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      機(jī)器人輔助手術(shù)在復(fù)雜大子宮中的應(yīng)用及療效分析(附手術(shù)視頻)

      2024-01-01 00:00:00王沖沖夏玉芳于嘯王靈芝婁艷輝
      機(jī)器人外科學(xué) 2024年3期
      關(guān)鍵詞:機(jī)器人輔助手術(shù)開腹手術(shù)腹腔鏡手術(shù)

      摘 要 目的:通過對(duì)比機(jī)器人輔助手術(shù)、傳統(tǒng)腹腔鏡手術(shù)及開腹手術(shù)3種不同術(shù)式在復(fù)雜大子宮切除術(shù)中的臨床應(yīng)用療效,為臨床醫(yī)生選擇術(shù)式提供參考。方法:收集2021年1月—2023年10月在青島大學(xué)附屬醫(yī)院因子宮腺肌病或子宮肌瘤、子宮體≥孕12周、行全子宮切除術(shù)、術(shù)后病理證實(shí)為良性腫瘤的143名患者資料。根據(jù)手術(shù)方式不同,將患者分為機(jī)器人組45例、腹腔鏡組60例、開腹組38例。比較三組患者一般資料及圍手術(shù)期相關(guān)指標(biāo)。結(jié)果:機(jī)器人組與開腹組子宮大小及體積均大于腹腔鏡組;機(jī)器人組術(shù)中操作出血量與腹腔鏡組相比差異無統(tǒng)計(jì)學(xué)意義,但均少于開腹組,總失血量與開腹組相比差異無統(tǒng)計(jì)學(xué)意義,但均多于腹腔鏡組;機(jī)器人組相對(duì)手術(shù)時(shí)間長于腹腔鏡組及開腹組,但絕對(duì)手術(shù)時(shí)間與腹腔鏡組及開腹組相比差異均無統(tǒng)計(jì)學(xué)意義;機(jī)器人組術(shù)后排氣時(shí)間均短于腹腔鏡組及開腹組,術(shù)后住院時(shí)間與腹腔鏡組相比差異無統(tǒng)計(jì)學(xué)意義,但均少于開腹組;機(jī)器人組住院總花費(fèi)均高于腹腔鏡組及開腹組。三組間手術(shù)并發(fā)癥相比差異無統(tǒng)計(jì)學(xué)意義。結(jié)論:達(dá)芬奇機(jī)器人輔助手術(shù)兼具腹腔鏡及開腹手術(shù)的優(yōu)勢(shì),可以完成體積更大的復(fù)雜大子宮手術(shù),而絕對(duì)手術(shù)時(shí)間、術(shù)中出血量及并發(fā)癥發(fā)生率等并未增加,且術(shù)后恢復(fù)快,住院時(shí)間短,雖花費(fèi)較高,但在合理選擇患者的情況下更有利于患者恢復(fù)。

      關(guān)鍵詞 機(jī)器人輔助手術(shù);腹腔鏡手術(shù);開腹手術(shù);復(fù)雜大子宮

      中圖分類號(hào) R737.4 文獻(xiàn)標(biāo)識(shí)碼 A 文章編號(hào) 2096-7721(2024)03-0426-06

      Clinical efficacy of robot-assisted surgery in complex enlarged uterus

      (with surgical video)

      WANG Chongchong, XIA Yufang, YU Xiao, WANG Lingzhi, LOU Yanhui

      (Department of Gynecology, the Affiliated Hospital of Qingdao University, Qingdao 266100, China)

