腹腔镜肝切除术的初步经验

目的 总结腹腔镜肝切除术的技术要点和效果。方法 回顾分析本中心2007年3月1Et至2007年6月30Et21例腹腔镜肝切除术患者的临床资料。结果 21例中2例中转开腹，1例改为手助式腹腔镜肝切除，其余18例在全腹腔镜下完成肝切除术。规则性肝叶（段）切除15例，其中左半肝切除5例，左外叶切除6例（其中1例联合右肝肿瘤射频消融术），Ⅵ段切除4例；不规则切除6例。7例在区域性半肝血流阻断条件下手术，3例行间歇性第一肝门血流阻断，11例未行人肝血流阻断；平均手术时间为185min，平均出血量320ml，术后恢复顺利，全组无手术死亡及并发症发生，平均住院时间为9d。随访2-6月，除1例多发性肝细胞癌患者术后40d出现再发肿瘤外，其余恶性肿瘤患者无复发，良性病变患者无症状再发。结论腹腔镜肝切除术是值得选择的微创方式，其技术要点是选择恰当的手术人路，有效控制人肝血流，其中选择性半肝血流阻断技术的应用和肝断面的妥善处理是确保手术成功和减少手术并发症的关键。     

不阻断肝血流状态下左半肝切除术的临床前瞻性研究

目的前瞻性分析研究不阻断肝血流状态下行左半肝切除术的临床可行性。方法 32例左半肝切除术患者随机分成AB两组:A组(n=16肝切除时阻断入肝血流);B组(n=16肝切除时不阻断入肝血流)。比较两组患者的相关临床及手术资料。结果两组患者在术中出血量、手术时间、并发症、术后住院天数等临床资料的差异无统计学意义;但不阻断肝血流组患者术后1、3天ALT、AST水平明显低于阻断肝血流组,有统计学差异。结论不阻断肝血流的左半肝切除术是一种安全、有效、可行的手术切除方法,但其总体疗效并不优于阻断肝血流。     

Prospective clinical research of the left hemihepatectomy without hepatic Blood Inflow Occlusion

目的 前瞻性分析研究不阻断肝血流状态下行左半肝切除术的临床可行性.方法 32例左半肝切除术患者随机分成AB两组:A组(n=16肝切除时阻断入肝血流)；B组(n=16肝切除时不阻断入肝血流).比较两组患者的相关临床及手术资料.结果 两组患者在术中出血量、手术时间、并发症、术后住院天数等临床资料的差异无统计学意义；但不阻断肝血流组患者术后1、3天ALT、AST水平明显低于阻断肝血流组,有统计学差异.结论 不阻断肝血流的左半肝切除术是一种安全、有效、可行的手术切除方法,但其总体疗效并不优于阻断肝血流.     

腹腔镜肝切除术治疗肝血管瘤22例临床分析

目的 探讨腹腔镜肝切除术治疗肝血管瘤的技术要点和疗效.方法 回顾分析第三军医大学西南医院2007年3月1日至2008年2月29日22例肝血管瘤病人行腹腔镜肝切除术的临床资料.结果 22例中2例中转开腹,20例完成全腹腔镜肝切除术.规则性肝叶(段)切除14例,其中左半肝切除5例,左外叶切除5例(其中1例联合右肝血管瘤射频消融术),Ⅵ段切除4例;不规则肝切除8例.10例在区域性半肝血流阻断条件下手术,7例行间歇性第一肝门血流阻断,5例未行人肝血流阻断.平均手术时间209 min,平均术中出血量360 ml.全组无手术死亡及并发症发生.术后恢复顺利,平均术后住院时间6 d.随访2～14个月,无症状再发及肿瘤复发.结论 腹腔镜肝切除术治疗肝血管瘤具有手术安全、并发症少和术后恢复快等优点,其技术要点是选择恰当适应证和手术入路,有效控制入肝血流和妥善处理肝断面,肝实质离断沿瘤体周围0.5～1 cm正常肝实质内进行或直接行荷瘤肝叶(段)规则性切除.     

