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中华疝和腹壁外科杂志(电子版)

中华疝和腹壁外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (04) : 376 -382. doi: 10.3877/cma.j.issn.1674-392X.2024.04.004

论著

机器人与腹腔镜食管裂孔疝修补术对比研究
刘明昊1, 李晨2, 王冰2, 万政2, 田文2,†()   
  1. 1. 100853　北京，解放军医学院；100853　北京，中国人民解放军总医院第一医学中心普通外科医学部甲状腺（疝）外科
    2. 100853　北京，中国人民解放军总医院第一医学中心普通外科医学部甲状腺（疝）外科
  • 收稿日期:2024-07-03 出版日期:2024-08-18
  • 通信作者: 田文
  • 基金资助:
    军队保健专项课题项目(21BJZ14)

A comparative study of robotic surgery versus laparoscopic repair of hiatal hernia

Minghao Liu1, Chen Li2, Bing Wang2, Zheng Wan2, Wen Tian2,†()   

  1. 1. Medicel School of Chinese PLA, Beijing 100853, China; Department of Thyroid & Hernia Surgery, Medical Department of General Surgery, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
    2. Department of Thyroid & Hernia Surgery, Medical Department of General Surgery, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
  • Received:2024-07-03 Published:2024-08-18
  • Corresponding author: Wen Tian
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引用本文：

刘明昊, 李晨, 王冰, 万政, 田文. 机器人与腹腔镜食管裂孔疝修补术对比研究[J]. 中华疝和腹壁外科杂志(电子版), 2024, 18(04): 376-382.

Minghao Liu, Chen Li, Bing Wang, Zheng Wan, Wen Tian. A comparative study of robotic surgery versus laparoscopic repair of hiatal hernia[J]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2024, 18(04): 376-382.

目的

探讨食管裂孔疝患者采用机器人术式与腹腔镜术式进行食管裂孔修补的疗效。

方法

回顾性分析2015年3月至2024年4月，中国人民解放军总医院第一医学中心普通外科医学部甲状腺（疝）外科收治的食管裂孔疝患者的临床资料。共计纳入128例患者，依据手术方法的不同，分为机器人组30例，腹腔镜组98例。统计患者术前基线资料、围手术期资料及术后症状改善情况。进一步通过年龄将患者进行分组，比较不同年龄的患者通过两种术式的获益情况。

结果

与腹腔镜组相比，机器人组患者术中出血量较少（20.0 ml比35.0 ml）、术后排气时间较短（2.0 d比3.0 d）、术后住院时间较短（4.0 d比5.0 d）、术后首日疼痛数字评定量表评分较低（3.0分比4.0分），而手术时间更长（120.0 min比101.5 min）、住院总费用更高（61 564元比40 407元），以上各项差异均有统计学意义（P<0.05）。术后中位随访时间51个月，2组患者症状均较术前得到改善。在中青年患者中，与腹腔镜组相比，机器人组患者术中出血量较少、术后排气时间短、手术时间较长、住院所需费用更多（分别为20.0 ml比32.5 ml，2.0 d比3.0 d，118.5 min比100.0 min，62 200元比40 027元），差异均有统计学意义（P<0.05）；而在术后住院时间及疼痛情况并无明显获益（P>0.05）。在老年患者中，机器人组术中出血相对较少、术后排气时间及住院时间更短、术后疼痛评分更低、手术时间更长及住院费用相对较高（分别为20.0 ml比35.0 ml，2.0 d比3.0 d，4.0 d比5.0 d，3.0分比4.0分；120.0 min比110.0 min和60 263元比40 749元），差异均有统计学意义（P<0.05）。中青年患者及老年患者的术后症状均较术前缓解。

结论

不论是通过腹腔镜术式还是机器人术式，食管裂孔疝患者均可从手术中获益，两者相比，机器人术式可以为老年患者带来更明显的获益。

关键词: 食管裂孔疝, 机器人手术, 腹腔镜手术, 疗效
Objective

To investigate the efficacy of robot-assisted versus laparoscopic repair for patients with hiatal hernia (HH).