      Abstract Objective: To compare the clinical efficacy of robot-assisted surgery, conventional laparoscopic surgery and open surgery for complex enlarged uterus. Methods: Clinical data of 143 patients with adenomyosis or uterine fibroids who were treated in the Affiliated Hospital of Qingdao University from January 2021 to October 2023 were collected. All the patients had the size of uterus body ≥ 12 weeks of pregnancy and received total hysterectomy, and postoperative pathology confirmed as benign tumors. According to different surgical methods, the patients were divided into the robotic group (n=45), laparoscopic group (n=60) and laparotomy group (n=38). The general data and related perioperative indexes were compared among the three groups. Results: The size and volume of uterus in the robotic group and the open group were larger than those in the laparoscopic group. Intraoperative bleeding in the robotic group was not statistically different with that in the laparoscopic group, but was less than that in the open group. Total blood loss of the robotic group was not statistically different with that in the open group, but was more than that in the laparoscopic group. Compared with the laparoscopic group and the open group, the relative operative time in the robotic group was longer, but the difference in absolute operative time of the two groups was not statistically significant. The postoperative time to exhaustion was shorter in the robotic group than that in the laparoscopic group and the open group. The difference in postoperative hospitalization time between the robotic group and the laparoscopic group was not statistically significant, but it was less in the robotic group than that in the open group. The total cost of hospitalization was higher in the robotic group than that in the laparoscopic and open groups. Conclusion: Da Vinci robot-assisted surgery has the advantages of both laparoscopic and open surgery, which can be used to perform complex enlarged uterus surgery even in larger size without increasing the absolute operative time, intraoperative bleeding and complications. With quick recovery and short length of hospital stay, although the hospitalization cost of Da Vinci robot-assisted surgery is higher, it is more conducive to the recovery of patients in the case of reasonable selection of patients.

      Key words Robot-assisted Surgery; Laparoscopic Surgery; Laparotomy; Complex Enlarged Uterus

      全子宮切除術(shù)是婦科常見手術(shù)之一,子宮腺肌病、子宮肌瘤是其常見病因[1]。手術(shù)方式包括腹腔鏡微創(chuàng)手術(shù)及開腹手術(shù),與開腹手術(shù)相比,腹腔鏡手術(shù)具有手術(shù)創(chuàng)傷小、術(shù)中操作出血少、并發(fā)癥發(fā)生率低且術(shù)后恢復(fù)快等優(yōu)勢(shì),是臨床醫(yī)師的首選[2-3]。目前對(duì)于巨大子宮的診斷標(biāo)準(zhǔn)尚無規(guī)范化和統(tǒng)一,臨床上根據(jù)經(jīng)驗(yàn)常以妊娠子宮大小作為衡量標(biāo)準(zhǔn),將孕12~16周子宮(子宮底到達(dá)或小于恥骨聯(lián)合上3橫指處)稱為大子宮,將超過孕16周子宮(子宮底到達(dá)或低于臍恥中點(diǎn))稱為超大子宮[4]。對(duì)于這些子宮體積較大的患者,即使是經(jīng)驗(yàn)豐富的婦科醫(yī)師進(jìn)行傳統(tǒng)腹腔鏡手術(shù)時(shí),仍要面對(duì)因傳統(tǒng)腹腔鏡本身所造成的一些局限,如巨大子宮占據(jù)盆腹腔而造成手術(shù)視野暴露不清、解剖結(jié)構(gòu)模糊、器械臂旋轉(zhuǎn)角度有限、手術(shù)時(shí)間長術(shù)者易疲勞,從而導(dǎo)致手術(shù)時(shí)間長、出血多、中轉(zhuǎn)開腹及術(shù)中并發(fā)癥發(fā)生率增加等風(fēng)險(xiǎn)[5]。而達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)不僅具有放大10倍的三維立體高清視野,而且具有540°可轉(zhuǎn)腕手術(shù)器械,在盆腔深部狹小空間內(nèi)進(jìn)行復(fù)雜大子宮切除及嚴(yán)重盆腔粘連等手術(shù)時(shí)具有明顯的優(yōu)勢(shì)[6],但設(shè)備昂貴、維護(hù)費(fèi)用及手術(shù)費(fèi)用高等原因局限了機(jī)器人手術(shù)系統(tǒng)在臨床中的應(yīng)用,且關(guān)于復(fù)雜大子宮的研究較少[7-10]。本研究回顧性分析對(duì)比3種不同術(shù)式在復(fù)雜大子宮切除術(shù)中的臨床應(yīng)用療效,為臨床醫(yī)生選擇術(shù)式提供參考。

      1 資料與方法

      1.1 患者選擇及分組 回顧性分析2021年

      1月—2023年10月青島大學(xué)附屬醫(yī)院收治的因子宮腺肌病或子宮肌瘤行全子宮切除術(shù)±雙附件切除術(shù)的患者。根據(jù)術(shù)式不同將患者分為機(jī)器人組、腹腔鏡組及開腹組。納入標(biāo)準(zhǔn):①年齡45~55歲;②查體評(píng)估子宮大小≥孕12周;③行全子宮切除術(shù)±雙側(cè)附件切除術(shù),術(shù)后病理回報(bào)為婦科良性腫瘤。排除合并嚴(yán)重內(nèi)外科疾病、具有手術(shù)禁忌證或不能耐受手術(shù)的患者。最終納入143例患者,其中機(jī)器人組45例,腹腔鏡組60例,開腹組38例。

