卵巢肿瘤腹腔镜手术——什么是可能的，什么是有用的？

由于技术进步和外科专业水平的提高，微创手术技术在妇科肿瘤学中的应用变得越来越重要。 除了用于治疗良性肿瘤的腹腔镜方法外，微创手术方法也已在一些领域建立用于治疗妇科恶性肿瘤。 对于子宫内膜癌和宫颈癌等肿瘤实体，有结论性研究强调腹腔镜在手术治疗中的作用。 相比之下，由于缺乏生存分析的前瞻性数据，无法就腹腔镜手术在卵巢癌手术治疗中的意义得出明确的结论。 然而，一些较小的，主要是回顾性病例对照研究和队列研究为讨论开辟了道路，提出了腹腔镜手术，特别是早期卵巢癌，在技术上可行且质量与传统纵向剖腹手术相当的可能性， 也可能与较低的围手术期发病率有关。

微创手术技术被认为是大多数主要通过手术治疗的妇科疾病的临床标准，因为围手术期发病率低且术后美容效果更好。 微创手术在治疗妇科恶性肿瘤方面也变得越来越重要。 然而，目前尚不清楚腹腔镜检查对于治疗卵巢癌有多重要。 根据指南，初次减瘤手术是通过中线纵向剖腹手术进行的。 然而，围绕可能的腹腔镜治疗方法存在相当大的争论； 这既是由于这种手术技术的不断发展，也是由于它为合理的手术降阶梯带来的潜力，特别是在早期卵巢癌中。 一些研究表明，对于这种肿瘤实体，腹腔镜方法的可行性似乎并不逊色于开腹手术； 此外，围手术期和术后并发症的发生率较低。 目前还没有关于这个问题的对照随机研究比较（早期）卵巢癌微创手术的治疗方法与传统开放手术后的结果； 因此，腹腔镜在卵巢癌治疗中的重要性尚无定论。

卵巢肿瘤腹腔镜手术——什么是可能的，什么是有用的？

图 诊断性腹腔镜检查结果，a 肝周围结节状植入物； b 腹壁粘连的网膜饼。

表 1 用于确定 PIV 的腹腔镜检查参数（基于 Fagotti 等人，2006 年）。

腹腔镜参数	分数
卵巢肿瘤（单侧或双侧）	0
网膜饼	2
腹膜癌	2
膈肌癌	2
肠系膜收缩	2
胃浸润	2
肠道浸润	2
肝转移	2

在过去的几十年中，微创手术方法在临床日常实践中变得越来越普遍，包括妇科。 由于围手术期并发症发生率较低和早期活动，腹腔镜已成为良性卵巢肿瘤手术治疗的金标准。 腹腔镜检查在妇科肿瘤学中也越来越重要，并且在前瞻性研究中得到了令人信服的验证，例如早期子宫内膜癌。 目前对卵巢癌的研究还不太清楚。

初步数据表明，通过腹腔镜对早期卵巢癌进行完整的手术分期似乎并不逊色于开腹手术，患者可以受益于微创手术方法的优势。 然而，有必要批判性地质疑腹腔镜手术分期在技术上是否可行。 目前没有前瞻性随机对照研究来评估所选手术方法对无进展生存期和总生存期的影响。 现有的讨论该主题的研究通常只包括少数受试者，报告的随访时间差异很大，而且手术方法对生存率的影响通常没有被介绍。 检查无进展生存期和总生存期的研究显示出不同的结果，部分支持腹腔镜检查，部分支持剖腹手术。 由于患者队列和随访时间差异很大，各个研究不能充分相互比较。

由于在早期诊断出卵巢癌的发生率相对较低，验证腹腔镜检查作为（早期）卵巢癌手术方法的难度也更大。 在获得其他科学发现之前，德国关于恶性卵巢肿瘤的诊断、治疗和随访的 S3 指南建议，如果怀疑卵巢有恶性表现，应避免进行腹腔镜手术。 然而，根据现有研究，可以假设经过精心挑选的患者队列可以从早期卵巢癌的腹腔镜分期中获益，特别是考虑到围手术期发病率较低。 美国国家综合癌症网络 (NCCN) 的指南指出，在选定的患者中可以考虑由经验丰富的外科医生进行微创手术。

关于腹腔镜检查的诊断优势，多项研究表明可以预测可手术性，但并未显示出生存率方面的优势。 尽管如此，诊断性腹腔镜检查可以通过识别不能手术的患者来帮助减少围手术期和术后并发症，这些患者可以从新辅助全身治疗和随后的间歇性减瘤术中获益。 总的来说，在接下来的几年里，卵巢癌的手术治疗是否会发生范式转变，以及诊断性腹腔镜检查是否会成为卵巢癌治疗算法的一部分，还有待观察。 在未来几十年内，包括机器人手术领域在内，可以预期对这些主题的有趣见解。

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