选择性肝血流阻断切肝术(附213例报道)

目的分析选择性肝血流阻断切肝术在防止术中肝脏大出血及术后肝功能衰竭方面的作用。方法根据肿瘤部位、大小及肝硬化情况,采用半肝血流阻断,半肝全血流阻断,交替半肝血流阻断,交替半肝全血流阻断,单纯门静脉阻断及肝褥式缝合等区域性肝血流阻断技术切除肝肿瘤共213例。观察肝门阻断时间、出血量、术后肝功能恢复情况及并发症发生率。结果半肝血流阻断144例,其中左肝门阻断32倒,右肝门阻断112例。半肝全血流阻断39例,其中右肝门 右肝静脉阻断26例,左肝门 左、中肝静脉阻断13例。交替半肝血流阻断7例,交替半肝全血流阻断5例,单纯门静脉阻断8例,局部褥式缝扎10例。肿瘤切除率100%, 第一肝门及肝静脉分离均成功。无一例发生肝静脉破裂出血及空气栓塞,术后无一例发生肝功能衰竭。术后胆漏6例,保守治疗痊愈。结论区域性肝血流阻断切肝术是一种安全、简便的方法,对防止肝静脉破裂出血,降低术后肝功能衰竭发生率具有重要作用。     

腹腔镜左半肝切除术的临床应用研究

目的探讨应用腹腔镜手术完成左半肝切除术的可行性。方法腹部Trocar的置放同LC,剑突下Trocar的置放于左肋弓下距中线3cm。CO2气腹压力10~12mmHg。超声刀切断镰状韧带、冠状韧带、做左三角韧带,切除胆囊。肝门血流阻断方式分别采用间歇性阻断2例、不阻断7例、选择性阻断23例。从胆囊窝中点向肝门左侧方向,应用超声吸引刀、双极电凝等器械向肝实质内分离至肝门左侧方。解剖左肝管、左门静脉横部后,将其分别结扎切断。肝内分离结扎切断肝左静脉,切除左半肝。结果 32例均行左半肝切除、胆道探查、T管引流术。手术均获成功,手术时间150~390min,平均190min。出血量280~1100ml,平均550ml。术后胆漏3例,引流治愈。1例术后4d肝创面急性大出血,腹腔镜下止血成功。多发性肝脓肿1例,反复超声引导下肝穿,术后6个月治愈。膈下脓肿1例,超声引导下穿刺治愈。32例随访6~12个月,均健在,无复发。结论腹腔镜左半肝切除术可行,术后恢复快,但行此类手术应慎重,一要具备相应的设备器械,二要有开腹肝切除和腹腔镜手术经验的医师行此手术。     

选择性左半肝血流阻断在腹腔镜左半肝切除术中的应用

目的探讨选择性左半肝血流阻断在腹腔镜左半肝切除术中的安全性和可行性。方法回顾性分析2014年1月至2015年12月广东省梅州市人民医院26例腹腔镜左半肝切除术和25例开腹左半肝切除术治疗左肝胆管结石病人的临床资料,术中均采取选择性左半肝入肝血流阻断。对比二组病人的手术时间、术中出血量和术后住院时间。结果腹腔镜组与开腹组相比手术时间短,分别为(338.9±53.6)min比(373.8±54.4)min,两组比较差异有统计学意义(t=-2.311,P=0.025);术中出血量少,分别为(303.8±155.5)ml比(450.2±259.0)ml,差异有统计学意义(t=-2.458,P=0.020);术后住院时间短,分别为(8.5±2.6)d比(11.3±2.3)d,差异有统计学意义(t=-4.223,P=0.000)。术后均未发生肝衰竭。结论选择性左半肝血流阻断在左腹腔镜半肝切除术中的应用安全可行。     

腹腔镜下右半肝血流阻断的肝右后叶切除术(附16例报告)

目的:探讨腹腔镜下采用右半肝血流阻断行肝右后叶切除术的可行性。方法:2016年1月至2016年12月为16例肝右后叶肿瘤患者行完全腹腔镜肝右后叶切除术,术中采用血流阻断。结果:16例手术均获成功,无一例中转开腹,手术时间150~290 min,平均(196.2±12.5)min;右半肝阻断时间20~40 min,平均(26.5±1.2)min;术中出血量150~400 ml,平均(255.0±8.3)ml。术后无出血、肝功能衰竭、胆漏、感染、死亡等严重并发症发生。术后住院5~12 d,平均(6.6±0.5)d。结论:在熟练掌握腹腔镜肝切除操作要点的前提下,采用右半肝血流阻断技术行腹腔镜肝右后叶切除术治疗肝肿瘤是安全、可行的。     

半肝血流阻断技术用于肝硬化肝癌的肝切除

目的 探讨半肝血流阻断技术在合并肝硬化的肝癌手术治疗中的意义.方法 回顾性分析山东大学齐鲁医院普外科2006年3月至2008年9月因肝癌行肝切除205例患者的临床资料,其中术中应用Pringle法第一肝门阻断入肝血流44例(A组)、半肝血流阻断76例(B组)、半肝血流阻断加选择性肝静脉控制85例(C组).比较3组患者肝切除手术时间和术中出血量,术后肝功能的恢复以及术后并发症.结果 3组患者肝切除手术时间比较差异无统计学意义(F=2.53,P>0.05);术中平均出血量分别为543.7、415.8、324.5 ml,3组间比较差异有统计学意义(F=98.96,P<0.001);在术后3 d和6 d的血清丙氨酸转氨酶、胆红素水平比较,B组和C组明显优于A组.结论 半肝血流阻断可防止健侧肝脏缺血再灌注损伤;肝外控制肝静脉,可显著减少肝切除术中的出血量.     