      1.2 術(shù)前準(zhǔn)備 ①詳細(xì)詢問病史,完善相關(guān)輔助檢查,影像學(xué)檢查評(píng)估子宮大小。②充分進(jìn)行術(shù)前談話,告知患者不同術(shù)式的利弊,與患者共同制定手術(shù)方案,簽署手術(shù)知情同意書。③術(shù)前完成備皮、腸道準(zhǔn)備,重度貧血者輸血改善貧血、備血,術(shù)前30 min預(yù)防性應(yīng)用抗生素。

      1.3 手術(shù)步驟 患者取截石位,全身麻醉后常規(guī)消毒鋪巾,置導(dǎo)尿管,再次消毒陰道,置舉宮器,術(shù)中采用頭低腳高位。機(jī)器人輔助手術(shù)穿刺點(diǎn):于臍上方距恥骨聯(lián)合22 cm處做1 cm切口,以Veress針建立氣腹,氣腹壓力設(shè)置為12 mmHg,置入1.2 cm Trocar建立觀察孔后連接鏡頭和光源;在直視下于觀察孔水平線左右各8 cm處做切口,分別置0.8 cm Trocar作為2號(hào)臂(左)和1號(hào)臂(右),在左側(cè)切口斜下方約45°、距離約8 cm處建1.2 cm Trocar。因本研究中患者均為復(fù)雜大子宮,穿刺時(shí)應(yīng)根據(jù)術(shù)前檢查避開可疑粘連部位及巨大子宮。其余手術(shù)步驟同常規(guī)腹腔鏡全切除子宮術(shù)(如圖1)。開腹手術(shù)按照常規(guī)全子宮切除術(shù)進(jìn)行[11]。對(duì)合并盆腔粘連患者行盆腔粘連松解術(shù),嚴(yán)重粘連、解剖界限不清晰時(shí)不可強(qiáng)行分離,應(yīng)辨別清楚器官的解剖位置后再進(jìn)行分離。

      1.4 觀察指標(biāo) ①一般情況:包括年齡、BMI、術(shù)前Hb、腹部手術(shù)史、內(nèi)外科并發(fā)癥。②圍手術(shù)期指標(biāo):包括子宮大小及體積(子宮大小由術(shù)者以妊娠子宮大小為標(biāo)準(zhǔn)目測(cè)評(píng)估所得,子宮體積由病理科醫(yī)生根據(jù)切除子宮的測(cè)量值計(jì)算所得)、手術(shù)時(shí)間[定義為自開皮至切口縫合完畢時(shí)間,本研究將機(jī)器人輔助手術(shù)時(shí)間分為相對(duì)手術(shù)時(shí)間(自切皮至皮膚縫合完畢時(shí)間)和絕對(duì)手術(shù)時(shí)間(自機(jī)器人手術(shù)系統(tǒng)連接完成至皮膚縫合完畢時(shí)間)]、術(shù)中失血量[分為術(shù)中操作出血量和總失血量,操作失血量=吸引瓶中總吸引液體量-沖洗鹽水量;總失血量=(術(shù)前HCT-術(shù)后HCT)/術(shù)前HCT×體重×7%×1000]、術(shù)后排氣時(shí)間、術(shù)后住院時(shí)間及住院總花費(fèi)等。③圍手術(shù)期并發(fā)癥:包括毗鄰臟器損傷(輸尿管、膀胱、直腸、血管、神經(jīng)等)、腸梗阻、尿潴留、切口愈合不良等。

      1.5 統(tǒng)計(jì)學(xué)方法 使用SPSS 26.0進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)數(shù)資料使用例數(shù)(百分比)[n(%)]表示,計(jì)量數(shù)據(jù)使用中位數(shù)(四分位數(shù))[M(Q1,Q3)]表示,如為正態(tài)分布則使用獨(dú)立樣本t檢驗(yàn),采用 χ2檢驗(yàn)或Fisher精確檢驗(yàn),如為非正態(tài)分布則使用Kruskal-Wallis檢驗(yàn)。Plt;0.05為差異具有統(tǒng)計(jì)學(xué)意義。

