关键词： 机器人手术系统；先天性巨结肠症；Soave 拖出术；疗效；体重
张茜，常晓盼，汤绍涛，曹国庆，李帅，李康
目的：探讨机器人辅助 Soave 样拖出术治疗小儿先天性巨结肠症的经验及中期疗效，研究体重对机器人辅助拖出术和术后结果的影响。方法：以 2015 年11 月 ~2020 年 12 月华中科技大学同济医学院附属协和医院小儿外科接受机器人辅助 Soave 样拖出术的 106 例先天性巨结肠症患儿为研究对象。根据体重分为两组，A 组≤ 10kg，B 组 >10kg。采用 Da Vinci 机器人 Si 系统，经盆腔浆膜下游离直肠至齿状线附近，经肛门拖出正常肠管与肛管吻合。前瞻性收集两组患者的基本资料、手术参数和术后结果并进行回顾性分析。年龄≥ 3 岁的巨结肠患儿进行术后肠功能问卷回访。采用肠功能评分（Holschneider 评分）问卷和术后大便失禁（Postoperative fecal continence，POFC）量
表评估两组患儿的排便功能。所有手术均由同一外科医生及其团队完成。结果：所有患儿均顺利完成手术。A 组的手术时间为（218±25.6）min，B 组为（206±29.7）min，差异无统计学意义（P=0.82）。A 组中 1 例患儿术后发生切口疝，再次手术痊愈；B 组中术后发生伤口感染 1 例，肺部感染 1 例，均保守对症治疗好转。两组患儿手术时间、术中出血量、术中并发症及住院时间等方面差异无统计学意义（P>0.05）。短期结果未显示 A 组患儿术后并发症发生率较高。Holschneider 评分和 POFC 评分的结果显示两组患儿的排便功能比较结果无统计学差异，且 90% 的患儿达到了优良排便功能。结论：机器人辅助 Soave 样拖出术是一种安全可行的手术方式，适合所有年龄患儿，小龄低体重患儿一样可以获得良好的术后疗效。
Objective: To investigate the mid-term outcomes and experience of robotic Soave-like pull-through (RSPT) procedure for Hirschsprung’s disease (HD) and the influence of body weight on operative and postoperative outcome in pediatric patients treated with RSPT. Methods: From November 2015 to December 2020, 106 consecutive patients treated with RSPT were recorded and divided into two groups according to their weight (group A ≤ 10kg, group B>10kg). The Da Vinci Si surgical system was used to separate rectum from its serosa to dentate line by keeping the anatomical plane away from the Denonvilliers’ fascia and presacral fascia. The normal intestinal canal was anastomosed to the anus using interrupted absorbable sutures. Basic information, operative parameters and postoperative outcomes of two groups were prospectively collected and retrospectively analyzed. Patients aged ≥ 3 years answered detailed questionnaires on bowel function. Holschneider score questionnaires and postoperative fecal incontinence (POFC) scales were used to evaluate the mid-term functional outcomes. All procedures were performed by the same robotic surgeon and team. Results: All the patients were successfully completed the robotic surgery. 32 patients were divided into group A with the weight of (7.6±1.8) kg and 74 patients into group B with the weight of (27.4±6.7) kg. The operative time was (218±25.6) min compared to (206±29.7) min (group A Vs group B). No significant difference was found (P=0.82). One case of incisional hernia was found after surgery in group A and recovered after reoperation. One wound infection and one lung infection were found in group B, which got better after conservative treatment. No difference was found in respect of operative time, estimated blood loss, intraoperative complication and length of hospital stay between the groups (P>0.05). Short-term outcomes failed to demonstrate higher rate of postoperative complications in group A ≤ 10 kg. Furthermore, the mid-term outcomes based on Holschneider and POFC scores in group A ≤ 10 kg were statistically equivalent to group B>10 kg, and showed 90% of patients reached excellent and good bowel function. Conclusion: Robotic Soave-like pull-through is a safe and feasible alternative for the treatment of HD, which is suitable to children on different ages, even small children with low weight can also get good postoperative outcomes.