改良机器人手术方式行房间隔缺损修补术22例

目的 总结使用“达芬奇”（da Vinci S）机器人手术系统行体外循环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 2013年7月至2013年10月回顾性研究,使用da Vinic S机器人系统,体外循环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22例.患者女16例,男6例;年龄平均（36.5±5.8）岁.房间隔缺损直径为2.5～4.1 cm,平均（3.8±1.3）cm,左向右分流,2例伴有三尖瓣中度关闭不全,2例伴有右侧胸膜腔部分粘连.手术经股动、静脉插管,于右侧胸壁打3个孔,采用我院成熟全腔镜心脏手术技术建立体外循环,阻断升主动脉,切开右心房后,再连接机器人手术系统,术者于操作台前遥控机器臂进行房间隔缺损修补,三尖瓣中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20例,补片修补房间隔缺损2例,同期三尖瓣成形及胸膜粘连松解各2例.结果 22例均成功接受机器人房间隔缺损修补术或房间隔缺损修补＋三尖瓣成形术,手术时间1.5 ～ 3.5 h,平均（2.3±0.6）h;后10例手术时间体外循环（58.6±18.3） min,升主动脉阻断（26.8±8.6） min,术后呼吸机辅助（5.8±1.6）h.胸液引流量50 ～ 300 ml,平均（150±32） ml,平均1～2d拔除胸腔闭式引流管.术后住院时间（5.6±1.4）d.均无中转开胸、院内死亡及术后并发症发生.全组术后3～5d超声心动图示手术效果满意,患者均顺利出院.随访1个月～3个月,无残余分流,下肢静脉血栓形成,心功能均为Ⅰ级,超声心动图检查结果满意.结论 改良达芬奇S机器人手术方式体外循环下房缺修补术安全可靠,疗效满意,且进一步缩短手术时间,创伤小、恢复快,具有良好的发展前景.

Improved totally robotic atrial septal defect closure using da vinci S surgical system

Objective To summarize the first 22 cases underwent robotic atrial septal defect（ASD） closure or atrial septal defect closure combined tricuspid valve plasty （TVP）using improved ＂da Vinci S＂ surgical system on pump. Methods twenty-two cases of atrial septal defect or combined moderate tricuspidvalve regurgitation were repaired using improved ＂da Vinic S＂surgical system from July 2013 to October 2013 in cardiovaseular department of xijing hospital.The average age was （36.5 ± 5.8）yeas old.16 eases were female and 6 cases were male.All patients were diagnosed atrial septal defect with or without pulmonary hypertension.The atrial defect diameter was 2.5 ± 4.1 cm, and the mean diameter was （3.8 ±1.3） em. 2 patients had sever tricuspid valve regurgitation,2 patients had chest membrane paste.The extracorporeal eirculation was established through groin artery,groin vein cannulation with the guidanee of transeophageal eehoeardio graphy. 2 troears of 10 - 15 mm and 1 working port of 2 cm were made in the right ehest wall. The ascending aorta was cross-elamped with long tailor-made forceps and the myocardium was protected by coronary perfusion with cold crystalloid （blood） eardioplegia. The＂da Vinci S＂system was set up with the assistant of bed-side surgeon after right atriotomy opened, the surgeon completed the atrial septal defect elosure or combined tricuspid valve plasty in the surgeon console with three dimensions visualization.The direct suturing was used in 20 cases and pericardial patch were used in 2 cases.2 patients accepted coneurrent DeVega tricuspid valve plasty, 2 patients accepted concurren chest membrane paste separate. Results All the operations were completed successfully.The mean operations time were （2.3 ±0.6）h, the mean extracorporeal eirculation and eross-clamping time were （58.6 ± 18.3）rain and （26.8± 8.6）min respectively. Postoperative ventilation was withdrawn in （5.8 ± 1.6）h, the mean bleeding were （150 ± 32）ml and the patients were diseharged from the hospital in （5.6 ±1.4）d. 2 of the patients had postoperative complications,including 1 ease of fat liquefaction of the incision at the right groin （delayed healing）, lcases of subeutaneous emphysema （healed by bandaged chest）. No severe eomplieations occurred in this series. UCG performed 3-5 days after the operation revealed surgieal results were satisfactory. Follow-up to 1 - 3 months were available in all cases. During the period, the heart funetion was confirmed as I level. There were no in-hospital death or serious post-operative complications,the patients recovered quickly with less bleeding and shorter hospital stay. Conclusion The improved da Vinci robotic surgery system is safe and reliable for atrial septal defect closure or combined tricuspid valve repair, with satisfactory outcome, mini-invasiveness, rapid recovery and bright future.