雙孔腹腔鏡手術在子宮附屬器病灶及子宮內膜癌的角色

The Role of Two-port Access Laparoscopic Surgery for Adnexal Lesions and Endometrial Cancer

黃冠儒(Kuan-Ju Huang)

指導教授 ： 許博欽

國立臺灣大學/醫學院/臨床醫學研究所/碩士(2022年)

https://doi.org/10.6342/NTU202200074

摘要

腹腔鏡手術自1970年代發展以來已經有半世紀以上的歷史。在這段期間，克服了光學顯像限制、改善手術器械侷限、加強電燒止血系統效率以及靠著各專家大量的經驗累積分享，讓微創手術朝著減少傷口數量、自然孔洞、降低轉開腹手術及減少出血等極限發展。傳統腹腔鏡技術包含藉由3個以上的傷口完成手術並取出檢體，而隨後發展的單孔腹腔鏡手術則以美觀及高手術技術為主要訴求，透過特殊鏡頭及專用的手術器械完成手術，手術檢體也可以從單一傷口簡單的取出。而雙孔腹腔鏡手術則取兩者所長，另外佔有一席之地。近年來，科技進步讓以遠端操作的機械手臂輔助腹腔鏡手術（達文西系統）蔚為風行，尤其是3D成像、減少操作者手震等優勢，讓術者可以在相對舒適的環境下執行較困難或是時間長的手術，而目前達文西系統通常需要4個以上的傷口才能完成手術。目前，應用在婦產科的腹腔鏡術式有三種，首先是子宮附屬器（即卵巢、輸卵管）相關的手術，此類手術需要基本的腹腔鏡操作技巧以及精細度，手術時間較短，通常大部分的醫師都能完成。其次為子宮切除手術及其延伸的癌症分期手術，此手術牽涉到對解剖構造更深層的認識，並對手眼協調、止血、分離組織的動作有更高的要求，需要一些經驗及學習才能完成手術。而腹腔鏡子宮肌瘤切除手術則除了以上的技巧之外，另外涉及了縫合、打結之類更精細的動作，另外在取出檢體使用的技巧也需要特別的學習。
由於臨床上手術適應症、手術難度、醫師經驗、病患能否支付昂貴的特殊耗材、病人對於預後要求、傷口美觀等考量各不相同，選擇使用哪種手術方式大致上取決於主治醫師主觀裁量，也使得大部分文獻回顧無法以客觀或是有良好證據等級的研究來支持臨床決策。因本院兼具操作不同手術經驗豐富之醫師，本研究透過以不同方式在子宮附屬器及子宮切除手術中，來探討最適合的手術平台以輔助臨床決策。
方法或程序
本研究第一個部分回溯追蹤2011-2018年間在台大醫院接受各種腹腔鏡子宮附屬器手術的病患，並分析其手術相關結果及預後。第二個部分則回溯追蹤2015-2019年間在台大醫院接受腹腔鏡子宮內膜癌症分期手術的病患，並分析其手術相關結果及預後。
結果
