机器人与经胸骨正中切开入路行房间隔缺损修补术的疗效对比

目的 比较机器人(da Vinci Si)辅助与经胸骨正中切开入路行房间隔缺损(atrial septal defect,ASD)修补术的短期疗效.方法 回顾性分析2016年1月至2020年5月于安徽医科大学第一附属医院心脏大血管外科接受ASD修补术140例患者的临床资料.根据手术方式将所有患者分为机器人组和正中开胸组...     

微创手术切口房间隔缺损修补术的探讨

房间隔缺损(ASD)是先天性心脏病中最常见的畸形。多年来,在治疗方面积累了丰富的经验。为了减少手术中的损伤,使术后切口瘢痕更为美观隐蔽。我院自1998年3月至2004年11月,对21例ASD患者采用右前外侧乳下小切口/胸腔镜辅助下腋下小横切口体外循环下心脏不停跳心内直视下修补手术,收到满意的手术和美观效果,现报道如下。临床资料1.一般资料:本组21例,男6例,女15例,年龄8~32岁(平均15岁)。其中中央型17例,下腔型3例,上腔型1例。2.手术方法:采用静脉复合麻醉,双腔气管插管。①胸腔镜辅助下腋下小横切口(3例):左侧卧位,右胸垫高60°~75°,全身…     

胸腔镜下行房间隔缺损修补一例

全胸腔镜体外循环下行心脏手术因其痛苦小、费用低、术后恢复快得到患者的认可,本院于2010年4月在全身麻醉体外循环下行胸腔镜房间隔缺损修补术1例,现报道如下. 一、一般资料 患者女,23岁.因"反复右上腹痛半月余"入院.入院后行心电图检查,结果示:窦性心动过速,完全性右束支传导阻滞.全胸片肺多血伴肺动脉段膨隆改变.心脏超声示:房间隔缺损,中度肺动脉高压伴轻中度三尖瓣返流.患者术前检查无明显手术禁忌证,在全身麻醉体外循环下行胸腔镜房间隔缺损修补术,插管全身麻醉,右胸背部稍垫高,常规消毒手术野,铺巾单,全身肝素化,右腹股沟下4 cm纵行切口分离右股动静脉,予股动静脉插管建立体外循环,经右胸骨旁第3肋间、腋前线第6肋间(置胸腔镜)、右腋中线第4肋间各行一3cm切口,腔镜下切取4 cm×3 cm心包(避开膈神经),上下腔静脉套带,升主动脉荷包缝线置灌注管,阻断上下腔静脉及升主动脉,灌注4℃含血高钾停跳液,停跳良好.     

全机器人心脏不停跳下房间隔缺损修补术

目的 总结使用"达芬奇S"(da Vinci S)机器人手术系统,心脏不停跳下房间隔缺损修补或房间隔缺损修补+三尖瓣成形术的经验体会.方法 2009年3月至2010年12月,使用da Vinic S机器人系统,心脏不停跳下完成继发孔型房间隔缺损修补或房间隔缺损修补+三尖瓣成形术40例.患者女23例,男17例;年龄平均(38±13)岁.房间隔缺损直径为1.5～3.5 cm,平均(2.8±1.3)cm,无右向左分流,伴有或不伴有三尖瓣重度关闭不全.手术经股动、静脉及右侧颈内静脉插管建立体外循环.于右侧胸壁打直径为0.8 cm的器械臂孔3个,直径为2 cm工作孔1个,术中不阻断升主动脉,经内窥镜套管持续给予二氧化碳,心脏跳动下,术者于操作台前遥控机器人进行房间隔缺损修补,三尖瓣重度关闭不全患者同期行三尖瓣成形术.其中直接缝合房间隔缺损22例,心包补片修补房间隔缺损18例,同期三尖瓣成形9例.术中食管超声评估修补及三尖瓣成形效果.对比不停跳与心脏停跳下全机器人房间隔缺损修补术的手术时间及体外循环时间.结果 所有患者均成功接受全机器人心脏不停跳下房间隔缺损修补术或房间隔缺损修补+三尖瓣成形术,无体循环气体栓子及残余分流等并发症.不停跳组的手术时间、机器人使用时间或体外循环时间少于停跳组.结论 机器人心脏不停跳下房间隔缺损修补术无需阻断升主动脉,简化了全机器人手术过程,手术效果安全可靠.