      2 結(jié)果

      2.1 一般資料 各組患者的一般資料比較,差異均無統(tǒng)計(jì)學(xué)意義(Pgt;0.05),見表1。

      2.2 圍手術(shù)期指標(biāo) 三組間圍手術(shù)期相關(guān)指標(biāo)比較,差異均有統(tǒng)計(jì)學(xué)意義(Plt;0.05)。機(jī)器人組與開腹組子宮大小及體積均大于腹腔鏡組;機(jī)器人組術(shù)中操作出血量與腹腔鏡組相比差異無統(tǒng)計(jì)學(xué)意義,但均少于開腹組,總失血量與開腹組相比差異無統(tǒng)計(jì)學(xué)意義,但均多于腹腔鏡組;機(jī)器人組相對(duì)手術(shù)時(shí)間長于腹腔鏡組及開腹組,但絕對(duì)手術(shù)時(shí)間與腹腔鏡組及開腹組相比差異均無統(tǒng)計(jì)學(xué)意義;機(jī)器人組術(shù)后排氣時(shí)間均短于腹腔鏡組及開腹組,術(shù)后住院時(shí)間與腹腔鏡組相比差異均無統(tǒng)計(jì)學(xué)意義,但少于開腹組;機(jī)器人組住院總花費(fèi)均高于腹腔鏡組及開腹組(見表2)。

      2.3 圍手術(shù)期并發(fā)癥 機(jī)器人組45例手術(shù)均順利完成,無中轉(zhuǎn)開腹,無術(shù)中、術(shù)后并發(fā)癥發(fā)生。腹腔鏡組中有3例(3/60,5.00%)患者中轉(zhuǎn)開腹,術(shù)中1例患者發(fā)生輸尿管損傷,1例腸管損傷,術(shù)中并發(fā)癥發(fā)生率為3.33%(2/60);術(shù)后2例(2/60,3.33%)患者發(fā)生盆腔感染。開腹組患者未發(fā)生術(shù)中并發(fā)癥,術(shù)后1例患者切口感染(1/38,2.63%)。三組患者并發(fā)癥發(fā)生率比較,差異無統(tǒng)計(jì)學(xué)意義(Pgt;0.05)。

      3 討論

      在過去幾十年,微創(chuàng)手術(shù)已被證實(shí)具有減少圍手術(shù)期并發(fā)癥、減少術(shù)中失血、改善術(shù)后疼痛、加快術(shù)后恢復(fù)等優(yōu)勢(shì),逐漸成為婦科醫(yī)生選擇的主流方式[2-3],但子宮肌瘤、子宮腺肌病相較于其他疾病來說具有子宮體積增大、宮體血供豐富的特點(diǎn),尤其當(dāng)子宮體積≥12周時(shí),巨大子宮占據(jù)盆腔,宮體貼近盆壁,宮旁組織難以充分暴露,盆腔解剖結(jié)構(gòu)不清,腹腔鏡操作空間狹窄,機(jī)械臂旋轉(zhuǎn)角度有限,無法對(duì)宮旁組織及子宮動(dòng)靜脈進(jìn)行滿意凝切,術(shù)中出血量多且難以找到出血點(diǎn),無法電凝止血,導(dǎo)致術(shù)中并發(fā)癥的發(fā)生以及中轉(zhuǎn)開腹的可能。開腹手術(shù)可以解決傳統(tǒng)腹腔鏡的問題,其視野直觀、操作方便,成為切除巨大子宮的首選手術(shù)方式[12],但仍面臨著諸多局限[13]。而達(dá)芬奇機(jī)器人輔助手術(shù)既具備傳統(tǒng)腹腔鏡本身的優(yōu)勢(shì),也彌補(bǔ)了腹腔鏡與開腹手術(shù)的不足。