在第一部分的研究中，643位病患裡有259位病患接受單孔腹腔鏡手術、384位病患接受雙孔腹腔鏡手術。相較於單孔腹腔鏡手術，雙孔腹腔鏡手術在處理子宮附屬器相關的病灶時可節省手術時間（63.83 ± 25.31 vs. 57.32 ± 26.38分鐘, P < 0.01, OR = 0.98, CI = 0.98–0.99），術式變更率亦較低 (6.25% vs. 24.38%, P < 0.01, OR = 0.20, CI = 0.11 - 0.35)，而總出血量高出約2.82毫升 (5.2 vs. 2.38毫升, P < 0.01 , OR = 1.04, CI = 1.02 – 1.07)。
在第二部分的研究中，共有89位病患接受雙孔腹腔鏡子宮內膜癌症分期手術，而有59位接受傳統腹腔鏡子宮內膜癌症分期手術。經多變項迴歸調整後，雙孔腹腔鏡手術可節省手術時間 (152.09 ± 44.26 vs. 187.15 ± 41.87分鐘, P < 0.01, OR = 0.98, CI = 0.97 – 0.99)，術後48小時疼痛指數較低 (2.5 ± 0.55 vs. 2.74 ± 0.76, P = 0.03, OR = 0.54, CI = 0.31 – 0.95)。手術併發症、五年復發率及存活率並無明顯差異。而雙孔腹腔鏡學習曲線只需3-4個個案即可掌握此手術。
討論及結論
在現實世界中，病患追求傷口美觀、減低疼痛、減少住院天數等需求漸增，而醫師則需平衡手術難度、手術耗時、醫療成本等來決定適當的處置原則。其中，有些可共同達成，有些則相互衝突。而在微創手術演進過程中，單孔腹腔鏡可為病患需求之代表，達文西手術則較偏醫師取向。惟雙孔腹腔鏡手術因較單孔腹腔鏡不美觀，也被認為操作難易不如傳統腹腔鏡手術，因此一直以來不被重視。本院的腹腔鏡發展涵蓋了傳統腹腔鏡、單孔腹腔鏡、機械手臂輔助腹腔鏡以及自2015年後的雙孔腹腔鏡手術，累積大量臨床經驗。我們證實，雙孔腹腔鏡對子宮附屬器手術可比擬單孔腹腔鏡，而卵巢囊腫切除手術需要較高手術技巧，手術耗時較長。而與傳統腹腔鏡相比，對於困難手術如子宮內膜癌症分期手術，雙孔腹腔鏡手術成效可以達到不劣於傳統腹腔鏡的表現。分析其中原因，因為雙孔腹腔鏡較單孔腹腔鏡手術多了一個操作角度，因此在手術時可以雙手同時靈活運用，並且承襲了單孔腹腔鏡手術單一大傷口的優點（約2公分），利於取出檢體。而對於傳統腹腔鏡來說，雖然雙孔腹腔鏡少使用1至2個器械孔角度輔助手術，但是事實上這些額外的器械孔一般來說是由助手在掌控鏡頭時同時來操作。在這個情況下，助手除了必須滿足與術者手眼協調的腹腔鏡視線外，還要分心來操作另外一個器械，而大多數的情況下，通常是助手無法兼顧，造成視野干擾或是操作干擾，反而影響手術表現。
本研究認為，雙孔腹腔鏡擁有傳統腹腔鏡及單孔腹腔鏡之優點，而減低兩者缺點的影響，使其在大部分的婦產科微創手術能有較好的表現。然而，因涉及資料回溯及本質上無法去除的手術者個人經驗、能力等因素，故本研究仍承襲相關的研究限制及判讀偏誤。或許未來仍需要完整良好設計的多平台腹腔鏡研究來證實我們的發現。