Methods

A retrospective analysis was conducted on the clinical data of patients with hiatal hernia treated in the Department of Thyroid & Hernia Surgery, Medical Department of General Surgery, the First Medical Center of Chinese PLA General Hospital from March 2015 to April 2024. A total of 128 patients were included and divided into two groups based on the surgical method: the robotic group (30 cases) and the laparoscopic group (98 cases). Preoperative baseline data, perioperative data, and postoperative symptom improvement were analyzed. Patients were further stratified by age to compare the benefits of the two surgical methods across different age groups.

Results

Compared to the laparoscopic group, the robot-assisted group exhibited less intraoperative bleeding (20.0 ml vs. 35.0 ml), shorter postoperative gas evacuation (2.0 days vs. 3.0 days), shorter postoperative hospitalization time (4.0 days vs. 5.0 days), and lower pain numerical rating scale score on the first day after surgery (3.0 points vs. 4.0 points), albeit with longer operative times (120.0 min vs. 101.5 min) and higher total hospital costs (61 564 yuan vs. 40 407 yuan), the above differences were statistically significant (P<0.05), During follow-up after surgery, symptoms improved in both groups of patients compared to preoperative conditions. Additionally, among young and mid aged patients, compared to laparoscopy, those in the robotic group experienced less intraoperative bleeding and shorter postoperative gas evacuation. However, robotic surgeries had longer operative times and incurred total hospital costs, with statistically significant differences (20.0 ml vs. 32.5 ml, 2.0 days vs. 3.0 days, 118.5 min vs. 100.0 min, 62 200 yuan vs. 40 027 yuan; P<0.05). There were no significant benefits observed in terms of postoperative hospitalization time or pain scores (P>0.05). In elderly patients, robotic-assisted surgery is associated with significantly reduced intraoperative bleeding, shorter postoperative gas evacuation, postoperative hospitalization time and lower postoperative pain scores. However, it is also linked to longer operative times and relatively higher hospitalization costs, with these differences being statistically significant (20.0 ml vs. 35.0 ml, 2.0 days vs. 3.0 days, 3.0 points vs. 4.0 points, 120.0 min vs. 110.0 min, 60 263 yuan vs. 40 749 yuan; P<0.05). Postoperative symptoms improved in both middle-aged and elderly patients compared to preoperative conditions.

Conclusion

Whether through laparoscopic or robot-assisted approaches, patients with hiatal hernia can benefit from surgery, However, robotic-assisted surgery offers more significant advantages for elderly patients compared to laparoscopic techniques.

