Percutaneous approach in early-stage ovarian cancer staging
Surgical Technique

经皮入路法在早期卵巢癌分期中的应用

Emanuele Perrone1, Stefano Cianci2, Cristiano Rossitto1, Camilla Fedele1, Salvatore Gueli Alletti1

1Gynecologic Oncology Unit, Women Wealth Area, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; 2Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy

Correspondence to: Emanuele Perrone, MD. Department of Women’s and Children’s Health Fondazione, Policlinico Universitario A. Gemelli, IRCCS, Largo F.Vito 1, 00168 Roma, Italy. Email: ema.perrone88@gmail.com.

摘要：上皮性卵巢癌(Epithelial ovarian cancer, EOC) 是致死率最高的妇科恶性肿瘤。单独手术或手术联合化疗被认为是早期EOC的有效治疗策略, 早期EOC的5年生存率接近90%。在过去的几十年里，一些研究评估和描述了早期EOC腹腔镜手术分期的可行性。内窥镜方法可以维持肿瘤充分性，有望提供更好的生活质量，减小手术创伤对患者身体的影响。在过去的几年里，微创手术(Minimally invasive surgery, MIS)取得了显著的进展，如经皮手术系统(Percutaneous Surgical System, PSS)。在本篇手术视频文章中，我们对早期卵巢癌患者进行了经皮手术分期。手术总时间为180 min，术中估计失血量为100 mL。无术后早期或晚期并发症记录。随访24个月后，未发现复发的证据。本手术视频旨在展示PSS在早期卵巢癌手术分期中的可行性和安全性。

关键词：卵巢癌；卵巢癌的分期；经皮入路法；超微创手术(Ultra-minimally invasive surgery, MIS)

Received: 10 April 2020; Accepted: 23 June 2020; Published: 25 September 2020.

doi: 10.21037/gpm-20-35

视频1 经皮入路法在早期卵巢癌分期中的应用

背景介绍

上皮性卵巢癌(Epithelial ovarian cancer, EOC) 是致死率最高的妇科恶性肿瘤。2019年，美国共发生14000例卵巢癌EOC相关死亡病例[1]。虽然晚期卵巢癌预后较差，但20%-25%的早期患者可通过单纯手术或手术加辅助化疗治愈，且5年生存率接近90%[2]。

在过去的几十年里，一些研究评估和描述了早期EOC腹腔镜(Laparoscopic, LPS)手术分期的可行性和充分性[3-7]。内镜手术方法可以维持肿瘤充分性，可提供更好的生活质量，减小手术创伤对患者身体的影响[4,8]。微创手术(Minimally invasive surgery, MIS)的最新一个创新是经皮手术系统(Percutaneous Surgical System, PSS)。PSS由轴径2.9 mm尖端直径5 mm的经皮穿刺器械(Percuvance TM, Teleflex Inc., USA)、直径2.4 mm的MiniGrip多功能手柄(MiniLap®经皮手术系统，M-PSS)和套管组成。已有研究报道了这套手术系统，它们的安全性、可行性和充分性在妇科良性和恶性病变中得到了证实[9-12]。与其他超微创手术(ultra-MIS)方法不同[13,14]，PSS在仪器的尺寸(5 mm手术尖端锁定在2.9 mm轴上)、位置和灵活性方面重现了标准的LPS设置，如之前的研究中所述[12,15]。

在这篇视频文章中，我们报告一位41岁的女性患者，发现其右侧附件有一30 mm实性肿块，无血管化，且CA125阴性，CT结果也没有显示远处有病灶。该患者为未产妇，有强烈的生育意愿，最初采用M-PSS进行经皮保守的交界性卵巢肿瘤分期。术中冰冻切片结果显示为交界性卵巢肿瘤，因此手术分期保留生育能力。不幸的是，最终的病理报告描述了交界性卵巢肿瘤背景下有局灶性低级别浆液性卵巢癌。因此，患者接受了PSS的全面手术分期。在MIS技术进步的时代，这篇视频文章（视频1）旨在展示PSS手术分期对早期卵巢癌患者的可行性和安全性。

手术步骤

卵巢交界性肿瘤的M-PSS保守分期手术

按照标准的LPS手术准备，经脐开腹镜切口到达腹腔，并使用5 mm Hasson套管针。另外在耻骨上区域插入5 mm套管针。然后经皮插入2个2.4 mm的微型针镜器械作为侧抓器。耻骨上5 mm口用于吸/灌、双极能量钳和剪刀。经腹膜显示右侧输尿管后，凝血切断卵巢蒂、子宫-卵巢韧带、右侧输卵管首段，完成右侧输卵管卵巢切除术。用内窥镜袋从脐部取出切除的组织，避免在腹腔内溢出。此外，保守分期程序完成了子宫内膜活检，阑尾切除术，多点腹膜活检，和结肠下区大网膜切除术。通过5 mm套管针使用多功能器械进行大网膜切除术。

