腹腔镜下结直肠癌标本体内切除经直肠拖出手术的关键操作技巧（附手术视频）

目的探讨腹腔镜下结直肠癌经自然腔道取标本手术(natural orifice specimen extraction surgery,NOSES)体内切除肿瘤经直肠拖出技术的关键操作技巧。方法对四川省肿瘤医院2017-06～2019-03采用标本体内切除经直肠拖出方式完成腹腔镜结直肠癌NOSES手术的29例患者的临床资料和术中操作技巧进行分析总结。结果 29例患者平均手术时间为(252.0±57.7)min,术中出血量为(44.6±20.8)ml,术后肛门排气时间为(20.7±9.2)h,住院时间为(10.7±2.5)d。术中无一例发生腹腔污染,术后所有患者恢复良好,无一例发生吻合口瘘。随访至2019-10,无一例发现肿瘤复发或转移。结论腹腔镜下结直肠癌NOSES标本体内切除经直肠拖出手术安全可行,术中严格遵守无菌和无瘤原则,熟练掌握相关操作技巧是保证手术成功的关键。     

机器人系统与腹腔镜手术在结直肠癌经自然腔道取标本手术中的效果比较

［摘要］　目的　比较机器人系统和腹腔镜手术在结直肠癌经自然腔道取标本手术（NOSES）中的效果。方法　回顾性分析2020年9月至2022年5月广西壮族自治区人民医院收治的36例结直肠癌患者的临床资料,包括乙状结肠癌24例,直肠癌12例。根据手术方式分为机器人组16例和腹腔镜组20例。比较两组一般情况、术中及术后情况、术后病理学结果及术后疼痛评分。结果　36例患者均完成手术。两组在性别、年龄、体质量指数、术前癌胚抗原水平、肿瘤最大径等方面比较差异均无统计学意义（P>0.05）。两组在引流管放置时间、术后3 d引流总量、术后住院时间、术后并发症发生率、术后第1天粒细胞比例、术后病理肿瘤分期、神经侵犯、脉管侵犯、术后疼痛评分和住院总费用等方面比较差异无统计学意义（P>0.05）。机器人组术中出血量少于腹腔镜组,排气时间、恢复流质饮食时间短于腹腔镜组,手术时间长于腹腔镜组,术后第1天C反应蛋白水平高于腹腔镜组,标本淋巴结检出数目少于腹腔镜组,差异有统计学意义(P<0.05)。结论　机器人结直肠癌NOSES是可行的,较腹腔镜结直肠癌NOSES手术具有更好的短期效果,术后胃肠道功能恢复更快,能使患者获益。     

老年患者经自然腔道取标本的腹腔镜下胰十二指肠切除术病例探讨

目的分析1例经自然腔道取标本的腹腔镜下胰十二指肠切除术老年患者的手术方法及临床表现,阐明其临床意义。方法收集1例行经自然腔道的腹腔镜下十二指肠切除术的老年十二指肠恶性肿瘤患者的临床资料,结合相关文献分析其临床特点。结果患者以"上腹部隐痛不适1个月伴发现黄疸1 w"为主诉入院,查胃镜提示:十二指肠大乳头区黏膜隆起。病理提示:腺上皮中-重度异型增生。胃增强CT:十二指肠大乳头区及邻近十二指肠占位性病变,继发肝内外胆管及胰管扩张。患者临床诊断为十二指肠癌,予以行经自然腔道取标本的腹腔镜下胰十二指肠切除术。术后患者症状缓解,胃肠功能恢复良好,肝功能明显好转,于术后第9天顺利出院。结论经自然腔道取标本的腹腔镜下胰十二指肠切除术安全可行,创伤小、恢复快,但是其操作复杂、切除范围广、手术耗时长,对术者及团队有着更高的要求。     