Key words: Hiatal hernia, Robotic surgery, Laparoscopic surgery, Efficacy
表1 2组患者术前基线资料比较
临床资料 腹腔镜组(n=98) 机器人组(n=30) Z/χ2/ t值 P值
年龄[岁, M(Q1,Q3)] 56.5 (49.0, 63.0) 62.0 (53.3, 64.8) -1.932① 0.053
性别[例(%)]     1.778② 0.182
女性 45 (45.9) 9 ( 30.0)    
男性 53 (54.1) 21 ( 70.0)    
体重指数[kg/m2, M(Q1,Q3)] 25.33 (23.76, 27.55) 26.30 (24.72, 27.44) -0.667① 0.505
原发性高血压[例(%)] 15 (15.3) 2 ( 6.7) 0.833② 0.361
冠心病[例(%)] 9 ( 9.2) 3 ( 10.0) 0.000② 1.000
有吸烟史[例(%)] 28 (28.6) 7 ( 23.3) 0.108② 0.742
有饮酒史[例(%)] 14 (14.3) 5 ( 16.7) 0.001② 0.978
腹部手术史[例(%)] 15 (15.3) 3 ( 10.0) 0.186② 0.666
糖尿病[例(%)] 7 ( 7.1) 1 ( 3.3) 0.104② 0.747
症状[例(%)]     1.290② 0.256
消化道症状 77 (78.6) 27 ( 90.0)    
消化道外症状 21 (21.4) 3 ( 10.0)    
症状持续时间[例(%)]     3.892② 0.143
<5年 48 (49.0) 10 ( 33.3)    
5~10年 15 (15.3) 9 ( 30.0)    
>10年 35 (35.7) 11 ( 36.7)    
近期加重[例(%)] 35 (35.7) 15 ( 50.0) 1.415② 0.234
应用PPI[例(%)] 64 (65.3) 18 ( 60.0) 0.098② 0.755
CT确诊[例(%)] 19 (19.4) 7 ( 23.3) 0.044② 0.833
消化道造影确诊[例(%)] 37 (37.8) 9 ( 30.0) 0.310② 0.577
食管测压确诊[例(%)] 58 (59.2) 16 ( 53.3) 0.127② 0.721
pH测定确诊[例(%)] 62 (63.3) 21 ( 70.0) 0.209② 0.647
胃镜确诊[例(%)] 69 (70.4) 17 ( 56.7) 1.393② 0.238
ASA分级[例(%)]     0.524② 0.469
≤Ⅱ级 93 (94.9) 30 (100.0)    
>Ⅱ级 5 ( 5.1) 0 ( 0.0)    
血红蛋白(g/L, ±s) 138.26±16.26 137.37±13.00 0.273③ 0.785
红细胞计数(×1012/L,±s) 4.55±0.53 4.52 ±0.31 0.316③ 0.752
白细胞计数[×109/L, M(Q1,Q3)] 5.52 (4.69, 6.72) 5.78 (4.92, 7.22) -0.760① 0.448
血小板计数[×109/L, M(Q1,Q3)] 221.00 (199.00, 270.00) 223.00 (176.50, 250.00) -1.457① 0.145
表2 2组患者围手术期及术后随访情况比较[例（%）]
观察指标 腹腔镜组(n=98) 机器人组(n=30) Z/χ2值 P值
出血量[ml, M(Q1,Q3)] 35.0 (30.0, 40.0) 20.0 (20.0, 25.0) -7.780① <0.001
术中输注晶体液量[ml, M(Q1,Q3)] 1200.0 (1100.0, 1600.0) 1500.0 (1100.0, 1925.0) -1.695① 0.090
术中输注胶体液量[ml, M(Q1,Q3)] 500.0 (0.0, 500.0) 500.0 (0.0, 500.0) -0.374① 0.708
手术时间[min, M(Q1,Q3)] 101.5 (95.0, 110.0) 120.0 (114.0, 127.0) -6.725① <0.001
应用补片[例(%)] 60 (61.2) 19 (63.3) 0.000② 1.000
术后排气时间[d, M(Q1,Q3)] 3.0 (2.0, 3.0) 2.0 (2.0, 2.0) -4.206① <0.001
术后住院时间[d, M(Q1,Q3)] 5.0 (5.0, 6.0) 4.0 (4.0, 5.0) -4.669① <0.001
术后首日疼痛评分[分, M(Q1,Q3)] 4.0 (4.0, 4.0) 3.0 (3.0, 4.0) -3.795① <0.001
