Objective: To explore the safety and feasibility of da Vinci robot surgical systems in natural orifice specimen extraction surgery (NOSES) for rectal neoplasms. Methods: A descriptive cohort study was used. Inclusion criteria: (1) age ≥18 years old; (2) diagnosis of rectal cancer by biopsy via colonoscopy or benign neoplasm locating in rectum that could not be resected locally through the anus; (3) R0 resection can be achieved by preoperative evaluation; (4) the CDmax (maximum circumferential diameter) was ≤5 cm or specimens could still be extracted from the anus despite a CDmax exceeding 5 cm but was along the longitudinal axis of the rectum. Exclusion criteria: (1) emergency operation due to gastrointestinal obstruction, perforation, or bleeding; (2) distal metastasis, induding lung, bone, or liver, that could not be resected simultaneously; (3) history of abdominal surgery or any other contraindications for robotic surgery. Clinicopathological data of 162 patients with rectal neoplasms who underwent robotic NOSES at the General Surgery Department of the Second Xiangya Hospital of Central South University from March 2016 to July 2019 were retrospectively collected. Of 162 patients, 94 were male and 68 were female; the average age was (57±13) years; the average BMI was (23.5±3.2) kg/m(2); the average distance from tumor to the anal verge was (8.2±2.9) cm. Five trocars were used to perform total mesorectal excision (TME), and the descending colon artery was preserved. Sterile endoscope sleeve for the specimen extraction was inserted into the pelvic cavity through the anus, and the resected specimen was pulled out through the sleeve. Outcomes of safety (operation time, intraoperative blood loss and postoperative morbidity of complication) and oncological outcomes (number of lymph nodes harvested, rate of lymph node metastasis and rate of positive resection margin) were collected. Results: All the 162 cases completed robotic NOSES successfully with no conversion to laparotomy. The average operation time was (188.7±79.8) minutes; the average blood loss was (47.1±33.2) ml; the average and the maximum CDmax of specimens were (3.4±1.5) cm and 12 cm respectively. A total of 154 patients underwent robotic TME. One underwent robotic TME plus resection of liver metastasis; one underwent robotic TME plus partial transverse colectomy; two patients underwent robotic TME plus ovariectomy; another two underwent robotic TME plus hysterectomy; one patient underwent robotic TME plus left partial nephrectomy due to renal angioleiomyoma; another one underwent robotic TME plus ureteral repair due to intraoperative injury of the left ureter. All the specimens were extracted through the anus. Protective ileostomy was performed in 6.8% (11/162) of the patients. The average number of lymph node harvested was 14.9±5.1. According to pathological reports, 156 neoplasms were adenocarcinoma. Tis stage was 1.3% (2/156), T1 stage was 9.0% (14/156), T2 stage was 26.3% (41/156), T3 stage was 35.9% (56/156), and T4 stage was 27.6% (43/156). Lymph node metastasis accounted for 34.6% (54/156), and simultaneous liver metastasis was observed in one case. Circumferential resection margins (CRMs) and upper and lower resection margins were negative in all the patients. The average postoperative feeding time and postoperative hospital stay were (4.2±4.1) days and (11.4±7.7) days, respectively. Postoperative morbidity of complication was 12.3% (20/162). The incidence of anastomotic leakage was 4.9% (8/162), of which only 4 cases (2.5%) received ileostomy. Within postoperative 90-day, no anal dysfunction or death were found. Conclusion: Robotic NOSES for rectal neoplasms is safe and feasible.
目的： 探讨经自然腔道取标本（NOSES）的机器人直肠肿瘤手术可行性和安全性。 方法： 采用描述性病例系列研究方法。纳入标准：（1）年龄≥18岁；（2）术前经肠镜病理证实为恶性肿瘤，或虽为良性肿物但无法局部切除或经肛切除者；（3）预期能达到R(0)切除；（4）术前评估肿瘤长径≤5 cm，或虽肿瘤长径>5 cm但与肠管长轴平行，预计标本能够从肛门拖出。排除合并肠梗阻、穿孔、出血或远处转移者以及存在腹腔镜手术禁忌证或既往有腹部大手术或粘连病史者。回顾性收集2016年3月至2019年7月期间，在中南大学湘雅二医院胃肠外科行NOSES机器人直肠肿瘤手术的162例患者病例资料。其中，男性患者94例，女性患者68例，年龄（57±13）岁，体质指数为（23.5±3.2）kg/m(2)，肿瘤下缘距离肛缘距离为（8.2±2.9）cm。采用5孔法放置机器人Trocar，行全直肠系膜切除术（TME），左结肠动脉常规予以保留。经肛门置入腔镜无菌套，套内将切除标本经肛门拖出。观察手术安全性指标（包括手术时间、术中出血量以及术后并发症情况等）和肿瘤根治性指标（淋巴结检出数、转移阳性淋巴结数以及阳性切缘情况等）。 结果： 162例患者均完成机器人NOSES，无中转开腹病例。手术时间为（188.7±79.8）min，术中出血量为（47.1±33.2）ml。肿瘤长径为（3.4±1.5）cm，最大为12 cm。按照手术方式统计，154例患者行TME术，1例患者为TME并肝转移瘤切除，1例TME并横结肠部分切除，2例TME并卵巢切除，2例TME并子宫切除，1例因左肾血管平滑肌瘤行TME并左肾部分切除，1例因术中左侧输尿管损伤行TME并左侧输尿管修补。所有患者均经直肠取出标本。行预防性回肠双腔造口率为6.8%（11/162）。淋巴结检出（14.9±5.1）枚。术后病理检查显示，156例为腺癌，其中Tis期1.3%（2/156）、T(1)期9.0%（14/156）、T(2)期26.3%（41/156）、T(3)期35.9%（56/156）、T(4)期27.6%（43/156）。34.6%（54/156）的腺癌患者有淋巴结转移，1例同时性肝转移。所有病例环周切缘（包括上下切缘）均为阴性。术后患者的进食时间为（4.2±4.1）d，术后住院天数为（11.4±7.7）d。术后总并发症发生率为12.3%（20/162），吻合口漏发生率4.9%（8/162）。4例（2.5%）因吻合口漏后行回肠造口。术后90 d内，无肛门功能异常及死亡病例。 结论： 机器人NOSES治疗直肠肿瘤具有良好的可行性及安全性。.
Keywords: Natural orifice specimen extraction surgery; Rectal neoplasms; Robotic surgery.