專題討論1:精準與人工智慧醫療

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Novel Technique in Robotic Surgery From Multiple Port, Single Port to NOTES
How do We Adjust It
Cheng-Ming Peng,Yao-Kun Yang, Ching-Lung,Hsieh, Min-Che Lin
Division of General Surgery, Department of Surgery
da Vinci Robotic Minimally Invasive Surgery Center
Chung Shan Medical University Hospital, Taiwan

Purpose:
  Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliopancreatic(HBP) and gastrointestinal(GI) surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incisional laparoscopic surgery(RSILS) in HBP and GI surgery using the GelPoint , LAGIS Port and Glove Port in a preliminary study.
  Peripancreatic surgery is considered as the most complex surgeries. The recently developed robotic technology allows surgeons to perform pancreaticoduodenectomy(PD). Robotic-assisted surgery, with magnified stereoscopic visualization and computer-enhanced 540 degree movement of the surgical instruments, has the potential to overcome the technical impediments to recreating time-tested techniques for open peripancreatic surgery in a minimal invasive technique.
  Natural orifice transluminal endoscopic surgery (NOTES) has gained considerable momentum in today’s surgical operative techniques. The innovative idea of accessing the abdominal cavity via natural orifices such as the stomach, rectum, or vagina has the potential to initiate fundamental changes comparable with those brought on by the development of minimally invasive surgery 20 years ago. After the first transgastric NOTES procedure was performed in a pig model by Kalloo et al1 in 2004, many groups started to develop novel NOTES approaches for clinical application. Initial reports confirm the safety and feasibility of natural orifice transluminal endoscopic surgery (NOTES) transvaginal cholecystectomy. Benefits of TC include no visible scars, less pain, and shorter recovery.
Materials and Methods:
  From January 2012 to September 2016, we collected 55 patients with da Vinci single incision hepatectomy. Perioperative outcomes, including blood loss, transfusion requirements, complications, and length of stay (LOS) were assessed as same as conventional robotic surgery but postoperative pain is less than conventional robotic surgery. All robotic SILS procedures were completed (81/81, 100%).16 patients with da Vinci total gastrectomy with lymph node dissection. There was 10 gastric cancer and 6 gastric stump cancer. About pancreas surgery,102 patients underwent da Vinci robotic pancreaticoduodenectomy (RPD) between January 2012 and March 2017 were analyzed by one surgeon. 32 patients underwent conventional robotic pancreaticoduodenectomy,25 patients with pure robotic single port pancreaticoduodenectomy(RSPPD) and 45 patients with robotic single port plus one pancreaticoduodenectomy (RSPPD+1 ) technique were performed.
  From July 2015 to September 2017, 14 patients performed NOTES cholecystectomy. We use single port platform such as Glove port, Lagis port and GelPoint. The port was introduced through the posterior vagina into the cul-de-sac. The gallbladder was visualized using an endoscope introduced through the vaginal port. Without extracorporeal stay sutures for retraction. The cystic duct and artery were dissected free, clipped, and divided by instruments. The gallbladder was then removed through the vaginal port.
Results:
  All procedure were safely performed under the da Vinci Si system. robotic SILS procedures were completed (55/55, 100%). The hepatectomy was safely performed in average operating times of 95 min (±25), with minimal blood loss. There was 46 pure single port hepatectomy and 9 single port plus one ( LAGIPORT: 12,Glove Port:38, Gelpoint:5). There were no conversions and no extension of the skin incision. Median hospital stay were 8 days (range: 5~13days). The RSPTG were safely performed in average operating times of 230 min (±45). There was no conversion to open approach, one wound infections, minimal blood loss. One pneumonia with medical treatment. Median lymph node dissection number was 26 (arrange: 21~ 72). Median hospital stay was 12 days (arrange:10~ 20 days).4 patients with conversion to single port plus one occurred. The robotic group had a significantly longer operative time ( mean: 405min), reduced blood loss (mean: 480 cc ), and shorter hospital stay( mean:25.5 days).
  The pure RSPPD group had a significantly longer operative time (mean: 395 min).The RSPPD+1 group with shorter operative time(men:336 min) ,more blood loss (mean: 480 cc ), and hospital stay with no difference ( mean:25.5 days).Postoperative complications showed pancreatic leakage, pneumonia (RPD:1), postoperative bleeding (RPD:1, RSPPD:1, RSPPD+1 :1) , wound infection and mortality (RPD: 1,RSPPD+1 :3).
  14 patients underwent a successful NOTES cholecystectomy. The average age was 34.9 years (27-65 years), average body mass index was 27.6 kg/m2 (17.2-35.1 kg/m2), and the mean operative time was 70.4 minutes (48-118 minutes).
Conclusion:
  Robotic single incision surgery in HBP and GI surgery is technically feasible and safe in well selected patients.Using the commercial port such as LAGIS Port(Taiwan), Gelpoint(USA) and Glove port(S.Korea) as a single-incision access platform. Robotic SILS is easily established and is enormously advantageous to the well selected patient.
  RPD, RSPPD and RSPPD+1 allows the resection of time-tested techniques for open peripancreatic surgery through a minimally invasive approach. The robotic system combined with single port platforms are able to overcome the current limitations of laparoscopic single port surgery including limited range of motion, poor surgeon ergonomics, and lack of 3-D view. This study showed that RSPPD and RSPPD+1 were safe and feasible in appropriately selected patients. NOTES cholecystectomy is a safe, feasible in well selected patients.