肝切除术中肝血流阻断技术的合理应用

血流阻断是肝肿瘤切除术中减少及控制出血的重要手段,但血流阻断也会在不同程度上影响血流动力学的变化,因此,在肝切除手术中必须合理、灵活地运用肝血流控制方法。Pringle第一肝门血流阻断法是目前肝脏切除中最常用的肝血流阻断方法,对肿瘤巨大需行半肝切除术、合并严重肝硬化或肝储备功能严重不足者可考虑用半肝血流阻断法,以避免残留肝脏因血流阻断缺血和再灌注受到伤害;对位于肝静脉主干,如肝、腔静脉结合部病变切除,各种全肝血流阻断方法因对血流动力学的严重影响而被逐渐慎用,目前以选择性血流性出入血流阻断法为首选。SHVE方法的应用完全改变了以往因害怕损伤肝、腔静脉而放弃手术切除的消极局面。笔者认为只要熟练掌握肝静脉和腔静脉的解剖特点,分离阻断右肝静脉及左、中静脉干并非难事,采用SHVE血流阻断技术对于第二、三肝门部肝肿瘤的手术切除是安全可行的血流阻断方法。     

大肝癌手术切除术中不同肝血流阻断方法的临床研究

目的：比较大肝癌手术切除术中3种不同的入肝血流阻断法的临床效果。
　　方法：回顾性分析2011年1月—2013年3月期间218例大肝癌（>5cm）手术患者的临床资料,术中88例采用Pringle法间断阻断全肝血流（肝门阻断组）,51例行选择性的半肝血流阻断（半肝阻断组）,79例行肝下下腔静脉阻断联合Pringle法阻断入肝血流（联合阻断组）。比较3组患者的术中与术后的相关指标。
　　结果：3组患者的术前情况、手术时间、入肝血流阻断时间及肝切除量的差异均无统计学意义（均P>0.05）;半肝阻断组与联合阻断组的术中出血量、输血量、输血率均明显低于肝门阻断组,且联合阻断组的输血量、输血率明显低于半肝阻断组（均P<0.05）;3组患者术后第1天肝功能指标差异无统计学意义（均P>0.05）,但半肝阻断组与联合阻断组第3、7天的转氨酶和总胆红素水平均明显低于肝门阻断组（均P<0.05）;3组术后并发症的发生率差异无统计学意义（P>0.05）。
　　结论：大肝癌切除术术中采用肝下下腔静脉阻断联合Pringle法阻断入肝血流不仅能够有效减少术中失血量,而且有利于术后肝功能的恢复。     

Tolerance of the cirrhotic liver to normothermic ischemia. A clinical study of 15 patients

Temporary occlusion of hepatic inflow, namely, the Pringle maneuver, was adopted for 15 patients with liver cirrhosis who underwent partial hepatectomy. The warm ischemia time ranged from 2 to 32 minutes with an average of 19 minutes. The procedure did not cause any harmful effects on systemic hemodynamic and postoperative liver function. The results in our patients were compared with those of 15 comparable control patients who had been operated on over the same period of time without inflow obstruction. The Pringle maneuver significantly diminished the estimated blood loss during surgery, intraoperative and postoperative complications, and suppressed the operative mortality rate from 20 percent to 0.     

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy

Background

Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes.

Methods

A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality.

Results

A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay.

Conclusions

All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.     