關鍵字

單一切口腹腔鏡 ； 雙孔腹腔鏡 ； 傳統腹腔鏡 ； 子宮附屬器手術 ； 子宮內膜癌症分期手術

並列摘要

It has been more than half of a century since the development of laparoscopic surgery in the 1970s. With the improvements in optical system, surgical instruments, hemostasis techniques, and accumulation of surgical experience, minimally invasive surgery evolves into reduced wounds number, better cosmetic outcomes via natural orifice, lower conversion rate, and blood loss. Conventional laparoscopic technique uses more than 3 penetrations (wounds), while single incision laparoscopic surgery (SILS) focuses on aesthetics via advanced surgical techniques and specific surgical instruments. Surgical specimens can also be easily removed from the wound. The two-port access laparoscopic surgery (TPA) is developed with the intention to take advantage of both methods. In recent years, robotic-assisted laparoscopy (Da Vinci system) is getting popular due to its 3D imaging, tremor filtration, and surgeon-friendly environment. The surgery is completed using 4 wound penetrations. There are three major types of laparoscopic surgeries in gynecology field. The first involves adnexal surgeries (ie ovaries, fallopian tubes), which requires basic laparoscopic operation skill, and the operation time is relatively short. The second is hysterectomy and staging surgery for gynecologic malignancies, which involves insight into pelvic anatomy, and is associated with higher technical requirements for surgical coordination, hemostasis, and tissue dissection. It takes a few cases for skill proficiency. The last is laparoscopic myomectomy, which generally requires delicate control including suturing, making surgical ties and specimen removal.
The surgical indications, surgical difficulty, physicians’ experience, financial concern, cosmetic outcome, etc. influence surgeons’ choice for surgical platform. Evidence is also limited due to most studies are associated with retrospective design and are subject to selection bias. We aimed to reduce these limitations using single center results by experienced surgeons with large sample size in adnexal and uterine surgeries.
Methods or Procedures
In the first part, patients who underwent various laparoscopic adnexal surgeries at National Taiwan University Hospital between 2011 and 2018 were identified. Surgical outcome and prognosis were classified and analyzed by surgical platforms. The second part identified endometrial cancer patients who received laparoscopic staging surgery at National Taiwan University Hospital from 2015 to 2019.
Results
In the first part of the study, 259 of the 643 patients underwent single incision laparoscopic surgery and 384 patients underwent two-port laparoscopic surgery. Compared with SILS, TPA needs less operation time for adnexal surgeries (63.83 ± 25.31 vs. 57.32 ± 26.38 minutes, P < 0.01, OR = 0.98, CI = 0.98–0.99). The conversion rate was low (6.25% vs. 24.38%, P < 0.01, OR = 0.20, CI = 0.11-0.35), and the blood loss was about 2.82 ml less (5.2 vs. 2.38 ml, P < 0.01, OR = 1.04, CI = 1.02-1.07).
In the second part of the study, a total of 89 patients underwent TPA staging surgery, while 59 underwent conventional laparoscopic staging surgery. After multivariate analysis, TPA costs less operation time (152.09 ± 44.26 vs. 187.15 ± 41.87 minutes, P < 0.01, OR = 0.98, CI = 0.97 – 0.99), and results in less pain 48 hours after surgery (2.5 ± 0.55 vs. 2.74 ± 0.76, P = 0.03, OR = 0.54, CI = 0.31 – 0.95). There was no significant difference in surgical complications, five-year recurrence rate, and overall survival. Operators achieve proficiency for TPA surgical staging after 3-4 cases.
Discussion and Conclusion
In the real-world experience, patients are seeking better cosmetic outcomes, less pain, and hospital stays. On the other hand, surgery difficulty, operative time, and medical costs are surgeons’ priorities. Several points can be achieved concomitantly, while others not. In the evolution of minimally invasive surgery, SILS develops in favor of patients, while robotic-assisted surgery is known for its surgeon-friendly environment. TPA is less popular due to its inferior cosmetic outcome than SILS, and control limitations compared to conventional laparoscopic surgery. Either SILS, conventional laparoscopy and robotic-assisted surgery are used in National Taiwan University Hospital, and TPA is also available since 2015. In this study, we found that TPA is comparable to SILS in term of operative time, and oophorocystectomy has more technical requirement and takes more operative time. In endometrial cancer staging surgery, TPA is not inferior to conventional laparoscopy. TPA is advantageous than SILS by one more trocar for larger surgical field, and inherits the advantages of a single large wound (about 2 cm) for specimen removal. Compared to conventional laparoscopy, the assistant of TPA can focus on laparoscope control rather than handle a laparoscope and an instrument simultaneously, which interferes operation by visual disturbance or confliction with operator in most cases.
This study reveals that TPA takes advantages of both conventional laparoscopy and SILS and results in better outcome in some of the minimally invasive gynecology. The study is limited by its retrospective nature, selection bias, and surgeons’ effects. Further well-designed study involving multi-platform laparoscopic surgery may be needed to confirm our findings.

並列關鍵字

single-incision laparoscopic surgery ； two-ports laparoscopic surgery ； conventional laparoscopic surgery ； adnexa surgery ； endometrial cancer surgical staging

參考文獻

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