達文西機器手臂由單側摘取雙側內乳動脈冠狀動脈繞道手術之早期經驗

Early Outcome of Robot-Assisted One Side Approach for Bilateral Internal Mammary Artery Mobilization in Coronary Artery Bypass Surgery

吳介任(Chieh-Jen Wu)

指導教授 ： 邱肇基

高雄醫學大學/醫學院/臨床醫學研究所/碩士(2017年)

摘要

心血管疾病始終是台灣十大死因的前三名，尤以冠狀動脈的阻塞疾病為重。冠狀動脈疾病以內科治療為首選，但心臟外科冠狀動脈繞道手術為最後一道防線。傳統的冠狀動脈繞道手術為全胸骨正中切開，有很大的胸部傷口，通常摘取左側內乳動脈吻合於左前降冠狀動脈支，多數合併使用腿部大隱靜脈連接主動脈與左後迴旋冠狀動脈支以及右側冠狀動脈，病患常須住院兩週，並休息數週至數月以利胸骨癒合與身體復原。一般而言，使用動脈血管行繞道手術在長時間追蹤，比使用靜脈血管有較高的通暢率。近年國內引用達文西機器手臂技術，協助外科醫師進行微創手術，以縮小手術傷口，在各外科領域已廣泛應用。對於冠狀動脈疾病，先利用達文西機器手臂摘取雙側內乳動脈，之後行左側開胸微創開心手術，來完成冠狀動脈繞道手術，技術上是否安全，與手術預後效果文獻報導仍然很少。
我們設計回溯對照性研究，探討此議題，一組為進行達文西機器手臂摘取兩側內乳動脈併左側開胸微創冠狀動脈繞道手術，另一組採傳統全胸骨正中切開，摘取兩側內乳動脈併冠狀動脈繞道手術，進行了手術後追蹤，為期一年的研究，研究目的如下：
1. 比較傳統全胸骨正中切開冠狀動脈繞道手術與達文西手術摘取兩側內乳動脈左側開胸微創冠狀動脈繞道手術，兩組在術前後與住院中的相關併發症，有無統計上不同。
2. 比較兩組在為期一年的追蹤，心血管事件上有無統計上差異。
我們的研究發現，利用達文西機器手臂摘取兩側內乳動脈併左側開胸微創冠狀動脈繞道手術，與採取傳統全胸骨正中切開，摘取兩側內乳動脈併冠狀動脈繞道手術，在住院中含術前與術後，傷口感染率和其他併發症，以及滿一年的短期追蹤，包括心血管事件，兩者均無明顯差異，但是達文西機器手臂摘取兩側內乳動脈併左側開胸微創冠狀動脈繞道手術很顯著傷口小，手術中使用人工心肺機時間相對短，有較低的腎臟傷害。所以，使用達文西機器手臂摘取兩側內乳動脈併左側開胸微創冠狀動脈繞道手術是不同於傳統全胸骨正中切開狀動脈繞道手術，另一安全可行的冠狀動脈繞道手術方法。

關鍵字

達文西機器手臂 ； 雙側內乳動脈 ； 冠狀動脈繞道手術

並列摘要

Cardiovascular disease is always the top three cause of death in Taiwan, especially in the coronary artery disease. Medical treatment and percutaneous coronary intervention (PCI) is the first choice for coronary artery disease, but the coronary artery bypass surgery is the last defense line of coronary artery disease. Conventional coronary artery bypass grafting (CABG) surgery with full-sternotomy remains the standard treatment for patients with coronary artery diseases and it generates a big chest surgical wound. In addition, left internal mammary artery (LIMA) is mobilized and anastomosed to left descending coronary artery, and saphenous veins are usually harvested for coronary grafting to left circumflex coronary artery and right coronary artery. In general, the long term patency rate is relatively higher in patients receiving artery graftings than those receiving vein graftings. In recent years, da Vinci robot assisted operator system (Intuitive Surgical, Sunnyvale, CA) has been introduced to help operators perform minimally invasive surgeries, minify surgical wounds. The operator system has been widely utilized in various surgical fields. In coronary artery disease, bilateral internal mammary artery (BIMA) mobilized by da Vinci robot assisted operator system from one side, and complete the coronary artery bypass surgery by the minimally invasive left thoracotomy surgery, the technical safety and surgical outcome is rarely reported.
We designed a retrospective study to investigate the safety and outcome of the two treatment modalities: da Vinci robot-assisted BIMA mobilization from one-side approach and left thoracotomy CABG, and conventional full sternotomy CABG with BIMA grafting. The study aims are:
1. To detect differences in technical complication and inhospital adverse events between the two treatment groups.
2. To detect differences in cardiovascular events within 1 year between the two treatment groups.
In conclusion, our study show that da Vinci robot-assisted BIMA mobilization from one-side approach and left thoracotomy CABG compared with conventional full sternotomy CABG with BIMA grafting did not increase in-hospital sternal wound infection and other side effect and no difference of cardiovascular events in short-term 1 year follow-up. But possibly lowered adverse renal events due to shorter time for heart-lung machine applying. Our study suggests that the robot-assisted BIMA grafting mobilization from one-side approach and left thoracotomy CABG is a safety surgical option for patients with coronary artery disease.

並列關鍵字

Bilateral Internal Mammary Artery ； Coronary Artery Bypass Surgery

參考文獻

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