发率显着降低。然而，?...

自 2000 年美国食品和药物管理局批准用于临床以来，达芬奇手术机器人已越来越多地用于不同的外科专业1。机器人手术系统具有使用灵活的多关节臂，高质量的三维相机，震颤过滤以及大大改进的人体工程学的优点，可以最大限度地减少手术的侵入性，从而使其成为复杂手术的理想选择。
几十年来，全直肠系膜切除术（TME）一直是治疗可切除直肠癌的标准。然而，对于位于腹膜反射下方的晚期（T3/T4）直肠癌，盆腔外侧淋巴结（LPLN）转移是术后局部复发的主要原因2。临床证据明确表明，盆腔外侧淋巴结清扫术（LPLND）可显著降低局部复发率3。与开放式手术相比，机器人辅助 TME 和 LPLND 的失血量更少，输血次数更少，术后并发症更少4。此外，两种手术之间的长期结果没有显著差异5。这些报告的结果表明，机器人辅助的LPLND可能是局部晚期直肠癌的可行方法。但是，应该注意的是，机器人辅助的TME和LPLND是复杂的程序，应由经验丰富的外科医生执行。
本文逐步描述了机器人辅助TME和LPLND的标准系统方法。该程序是在该中心开发的，该中心具有执行三千多个机器人程序的经验6。此外，这种方法基于正常的解剖学特征;应注意罕见的解剖学变异。
我们以一名 64 岁男性患者为例，该患者间歇性便血发作约 3 个月。直肠指检显示，直肠前壁和右外侧壁上有一个肿块，距离肛门5厘米。增强型计算机断层扫描（CT）和内镜超声（EUS）显示下直肠癌伴髂内淋巴结转移。结肠镜活检证实存在中度分化性腺癌。术前评估提示临床分期为cT3N+M0。因此，我们决定执行机器人辅助TME和LPLND。在执行这些程序之前已获得患者的同意。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0 Silk suture</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Secure the anvil</td>
		</tr>
		<tr>
			<td>12mm Trocar</td>
			<td>Medtronic (Minneapolis, MN)</td>
			<td>NONB12STF</td>
			<td>Assistant port 1</td>
		</tr>
		<tr>
			<td>19 Fr drain</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Pelvic drain</td>
		</tr>
		<tr>
			<td>2-0 Silk suture</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Close skin incisions</td>
		</tr>
		<tr>
			<td>2-0 V-Loc sutures</td>
			<td>Covidien (Dublin, Ireland)</td>
			<td>VLOCL0315</td>
			<td>Barbed Absorable Suture</td>
		</tr>
		<tr>
			<td>4-0 PDS</td>
			<td>Ethicon (Somerville, NJ)</td>
			<td>SXPP1A400</td>
			<td>Synthetic Absorbable Suture</td>
		</tr>
		<tr>
			<td>8mm Trocar</td>
			<td>Medtronic (Minneapolis, MN)</td>
			<td>NONB8STF</td>
			<td>Assistant port 2</td>
		</tr>
		<tr>
			<td>Bipolar forceps</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470172</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Cadiere grasping forceps</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470049</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Circular stapler</td>
			<td>EzisurgMed (Shanghai, China)</td>
			<td>CS2535</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr>
			<td>Da Vinci Si</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>N/A</td>
			<td>Surgical Robot</td>
		</tr>
		<tr>
			<td>Da Vinci Xi</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>N/A</td>
			<td>Surgical Robot</td>
		</tr>
		<tr>
			<td>Hem-o-lok ligation clip</td>
			<td>Weck (Morrisville, NC)</td>
			<td>544995</td>
			<td>Ligation of vessel</td>
		</tr>
		<tr>
			<td>Laparoscopic single use linear cutting stapler</td>
			<td>EzisurgMed (Shanghai, China)</td>
			<td>U12M45</td>
			<td>Laparoscopic Surgical Stapler</td>
		</tr>
		<tr>
			<td>Large needle driver</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470006</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Monopolar scissors</td>
			<td>Intuitive (Sunnyvale, CA)</td>
			<td>470179</td>
			<td>Operation</td>
		</tr>
		<tr>
			<td>Ribbon retractor</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Control movement of rectum</td>
		</tr>
		<tr>
			<td>Specimen Bags</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Extract specimen</td>
		</tr>
		<tr>
			<td>Veress needle</td>
			<td>N/A</td>
			<td>N/A</td>
			<td>Saline drop test</td>
		</tr>
	</tbody>
</table>

robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer

自批准用于临床以来，达芬奇手术机器人在胃肠道外科手术中显示出巨大的优势，特别是在复杂的程序中。高质量的3-D视觉，多关节臂和自然震颤过滤使外科医生能够以最小的侵入更准确地暴露和解剖。全直肠系膜切除术是治疗可切除直肠癌的标准手术技术。为了降低侧向复发率，可以进行盆腔外侧淋巴结清扫术，因为它是局部晚期中低直肠癌的安全可行的手术，转移至侧淋巴结的可能性很高。然而，解剖结构的复杂性和术后并发症的高率限制了其应用。最近，一些外科医生越来越多地使用机器人技术进行全直肠系膜切除术和盆腔外侧淋巴结清扫术。与开放和腹腔镜手术相比，机器人技术具有几个优点，例如失血量少，输血量少，创伤最小，术后住院时间短，恢复更快。机器人方法通常被认为是复杂手术（如盆腔外侧淋巴结清扫术）的合理替代方案，尽管报告直接证据的高质量前瞻性随机对照研究数量有限。在这里，我们提供了在西安交通大学第一附属医院进行的机器人辅助全直肠系膜切除术和侧向盆腔淋巴结清扫术的详细步骤。

视频中所示病例的详细围手术期信息如 表1 和 图3所示。该程序由通讯作者于2019年4月使用达芬奇Si机器人系统执行。手术期间估计失血量为90毫升，不需要输血。术后管理遵循ERAS的原则。手术后第6天第一次排便后，我们给予葡甲胺二氮酸盐灌肠，并进行X射线照相，以确定是否发生吻合口渗漏。然后，在确认没有泄漏证据后，我们移除了排水管。患者在随访期间...

Watch this Scientific Journal Video about Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer at JoVE.com

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

本文描述的机器人技术旨在详细说明机器人辅助全直肠系膜切除和盆腔外侧淋巴结清扫的逐步方法，用于位于腹膜反射下方的局部晚期（T3 / T4）直肠癌。

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 ...