PSS对早期卵巢癌的全面分期手术

在明确的病理报告后，患者接受了采用PSS进行的早期卵巢癌根治性手术分期。重复前面手术过程中所述的设置，通过脐部使用10 mm Hasson套管针实现气腹。在耻骨上位置放置一个5 mm套管针，两侧放置两个横向穿刺针。对于这个程序，多功能仪器是组成性的使用。

手术步骤

  • 电凝双侧圆韧带，打开阔韧带腹膜；
  • 看清楚重要血管和输尿管的解剖位置后，用血管夹在子宫动脉的起始处夹闭子宫动脉；
  • 凝固并切断左卵巢血管，注意看清楚输尿管，避免损伤输尿管；
  • 分离膀胱外侧的间隙至耻骨宫颈筋膜；
  • 凝固及离断子宫血管；
  • 切开阴道，经阴道取出子宫及左侧附件。连续单层缝合阴道断端；
  • 打开膀胱旁和直肠旁间隙，暴露髂外血管、髂内血管和闭孔神经后，行双侧盆腔淋巴结切除术；
  • 通过骶前筋膜切口，暴露下腔静脉、腹主动脉和肠系膜下动脉的起始段。行腹主动脉旁淋巴结切除术。

围手术期记录及随访情况

手术总时间为180 min，术中估计失血量为100 mL。无术后早期和远期并发症记录。随访24个月后，未发现疾病复发的证据。

讨论

在这篇视频文章（视频1）中，我们首次论证了在早期卵巢癌手术分期中经皮入路的可行性。PSS方法是MIS的最新一个创新。近十年来技术的快速发展使得MIS可以与传统外科方法相媲美，具有重叠的外科和临床安全性，创伤较小。本文介绍并研究了经皮入路作为妇科良恶性疾病手术治疗的有效选择[9-11]。这一外科视频文章代表了第一步，以评估这一新的工具在早期卵巢癌手术管理的潜在科学研究。

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Laparoscopic Surgery for Ovarian Cancer”. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.org/article/view/10.21037/gpm-20-35/coif). The series “Laparoscopic Surgery for Ovarian Cancer” was commissioned by the editorial office without any funding or sponsorship. SC served as the unpaid Guest Editor of the series, and serves as an unpaid editorial board member of Gynecology and Pelvic Medicine from Nov 2019 to Oct 2021. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this study and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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译者介绍
师厚辉
妇产科博士研究生在读，本科毕业于四川大学华西临床医学院。2017年进入四川大学华西临床医学院攻读研究生。（更新时间：2022-07-02）
审校介绍
谢川
副主任医师，博士研究生。中国妇幼保健院协会妇科腹腔镜外组青年委员。四川省肿瘤学会基因与免疫细胞治疗专业委员会委员。成都市抗癌协会肿瘤整合医学专业委员会委员。四川省医学传播学会妇幼健康发展分会委员。在攻读硕博士学位期间，主要研究妇科恶性肿瘤的生物学基础及治疗，在国际杂志期刊上发表SCI论文十多篇。博士毕业留院工作至今一直从事妇科的临床工作。擅长妇科恶性肿瘤（如宫颈癌、卵巢癌及子宫内膜癌等恶性肿瘤）、妇科良性疾病（如子宫肌瘤、卵巢畸胎瘤及卵巢子宫内膜异位囊肿等疾病）和盆底疾病（如子宫脱垂、阴道壁脱垂及压力性尿失禁等疾病）的手术治疗。擅长各种妇科疾病的微创手术（如经脐部单孔腹腔镜手术及经阴道自然腔道内镜手术V-NOTES）。主要参研多项国家级自然科学基金项目及省部级自然科学基金项目。2019年获得曼医妙术第二届腹腔镜手术精英赛全国三等奖。2021年获得全国首届单孔腹腔镜手术比赛二等奖。（更新时间：2022-07-02）

（本译文仅供学术交流，实际内容请以英文原文为准。）

doi: 10.21037/gpm-20-35
Cite this article as: Perrone E, Cianci S, Rossitto C, Fedele C, Gueli Alletti S. Percutaneous approach in early-stage ovarian cancer staging. Gynecol Pelvic Med 2020;3:29.

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