经阴道拖出标本在老年女性中低位直肠癌手术中的应用

目的通过观察完全腹腔镜下经阴道取标本在老年女性中低位直肠癌手术操作过程和术后并发症发生情况,探讨该术式在老年女性直肠癌中应用的可行性及临床效果。 方法纳入2017年1月至2018年4月陕西省人民医院普外一科符合经自然腔道取标本手术（NOSES）条件的5例老年女性中低位直肠癌患者,均成功实施了经阴道取标本手术,观察5例患者的术中情况及术后近期恢复情况及并发症发生情况。 结果所有患者均按照预期目标完成手术,无中转其他手术方式,无吻合口瘘,无阴道溢液,无伤口感染,无肺部感染。1例89岁患者在术后12月时诊断12 mm戳孔疝并手术治疗。 结论经阴道取标本在老年女性中低位直肠癌患者的应用安全有效、并未增加手术相关并发症、减少了腹壁切口对患者呼吸功能的影响,避免了切口相关并发症,符合术后快速康复的要求,可以在符合条件的患者中使用。     

中国经自然腔道取标本手术开展现状分析

目的 了解目前我国经自然腔道取标本手术(NOSES)开展现状,分析其主要优势与面临的挑战,为未来发展提供有力依据.方法 2020年11～12月选取全国范围内从事胃肠外科、普通外科、妇科等专业的医师作为调查主要对象.本调查从医师的基本信息、开展NOSES现状、NOSES优势与挑战、NOSES教学培训及科研现状四方面进行问...     

同时性多原发结直肠癌经自然腔道取标本手术临床分析

目的通过对同时性多原发结直肠癌经自然腔道取标本手术（NOSES）病例进行临床分析,探讨手术的疗效及短期预后。 方法纳入2014年9月至2017年3月行NOSES手术的同时性多原发结直肠癌病例10例,收集的资料包括患者一般信息、病理信息、手术资料及随访资料。 结果患者平均年龄为（67.0±8.3）岁,平均BMI指数为（22.8±2.5）kg/m²,两处癌灶分别位于右半结肠和直肠的最多见。两处癌灶病理特征存在差异,绝大部分癌灶最大直径<5 cm,平均淋巴结检出总数为（20.1±16.0）枚。手术资料显示平均手术时间为（267.0±99.8）分钟,平均术中出血量为（110.0±76.8）ml。经直肠取标本者占80%,经阴道取标本者占20%。平均术后排气时间为（50.9±17.8）小时,平均术后住院天数为（11.8±3.2）天。仅1例患者出现术后并发症,住院期间无二次手术者。随访资料显示,术后无肛门功能及阴道功能障碍者,术后1年、2年和3年生存率分别为100%、85.7%和66.7%。 结论NOSES术治疗同时性多原发结直肠癌具有良好的疗效及短期预后,但仍需在临床实践中不断探索和发展。     

腹腔镜下直肠低位前切除经肛门取标本手术八例

目的探讨腹腔镜下直肠低位前切除经肛门取标本手术的安全性和可行性。 方法采用回顾性描述性研究方法,收集2015年4月至2017年3月成都医学院第一附属医院胃肠外科开展的8例腹腔镜下直肠低位前切除经肛门取标本手术患者的临床和病理资料、随访情况。 结果患者平均年龄（66.9±11.7）岁,平均BMI（22.2±4.3）Kg/m²,手术平均用时（247.5±66.3）min,平均出血（22.5±3.8）ml;患者术后首次排气时间为（56.6±11.7）h,术后首次进流食时间为（36.6±7.6）h;TNM分期：Ⅰ期4例,Ⅱ期2例,Ⅲ期2例;一例患者术后出现吻合口漏,患者术后平均住院时间为（15.5±5.1）d;患者随访术后肛门功能正常,未见肿瘤复发和转移征象。 结论腹腔镜下直肠低位前切除经肛门取标本手术安全、可行。     

结直肠肿瘤经自然腔道取标本手术陷阱与对策

外科技术发展日新月异,NOSES理论框架也日趋完善,随着NOSES的开展越来越多,不可避免的会出现各种各样的问题,比如技术操作不成熟,手术团队成员不固定,手术适应证把握不准确等,只有对现有的技术理念不断的进行总结完善,才能实现NOSES的可持续发展,使其更具生命力.笔者结合自己多年的临床经验将NOSES手术中可能遇到的...     

