机械人辅助子宫切除术与开放性子宫切除术相比的围手术期结局
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Perioperative Outcomes of Robotic-Assisted Hysterectomy Compared With Open Hysterectomy
背景与目的
机器人辅助子宫切除术（RH）这一技术的应用越来越多。这一技术的通气（气腹和头低脚高位），利用限制气道压力和潮气量的肺保护策略很困难，关于术中机械通气和高峰值气道压力对围手术期并发症的影响知之甚少。因此，我们进行了回顾性调查以确定与经腹部子宫切除术（TAH）的患者相比，接受RH的患者的肺部并发症是否增加。
方 法
我们进行了一项单中心回顾性调查，比较了接受RH和TAH的患者在手术中，麻醉即刻和术后30天的状况，包括术中通气参数和呼吸道并发症。纳入2004年至2006年接受TAH（201例）的患者与2009年至2012年的接受RH（251例）的患者，进行了比较。我们的假设是，接受RH患者的术后肺部并发症发生率较接受TAH的患者增加。次要假设是病态肥胖可预测接受RH患者的肺并发症。组间的并发症采用Fisher确切概率法。为了解释潜在的混杂因素，对于接受RH的患者进行了倾向匹配亚组分析。
结 果
共纳入351个接受RH和201个接受TAH的患者。与TAH组 (23 [19, 27] cm H2O相比，手术30分钟时，RH组（中位数[25，75th] 31 [26,36] cm H 2 O）需要更高的通气压力，吸气压峰值升高（P <0.001）。纳入163个RH和163个TAH患者进行了倾向匹配分析。这一分析结果显示，接受RH与接受TAH的心肺并发症组间无统计学意义（0.6％vs 1.2％;优势比= 2.0,95％置信区间= 0.2-2.4; P = 1.00）。与TAH组相比，RH组手术部位感染显著降低（0.6％vs 8.6％; P <0.001）。与RH相比，TAH组住院时间更长（中位数[25，75th] 2 [2,3] vs 1 [0,2]天; P <0.001）。
结 论
接受RH的肥胖和病态肥胖妇女的围手术期肺部并发症的发生率与非肥胖相比，组间无差异（病态肥胖不可预测接受RH患者的肺并发症）。与接受TAH的患者相比，接受RH的患者住院时间较短，感染性并发症较少，整体并发症并未见增加。RH组和TAH组相比，肥胖和非肥胖相比，接受RH的肥胖患者的高气道压不会导致心肺并发症的增加。我们认为腹腔充气可通过提高胸腔内压力，减少横跨末端细支气管和跨肺泡的梯度，以减轻高气道压力的影响。因此，对于接受RH的患者，肺保护的策略是升高腹腔压和胸腔内压，而跨气道压仍保持不变。这种跨肺组织梯度的降低，减轻在高压通气下引起的肺组织损伤。
原始文献摘要
Address correspondence to Bhargavi Gali, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Address e-mail to gali.bhargavi@mayo.edu. Copyright © 2017 International Anesthesia Research Society DOI:10.1213/ANE.0000000000001935
BACKGROUND: Increasing numbers of robotic hysterectomies (RH) are being performed. To provide ventilation (with pneumoperitoneum and steepTrendelenburg position) for these procedures, utilization of lung protective strategies with limiting airway pressures and tidal volumes is difficult. Little is known about the effects of intraoperative mechanical ventilation and high peak airway pressures on perioperative complications. We performed a retrospective review to determine whether patients undergoing RH had increased pulmonary complications compared to total abdominal hysterectomy (TAH).
METHODS: We performed a single center retrospective review comparing the intraoperative, anesthetic, and immediate and 30-day postoperative course of patients undergoing RH to TAH, including intraoperative ventilatory parameters and respiratory complications. Patients undergoing TAH (201) from 2004 to 2006 were compared to RH (251) from 2009 to 2012. It was our hypothesis that patients undergoing RH would have increased incidence of postoperative pulmonary complications. A secondary hypothesis was that morbid obesity predicts pulmonary complications in patients undergoing RH. Complications were compared between groups using Fisher’s exact test. To account for potential confounders, the primary analysis was performed for a subgroup of patients matched on the propensity for RH.
RESULTS: A total of 351 RH and 201 TAH procedures are included. Higher inspiratory pressures were required in ventilation of the RH group (median [25th, 75th] 31 [26, 36] cm H2O) than the TAH group (23 [19, 27] cm H2O) (P < .001) at 30 minutes after incision. Peak inspiratory pressures at 30 minutes after incision for RH increased according to increasing body mass index group (P < .001). There were 163 RH and 163 TAH procedures included in the propensity matched analysis. From this analysis, there were no significant differences in cardiopulmonary complications between RH and TAH (0.6% vs 1.2%; odds ratio = 2.0, 95% confidence interval = 0.2–2.4; P = 1.00). Surgical site infection was significantly lower in the RH compared to TAH group (0.6% vs 8.6%; P < .001). Hospital length of stay was longer for those who underwent TAH versus RH (median [25th, 75th] 2 [2, 3] vs 1 [0, 2] days; P < .001).
CONCLUSIONS: There was no significant difference in perioperative complications in obese and morbidly obese women compared to nonobese undergoing RH. Patients undergoing RH had shorter hospital stays, fewer infectious complications, and no increase in overall complications compared to TAH. Higher ventilatory airway pressures (RH versus TAH and obese versus nonobese) did not result in an increase in cardiopulmonary or overall complications. We believe that peritoneal insufflation attenuates the effect of high airway pressures by raising intrapleural pressure and reducing the gradient across terminal bronchioles and alveoli. Thus, we propose that lung protective strategies for patients undergoing RH account for the markedly elevated intraperitoneal and intrapleural pressures, whereas transpulmonary airway pressures remain static. This reduced transpulmonary gradient attenuates the strain on lung tissue that would otherwise be imposed by ventilation at high pressures. (Anesth Analg 2017;XXX:00–00)
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