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目的尝试应用达芬奇机器人辅助完成全腔镜下右肾癌根治切除+腔静脉Ⅱ级癌栓取出术。方法患者女性,73岁,因“右腰痛伴肉眼血尿4个月”行CT检查提示:右肾癌伴下腔静脉癌栓,肿瘤大小4.9cm×4.7cm,下腔静脉内癌栓长度4.6cm。术前行靶向药物治疗3个月,复查肿瘤大小4.3cm×4.4cm,癌栓长度缩短为3.3cm。术前2d于下腔静脉癌栓近心端放置滤器。患者取左侧斜卧位,在右侧腹直肌外侧缘脐上2cm处经12mm套管置入镜头,直视下分别置入1、2号机械臂8mm套管及第1、2、3辅助孔套管,装配机械臂。将升结肠及十二指肠翻至左侧,暴露右肾周筋膜,打开下腔静脉鞘,沿下腔静脉表面充分游离。游离并夹闭右肾动脉后,使用血管吊带依次阻断癌栓尾侧下腔静脉、左肾静脉、癌栓头侧下腔静脉。于右肾静脉根部向上纵行切开下腔静脉5cm,完整取出下腔静脉内癌栓并切除部分与之粘连的右侧下腔静脉壁,关闭下腔静脉切口,开放血流。彻底止血,取出标本,放置引流后逐层关闭切口。结果手术顺利,历时363min,下腔静脉共阻断47min,术中出血1 200mL,术中输血1 200mL。术后因贫血输血1 000mL,无其他手术并发症发生,术后第3天肠道恢复通气,引流管留置时间3d,术后住院16d。结论成功完成中国首例达芬奇机器人辅助全腔镜下肾癌根治切除+腔静脉Ⅱ级癌栓取出术,手术安全、可行,但难度较大,应严格把握适应证,确保手术安全。
Objective To use Da Vinci robot to assist in the completion of endoscopic radical resection of right renal cell carcinoma + vena cava tumor thrombectomy. Methods A 73-year-old female patient with right lower back pain with gross hematuria for 4 months underwent CT examination. The right renal cancer with IVC tumor thrombus, tumor size 4.9cm × 4.7cm, IVC thrombus length 4.6cm. Preoperative targeted drug therapy for 3 months, review the size of the tumor 4.3cm × 4.4cm, shortening the length of the embolus to 3.3cm. Preoperative 2d in the inferior vena cava tumor embolization near the filter placed. Patients take the left oblique position, the right lateral rectus abdominis umbilical 2cm at the 12mm cannula into the lens, respectively, into the 1,2 arm under 8mm cannula and 1, 2, 3 Auxiliary hole bushing, assembly arm. The ascending colon and duodenum turned to the left, exposing the right renal fascia, open the inferior vena cava sheath, along the surface of the inferior vena cava full free. Free and clipping the right renal artery, the use of vascular sling in turn blocking the tail vein tumor thrombus, left renal vein, tumor thrombus side of the inferior vena cava. In the right renal vein root up longitudinal incision of the inferior vena cava 5cm, complete removal of the inferior vena cava tumor thrombus and removal of some of the adhesion with the right inferior vena cava wall, close the inferior vena cava incision, open the bloodstream. Thorough bleeding, remove the specimen, place the drainage layer after layer close the incision. Results The operation was successful and lasted for 363 minutes. The inferior vena cava was blocked for 47 minutes. The intraoperative blood loss was 1,200 mL and the intraoperative blood transfusion was 1,200 mL. Postoperative anemia blood transfusion 1 000 mL, no other complications occurred, the first 3 days postoperative recovery of intestinal ventilation, drainage tube indwelling time 3d, postoperative hospitalization 16d. Conclusions Successful completion of radical nephrectomy in China by Leonardo da Vinci robotic-assisted endoscopic carotid angioplasty + grade II tumor embolization is safe and feasible. However, it is more difficult and should be strictly controlled to ensure the safety of the operation.