经自然腔道取标本手术在胃部不同疾病中的研究进展

随着微创技术的不断发展,腹腔镜技术在我国胃肠外科疾病的诊治中得到极大推广。在此基础上,经自然腔道取标本手术（NOSES）结合腹腔镜操作技术及微创理念,既达到了微创,同时美容效果更佳。然而,关于NOSES在胃部疾病的应用报道较少,本文将对NOSES在胃部不同疾病中的研究进展进行综述。     

腹腔镜下全直肠系膜切除经肛门取出标本的直肠癌根治术

目的探讨应用腹腔镜技术经人体自然通路对直肠癌患者行全直肠系膜切除术的可行性。 方法对2011年3至7月,中山大学附属第一医院12例经病理活检确诊的直肠癌患者,在腹腔镜下进行根治性全直肠系膜切除,低位直肠癌8例,高位直肠癌4例;男5例,女7例,平均年龄(61.18±7.5)岁。操作如下：肠系膜下动静脉根部切断,夹闭,切断左结肠和乙状结肠动静脉Ⅰ～Ⅲ分支,保留边缘动脉弓,用腔镜下切割缝合器在肿瘤近端预切断处切断、闭合肠管,经肛门在肿瘤远端预切断处缝闭直肠,在缝闭处下缘切断肠管。扩肛到5～6 cm直径大小,用标本袋保护,经肛门取出标本。近端结肠经肛门拖出并行荷包缝合,置入抵钉座、结扎。远端直肠(肛管)用肛门直肠扩张器显露,经肛门荷包缝合直肠残端,腹腔镜下完成经肛的结肠直肠(肛管)吻合。 结果无一例中转开腹,手术时间平均(123±85)min,平均失血量为87 ml。下切缘为2～5 cm;术后平均住院时间为8 d ;吻合口漏1例,无盆腔感染、肠梗阻、腹腔以及盆腔出血、吻合口出血以及吻合口狭窄等并发症。术后标本评估：全直肠系膜完全切除12例,环周切缘阴性12例,下切缘均为阴性,R0切除12例;平均淋巴结个数为(16.7±4.6)个,阳性淋巴结数为(4.6±1.8)个;高分化腺癌8例,低分化及黏液腺癌4例;TNM分期：Ⅱ期5例,Ⅲ期7例。 结论对直肠癌患者行腹腔镜辅助下根治性全直肠系膜切除术,经自然腔道取出标本,完成低位(超低位)前切除术,不违背肿瘤根治原则,同时在技术上是安全和可行的,可避免另加腹部小切口取出标本。     

Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer

AIM:To investigate whether transanal natural orifice specimen extraction(NOSE)is a better technique for rectal cancer resection.METHODS:A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classifcations from March 2011to February 2012 at the First Affliated Hospital of Sun Yat-Sen University was analyzed.Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge.Demographic data,operative parameters,and postoperative outcomes were assessed.RESULTS:None of the patients was converted to laparotomy.Respectively,there were 16 cases in the low anastomosis and fve in the ultralow anastomosis groups.Mean age of the patients was 45.4 years,and mean body mass index was 23.1 kg/m2.Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm.Mean operating time was 132 min,and mean intraoperative blood loss was 84 mL.According to the principle of rectal cancer surgery,we performed D2 lymph node dissection in 13 cases and D3 in eight.Mean lymph nodes harvest was 17.8,and the number of positive lymph nodes was 3.4.Median hospital stay was 6.7 d.No serious postoperative complication occurred except for one anastomotic leakage.All patients remained disease free.Mean Wexner score was 3.7 at11 mo after the operation.CONCLUSION:Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible,safe and oncologically sound.Further studies with long-term outcomes are needed to explore its potential advantages.     

Left colic artery preservation in laparoscopic rectal cancer surgery with transanal natural orifice specimen extraction and extracorporeal anvil placement

Techniques in Coloproctology -     

Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m²) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.     

Three-port laparoscopic anterior resection for sigmoid cancer with transanal natural orifice specimen extraction (NOSE) and single-stapling colorectal anastomosis

Techniques in Coloproctology -     

经自然腔道标本取出结直肠肿瘤手术

随着科技的不断发展,日新月异的微创外科技术已成为现如今结直肠肿瘤手术的重要方式。如今医患双方对外科手术的要求也越发严苛,过去结直肠肿瘤手术医患主要关注的是肿瘤是否完全切除,而如今却更多地开始注重提升术后的生活质量。由此,经自然腔道标本取出术（NOSE）的出现,成为了目前微创外科热捧的新兴产物,开创了结直肠肿瘤外科手术的新纪元。本文结合近几年国内外文献的相关研究与报道,将NOSE手术在结直肠肿瘤手术中的应用现状与发展做一总结。     