Abstract：

Objective To Summary the first 40 cases underwent robotic atrial septal defect (ASD) closure or atrial septal defect closure combined bicuspid valve plasty (TVP) using "da Vinci S" surgical System on beating heart. Methods 40 cases of atrial septal defect or combined sever tricuspid valve regurgitation were repaired using "da Vinic S" surgical system on beating heart from March 2009 to December 2010 in cardiovascular department of PLA general hospital. The average age was (38 ± 13) yeas old. 23 cases were female and 17 cases were male. All patients were ostium atrial septal defect with or without pulmonary hypertension. The atrial defect diameter was 1.5 -3.5 cm, and the mean diameter was(2. 8 ±1.3)cm. 9 patients had sever tricuspid valve regurgitation. Without sternotomy, the extracorporeal circulation was established through groin artery,groin vein and internal jugular vein cannulation with the guidance of transeophageal echocardiography. 3 ports of 8 mm and 1 working port of 2 cm were made in the right chest wall. After "da Vinci S" syetem was set up, with the assistant of bed-side surgeon, the surgeon completed the atrial septal defect closure or combined tricuspid valve plasty in the surgeon console with three dimensions visualization. During the operation, without cardioplegia administrated and aortic occlusion, the procedure was completed through right atriotomy. The pleural space was insufflated with carbon dioxide to avoid the air embolism. The direct suturing was used in 22 cases and pericardial patch were used in 18 cases. 9 patients accepted concurrent De Vega tricuspid valve plasty. The transesophageal echocardiography were used to evaluate the result of atrial defect closure or tricuspid valve repair. The operation time, robotic using time and cardiopulmonary time were compared with totally robotic atrial defect repair in arrested heart. Results All cases were accomplished successfully without complication. There was no residual shunt and air embolism. The operation time, robotic using time and cardiopulmonary time were less than the arrested group. Conclusion Robotic atrial septal defect closure or combined tricuspid valve repair on beating heart can avoid aortic ocllusion and can be utilized effectively and safely.     

机器人微创心脏手术的应用现状

微创是心脏外科的发展方向之一.随着自动机械和计算机技术的进步,机器人微创外科手术已成为现实.机器人微创心脏手术具有创伤小、操作精细等优点,是微创心脏外科的前沿技术之一.作为一种革新的手术方式,机器人辅助下微创心脏手术得到了极大的关注,本文就机器人心脏手术的临床应用及手术效果作一综述.     

机器人心脏外科手术的发展历史和现状

机器人手术是一种新兴的微创手术方式,其优势在于更小的创口、更少的疼痛、更短的住院时间、更快的恢复速度及更好的美容效果.目前,机器人心脏手术已经广泛应用于各类心脏疾病的治疗,包括先天性心脏病、心脏瓣膜病、冠心病和心脏肿瘤等,在心脏手术领域已取得了长足的发展,但临床应用落后于其他外科机器人手术,在未来仍有较大的发展空间.     

蚕豆病合并脊柱侧弯患者行房间隔缺损修补术一例

正患者,男,15岁,身高164cm,体重44kg,因心脏杂音2月余入院。患者平素活动能力无明显受限,活动后无胸闷、心悸,无胸痛,无反复上呼吸道感染,生长发育尚可。心超提示"先天性心脏病,房间隔缺损"。遂收治入院。既往患者有蚕豆病史,1岁时曾发病。对青霉素、氨基比林、四环素类药物过敏。无哮喘史,无手术外伤史。体检提示胸骨左缘第二肋间可闻及Ⅱ或Ⅲ级收缩期吹风样杂音,无明显传导,P2亢     

全机器人不开胸房间隔缺损修补术

目的总结“达芬奇S”（da Vinci S）全机器人下不开胸房间隔缺损（ASD）修补术临床经验。方法1月至2007年7月，使用da Vinci S全机器人系统，不开胸完成房间隔缺损修补15例中男3例，女12例；平均年龄为（38．5±7．8）岁。均为继发孔型房间隔缺损，缺损直径2．0cm～3．6cm，无右向左分流，肺动脉压轻到中度升高。全组肺功能良好，无胸膜炎病史。超声引导下股动静脉及右侧颈内静脉插管建立体外循环。于右侧胸壁做3个直径均为1cm的器械臂孔，分别插入机器人系统的内窥镜和机械臂；1个直径为2cm工作孔。机器人操控医师于操作台前、三维成像系统下遥控机器人进行手术。直接修补10例，心包补片修补5例。术中食管超声评估修补效果。结果全组手术均成功，无术中手术方式的转变。平均体外循环（109．5±12．6）min，主动脉阻断（41．2±11．7）min。术中及术后出血明显减少，术后第2d出监护室，术后恢复明显加快，无残余分流和恶性心律失常等并发症的发生。结论全机器人不开胸房间隔缺损修补手术效果确实、可靠，是微创心脏外科的发展方向。     

