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机器人辅助右半结肠癌根治术显露与解剖研究
王凯, 符炜, 张轩, 李腾腾, 刘浩, 王庆, 刘炜, 陈帅伟, 张文卓, 付海啸
中国实用外科杂志 ›› 2026, Vol. 46 ›› Issue (2) : 247-253.
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机器人辅助右半结肠癌根治术显露与解剖研究
Exposure and anatomical study of robot-assisted radical resection of right colon cancer
目的 探讨机器人辅助右半结肠癌根治术中基于“主桅杆”式牵拉的程序化显露与解剖策略的临床应用价值。方法 回顾性分析2021年1月至2025年8月徐州医科大学附属医院胃肠外科收治的79例行机器人辅助右半结肠切除术病人，均采用“主桅杆”式牵拉下的系统性游离策略，包括尾侧“三阶梯”爬坡式游离与头侧“双层卷帘式”游离。观察指标包括手术时间、出血量、中转开放手术比例、术中器官损伤率、术后并发症（Clavien-Dindo分级）发生情况、术后恢复指标、淋巴结清扫数目及肠系膜完整性。结果 所有手术均顺利完成，无中转开放手术。手术时间（168.1±18.5）min，术中出血量（18.1±8.5）mL。术中大血管意外出血1例（1.3%），无十二指肠或胰腺损伤。术后总并发症发生率为17.7%，均为并发症Clavien-Dindo Ⅰ~Ⅱ级。术后首次排气时间（36.5±8.2）h，术后住院时间（7.5±1.5）d。淋巴结清扫总数（35.4±6.8）枚，肠系膜完整切除率为94.9%。结论 “主桅杆”式牵拉结合程序化游离策略构建了一套可控、可教、可复制的机器人右半结肠癌根治术流程，可能有助于推动手术显露和解剖程式化，缩短学习曲线并实现高质量手术。
Objective To evaluate the clinical application value of a systematic exposure and dissection strategy based on mainmast-style traction in robot-assisted radical resection of right colon cancer. Methods A retrospective analysis was performed on 79 patients undergoing robot-assisted right hemicolectomy between January 2021 and August 2025 at the Department of Gastrointestinal Surgery, the Affiliated Hospital of Xuzhou Medical University. All patients underwent systematic dissection under mainmast-style traction, including caudal “three-step climbing” and cephalad “double-layered curtain” dissection. Operative time, blood loss, conversion to open surgery rate, intraoperative organ injury rate, postoperative complications (Clavien-Dindo), recovery indicators, lymph node yield, and mesenteric integrity were recorded as outcome measures. Results All procedures were completed without conversion. Operative time was (168.1±18.5) min, and blood loss was (18.1±8.5) mL. One case (1.3%) of major vascular injury occurred, with no duodenal or pancreatic injuries. The overall postoperative complication rate was 17.7%, all Clavien-Dindo grades Ⅰ-Ⅱ. The time for first flatus was (36.5±8.2) h, and postoperative hospital stay was (7.5±1.5) d. Mean lymph node harvest was (35.4±6.8), and mesenteric integrity was “complete” in 94.9%. Conclusion The mainmast-style traction combined with programmed dissection constitutes a controllable, teachable, and reproducible robotic surgical workflow, which may help promote the standardization of surgical exposure and dissection, shorten the learning curve, and facilitate high-quality right hemicolectomy.
机器人辅助手术系统 / 右半结肠癌根治术 / 显露 / 解剖
robotic system / radical right hemicolectomy / exposure / anatomy
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We evaluated the safety of robotic surgery for right‐sided colon cancer in Japan.
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During the past decade, the concept of complete mesocolic excision (CME) has been developed in an attempt to minimize recurrence for right-sided colon cancer. This study aims to compare outcomes of robotic versus laparoscopic right hemicolectomy with CME for right-sided colon cancer.
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Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.
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中华医学会外科学分会结直肠外科学组,中国结直肠临床研究协作组. 右半结肠癌手术中国专家共识(2024 版)[J]. 中华胃肠外科杂志, 2024, 27(9): 879-890. DOI: 10.3760/cma.j.cn441530-20240817-00287.
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The greater omentum is derived from the foregut, and the right hemicolon is derived from the midgut based on developmental anatomy. This study aimed to investigate whether the greater omentum should be resected in laparoscopic complete mesocolic excision based on developmental anatomy for right-sided colon cancer.A total of 183 consecutive patients with right-sided colon cancer were recruited in this study between February 2020 and July 2022. Ninety-eight patients underwent standard laparoscopic complete mesocolic excision surgery (CME group). The presence of isolated tumor cells and micrometastases was detected in resected greater omentum by the HE staining and immunohistochemistry analysis. Based on developmental anatomy, laparoscopic CME surgery with greater omentum preservation (DACME group) was proposed and performed on 85 right-sided colon cancer patients. To overcome selection bias, we performed a 1:1 match between two groups using four variables: age, sex, BMI, and ASA scores.No isolated tumor cells and micrometastases were found in the resected greater omentum specimen in the CME group. After the propensity score, 81 pairs were balanced and analyzed. Patients in the DACME group showed shorter operative time (194.9 ± 16.4 min vs.201.5 ± 11.5 min, p = 0.002), less blood loss (23.5 ± 24.7 ml vs.33.6 ± 26.3 ml, p = 0.013), and the shorter hospital stays (9.6 ± 1.7 days vs.10.3 ± 2.0 days, p = 0.010) compared with patients in the CME group. In addition, patients in the DACME group had a lower incidence of postoperative complications (4.9% vs.14.8%, p = 0.035) than patients in the CME group.The greater omentum should be preserved during right-sided colon cancer surgery, laparoscopic CME surgery based on developmental anatomy is technically safe and feasible for right-sided colon cancer.© 2023. The Author(s).