Complete laparoscopic resection of the rectum using natural orifice specimen extraction

AIM: To investigate how complete laparoscopic anterior resection with natural orifice specimen extraction(NOSE), as a novel minimally invasive surgery, compares to conventional laparoscopic surgery.METHODS: Twenty patients who underwent complete laparoscopic anterior resection with NOSE and 50 patients who underwent laparoscopic assisted anterior resection by the conventional method between 2011 and 2012 were studied. Selection for complete laparoscopic anterior resection with NOSE was decided on the basis of tumor size, localization of the tumor, and body mass index. Outcomes related to surgery, including operation time, postoperative wound pain, hospital stay after surgery, the number of totally dissected lymph nodes, postoperative complications(suture failure and wound infection), and anal function, were reviewed retrospectively. Anal function was assessed at 3 and 6 mo after surgery using the Wexner fecal incontinence scoring system.RESULTS: Complete laparoscopic resection with NOSE was performed to completion in all 20 patients. There was no patient emergency that required conversion to conventional laparoscopic surgery or open surgery. The comparison between complete laparoscopic resection with NOSE and conventional laparoscopic surgery showed no significant differences in the maximal diameter of the tumor, number of totally dissected lymph nodes, bleeding volume, mean operation time, time to start of oral ingestion, postoperative hospital stay, and postoperative complications. On the other hand, with regard to pain after epidural anesthesia, the total usage of analgesia in this novel surgical technique was 1.85 ± 1.8 times, whereas it was 5.89 ± 2.86 in conventional laparoscopic surgery(P < 0.001). The postoperative pain period was 1.9 ± 1.9 d in this novel surgical technique, whereas it was 3.43 ± 1.41 d in conventional laparoscopic surgery(P < 0.004). In complete laparoscopic surgery with NOSE, the mean postoperative follow-up period was 20 mo(range: 12-30 mo). Neither local recurrence nor remote metastasis was observed during the follow-up period.CONCLUSION: Complete laparoscopic anterior resection using NOSE does not require any incision and has excellent cosmetic properties, with mitigated postoperative pain.     

机器人辅助下经自然腔道取标本手术应用于乙状结肠癌和直肠癌患者的近期疗效分析

目的探讨机器人辅助下经自然腔道取标本手术（NOSES）应用于乙状结肠癌和直肠癌患者的近期疗效。 方法回顾性分析2021年7月至2021年10月于中国医学科学院肿瘤医院接受机器人辅助的结直肠癌患者31例,包括直肠肿瘤18例,乙状结肠肿瘤13例。所有患者根据术中情况决定手术方式,观察手术和术后恢复情况、术后病理学结果,了解患者术后生存、肿瘤进展情况。 结果31例患者顺利完成手术,17例患者接受NOSES手术,剩余14例采取常规手术方式取标本。NOSES组患者的BMI更低［（22.59±2.70）cm比（25.48±2.34）cm,t=1.142,P=0.004］;N分期淋巴结转移率更低（χ²=7.343,P=0.025）;术中出血量更少［（24.12±14.17）cm比（35.71±11.58）cm,t=0.896,P=0.020］,并且术后首次离床活动时间更早［（27.41±10.95）cm比（40.00±9.51）cm,t=1.227,P=0.002］。31名患者在围手术期内均未发生手术相关并发症。术后随访时间3~6个月,所有患者均未发生肿瘤复发、进展和死亡。 结论机器人辅助下NOSES应用于乙状结肠癌和直肠癌患者安全可行,近期疗效满意。     

“机器人”结直肠肿瘤经自然腔道取标本手术专家共识

“机器人”手术和经自然腔道取标本手术（NOSES）是目前结直肠肿瘤外科手术治疗的热点之一。“机器人”平台行结直肠肿瘤NOSES,恰好结合了两者的优势,引起了结直肠外科医生的广泛关注。但该技术尚处于初始阶段,很多临床问题并没有统一的共识和标准。因此,急需制定一部专家共识,指导“机器人”结直肠肿瘤NOSES更加科学规范地开展,这对“机器人”结直肠肿瘤NOSES的长远发展具有重要意义。