2021年 · 第36卷第08期

A 60-year-old male was admitted to the hospital due to "the discovery of a reversible mass in the right groin for more than 10 months". Physical examination: Standing position, a tumor with a size of about 5 cm ×5 cm ×6 cm can be seen above the right scrotum. It is soft in texture, with no redness, swelling and tenderness on the local skin, smooth surface, and a large range of movement with the surrounding boundary. After lying down, the tumor seems to be partially incorporated into the inguinal area after being pressed by hand. Ultrasound examination: A pouch-shaped mass can be detected in the right inguinal area, with a size of about 8.8 cm ×3.3 cm, a clear boundary and a regular shape. An omentum-like echo can be seen in it, which is connected to the abdominal cavity upward, and the inner diameter of the narrowest part is about 0.5 cm. It becomes slightly larger during Valentine action, and the probe pressure becomes slightly smaller, and its contents partially retreat to the abdominal cavity. The size and morphology of the testes in the bilateral scrotum were normal (Figure 1）。 Preoperative diagnosis by ultrasound: right inguinal hernia. Laparoscopic exploration was performed, and laparoscopic hernia repair was proposed. There was no obvious defect in the area of bilateral pubic foramen during the operation, which was inconsistent with the results of preoperative ultrasonography. The right inguinal area was explored, and then the free spermatic cord of the inguinal canal was incised. No clear hernia sac was found. An intact mass was found above the scrotum, about 8 cm in diameter, with an intact capsule and clear boundaries. It was drawn to the outside of the scrotum, and the root pedicle was connected to the anterior intestinal wall. Then, the root was sutured and disconnected, and the mass was completely removed (Figure 2）。

The patient, a 72-year-old male, was admitted to hospital for "more than half a month after discovering gastric malignancy". Gastroscopy revealed multiple bulging lesions in the gastric antrum. Gastroscopic pathological examination showed: (gastric antrum) severe dysplasia of some glands of the mucosa submitted for examination, and local carcinogenesis was considered. Physical examination: weight loss, multiple swollen lymph nodes in the supraclavicular, underarm and groin area. Laboratory tests revealed anemia, hypoalbuminemia, hypothyroidism. Enhanced abdominal CT examination showed that the gastric wall in the gastric antrum was slightly thickened; Multiple enlarged lymph nodes in the abdominopelvic cavity and retroperitoneal cavity, splenomegaly; Small amount of pelvic effusion (Figure 1）。 Gastric cancer with lymph node metastasis was diagnosed. "Subtotal gastrectomy (Bi 2 type)" was performed. Intraoperative exploration found that multiple swollen lymph nodes could be palpable in the abdominopelvic cavity, mesentery and retroperitoneum, and a mass about 1 cm ×1 cm in size could be palpable in the gastric antrum, which did not infiltrate the serous layer, and swollen lymph nodes could be palpable around the stomach. Postoperative pathological examination showed: gastric multiple adenoma with severe epithelial dysplasia and carcinogenesis (intramucosal carcinoma), perigastric lymph nodes: proliferative lymph node tissue scattered with large lymphoid follicles, increased blood vessels between follicles, and the blood vessels between lymph nodes can be seen vertically inserted into the germinal center to form a "lollipop"-like germinal center, some with onion skin-like changes, morphologically consistent with Castleman's disease changes (Figure 2,3,4）。

A 56-year-old male was admitted for "melena for 4 d". Preoperative gastroscopy showed ulcer-like changes on the anterior wall of the lower part of the stomach body, with a central depression and a surrounding mucosa bulge, about 2~2.5 cm. Pathological examination showed: poorly differentiated adenocarcinoma. Chest + whole abdomen CT showed: left upper lobe mass, considering lung cancer; The wall of the gastric antrum was thickened, the wall of the small intestine in the abdomen and pelvis was thickened, the small intestine on the right side was intussuscepted, and the local intestinal tube was obviously dilated (Figure 1,2,3）。 Upright abdominal X-ray plain film showed that multiple fluid levels were visible in the whole abdomen, considering intestinal obstruction (Figure 4）。 Pathological examination of lung puncture showed: poorly differentiated adenocarcinoma, with atypical hyperplasia of alveolar epithelium and excessive carcinoma in situ under light microscope; Pathological examination by gastroscopy showed poorly differentiated adenocarcinoma, TTF-1 (-) and Napsin A (-), suggesting that both of them were primary lesions. PET-CT examination showed: nodular shadow in the upper lobe of left lung, abnormal glucose hypermetabolism; The wall of the gastric antrum is slightly thicker, and no abnormal glucose hypermetabolism is seen; The peritoneum of the right lower abdomen and pelvic cavity was thickened, and the boundary with the adjacent intestine was unclear, and abnormal glucose hypermetabolism was observed in the corresponding parts.

