Objective: To explore the technical characteristics and short-term clinical efficacy of robotic-assisted intersphincteric resection (ISR) for patients with low rectal cancer. Methods: A retrospective cohort study was used. Inclusion criteria: (1) rigid colonoscopy showed lower margin of the tumor ≤5 cm from the anal verge; (2) preoperative rectal MRI or endorectal ultrasound revealed staging T1-2, or T3 patients receiving concurrent chemoradiotherapy; (3) patients less than 70 years old with good function of anal sphincter before surgery; (4) no synchronous multiple primary carcinoma, and no distant metastasis; (5) the method of operation was agreed by the patient. Exclusion criteria: (1) T4 stage tumors; (2) sphincter dysfunction before operation; (3) recurrent tumors; (4) lower edge of tumors beyond the dentate line; (5) death due to non-rectal cancer during follow-up and unsatisfactory follow-up data. The clinical data of 21 patients with low rectal cancer meeting inclusion criteria undergoing robotic-assisted ISR at our department from January 2015 to June 2018 were collected. Parameters during and after operation were observed. Anorectal manometry was performed at 3, 6, and 12 months after the operation, and anal function was evaluated at 3, 6, and 12 months after the closure of the stoma by Kirwan classification and Wexner fecal incontinence score. The key steps of the operation are as follows: according to the principle of total mesorectal excision, the robot continued to enter into the levator ani hiatusdistally, and dissectin the sphincter space; according to the scope of sphincter resection, ISRwas divided into partial ISR, subtotal ISR, and total ISR; subtotal and total ISR usually needed to be combined with transanal pathway. The reconstruction of digestive tract was performed by double stapler anastomosis under laparoscope orhand-sewnanastomosis under direct vision, and preventive ileostomy was completed in the right lower abdomen. Results: Of 21 patients, 13 were male and 8 were female with mean age of (57.5±16.3) years. All the patients successfully completed the operation without conversion to laparotomy. Fourteen cases (66.7%) adopted partial ISR through complete transabdominal approach, 6 cases (28.6%) adopted the subtotal ISR through combined transabdominal and transanal approachs, and 1 case (4.8%) adopted the total ISR through the combined transabdominal and transanal approachs. The total operation time was (213.1±56.3) minutes, including (27.3±5.4) minutes for mechanical arm installation and (175.7±51.6) minutes for robotic operation. The amount of intraoperative hemorrhage was (62.8±23.2) ml, and no blood transfusion was performed in any patient. All patients underwent prophylactic ileostomy, and the stoma was closed 3-6 months after the operation. Except one case of anastomotic leakage, all other stomas were closed successfully. The postoperative hospitalization time was (7.6±2.2) days, and time to fluid intake was (3.3±0.9) days. One case of anastomotic leakage, one case of anastomotic stenosis, one case of inflammatory external hemorrhoids and one case of urinary retention occurred after surgery,and all of them were cured by conservative treatment. The mean diameter of tumors was (2.9±1.2) cm, and the number of harvested lymph node was 12.8 ± 3.3. In the whole group, the circumcision margin was negative, the proximal margin was (12.2 ± 2.1) cm, the distal margin was (1.1 ± 0.4) with all negative, and the R0 resection rate was 100%. The results of anorectal manometry showed that the preoperative rest pressure, rectal maximum squeeze pressure, initial sensory volume and maximum tolerated volume were (45.19±8.46) mmHg, (128.18±18.80) mmHg, (44.33±10.11) ml and (119.00±19.28) ml, respectively;these parameters reduced significantly 3 months after operation and they were (23.44±5.54) mmHg, (93.72±12.15) mmHg, (17.72±5.32) ml and (70.44±10.9) ml, respectively. The differences were statistically significant (all P<0.001). The resting pressure and the rectal maximum squeeze pressure returned to preoperative levels 12 months after operation, which were (39.33±6.64) mmHg and (120.58±16.47) mmHg, respectively (both P>0.05), while the initial sensory volume and the maximum tolerated volume failed to reach the preoperative state, which were (30.67±7.45) ml and (92.25±10.32) ml, respectively (both P<0.05). The patients were followed up for (22.1±10.6) months without local recurrence and distant metastasis. Eighteen patients were evaluated for anal function: Kirwan classification was grade I for 6 cases, grade II for 7 cases, grade III for 4 cases, and grade IV for 1 case; Wexner incontinence score was 8.6±0.8; 14 cases had good defecation control. Conclusion: The clinical efficacy of ISR with Da Vinci robot in the treatment of low rectal cancer is satisfactory.