微波止血分离器在降低肝门板的肝癌切除术中的应用

目的探讨微波止血分离器在降低肝门板的肝癌切除手术中的临床应用价值。方法回顾分析2010年至2012年70例应用微波止血分离器进行的降低肝门板的肝癌切除手术资料,采用微波止血分离器(HeSetor)进行肝门板解剖及断肝,术中仅阻断切除侧肝门;与同期40例常规手术对照组资料进行比较,该组采用常规Pringle阻断肝门及钳夹断肝。结果两组手术均顺利完成。HeSetor结合降低肝门板组手术时间平均(115.4±42.3)min;术中出血量平均(120.0±105.2)ml,术中均无输血;术后肝功能生化检查平均在(6.3±2.7)d恢复;术后并发症发生率为15.7%(11/70),其中胸腔积液5例(7.1%),腹水6例(8.6%);术后平均住院(6.4±3.5)d。常规手术对照组手术时间平均(169.1±86.5)min;术中出血量平均(360.5±153.1)ml,术中3例输血(7.5%);术后肝功能生化检查平均在(9.1±5.6)d恢复;术后并发症发生率为30.0%(12/40),其中胸腔积液5例(15.0%),腹水5例(15.0%),胆瘘2例(7.5%);术后平均住院(11.1±6.3)d。两组间以上指标比较,P值均小于0.05。结论应用微波止血分离器进行的降低肝门板的肝癌切除手术是一种安全可靠的肝切除方法,术中出血少,容易掌握,术后恢复快,值得临床推广应用。     

机器人肝切除术：附17例报告

目的：总结机器人手术系统在肝脏切除术应用中的临床经验。方法：对于2009年1月至2010年7月实施的17例机器人外科手术系统所行肝切除术的资料进行回顾性分析。结果：17例机器人肝脏手术病人中男∶女=8：9,平均年龄（55±16）（27～85）岁。包括原发性肝细胞癌3例;胆管细胞癌3例（BismuthⅢb型肝门部胆管癌1例,肝内胆管囊腺癌2例）;转移性肝癌3例;良性肝脏肿瘤4例（肝血管瘤3例,胆管囊腺瘤1例）;左肝内胆管结石4例。手术方式：规则性左半肝切除术2例,左肝外叶切除术5例,肝局部或楔形切除7例,亚肝段（s5a）切除术1例,联合其他机器人术式12例。机器人肝切除的平均手术时间为280 min,术中出血量为150 mL。术中发生大出血3例,其中2例（11.8%）为巨大肝血管瘤中转开腹切除。采用Pringle法肝切除4例,采用肝实质缝扎和超声刀离断肝实质交替法实施左肝外叶切除4例。机器人肝切除病例的平均住院时间为7（5～16）d。术后发生严重并发症2例（11.8%）：腹腔内出血1例,肺部感染1例,经保守治疗治愈,无胆漏等严重并发症和围手术期死亡。结论：机器人肝切除术安全、可行,疗效确切。探索适合机器人手术系统优势的肝切除止血方法等创新性技术将是今后机器人肝切除的重点之一。     

Pringle′s法联合肝静脉阻断技术在复杂肝切除术中的应用

目的: 探讨Pringle′s法联合肝静脉阻断技术在复杂肝切除术中的应用价值。方法: 对37例第二肝门区肿瘤施行Pringle′s法＋肝静脉阻断切肝术患者的临床资料进行回顾性分析。结果:37例患者中原发性肝癌27例，转移性肝癌2例，肝巨大血管瘤8例。肿瘤平均直径12.7cm（6～35cm）。肿瘤侵犯1根主肝静脉6例，侵犯2根主肝静脉20例，侵犯3根主肝静脉11例。行右三叶切除11例，右半肝切除5例，中肝叶切除9例，Ⅷ段切除4例，左三叶切除5例，尾状叶切除3例。平均第一肝门阻断时间29min（17～48min），平均肝静脉阻断时间21min（8～32min）。行肝静脉修补1例。平均术中出血量950mL（200～4 000mL）。全组术后发生并发症18例次，均经治疗后愈。无死亡病例。结论:Pringle′s法联合肝静脉阻断技术在复杂肝切除术中既能达到减少术中出血的目的，又能防止术中肝静脉破裂导致空气栓塞，还避免了下腔静脉阻断所引起全身血流动力学紊乱，是一种更安全、有效的血流阻断技术。     