本文描述的机器人技术旨在详细说明机器人辅助全直肠系膜切除的逐步方法，以及针对位于腹膜反射下方的局部晚期直肠癌的盆腔外侧淋巴结清扫术。该协议符合西安交通大学第一附属医院伦理委员会的指导方针。我们介绍了一位 64 岁男性患者的病例，该患者间歇性便血发作约 3 个月。直肠指检显示，直肠内部和右侧外侧壁上有一个肿块，距离肛门五厘米。增强型计算机断层扫描和内镜超声检查显示下直肠癌伴髂内淋巴结转移。结肠镜活检证实存在中度分化性腺癌。因此，我们决定进行机器人辅助全直肠系膜切除术和盆腔外侧淋巴结清扫术。在执行这些程序之前已获得患者的同意。诱导全身麻醉。将患者置于劳埃德·戴维斯（Lloyd Davis）的所有位置，并小心地将其固定在手术台上。确保腿部小心地用马镫填充，并且双臂都塞在侧面。确保主治外科医生从机器人控制台进行操作，并自定义其设置。让助理腹腔镜外科医生站在患者的右侧。让护士站在病人的左侧。如图所示放置机器人和辅助端口。在进行横向皮肤切口后放置每个穿刺器。设置可视端口。在脐上方2至3厘米处做一个12毫米的切口，稍微向左，并设置一个12毫米的穿刺器作为视觉端口。设置三个机械臂端口。在为每个穿刺器做横向8毫米皮肤切口后放置穿刺器。将手臂1放在麦克伯尼的右点。将手臂2放在锁骨中线的视觉端口水平。将手臂三放在视觉端口水平面的左侧内腋窝线上。设置两个辅助端口。将一个 12 毫米辅助端口 1 放置在视觉端口水平面的右锁骨中线。将一个 8 毫米的辅助端口 2 放置在耻骨联合上方约 1 至 2 厘米处。第三章.全直肠系膜切除术。第一节.调动左结肠。通过卡迪尔抓住 R 3 中的镊子将下降结肠和乙状结肠向内侧缩回，以暴露左结肠旁沟。在R 1中用单极剪刀释放下降和乙状结肠沿结肠旁沟的生理粘连。沿着结肠旁沟切开腹膜。在R 1中用单极剪刀将降结肠从上结肠从上结肠解剖到下结肠，直到输尿管暴露以动员下降结肠的外侧和脾弯曲结肠。在输尿管附近放置一块无菌纱布作为指示器。抓住并继续抬高乙状结肠，其肠系膜向前，使用红毛腩抓在R 3中镊子。在R 2中用双极抓握器张紧肠系膜，并在助手的手中使用镊子，然后识别出托尔特筋膜的白线。沿着白线切开腹膜。在R 1中用单极剪刀沿着该平面向外侧结肠旁沟分开以动员乙状结肠。之后，在先前设置的指示纱布的指导下，在内侧和侧室之间创建一个隧道。使用电烙术继续将这个平面向下发展到骶角，并结合尖锐和钝的扩散来快速解剖，以完全调动降结肠和乙状结肠。第二节.横断肠系膜下动脉和肠系膜下静脉。在动员乙状结肠后，抓住并用R 3中的镊子继续抬高乙状结肠以暴露主动脉。在R 1中用单极剪刀沿着主动脉上部解剖，以暴露肠系膜下动脉。将 R 1 中的乐器从单极剪刀更改为谐波手术刀。从肠系膜下动脉的根部，用R 1中的超声手术刀将淋巴组织与血管分开，直到左绞痛动脉出现。继续用R 1中的谐波手术刀将淋巴组织与左绞痛动脉分开。识别肠系膜下静脉和左绞痛动脉的下降分支。让助理外科医生用一个大的锁定夹夹将左绞痛动脉起源下方的下肠系膜动脉夹住，然后用谐波手术刀横断，以尽量减少出血。让助理外科医生夹住，并横切下肠系膜静脉和左绞痛动脉的下降分支。第三节.进行直肠盆腔解剖。使用带状牵开器抬起直肠。由助理外科医生将抓取镊子放在A 2中，并通过握住带状牵开器来控制直肠的运动。将 R 1 中的仪器更改为单极剪刀。用卡迪尔抓住镊子向前提起直肠，通过乙状结肠后缘插入骶骨，露出骶角，然后在R 1中用单极剪刀解剖到直肠间筋膜和下胃前神经筋膜之间的直肠后平面。沿着这个平面发展，并使用R 1中的单极剪刀将直肠系膜筋膜与下胃前神经筋膜分开，直到达到肛提肌的水平。注意，应保留直肠系膜筋膜的完整性。切开腹膜，并在R 1中用单极剪刀打开靠近直肠的外侧直肠系膜平面。让助理外科医生将直肠移到另一侧。将 R 1 中的乐器更改为谐波手术刀。小心地解剖并展开这个平面，直到达到肛提肌的水平。对侧重复此步骤。如果操作似乎很困难，请考虑先处理内部平面。用R 1中的谐波手术刀将腹膜切除在内脏腹膜反射上方1厘米处。切开内脏腹膜的反射后，确定覆盖精囊后壁的精囊和Denonvilliers筋膜。继续发展Denonvilliers筋膜和直肠间筋膜之间的平面，直到R 3中的谐波手术刀达到肛提肌的水平。注意，在女性中，应在阴道后壁和直肠系膜筋膜之间进行解剖。外科医生应避免损伤薄薄的阴道后壁。此时，进行肛门手指检查，以确认解剖已超过肿瘤的远端边缘，并且有适当的切缘进行切除。第四章.盆腔外侧淋巴结清扫术。从左侧开始，用R 1中的谐波手术刀切开输尿管外侧的腹膜。将切口向上延伸到输精管。识别左输尿管与髂血管交叉的水平，然后动员输尿管并将其移动到内侧，用R 3中的镊子。如果可能的话，避免输尿管完全骨架化。让输尿管和下胃前神经筋膜成为外侧淋巴结夹层的内侧平面。从外侧到髂外动脉，用R 1中的谐波手术刀分离髂外动脉周围的淋巴组织和静脉。用助手手中的抽吸器横向缩回髂外静脉。在髂内动脉和髂外动脉的分叉处，用R 1中的谐波手术刀分离淋巴组织，并识别闭孔神经和脐动脉。在侧壁，从腰大肌表面完全释放淋巴组织，以及内部闭塞肌。