      達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)具有可以放大10~15倍的高清三維成像及獨(dú)特的術(shù)野縱深[14],可以清晰辨認(rèn)子宮周圍毗鄰關(guān)系、血管層次及神經(jīng)等解剖結(jié)構(gòu),從而減少鄰近器官及大血管損傷。仿人手內(nèi)腕設(shè)計(jì)可以實(shí)現(xiàn)屈伸、內(nèi)旋、外展等動(dòng)作[15],震顫過濾系統(tǒng)能有效地濾除人為導(dǎo)致的器械震顫,使操作更加穩(wěn)定[16],讓術(shù)者更好地進(jìn)行術(shù)中精細(xì)化操作。當(dāng)患者子宮增大≥12周時(shí),盆腔手術(shù)空間更加狹小,術(shù)野暴露困難,機(jī)器人手術(shù)系統(tǒng)更適用于這類需要在狹小盆腔空間操作、術(shù)野有限或存在嚴(yán)重盆腔粘連的婦科手術(shù)。術(shù)者可以自行調(diào)控最佳鏡頭角度,配合三號(hào)臂抓鉗推壓子宮清晰暴露術(shù)野,完成術(shù)中子宮動(dòng)脈暴露、凝閉切斷,輸尿管膀胱分離暴露等關(guān)鍵步驟,有效避免出血及損傷。本研究結(jié)果顯示,機(jī)器人組可以順利完成妊娠16~20周大小的子宮切除手術(shù),而腹腔鏡可完成的巨大子宮主要集中在妊娠12~14周,機(jī)器人組患者的子宮大小及體積均明顯大于腹腔鏡組,且未發(fā)生重要臟器損傷及大出血等并發(fā)癥。在巨大后壁或?qū)m頸肌瘤手術(shù)中,肌瘤部位特殊,舉宮困難,后盆視野更加暴露不清,手術(shù)難度更大,盡管本研究中機(jī)器人組絕對(duì)手術(shù)時(shí)間與其余兩組沒有顯著差異,但綜合各項(xiàng)指標(biāo)顯示,機(jī)器人輔助手術(shù)在難度高于腹腔鏡手術(shù)的前提下,手術(shù)操作出血量、絕對(duì)手術(shù)時(shí)間、術(shù)后排氣與住院時(shí)間并未增加。開腹手術(shù)雖也可彌補(bǔ)腹腔鏡手術(shù)的不足,但其術(shù)中出血多、術(shù)后疼痛感強(qiáng)、術(shù)后恢復(fù)慢、不美觀等[2-3]也導(dǎo)致患者更加傾向于選擇機(jī)器人輔助手術(shù)。

      本研究腹腔鏡組中3例中轉(zhuǎn)開腹,其中1例發(fā)生輸尿管損傷、2例術(shù)中出血過多腔鏡難以完成而中轉(zhuǎn)開腹手術(shù),均為宮體大于孕14周患者,2例術(shù)后發(fā)生盆腔感染;開腹組中1例患者出現(xiàn)切口愈合不良,而機(jī)器人組患者圍手術(shù)期均無并發(fā)癥發(fā)生。本研究結(jié)果顯示,腹腔鏡在處理巨大子宮手術(shù)時(shí),具有發(fā)生中轉(zhuǎn)開腹和鄰近器官損傷的風(fēng)險(xiǎn),盡管三組間并發(fā)癥的差別無統(tǒng)計(jì)學(xué)意義,這可能與本研究中納入病例數(shù)較少,而且沒有絕對(duì)限制復(fù)雜子宮的條件相關(guān)。Herrinton L J等人[17]在研究中嚴(yán)格限定了復(fù)雜大子宮的條件,結(jié)果顯示當(dāng)由操作經(jīng)驗(yàn)豐富的婦科醫(yī)生進(jìn)行機(jī)器人輔助手術(shù)時(shí),對(duì)于復(fù)雜大子宮患者,機(jī)器人手術(shù)絕對(duì)時(shí)間短、出血量少,與本研究結(jié)果相似。也有研究報(bào)道,達(dá)芬奇手術(shù)輔助手術(shù)和傳統(tǒng)腹腔鏡手術(shù)相比手術(shù)時(shí)間、失血量、住院時(shí)間及并發(fā)癥發(fā)生率沒有顯著差異,這可能與入組患者子宮多為普通子宮以及醫(yī)師技術(shù)水平相關(guān)[18-19]。