目的： 探讨达芬奇机器人低位直肠癌经括约肌间切除术（ISR）的技术特点和近期临床疗效。 方法： 采用回顾性病例队列研究方法。病例入选标准：（1）硬质肠镜检查肿瘤下缘距肛缘≤5 cm；（2）术前直肠MRI或腔内超声分期T(1~2)期和接受同步放化疗的T(3)期患者；（3）年龄<70岁，术前肛门括约肌功能良好；（4）非同时性多原发癌，无合并脏器转移；（5）手术方式获患者同意。排除标准：（1）T(4)期肿瘤；（2）术前检查患者括约肌功能障碍；（3）复发性肿瘤；（4）肿瘤下缘超过齿状线；（5）随访期间因非直肠癌导致的死亡及随访资料不满意者。收集2015年1月至2018年6月期间陆军军医大学西南医院收治的符合病例纳入标准的行达芬奇机器人ISR的21例低位直肠癌患者临床资料，年龄（57.5±16.3）岁，男性13例，女性8例，观察术中、术后情况以及术后肛门功能（术后3、6、12个月进行肛门直肠测压，关闭造口术后3、6、12个月采用Kirwan分级和Wexner失禁评分进行肛门功能评估）。手术关键步骤为：按照全直肠系膜切除术原则手术，继续向远端进入肛提肌裂孔在括约肌间隙分离，根据括约肌切除范围分为部分ISR、次全ISR、完全ISR，次全或完全ISR通常需要联合经肛门路径。消化道重建方式为腔镜下双吻合器吻合法和直视下手工吻合完成结肠-肛管端-端吻合，并在右下腹完成预防性回肠造口。 结果： 全组患者均顺利完成手术，无中转开腹。14例（66.7%）为完全腹腔路径部分ISR，6例（28.6%）为经腹-经肛联合路径次全ISR，1例（4.8%）为经腹-经肛联合路径完全ISR。总手术时间为（213.1±56.3）min，其中机械臂装卸时间（27.3±5.4）min，机器人手术操作时间（175.7±51.6）min。术中出血量为（62.8±23.2）ml，均无输血。所有患者均行预防性回肠造口，于术后3~6个月行造口还纳，除1例吻合口漏患者未在规定时间内行造口还纳，其余均还纳成功。术后住院时间（7.6±2.2）d，术后进流质时间（3.3±0.9）d。术后出现吻合口漏、吻合口狭窄、炎性外痔及尿潴留各1例，均保守治疗治愈。肿瘤直径为（2.9±1.2）cm，淋巴结清扫数为（12.8±3.3）枚，全组患者环周切缘阴性，近切缘长（12.2±2.1）cm，远切缘长（1.1±0.4）cm，远切缘呈阴性，R(0)切除率为100%。肛门直肠测压结果显示，术前测量值静息压、最大缩窄压、初始感知容积和最大耐受容积分别为（45.19±8.46）mmHg、（128.18±18.80）mmHg、（44.33±10.11）ml及（119.00±19.28）ml，术后3个月均明显降低，分别为（23.44±5.54）mmHg、（93.72±12.15）mmHg、（17.72±5.32）ml及（70.44±10.90）ml，差异均有统计学意义（均P<0.001）；术后12个月静息压和最大缩窄压升高至术前状态，分别为（39.33±6.64）mmHg和（120.58±16.47）mmHg（与术前测量值比较，均P>0.05），初始感知容积和最大耐受容积未能达到术前状态，分别为（30.67±7.45）ml及（92.25±10.32）ml（与术前测量值比较，均P<0.05）。术后随访（22.1±10.6）月，未出现肿瘤局部复发及远处转移。18例患者进行了肛门功能评价，Kirwan分级Ⅰ级6例，Ⅱ级7例，Ⅲ级4例，Ⅳ级1例；Wexner失禁评分（8.6±0.8）分；其中为排粪控制良好者14例。 结论： 达芬奇机器人经括约肌间切除术治疗低位直肠癌临床疗效确切。.
Keywords: Intersphincteric resection; Rectal neoplasms; Robot; Surgical procedures.