A 13-year-old female developed redness and swelling of the right nipple, obvious local pain, and a small amount of purulent and bloody discharge from the nipple one month ago. The breast gland did not touch the tumor, the skin around the nipple was not reddened, swollen or ulcerated, and the body temperature was normal. Physical examination: the left nipple was inverted, the right nipple was obviously red and swollen, about 4.0 cm ×3.0 cm in size, the nipple skin was thin, partly dark black, and local tenderness was obvious, no nipple discharge was seen, the skin of both breasts was not red, swollen or ulcerated, no orange peel-like changes, satellite nodules, no varicose veins on the surface, and no tumors were palpable in both breasts (Figure 1）。 No enlarged lymph nodes were palpable in bilateral axillary and bilateral superior and inferior clavicular regions. Ultrasound examination showed that the structure of both breasts was clear, with hypoechoic detection in the right nipple, about 3.3 cm ×2.0 cm ×2.1 cm in size, with unclear boundary. No abnormal nodules and mass echoes were detected in both breasts, and hypoechoic detection in the right axilla, about 0.8 cm ×0.6 cm ×0.8 cm in size, with clear boundary and uneven internal echoes. Color Doppler flow imaging with abundant hypoechoic blood flow in the nipple. The preoperative diagnosis was right nipple inflammation, and right nipple abscess incision and drainage were performed: a radial incision was taken on the lower side wall of the right nipple, about 2 cm long, and a large amount of pus and necrotic tissue were found in the right nipple. Part of the pus was taken to be sent to bacteria culture, and part of the tissue was taken from the inner wall of the abscess cavity to be sent to pathology. It was suggested that the tissue (right nipple) was covered with squamous epithelium and showed papillary hyperplasia. Combined with clinical consideration, squamous epithelial papilloma was considered. Bacterial culture results were negative. The redness and swelling of the nipple were slightly reduced after operation, and there was still a small amount of necrotic material exudating from the incision, and the skin of the nipple was necrotic in a large area. Right nipple and mass resection: a fusiform incision was taken in the right areola area, about 4 cm long, and a tumor was seen in the right nipple and its interior, about 5.0 cm ×4.0 cm in size, tough in texture, with clear boundary, and the tumor almost occupied the whole nipple. The skin necrosis of the nipple was serious. The right nipple and mass were completely removed (Figure 2）。 Postoperative pathological examination showed: (right nipple) squamous epithelial papillary tumor, cell proliferation, partial abnormality, chaotic structure, more keratinization, not excluded malignancy. Pathological consultation opinion of Tianjin Cancer Hospital: (Right nipple) squamous epithelial hyperplasia, part of which is papillary hyperplasia, accompanied by moderate to severe abnormality, and the base is extruded infiltrating growth (Figure 3), combined with immunohistochemical staining results consistent with well-differentiated squamous cell carcinoma, basal margin (-); Some breast duct epithelium showed papillary hyperplasia. Immunohistochemical staining showed: P63 (+), CK7 (ductal epithelium +), EGFR (partial +), P16 (partial +), P53 (50% +), ER (partial ductal epithelium +), PR (partial ductal epithelium +), Ki-67 (30% +). After the operation, the whole body examination was performed again, and no squamous cell carcinoma lesions in other parts such as skin, oral cavity, esophagus and lung were found, which could rule out the possibility of squamous cell carcinoma metastasis to the nipple in other parts.