      本研究結(jié)果顯示,與開腹手術(shù)相比,微創(chuàng)困難大子宮切除術(shù)中出血少、術(shù)后恢復(fù)快,但腹腔鏡手術(shù)在面對(duì)gt;14周的子宮上具有一定的局限性,中轉(zhuǎn)開腹及并發(fā)癥發(fā)生風(fēng)險(xiǎn)增加,應(yīng)合理選擇患者。達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)相對(duì)于腹腔鏡可以完成更大子宮的手術(shù)以及巨大后壁或?qū)m頸肌瘤等特殊部位肌瘤手術(shù),手術(shù)難度增加,但絕對(duì)手術(shù)時(shí)間、術(shù)中出血、并發(fā)癥風(fēng)險(xiǎn)等并未增加,術(shù)后恢復(fù)快,同時(shí)兼具腹腔鏡手術(shù)及開腹手術(shù)兩者優(yōu)勢(shì),雖花費(fèi)較高,但在合理選擇患者的情況下更有利于患者。然而,雖然自2005年FDA批準(zhǔn)達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)應(yīng)用于婦科手術(shù)以來,機(jī)器人手術(shù)系統(tǒng)數(shù)量逐年增加[20-21],但因購入及維修成本高,手術(shù)費(fèi)用相較于普通腹腔鏡多2~3萬元,也使得許多患者望而卻步。因此,有關(guān)達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)與傳統(tǒng)腹腔鏡間的優(yōu)勢(shì)及性價(jià)比仍存在爭議。近年來,隨著國產(chǎn)機(jī)器人的發(fā)展,機(jī)器人手術(shù)系統(tǒng)價(jià)格高昂的缺陷有望得到解決,從而使更多的患者受益。

      利益沖突聲明:本文不存在任何利益沖突。

      作者貢獻(xiàn)聲明:王沖沖負(fù)責(zé)設(shè)計(jì)論文框架,起草論文;夏玉芳負(fù)責(zé)操作實(shí)驗(yàn),實(shí)施研究過程;于嘯負(fù)責(zé)收集數(shù)據(jù),統(tǒng)計(jì)學(xué)分析,繪制圖表;王靈芝負(fù)責(zé)論文修改;婁艷輝負(fù)責(zé)擬定寫作思路,指導(dǎo)撰寫文章并最后定稿。

      參考文獻(xiàn)

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      [2] Lee S H, Oh S R, Cho Y J, et al. Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis[J]. BMC Womens Health, 2019, 19(1): 83.

      [3] Abitbol J, Munir A, How J A, et al. The shifting trends towards a robotically-assisted surgical interface: clinical and fnancial implications[J]. Health Policy Technol, 2020, 9(2): 157-165.

      [4] 張海艷, 范文生, 王軍童, 等. 機(jī)器人手術(shù)巨大子宮切除62例臨床經(jīng)驗(yàn)分析研究[J].華西醫(yī)學(xué), 2020, 35(2): 187-191.

      [5] HAN Z H, ZHENG Z, TAO K, et al. The effect of surgical approach on the outcomes and prognosis of high-risk histologic endometrioid carcinomas[J]. Gland Surgery, 2021, 10(1): 355-363.

      [6] Uccella S, Cromi A, Serati M, et al. Laparoscopic hysterectomy in case of uteri weighing ≥1 kilogram: a series of 71 cases and review of the literature[J]. J Minim Invasive Gynecol, 2014, 21(3): 460-465.

      [7] Muaddi H, Hafid M E, Choi W J, et al. Clinical outcomes of robotic surgery compared to conventional surgical approaches (laparoscopic or open): a systematic overview of reviews[J]. Ann Surg, 2021, 273(3): 467-473.

      [8] Perutelli A, Domenici L, Garibaldi S, et al. Efficacy and safety of robotic-assisted surgery in challenging hysterectomies-a single institutional experience[J]. Eur Rev Med Pharmacol Sci, 2022, 26(4): 1235-1240.

      [9] WANG P Y, LEE Y C, LIU W M, et al. Surgical outcome of benign cases with pelvic adhesions undergoing robotic total hysterectomy[J]. J Chin Med Assoc, 2022, 85(8): 853-858.

      [10] 馮淑杰, 曲波, 聶夏子, 等. 機(jī)器人手術(shù)在婦科領(lǐng)域的應(yīng)用現(xiàn)狀及進(jìn)展[J]. 機(jī)器人外科學(xué)雜志(中英文), 2020, 1(3): 212- 219.

      [11] 鄭果, 劉亞娜, 趙孟玲, 等. 3種不同術(shù)式行復(fù)雜大子宮切除術(shù)療效及安全性對(duì)比分析[J].中國實(shí)用婦科與產(chǎn)科雜志, 2023, 39(9): 948-952.

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      編輯:張笑嫣

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