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Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.
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\n Background Robotic liver surgery is emerging as the future of minimal invasive surgery. The robotic surgical system offers a stable camera platform, elimination of physiologic tremor, augmented surgical dexterity as well as improved ergonomics because of a seated operating position. Due to the theoretical advantages of the robotic assisted system, complex liver surgery might be an especially interesting indication for a robotic approach since it demands delicate tissue dissection, precise intracorporeal suturing as well as difficult parenchymal transection with subsequent need for meticulous hemostasis and biliostasis.
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付海啸, 符炜, 张轩, 等. “主桅杆”式牵拉法在机器人结直肠手术中的应用[J]. 结直肠肛门外科, 2025, 31(5):437-446.DOI:10.19668/j.cnki.issn1674-0491.2025.05.010.
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付海啸, 符炜, 李腾腾, 等. 尾外侧入路翻页式达芬奇机器人辅助右半结肠完整结肠系膜切除术流程化经验交流[J]. 结直肠肛门外科, 2024, 30(4): 435-441.DOI:10.19668/j.cnki.issn1674-0491.2024.04.006.
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Total laparoscopic right hemicolectomy with complete mesocolic excision (CME), central vascular ligation (CVL), and D3 lymphadenectomy is still the most challenging colon procedures for gastrointestinal surgeons. We herein report the technical details and our preliminary experience of Bach Mai Procedure - a novel-combining (cranial, medial to lateral, and caudal) approach with early resection of the terminal ileum.The dissection stage was central vascular isolation and ligation by a combined multiple approaches in the following four steps: cranial approach, dissecting along the inferior aspect of pancreatic isthmus to reveal the middle colic vessels and the anterior aspect of the superior mesentery vein and then exposed the right gastroepiploic vein and the trunk of Henle; medial-to-lateral approach, exposing the surgical axis - the superior mesenteric vascular axis and then early resection of the terminal ileum to open the dissection from the bottom up; and caudal approach, radical ligation of the ileocecal artery and right colic artery (central vascular ligation), lymph node dissection (D3 lymphadenectomy), and resecting the Toldt fascia of the colon to release the entire right colon from the abdominal wall.In 12 months, there were 32 cases of primary right-sided colon malignancies that have undergone tLRH based on the Bach Mai Procedure. In 3 cases (9.4%), the tumor site was hepatic flexure. The median of lymph node number (LNN) was 38, with the maximum number which was 101. No serious postoperative complications (grade 3 or higher) neither inhospital mortality was detected.This Bach Mai procedure, a novel-combining approach with early resection of the terminal ileum, is technically feasible and safe for tLRH. Further investigations and follow-up must be proceeded to evaluate the long-term outcomes of our technique.© 2023. The Author(s).
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Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation.
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Laparoscopic complete mesocolic excision (CME) right colectomy is a technically demanding procedure infrequently employed in Western centers. This retrospective cohort study aims to analyze the safety of laparoscopic CME colectomy compared to standard colectomy for right-sided colon cancer in a Western series.Prospectively collected data from 60 patients who underwent laparoscopic CME right colectomy were compared to the ones of 55 patients who underwent laparoscopic standard right colectomy.No differences in clinical characteristics were observed between the CME and standard right colectomy groups. No differences were demonstrated in terms of blood loss (P = 0.060), intraoperative complications (P = 1), conversion rate (P = 0.102), and operative time (P = 0.473). No deaths were observed in either group, while complication rate was 40.0% in the CME and 49.1% in the standard group (P = 0.353). Severe complications occurred in 10.0% vs. 9.1% (P = 0.842), redo surgery in 5.0% vs. 7.3% (P = 0.708), and unplanned readmission in 5.0% vs. 5.5% (P = 1) after CME and standard colectomy, respectively. A significant difference in favor of CME was observed in the total length of specimen (P < 0.001), proximal (P = 0.018), and distal margins (P = 0.037). The number of lymph nodes harvested was significantly higher in the CME group (27 vs. 22, P = 0.037).In Western series, where patients have less favorable clinical characteristics, laparoscopic CME allows to obtain better quality surgical specimens and comparable short-term outcomes compared to standard right colectomy.
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Background: Fredet’s fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet’s fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet’s fascia or area. Hence, we undertook a systematic review of articles that include the terms “Fredet’s fascia or area”, or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments. Methods: We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar. Results: The results of the study revealed that the term “Fredet’s fascia” is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of “Fredet’s fascia” and its topographical limits. Conclusions: Knowledge of Fredet’s fascia’s surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a “descriptive term” instead, based on the fascia’s anatomic structure. Fredet’s fascia could, therefore, be more appropriately renamed “sub-mesocolic pre-duodenopancreatic fascia”.
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牛敏娟, 厉琳杰, 孙凌宇, 等. 从胚胎学与膜解剖理解完整结肠系膜切除手术[J]. 结直肠肛门外科, 2021, 27(3):188-196.DOI:10.19668/j.cnki.issn1674-0491.2021.03.002.
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郭释琦, 于涛, 崔明明, 等. CT三维重建导航下行中间入路“六步法”腹腔镜右半结肠切除术近期疗效研究[J]. 中国实用外科杂志, 2023, 43(2):184-192. DOI:10.19538/j.cjps.issn1005-2208.2023.02.12.
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利益冲突 所有作者均声明不存在利益冲突
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