单切口腹腔镜手术治疗结直肠手术的回顾

概要
随着外科技术继续朝着侵入性较小的技术发展，单切口腹腔镜手术（SILS），传统多端口腹腔镜与自然孔腔内镜手术之间的混合，被引入，以进一步增强多端口腹腔镜检查的结果。已证实SILS对良性和恶性结直肠疾病的安全性和可行性。 SILS具有改善美容，术后疼痛，恢复时间和生活质量的潜力，具有所需技术水平较高的缺点。在本文中，作者回顾了历史，描述了可用的技术和技术，并在已发表的文献中评估了SILS对结肠直肠手术的益处和局限性。

关键词：腹腔镜结肠切除术，微创结直肠手术，单切口腹腔镜手术
核心提示：随着手术技术不断向少侵入性技术发展，单切口腹腔镜手术（SILS）是一个有价值的平台，与其他微创平台相比具有明显的优势和相当或更好的结果。 SILS对良性和恶性结直肠疾病的安全性和可行性已经得到证实，对这一历史，现状，现有技术，广泛使用的局限性及其解决方案的综述将是对已发表文献的有益补充。它将引起人们对益处的关注，并可能增加平台和微创手术的整体使用。

介绍
自1991年第一次腹腔镜结肠切除术以来，微创结直肠手术持续增长[1]。腹腔镜检查的广泛应用是结直肠手术领域最大的技术和临床进步。与开放手术相比，腹腔镜结直肠手术已被证明可以改善患者的预后，包括更快的胃肠功能恢复，更少的术后疼痛，更短的住院时间，更低的并发症和再入院率，以及更低的总医疗保健利用率[1-14]。尽管已证实有益，但在美国，腹腔镜检查的使用估计仅占所有结直肠手术的50％，结肠癌的20％和直肠癌手术的10％[15,16]。因此，存在增加利用率和益处的空间。此外，还在继续努力减少端口和“无疤痕”手术，并且已经做出巨大努力来最小化手术创伤，改善美容和手术相关的疼痛和发病率。已经开发出诸如自然孔腔内腔镜手术（NOTES）和单切口腹腔镜手术（SILS）的技术以实现目标。 NOTES仍处于实验阶段，但SILS已准备好纳入常规实践，目前被认为是广泛使用中可行的微创手术方法进展的下一个重大进展[17,18]。

单切口腹腔镜手术
SILS的开发是为了进一步推动多端口腹腔镜检查的结果。 2008年，当Remzi等[19]和Bucher等[20]报道用于右结肠切除术时，首次报道了SILS技术用于结肠直肠手术。 从那时起，多项研究证明，SILS对于全面的良性和恶性结直肠疾病是安全可行的，并且其应用继续增长[21-35]。 SILS目前被认为是适用于全身使用的结直肠疾病微创手术方法进展的下一个重大进展[17]（图11）。


图1
单切口腹腔镜手术动画。

技术说明
大多数SILS手术进入脐部的腹膜，形成“隐藏”的切口，并允许延长筋膜切口，而不会延伸覆盖的皮肤切口[36]。如果计划造口，可以使用造口术部位进行检查，从而进行“无疤痕”手术[23,37,38]。

为了进入，有几个商业生产的SILS端口，以及自制手套端口。最常见的端口是SILS™端口（Covidien，Mansfield，马萨诸塞州，美国），GelPOINT®平台（Applied Medical，Rancho Santa Margarita，CA，美国），以及TriPort或QuadPort（Olympus Medical，Center Valley， PA，美国）。所有设备在单个端口中具有三个或更多个工作通道，以通过单独的切口将腹腔镜器械和相机引入手术区域。单个切口有助于减少筋膜缺损，腹壁创伤及其相关的术后疼痛和疝气风险[39-41]。每个端口通过2-4厘米的皮肤和筋膜切口引入，并且具有成本和益处。 SILS™端口（Covidien，Mansfield，MA，美国）是柔韧的弹性泡沫，可与皮肤形成密封，保持气腹，提供增强的活动性，并允许外科医生互换5毫米和12毫米端口。但是，SILSTM端口限制为3个套管针，并且没有用于标本提取的伤口保护器。 GelPOINT®使用插入腹膜的伤口保护套和GelSeal®帽，根据外科医生的喜好插入套管针。该端口具有较低的内部轮廓，可以帮助适应各种腹壁尺寸，并且套管在肿瘤种植和浅表伤口感染的标本提取期间提供保护[42,43]。 GelPOINT®在腹壁上具有较大的轮廓，并且可能在极端扭矩下失去气腹。 TriPort和QuadPort通道分别具有三个或四个仪器通道，类似于GelPOINT®，外部轮廓较低。然而，据报道，组装，插入和体外化比其他平台更难。手套端口使用固定在小伤口保护器上的无菌非乳胶手套，手套的手指用于仪器和相机接入。这种方法简单，便宜且易于再现，但与市售设备相比，手指端口提供的密封性差，缺乏刚性[35,44-47]。

标准的腹腔镜工具通常与SILS一起使用，但可以使用直的，弯曲的和铰接的器械。直通式仪器具有刚性，但在平行固定空间工作时，工作端口和摄像头之间可能会发生碰撞。引入曲线仪器来弥补碰撞，但它们不能通过传统的直线套管针。铰接式仪器设计用于克服缺少三角测量的问题，因为它们在尖端处清晰地旋转，围绕仪器轴旋转360°。然而，使用灵活的工具会导致刚性和触觉反馈的损失[48-50]。一般认为直接腹腔镜器械是优选的，并且弯曲或铰接器械在实践中不是必需的或通常使用的。