三度房室传导阻滞行房间隔缺损修补术麻醉一例

患者．女，２６岁，体重４６ｋｇ。先天性心脏病、房间隔缺损（ＡＳＤ），拟行ＡＳＤ修补术。术前心电图诊断为三度房室传导阻滞（ⅢＡ－ＶＢ）、结性逸搏心率。超声心动：ＡＳＤⅡ孔型３３．５ｍｍ，三尖瓣中度返流；胸部正位片：肺血多、右房及右室大。术前３０分钟肌肉注射阿托品０．５ｍｇ、哌替啶５０ｍｇ。入手术室监护仪连接后ＨＲ７２次／分，心电图仍为典型皿Ⅲ１－ＶＢ（交界部），桡动脉穿刺直接测压（ＡＢＰ）１８．６７／１０．６７ｋＰａ。麻醉诱导以静脉注射安定５ｍｇ、２．５％硫喷妥钠（ＳＰ）１０ｍｌ、氯胺酮７０ｍｇ、…     

62例机器人心脏手术的麻醉管理

目的 对达芬奇(da Vinci)手术系统完成的机器人心脏手术的麻醉方法进行总结.方法 实施机器人心脏手术62例,其中房间隔修补32例、冠状动脉搭桥22例、二尖瓣成形5例和左房黏液瘤摘除3例.全麻诱导后插入双腔支气管导管,术中单肺通气.监测经食管超声心动图(TEE)、血气和血流动力学变化.结果 多数病人在CPB前能够耐受单肺通气.但CPB前有1例肺功能差的病人和CPB后有17例(27%)病人单肺通气时SpO2降至90%而使用持续气道正压装置(CPAP)治疗.CO2气胸引起的血压下降通过输入羟乙基淀粉130/0.4氯化钠注射液和升压药予以纠正.升主动脉阻断时间(56.2±19.6)min,CPB时间(103.7±43.1)min,平均ICU停留时间1.3d,术后平均住院时间6.5 d.无住院死亡发生.结论 机器人心脏手术的麻醉所需要的复杂设备和监护,以及CO2气胸并单肺通气是对麻醉医师的新挑战,麻醉医师与术者和灌注师之间的团队配合对保证手术成功非常重要.     

Anesthesia management of totally endoscopic atrial septal defect repair with a robotic surgical system

Study Objective

To investigate anesthetic techniques for robot-assisted endoscopic atrial septal defect (ASD) repair.

Design

Clinical observational study.

Setting

Operating room of a general military hospital.

Patients

56 adult, ASA physical status 1 and 2 patients undergoing elective general anesthesia.

Interventions

After induction of general anesthesia, a left-sided, double-lumen endotracheal tube was positioned to allow single left-lung ventilation and contralateral CO₂ pneumothorax (capnothorax). With ultrasound guidance, peripheral cardiopulmonary bypass (CPB) catheters were placed.

Measurements and Main Results

All patients tolerated single left-lung ventilation before CPB; however, hypoxia (oxygen saturation < 90%) occurred in 11 (19.6%) patients post-CPB, which required treatment with continuous positive airway pressure. Fifteen (26.8%) patients had hypotension secondary to capnothorax, which was treated with transfusion and vasopressors. Aortic cross-clamp time was 43.6 ± 11.2 minutes, and CPB time was 106.7 ± 12.4 minutes. The median intensive care unit stay was 21 hours and postoperative hospital stay was 4 to 7 days.

Conclusions

The key issue for anesthetic management of robot-assisted totally endoscopic ASD repair is maintaining stable hemodynamics and oxygenation, especially during one-lung ventilation and capnothorax.     

Surgical closure of atrial septal defect

Background: Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions. Methods: We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure. Results: The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 ± 12) and 14 to 158 min (27 ± 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt. Conclusion: Our results suggest that MICS is a good option for surgical closure of ASD. Received: 4 June 1997/Accepted: 29 October 1997     

Totally endoscopic closure of an atrial septal defect using the da vinci surgical system: Report of four cases

This report presents four cases of totally endoscopic closure of an atrial septal defect using the da Vinci Surgical System (Intuitive Surgical, Mountain View, CA, USA). The patients were diagnosed with an ostium secundum atrial septal defect and elected to undergo minimally invasive surgery. A cardiopulmonary bypass was established via cannulation of the femoral vessel and jugular vein, and blood cardioplegic arrest was induced using a transthoracic cross-clamp. The mean extracorporeal circulation and cardiac arrest times were 86 ± 21 and 22 ± 8 min, respectively. No patient experienced pain after surgery, and all were fast-tracked for early discharge and released on postoperative day 3. No intraoperative or postoperative complications occurred. This procedure permitted a short hospital stay, quick return to an active lifestyle, and had an excellent cosmetic outcome. The success of this procedure therefore encourages that this procedure should be considered as day surgery.     