用助手手中的吸气器将脐动脉和囊泡向下胃筋膜缩回内侧。将淋巴组织与囊泡下胃筋膜分开。让脐动脉和囊泡下胃筋膜成为闭孔结夹层的内侧壁。用R 1中的谐波手术刀小心地将淋巴组织与筋膜和神经沿着闭孔神经分开，并识别闭塞动脉和静脉，它们是髂内动脉和静脉的分支。小心隔离闭孔动脉和静脉，避免损伤。用助手手中的吸气器将输尿管和下腹部前神经筋膜内侧缩回。用R 1中的谐波手术刀从筋膜中完全释放淋巴组织。识别并分离 2 至 3 条上囊泡动脉，它们是脐动脉的分支。避免连接所有囊泡上动脉分支，以尽量减少尿功能障碍。应至少保留一条上囊泡动脉，尤其是进行双侧 LPL 和 D 时。继续用R 1中的谐波手术刀远端解剖淋巴和脂肪组织，直到达到输精管。使用无菌标本袋从窝中取出作为单个标本的淋巴脂肪组织。如有必要，请在右侧重复这些步骤以完成右侧解剖。我们在视频中介绍的程序是由通讯作者使用DaVinci C机器人系统于2019年4月执行的。手术期间估计失血量为90毫升，不需要输血。术后管理坚持术后恢复增强的原则。手术后第6天第一次排便后，我们进行了葡甲胺二氮酸盐灌肠，并进行了X射线照相，以确定是否发生了吻合口渗漏。然后，在确认没有泄漏证据后，我们移除了排水管。患者在随访期间未报告任何泌尿或性功能障碍。标本病理检查显示腺癌有中度分化。在19个直肠系膜淋巴结或18个侧淋巴结中的任何一个中均未检测到阳性淋巴结。我们建议患者接受辅助化疗。直到2021年1月，患者仍然没有任何复发或转移的证据。在我们的中心，这种机器人技术已经在89名患者中进行了。所有程序都在机器人协助下成功完成，没有转换为开放手术。详细信息如表所示。总之，这种机器人技术是安全的，并且对于局部晚期中低直肠癌患者是可行的。这种技术可以更好地暴露复杂的解剖结构，并且可以减少意外的伤害。随着微创手术的发展趋势，适当选择手术适应症和对解剖结构的深刻理解是成功手术的关键因素。此外，我们建议根据个别外科医生的偏好和经验进行适当的个性化调整。

Research

JoVE Journal

Medicine

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

多光谱实时荧光成像术在妇科肿瘤前哨淋巴结的检测

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

科研

医学

High-frequency Ultrasound Imaging of Mouse Cervical Lymph Nodes

鼠标颈淋巴结高频超声成像

High-frequency ultrasound (HFUS) is widely employed as a non-invasive method for imaging internal anatomic structures in experimental small animal ...

Vessel-sparing Excision and Primary Anastomosis

血管保留切除术与原发性吻合术

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

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 ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

慢性胰腺炎的机器人侧胰腺肌切除术

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

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

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 ...

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 ...

An In Vivo Mouse Model of Total Intravenous Anesthesia During Cancer Resection Surgery

An In Vivo Mouse Model of Total Intravenous Anesthesia During Cancer Resection Surgery

癌症切除手术中全静脉麻醉的 体内 小鼠模型

Anesthesia is a routine component of cancer care that is used for diagnostic and therapeutic procedures. The anesthetic technique has recently been ...

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 ...