与SILS结合
在所有临床和质量指标中，SILS具有与传统腹腔镜相似的结果[34,39]。研究证明，SILS对于良性和恶性结直肠疾病是可行且安全的[22,28-30,32,33]。从早期报告来看，SILS的术后结果相似，包括并发症，术中转换和再入院率[39]。肿瘤学结果，包括R0切除的可行性，标本长度，收获的淋巴结数量，以及近端和远端边缘与多端口腹腔镜相当[51-54]。 SILS在直肠切除术中已被证明是安全可行的[29]。初步研究报告了SILS的手术时间增加，但没有考虑到学习曲线和经验需求[52,55]。手术时间随着累积经验而减少，学习曲线定义在30至36例之间[56]。

SILS与传统的腹腔镜手术相比具有明显的优势。使用具有多个结合工作通道的单个端口，SILS减少了手术所需的切口和组织创伤的数量，改善了美容，并降低了端口部位相关并发症和切口疝的发生率[39-41,57]（图（图2）0.2）。减少围手术期疼痛是SILS相对于传统多端口腹腔镜检查的另一个优势，疼痛减轻转化为疼痛评分和阿片类药物使用从术后即刻到术后第2天[39,41]。 SILS还显示出显著缩短的停留时间（LOS）;研究表明，与多端口腹腔镜相比，SILS的LOS缩短了1天以上[28,39]。最近的一项荟萃​​分析回顾了比较SILS与传统多端口腹腔镜检查的14项研究，结果显示SILS具有较低的失血量，减少输血需求，缩短住院时间，缩短住院时间和缩小切口[51]。


图2
通过单个切口平台移除标本。

技术挑战
SILS的使用引入了一些新的技术挑战，这可能会限制平台的广泛使用[58]。 SILS的人体工程学和技术要求与传统的多端口腹腔镜检查不同，最初为经验丰富的腹腔镜外科医生增加了难度[59,60]。结直肠手术中的技术挑战进一步扩大，需要在一个以上的象限中工作[58,61]。首先，工作套管针通过单一进入端口的在线方向的挑战导致视轴变得更加直线，相机移动导致相邻仪器的无意移动[17,62]。通过具有多个平行的小型单个切口，在入口支点处竞争相同空间的仪器减小了运动范围和外部工作空间，增加了仪器碰撞[28,58,63]。这些碰撞既在体内经历，也难以维持气腹，并且在体外，使得持有相机的助手的作用变得复杂[28]。这迫使外科医生用双手操作以适应[17,62]。套管针在固定位置的接近，限制自由以及器械的碰撞与腹腔镜检查中传统的三角测量教学相矛盾[64]。暴露和“拥挤”中的这些问题增加了SILS技术的难度，并且可能导致可视化受限，解剖和动员不充分，以及潜在的无意伤害[53,55]。

随着操作员经验的增加，可以轻松克服这些人体工程学和技术挑战。已经制定了技术手段和程序调整，以帮助应对这些挑战。为了提高外科医生的效率并减少碰撞，还建议将腹腔镜远离外科医生的手，例如使用带有弹性尖端或肥胖的腹腔镜[24,28,66,67]。可以使用关节或曲面器械来帮助重建熟悉多端口腹腔镜检查的三角测量[58]。对于骨盆和多象限病例的帮助，已经开发并验证了SILS +1技术[65]。使用SILS +1，通过Pfannenstiel切口引入单一进入装置，并通过肚脐为腹腔镜摄像机放置另外的5mm端口，允许进入多个腹部象限并最大限度地减少外科医生与之间的“剑斗”。相机支架[65]。为了精通SILS，一个想法是熟练减少端口腹腔镜检查 - 使用3个端口;那么向SILS的过渡将更加自然

当前状态和前进与SILS
尽管有证据支持使用和证明有益，但SILS尚未被广泛采用。引用的主要原因是符合人体工程学的要求以及所需的额外时间，成本和技能，特别是在早期案例中[55,59,64,68]。外科医生的经验可以克服技术和人体工程学的挑战，并且已经开发出专门的仪器和平台来帮助提升学习曲线[17,62]。

该技术也被提倡用于腹腔镜检查和微创技术的外科医生，并且已发表的文献中描述的结果是由熟练的腹腔镜外科医生在超出学习曲线的情况下实现的[32,34,69,70]。此外，已发表的经验集中在非肥胖患者[23,66,70-74]。为了提高这种微创技术的利用率，必须探索其在不同患者群体中的可行性[72]。已经确定了使用该技术实现能力的学习曲线，并且在学习曲线的早期阶段没有报告增加的并发症或负面结果[56,72]。因此，鼓励增加SILS用于患者益处和增加微创结肠直肠手术的总体使用。

结论
由于结直肠外科领域一直强调向侵入性较小的技术发展，单切口腹腔镜手术是传统多端口腹腔镜与NOTES的混合，是微创手术的自然演变。与传统的多端口腹腔镜相比，SILS具有明显的优势，但广泛使用受到技术，人体工程学和患者选择挑战的限制。凭借经验证明安全性和可行性，以及确定能力的学习曲线，鼓励在结肠直肠手术中更多地使用SILS。

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