A 57-year-old male was seen in the emergency department of another hospital because of acute abdominal pain after drinking and eating. The white blood cells were 10.81×10⁹/L, neutrophil percentage 81.8%, amylase 195.5 IU/L, lipase 420.3 U/L, acute pancreatitis was considered for diagnosis, and treatment such as fasting water, anti-infection and inhibition of pancreatic juice secretion was given, and abdominal pain symptoms were relieved. Four days later, he went to the emergency department of our hospital and complained of mild abdominal pain and yellow urine. On physical examination, the sclera was mild-moderate yellowing, and mild tenderness under the xiphoid process. WBC 9.80×10⁹/L, neutrophil percentage 88.0%, amylase 110 U/L, total bilirubin 36.5 μ mol/L, direct bilirubin 27.0 μ mol/L, ALT 213 U/L, AST 384 U/L. Abdominal B-ultrasound showed blurred pancreatic margin, dilated intrahepatic bile duct, and poor sound transmission of left hepatic duct. Diagnosis: acute pancreatitis, abnormal liver function, admitted to undergraduate degree. After admission to the department, the amylase was 256 U/L, total bilirubin was 25.7 μ mol/L, direct bilirubin was 21.8 μ mol/L, ALT was 56 U/L, and AST was 24 U/L after 5 days of anti-infection, liver protection and enzyme reduction, inhibition of amylase secretion and nutritional support. Abdominal MRI plain scan + enhancement: intrahepatic bile duct dilatation, left hepatic duct wall thickness, abnormal signal in it (Figure 1）。 MRCP: filling defect in the left hepatic duct, considering obstruction. Diagnosis: acute pancreatitis (biliary), biliary duct space-occupying stones? Tumor? During exploratory laparotomy, the left lobe of the liver was palpable and hard, with a diameter of about 3.0 cm, which considered the possibility of neoplastic lesions. Intraoperative ultrasound exploration showed diffuse embolus in the left hepatic duct. After removing the gallbladder, the common bile duct was opened, and there was a clear tumor thrombus combined with thrombi. After the left liver was removed and the tumor thrombus in the bile duct was removed (Figure 2), choledochoscopy to explore the patency of the biliary tract and right hepatic duct without tumor thrombus. The broken end of the left hepatic duct was closed by suture, and the common bile duct was drained by T tube. Postoperative pathology: Biliary embolus was hepatocellular carcinoma thromb with necrosis formation; (Left hemihepatic) hepatocellular carcinoma, moderately differentiated, with hemorrhagic necrosis, intravascular tumor thrombosis; Hepatocellular tumor thrombus with necrotic formation (in the left hepatic duct). Two months later, the biliary drainage was unobstructed during cholangiography, and the T-tube was removed. After more than 2 years of follow-up, no tumor recurrence was observed.

Gastric cancer is a malignant tumor originating from gastric mucosal epithelium, which occurs from normal gastric mucosa to chronic gastritis, atrophic gastritis, intestinal epithelial metaplasia, atypical hyperplasia and cancer^［1］。 Gastric cancer as the fourth leading cause of cancer death worldwide^［2］In 2019, the incidence and mortality of gastric cancer in China were 43.1/100,000 and 29.6/100,000, respectively.^［3］。 In recent years, robotic surgery system has become a new way of gastric cancer treatment by virtue of its own advantages. In 2015, Professor Yu Peiwu organized relevant experts in China to formulate the Expert Consensus on Robotic Gastric Cancer Surgery (2015 Edition)^［4］。 However, so far, there are no publications on robotic gastric cancer surgery guidelines at home and abroad. With the development of evidence-based medicine, the research on robotic surgery for gastric cancer is deepening, and more and more clinical evidences are emerging. In order to further standardize the diagnosis and treatment of robotic gastric cancer surgery, ensure the medical quality and improve the clinical work level, it is urgent to formulate robotic gastric cancer surgery guidelines, in order to provide scientific and specific guidance for medical workers who perform robotic gastric cancer surgery, and effectively promote the standardized application of robotic gastric cancer surgery in clinical practice.