住院费用[元, M(Q1,Q3)] 40 407 (33 442, 47 156) 61 564 (51 553, 64 686) -8.244① <0.001
术前GERD-Q评分[分, M(Q1,Q3)] 10.50 (8.25, 13.00) 11.50 (9.00, 14.00) -0.388① 0.698
术后GERD-Q评分[分, M(Q1,Q3)] 6.00 (6.00, 7.00) 6.00 (6.00, 6.00) -0.943① 0.346
随访时存在吞咽困难[例(%)] 4(4.1) 1(3.3) 0.000② 1.000
表3 中青年、老年患者中不同术式的2组患者术前基线资料比较[例(%)]
基线资料 中青年 老年
腹腔镜组(n=60) 机器人组(n=10) Z/t/χ2值 P值 腹腔镜组(n=38) 机器人组(n=20) Z/t/χ2值 P值
年龄[岁, M(Q1,Q3)] 50.0(45.0, 55.0) 49.5(45.0, 53.0) -0.337① 0.736 64.0(63.0, 66.5) 63.5(62.0, 66.0) -0.775① 0.438
性别[例(%)]     0.583② 0.445     1.908② 0.167
女性 23 (38.3) 2 ( 20.0)     22 (57.9) 7 ( 35.0)    
男性 37 (61.7) 8 ( 80.0)     16 (42.1) 13 ( 65.0)    
体重指数(kg/m2,±s) 26.21±3.47 25.04±1.69 1.041③ 0.302 25.30±2.15 26.30±2.21 -1.668③ 0.101
原发性高血压[例(%)] 9 (15.0) 2 ( 20.0) 0.000② 1.000 6 (15.8) 0 ( 0.0) 2.026② 0.155
冠心病[例(%)] 3 ( 5.0) 2 ( 20.0) 1.086② 0.297 6 (15.8) 1 ( 5.0) 0.600② 0.438
有吸烟史[例(%)] 21 (35.0) 3 ( 30.0) 0.000② 1.000 7 (18.4) 4 ( 20.0) 0.000② 1.000
有饮酒史[例(%)] 9 (15.0) 0 ( 0.0) 0.643② 0.423 5 (13.2) 5 ( 25.0) 0.592② 0.442
腹部手术史[例(%)] 13 (21.7) 1 ( 10.0) 0.182② 0.669 2 ( 5.3) 2 ( 10.0) 0.017② 0.895
糖尿病[例(%)] 2 ( 3.3) 0 ( 0.0) 0.000② 1.000 5 (13.2) 1 ( 5.0) 0.266② 0.606
症状[例(%)]     2.110② 0.146     0.000② 1.000
消化道症状 44 (73.3) 10 (100.0)     33 (86.8) 17 ( 85.0)    
消化道外症状 16 (26.7) 0 ( 0.0)     5 (13.2) 3 ( 15.0)    
症状持续时间[例(%)]     4.815② 0.090     3.425② 0.180
<5年 28 (46.7) 4 ( 40.0)     20 (52.6) 6 ( 30.0)    
5~10年 12 (20.0) 5 ( 50.0)     3 ( 7.9) 4 ( 20.0)    
>10年 20 (33.3) 1 ( 10.0)     15 (39.5) 10 ( 50.0)    
近期加重[例(%)] 22 (36.7) 5 ( 50.0) 0.203② 0.652 13 (34.2) 10 ( 50.0) 0.785② 0.376
应用PPI[例(%)] 40 (66.7) 6 ( 60.0) 0.003② 0.959 24 (63.2) 12 ( 60.0) 0.000② 1.000
CT确诊[例(%)] 10 (16.7) 2 ( 20.0) 0.000② 1.000 9 (23.7) 5 ( 25.0) 0.000② 1.000
消化道造影确诊[例(%)] 24 (40.0) 2 ( 20.0) 0.737② 0.391 13 (34.2) 7 ( 35.0) 0.000② 1.000
食管测压确诊[例(%)] 33 (55.0) 2 ( 20.0) 2.917② 0.088 25 (65.8) 14 ( 70.0) 0.001② 0.976
pH测定确诊[例(%)] 34 (56.7) 6 ( 60.0) 0.000② 1.000 28 (73.7) 15 ( 75.0) 0.000② 1.000
胃镜确诊[例(%)] 44 (73.3) 7 ( 70.0) 0.000② 1.000 25 (65.8) 10 ( 50.0) 0.785② 0.376
