探讨改良的序贯血管阻断策略在机器人辅助腹腔镜肾癌伴Ⅲ~Ⅳ级下腔静脉癌栓手术中的应用 及临床价值。方法：2013 年 5 月 ~2019 年 9 月收治 35 例肾癌伴Ⅲ~Ⅳ级下腔静脉癌栓患者，其中Ⅲ级 19 例，Ⅳ级 16 例。所有患者均行机器人辅助腹腔镜手术治疗，其中 18 例采用了改良的序贯血管阻断策略。通常Ⅲ级以上癌栓 需要阻断第一肝门和肝上下腔静脉。根据以往经验，直到完全切除癌栓并缝合下腔静脉后才解除第一肝门阻断，并 在手术结束前停止体外循环。而在本次研究中，笔者针对以往的血管阻断策略做了相应的改良。在血管阻断确切后， 首先将癌栓近心端取出；当癌栓近心端低于肝静脉水平后，立即在第二肝门下方阻断下腔静脉，并提前恢复肝脏 血供，停止体外循环；然后，继续将剩余的癌栓完整切除并缝合下腔静脉；最后，依次解除其余血管阻断并完成 根治性肾切除。结果：与以往的血管阻断策略相比，改良的序贯血管阻断策略显著缩短了术中肝脏中位热缺血时 间（19.0 Vs 45.5 min，P<0.001）和体外循环转机时间（63.5 Vs 87.0 min，P<0.05），显著降低了术后Ⅱ级以上并 发症的发生率（27.8% Vs 64.7%，P<0.05），并显著改善了术后的肝、肾及凝血功能指标，其中主要包括血清谷丙 转氨酶（173.2 Vs 518.9 U/L，P<0.001）、谷草转氨酶（250.7 Vs 790.8 U/L，P<0.001）肌酐（127.2 Vs 215.6 μmol/L， P<0.05）、尿素氮（7.2 Vs 9.7 mmol/L，P<0.01）以及血浆 D 二聚体（6.0 Vs 19.4 mg/L，P<0.001）。结论：改良的 序贯血管阻断策略在机器人辅助腹腔镜肾癌伴Ⅲ级以上下腔静脉癌栓手术中安全可行，显著降低了患者的围手术 期风险，值得进一步推广。但对该技术的评价仍需多中心、大样本研究和长时间随访。

To explore the application and clinical value of a modified sequential vascular control strategy in robot-assisted laparoscopic nephrectomy combined with level Ⅲ - Ⅳ inferior vena cava (IVC) thrombectomy. Methods: From March 2013 to September 2019, 35 patients with a level Ⅲ - Ⅳ IVC tumor thrombus (IVCTT) underwent robot-assisted IVC thrombectomy (RA-IVCTE) in our department. The sequential vascular-blocking strategy was applied in 18 cases. Previously, we kept controlling the first porta hepatis (FPH) after the thrombus was resected and the IVC was closed completely and stopped the cardiopulmonary bypass (CPB) at the end of the surgery. Unlike the previous strategy, we clamped the IVC inferior to the second porta hepatis (SPH) once the proximal thrombus was removed from the IVC below the hepatic veins (HVs). Then, we early recovered the liver circulation and stopped the CPB. Finally, tumor thrombectomy, IVC reconstruction, and radical nephrectomy were performed. Results: Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping time (19.0 Vs 45.5 min, P<0.001) and CPB time (63.5 Vs 87.0 min, P<0.05), a lower rate of grade Ⅱ-Ⅳ perioperative complications (27.8% Vs 64.7%, P<0.05), and a better postoperative liver, renal, and coagulation function, including better median serum ALT (173.2 Vs 518.9 U/L, P<0.001), AST (250.7 Vs 790.8 U/L, P<0.001), Cr (127.2 Vs 215.6 μmol/L, P<0.05), BUN (7.2 Vs 9.7 mmol/L, P<0.01), and D-dimer (6.0 Vs 19.4 mg/L, P<0.001) levels. Conclusion: The sequential vascular-blocking strategy reduced the perioperative risk of level Ⅲ-Ⅳ RA-VICTE and improved the feasibility and safety of the surgery, which might be recommended in the future. However, further study shall be made under multicenter, larger sample and longer follow-up.

收稿日期：2020-03-02 录用日期：2020-04-10

Received Date: 2020-03-02 Accepted Date: 2020-04-10

通讯作者：薛敏，Email: xuemin5908@sina.com

Corresponding Author: XUE Min, Email: xuemin5908@sina.com

引用格式：叶明珠，邓新粮，贺斯黎，等 . 机器人腹腔镜下腹股沟淋巴结切除术在外阴癌治疗中的近期疗效研究 [J]. 机器人外科学

杂志 , 2020, 1（1）：26-33.

Citation: YE M Z, DENG X L, HE S L, et al. Study on short-term efficacy of robotic-assisted laparoscopic inguinal 

lymphadenectomy in the treatment of vulvar cancer[J]. Chinese Journal of Robotic Surgery, 2020, 1(1):26-33.

