重视肿瘤外科基本概念的应用与时代变迁
Emphasis on the application of basic concepts in oncological surgery and their evolution over time
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摘要: 结直肠肿瘤外科历经百年发展,已从传统开放手术时代迈入机器人辅助微创时代。在技术革新的浪潮中,如何理性审视与传承肿瘤外科经典概念成为关键议题。笔者结合循证医学证据与临床实践,系统探讨“不接触技术”“肿瘤供血血管高位结扎”“安全切缘”及“肿瘤根部淋巴结清扫”等传统理念的时代变迁。“不接触技术”虽在开放手术时代被奉为圭臬,但多项随机对照试验及Meta分析显示,腹腔镜、机器人手术与传统技术在长期生存结局上无显著差异。这提示需客观评估其理念现代临床价值。关于肠系膜下动脉高位结扎,近年研究证实其对多数患者无生存获益,而保留左结肠动脉的低位结扎可降低便秘发生率,结合鞘内分离保留神经技术可进一步减少泌尿生殖功能障碍。直肠癌安全切缘标准正从经验医学向精准医学跨越,新辅助治疗的普及推动远切缘缩短至1~2 cm,部分情况下0.5~1.0 cm亦被视为可接受,但需结合肿瘤基因分型实现个体化精准判断。肿瘤根部淋巴结(如No.253淋巴结)清扫则从扩大根治转向个体化策略,仅推荐用于术前影像学怀疑转移的患者,以避免过度治疗。笔者认为:青年外科医师需在传承经典理念核心价值(如肿瘤根治原则、解剖精准性)的基础上,以循证医学为依据,结合微创技术与分子分型,推动传统概念的革新与优化。唯有在守正与创新的辩证统一中,才能实现肿瘤外科的精准化、人性化发展,最终提升患者预后与生命质量。Abstract: Colorectal oncology surgery has evolved from traditional open surgery to robotic-assisted minimally invasive surgery over a century. Amidst technological innovations, rational evaluation and inheritance of classic oncological surgical concepts have become critical. The author systematically discusses the evolution of traditional principles, including the "no touch technique" "high ligation of tumor‑feeding vessels" "safety margin" and "radical lymph node dissection" based on evidence‑based medicine and clinical practice. While the "no touch technique" was once a cornerstone in open surgery, multiple randomized controlled trials and Meta‑analyses have shown no significant difference in long‑term survival between this technique and conventional methods in laparoscopic and robotic surgery, suggesting the need for objective reassessment of its modern clinical relevance. Regarding high ligation of the inferior mesenteric artery, recent studies have demonstrated no survival benefit for most patients, while low ligation with preservation of the left colic artery reduces constipation rates. Combined with the intrafascial nerve‑sparing technique, urogenital dysfunction can be further minimized. The safety margin for rectal cancer is shifting from empirical to precision medicine. The popularity of neoadjuvant therapy has allowed distal margins to be shortened to 1-2 cm, with 0.5-1.0 cm acceptable in some cases, though individualization based on tumor genotyping is essential. Radical lymph node dissection (e.g., No.253 lymph nodes) has transitioned from extended radical resection to a personalized strategy, recommended only for patients with preoperative imaging suspicion of metastasis to avoid overtreatment. The author emphasizes that young surgeons must inherit the core values of classic concepts (e.g., oncological radical resection, anatomical precision) while leveraging evidence‑based medicine, minimally invasive techniques, and molecular profiling to drive innovation and optimization. Only through the dialectical unity of tradition and innovation can colorectal oncology surgery achieve precision and humaniza-tion, ultimately improving patient outcomes and quality of life.

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