微创小切口手术修补与介入封堵治疗单纯继发孔型房间隔缺损

目的比较微创小切口手术修补与介入封堵治疗房间隔缺损(atrial septal defect,ASD)的优缺点。方法回顾分析2004年1月～2006年6月采用微创方法治疗单纯继发孔型ASD69例资料,其中行小切口心脏不停跳下手术修补37例(小切口组),行介入封堵32例(介入组)。结果两组均无死亡病例。小切口组37例手术全部成功,手术时间(145.86±27.84)min,体外循环时间(35.11±8.45)min,住院时间(15.46±3.09)d,发生主要并发症2例、次要并发症6例,住院费用(2.19±0.36)万元。介入组2例封堵失败,余30例成功,手术时间(88.59±7.75)min,住院时间(10.81±5.02)d,发生主要并发症1例、次要并发症2例,住院费用(2.78±0.39)万元。小切口组随访3～12个月20例、12～30个月17例,介入组随访3～12个月16例、12～30个月14例,均无残余分流。结论两种微创方法均可安全有效地用于单纯继发孔型ASD的治疗,微创小切口方法的费用低,成功率高,适应证广,而介入封堵方法的住院时间短,创伤更小,美容效果更好。     

Results of surgical closure of isolated secundum atrial septal defect

Methods A retrospective analysis of all patients undergoing surgical closure of an isolated secundum atrial septal defect, at the Postgraduate Institute, Chandigarh between January 1974 and June 2000 was performed. 740 patients were divided into two groups. Group I. Included 435 patients under 20 yrs of age (223 male), 315 (72%) were asymptomatic, 265(61%) were in sinus rhythm. Group II. included 305 patients between 21 and 53 years (96 males), 27 patients (9%) were asymptomatic, 102(33%) were in sinus rhythm. Cardiopulmonary bypass with fibrillatory arrest and/or cold blood cardioplegia were used. In group I 291 patients (67%0 and in group II 64 patients (54%) underwent direct closure of the defect. In the remaining a patch was used for closure. Results There was 1 early death in group I (0.2%) and four in group II (1.3%) 96% of symptomatic patients in group I and 87% of patients in group II were improved. There were no instances of residual shunt. Follow up ranged from 6 months to 25 years (mean 8.3 yrs) and was 89% complete. Conclusions Closure of isolated secundum ASD is best performed before the patient attains adulthood.     

复合技术治疗低龄低体重病儿房间隔缺损

目的 介绍一种房间隔缺损(ASD)"复合"技术介入封堵方法,并探讨该手术方法的优缺点.方法 2007年6月至2008年3月,27例婴幼儿房间隔缺损者接受新"复合"技术治疗.其中男15例,女12例.年龄3个月-4岁,平均(2.00±O.22)岁.采用浅镇静加局部麻醉,非气管插管单纯面罩吸氧或喉罩下辅助通气支持,胸骨旁第4肋间小切口,保留胸膜,经胸膜外进入心包腔显露右心房壁,切开右房壁置入ASD封堵器及输送器.心前区或剑突下超声引导进行ASD介入封堵术.结果 全部病儿3d后康复出院,随访0.5-9.5个月,平均(5.9±0.5)个月,仅l例病儿因心包压塞行心包穿刺引流术,余无异常.超声检查没有残余分流或其它并发症.结论 该手术方法创伤小、疗效好,费用低,是婴幼儿ASD病例一种较为理想手术方法.     

Amorphous cardiac tumor of right atrium late after atrial septal defect closure

We describe an unusual case of calcified cardiac mass in a patient seventeen years after Dacron patch closure of atrial septal defect. Presenting symptom was prolonged fever and after surgical excision the patient remains afebrile at one year of follow up. The clinical course and histopathological features were consistent with cardiac calcified amorphous tumor (cardiac CAT) Amorphous cardiac tumors are rare non-neoplastic cardiac masses, which are often indistinguishable clinically from true neoplasms. The surgical excision of these tumors is curative and recurrence is unknown.