ASA分级[例(%)]     0.000② 1.000     0.082② 0.774
≤Ⅱ级 57 (95.0) 10 (100.0)     36 (94.7) 20 (100.0)    
>Ⅱ级 3 ( 5.0) 0 ( 0.0)     2 ( 5.3) 0 ( 0.0)    
血红蛋白(g/L,±s) 140.33±15.74 131.50±15.48 1.646③ 0.104 134.97±16.73 140.30±10.82 -1.286③ 0.204
红细胞计数(×1012/L,±s) 4.64±0.53 4.47±0.29 1.010③ 0.316 4.41±0.51 4.54±0.33 -1.076③ 0.287
白细胞计数[×109/L, M(Q1,Q3)] 5.52 (4.69, 6.30) 5.78 (5.12, 6.43) -0.722① 0.470 5.43 (4.84, 7.30) 5.78 (4.78, 7.54) -0.524① 0.600
血小板计数[×109/L, M(Q1,Q3)] 245.00(206.00, 278.50) 225.00(179.50, 238.00) -1.654① 0.098 214.00(195.00, 231.75) 223.00(179.50, 252.00) -0.049① 0.961
表4 中青年、老年患者中不同手术方法的2组患者围手术期及术后随访情况比较
观察指标 中青年 老年
腹腔镜组(n=60) 机器人组(n=10) Z/χ2值 P值 腹腔镜组(n=38) 机器人组(n=20) Z/χ2值 P值
出血量[ml, M(Q1,Q3)] 32.5(30.0, 40.0) 20.0(20.0, 25.0) -4.389① <0.001 35.0(30.0, 40.0) 20.0(18.8, 25.0) -6.284① <0.001
术中输注晶体液量[ml, M(Q1,Q3)] 1500.0(1100.0, 1600.0) 1200.0(1100.0, 1500.0) -0.338① 0.736 1100.0(1100.0, 1600.0) 1600.0(1100.0, 2100.0) -1.867① 0.062
术中输注胶体液量[ml, M(Q1,Q3)] 500.0(0.0, 500.0) 500.0(0.0, 500.0) -0.201① 0.841 0.0(0.0, 500.0) 500.0(0.0, 500.0) -1.095① 0.273
手术时间[min, M(Q1,Q3)] 100.0(80.8, 103.3) 118.5(110.0, 135.0) -4.403① <0.001 110.0(100.5,110.0) 120.0(114.8,127.0) -5.108① <0.001
应用补片[例(%)] 38 (63.3) 6 (60.0) 0.000② 1.000 22 (57.9) 13 ( 65.0) 0.059② 0.808
术后排气时间[d, M(Q1,Q3)] 3.0 (2.0, 3.0) 2.0 (2.0, 2.0) -3.399① 0.001 3.0 (3.0, 3.0) 2.0 (2.0, 3.0) -3.321① 0.001
术后住院时间[d, M(Q1,Q3)] 5.0(5.0, 5.0) 5.0(4.0, 5.0) -1.807① 0.071 5.0 (5.0, 7.0) 4.0 (4.0, 5.0) -4.911① <0.001
术后首日疼痛评分[分, M(Q1,Q3)] 4.0 (4.0, 4.0) 4.0 (3.3, 4.0) -0.282① 0.778 4.0 (4.0, 4.0) 3.0 (2.0, 3.0) -3.728① <0.001
住院费用[元, M(Q1,Q3)] 40 027(36035, 47156) 62 200(52041, 70497) -4.977① <0.001 40 749(31568, 47156) 60 263(51543, 63483) -6.273① <0.001
术前GERD-Q评分[分, M(Q1,Q3)] 10.50(9.00, 12.00) 8.50(8.00, 10.50) -1.618① 0.106 10.50(8.00, 15.00) 12.50(9.00, 14.00) -0.840① 0.401
术后GERD-Q评分[分, M(Q1,Q3)] 6.00(6.00, 7.00) 6.00(6.00, 6.00) -0.580① 0.562 6.00(6.00, 7.00) 6.00(6.00, 6.00) -1.129① 0.259
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