[1] Marshall F F. Renal cell carcinoma: surgical management of regional lymph nodes and inferior venacaval tumor thrombus[J]. Seminars in Surgical Oncology,1988, 4 (2): 129-132. 

[2] Hatcher P A, Anderson E E, Paulson D F, et al. Surgical management and prognosis of renal cell carcinoma invading the vena cava[J]. The Journal of Urology, 1991, 145 (1): 20-24. 

[3] JUN H, HAN Y, PARK H, et al. Clinical outcomes related to the level of clamping in inferior vena cava surgery. World Journal of Surgery[J], 2015, 39 (5): 1294-1300. 

[4] 黄庆波 , 彭程 , 马鑫 , 等 . 机器人辅助腹腔镜 Mayo Ⅲ ~ Ⅳ级下腔静脉癌栓取出术的经验总结 : 附 5 例报告 [J]. 中华泌尿外科杂志 , 2019, 40 (2): 81-85. 

[5] Amin M B ES, Greene F L, et al. AJCC cancer staging manual [M]. Springer, 2016: 739-749. 

[6] Blute M L, Leibovich B C, Lohse C M, et al. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus[J]. BJU International, 2004, 94 (1): 33-41. 

[7] Dindo D, Demartines N, Clavien P A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey[J]. Annals of Surgery, 2004, 240 (2): 205-213. 

[8] Man K, Fan S T, et al. Tolerance of the liver to intermittent pringle maneuver in hepatectomy for liver tumors[J]. Archives of Surgery (Chicago, Ill: 1960), 1999, 134 (5): 533-539. 

[9] Ciancio G, Vaidya A, Savoie M, et al. Management of renal cell carcinoma with level Ⅲ thrombus in the inferior vena cava[J]. The Journal of Urology, 2002, 168 (4 Pt 1): 1374-1377. 

[10] Hevia V, Ciancio G, Gomez V, et al. Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results[J]. SpringerPlus, 2016, 5: 132. [11] Novick A C, Kaye M C, Cosgrove D M, et al. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi[J]. Annals of Surgery, 1990, 212 (4): 472-476; discussion 476-477. 

[12] Pouliot F, Shuch B, Larochelle J C, et al. Contemporary management of renal tumors with venous tumor thrombus[J]. The Journal of Urology, 2010, 184 (3):833-841; quiz 1235.

[13] Stewart J R, Carey J A, Mcdougal W S, et al. Cavoatrial tumor thrombectomy using cardiopulmonary bypass without circulatory arrest[J]. The Annals of Thoracic Surgery, 1991, 51 (5): 717-721. 

[14] Patil M B, Montez J, et al. Level Ⅲ ~ Ⅳ inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control[J]. The Journal of Urology, 2014, 192 (3): 682-688. 

[15] Gill I S, Metcalfe C, Abreu A, et al. Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series. The Journal of urology[J]. 2015, 194 (4): 929-938. 

[16] Abaza R, Shabsigh A, Castle E, et al. Multi-Institutional Experience with Robotic Nephrectomy with Inferior Vena Cava Tumor Thrombectomy[J]. The Journal of Urology, 2016, 195 (4 Pt 1): 865-871. 

[17] Chopra S, Simone G, Metcalfe C, et al. Robotassisted Level Ⅱ ~ Ⅲ Inferior Vena Cava Tumor Thrombectomy: Step-by-Step Technique and 1-Year Outcomes[J]. European Urology, 2017, 72 (2): 267-274. 

[18] Murphy C, Abaza R. Complex robotic nephrectomy and inferior vena cava tumor thrombectomy: an evolving landscape[J]. Current opinion in Urology, 2020, 30 (1): 83-89. 

[19] de Castro Abreu A L, Chopra S, Azhar R A, et al. Robotic Transabdominal Control of the Suprahepatic, Infradiaphragmatic Vena Cava to Enable Level 3 Caval Tumor Thrombectomy: Pilot Study in a PerfusedCadaver Model[J]. Journal of Endourology, 2015, 29 (10): 1177-1181. 

[20] 秦超 , 邵鹏飞 , 李普 , 等 . 体外循环下腹腔镜、胸腔 镜联合小切口治疗肾癌合并Ⅳ级癌栓的安全性和 疗效分析 [J]. 中华泌尿外科杂志 , 2014, 35(6): 414- 417. 

[21] SHEN D, WANG H, WANG C, et al. Cumulative Sum Analysis of the Operator Learning Curve for RobotAssisted Mayo Clinic Level Ⅰ ~ Ⅳ Inferior Vena Cava Thrombectomy Associated with Renal Carcinoma: A Study of 120 Cases at a Single Center[J]. Medical Science Monitor, 2020, 26: e922987. 

[22] Kassite I, Bejan-Angoulvant T, Lardy H,. A systematic review of the learning curve in robotic surgery: range and heterogeneity[J]. Surg Endosc, 2019, 33 (2): 353- 365.