关键词： 机器人手术；肾癌；癌栓；下腔静脉；肝静脉
沈东来，杜松良，王晨峰，黄庆波，高宇，范阳，顾良友，刘侃，彭程，李宏召，马鑫，王保军，张旭
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.