How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies

OBJECTIVE: To identify the most efficient parenchyma transection technique for liver resection using a prospective randomized protocol. SUMMARY BACKGROUND DATA: Liver resection can be performed by different transection devices with or without inflow occlusion (Pringle maneuver). Only limited data are currently available on the best transection technique. METHODS: A randomized controlled trial was performed in noncirrhotic and noncholestatic patients undergoing liver resection comparing the clamp crushing technique with Pringle maneuver versus CUSA versus Hydrojet versus dissecting sealer without Pringle maneuver (25 patients each group). Primary endpoints were intraoperative blood loss, resection time, and postoperative liver injury. Secondary end points included the use of inflow occlusion, postoperative complications, and costs. RESULTS: The clamp crushing technique had the highest transection velocity (3.9 +/- 0.3 cm/min) and lowest blood loss (1.5 +/- 0.3 mL/cm) compared with CUSA (2.3 +/- 0.2 cm/min and 4 +/- 0.7 mL/cm), Hydrojet (2.4 +/- 0.3 cm/min and 3.5 +/- 0.5 mL/cm), and dissecting sealer (2.5 +/- 0.3 cm/min and 3.4 +/- 0.4 mL/cm) (velocity: P = 0.001; blood loss: P = 0.003). Clamp crushing technique was associated with the lowest need for postoperative blood transfusions. The degree of postoperative reperfusion injury and complications were not significantly different among the groups. The clamp crushing technique proved to be most cost-efficient device and had a cost-saving potential of 600 to 2400 per case. CONCLUSIONS: The clamp crushing technique was the most efficient device in terms of resection time, blood loss, and blood transfusion frequency compared with CUSA, Hydrojet, and dissecting sealer, and proved to be also the most cost-efficient device.     

Bleeding during hepatectomy can be reduced by clamping the inferior vena cava below the liver

BACKGROUND: Control of blood loss is a crucial problem during hepatectomy. Bleeding from the inflow system can be controlled by the Pringle maneuver or selective vascular occlusion. Bleeding from the outflow system is closely related to central venous pressure (CVP). Therefore, in this study, we evaluated whether vascular outflow control by clamping the inferior vena cava (IVC) below the liver (IVC clamping) during hepatectomy is a safe and effective method to reduce blood loss and CVP. METHODS: We reviewed the outcomes of 103 consecutive patients whose CVP values were >5 cm H(2)O and who had undergone right or left hemihepatectomy between 1995 and 2000. Forty-seven patients who underwent hepatectomy with IVC clamping (Group A) between 1998 and 2000 were compared with the previous 56 patients who underwent hepatectomy without IVC clamping between 1995 and 1997 (Group B). RESULTS: The CVP decreased by 3.7 cm H(2)0 after IVC clamping. Estimated blood loss was 910 mL in Group A and 1177 mL in Group B. (P=.008) No severe renal or cardiovascular damage occurred after IVC clamping. CONCLUSIONS: IVC clamping is very effective in reducing blood loss during hepatectomy when the CVP is elevated and cannot be reduced pharmacologically or by fluid restriction.     

持续肝动脉阻断预防破裂性肝癌肝切除术中大出血

目的 探讨应用持续肝动脉阻断技术对预防破裂性肝癌肝切除术中大出血的价值.方法 回顾性分析2006年5月至2010年4月第三军医大学西南医院收治的36例应用Pringle法+持续肝动脉阻断技术对破裂性肝癌患者(研究组)行肝切除术的临床资料.在肝癌数据库中配对选取同期36例采用纱布压迫止血的肝癌破裂出血手术患者(对照组).对两组患者术中和术后的相关指标采用方差分析、x2检验、Fisher确切概率法进行对比分析.结果 研究组患者动脉持续阻断中位时间为58 min(36～98 min);术中中位出血量为400ml,明显少于对照组的750ml(F=16.47,P＜0.05);研究组78%(28/36)的患者未进行输血治疗,明显优于对照组的53%(19/36),两组比较,差异有统计学意义(x2=6.01,P＜0.05).两组患者围手术期AST、TBil均在术后第2天达到最高值,然后逐渐下降,1周左右降至正常范围.两组患者的术后并发症发生率和并发症分级比较,差异无统计学意义(x2=1.83,0.89,P＞0.05).结论 应用持续肝动脉阻断技术可明显减少破裂性肝癌肝切除术的术中出血量,且不会对肝功能产生明显的不良影响.     

Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study.

OBJECTIVE: To evaluate whether vascular inflow occlusion by the Pringle maneuver during hepatectomy can be safe and effective in reducing blood loss. SUMMARY BACKGROUND DATA: Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during surgery remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but there is a potential harmful effect on the metabolic function of hepatocytes. There has been no prospective randomized study to determine whether the Pringle maneuver can decrease blood loss during hepatectomy, improve outcome, or affect the metabolism of hepatocytes. METHODS: From July 1995 to February 1997, we studied 100 consecutive patients who underwent hepatectomy for liver tumors. The patients were randomly assigned to liver transection under intermittent Pringle maneuver of 20 minutes and a 5-minute clamp-free interval (n = 50), or liver transection without the Pringle maneuver (n = 50). The surface area of liver transection was measured and blood loss during transection per square centimeter of transection area was calculated. Routine liver biochemistry, arterial ketone body ratio (AKBR), and the indocyanine green (ICG) clearance test were done. RESULTS: The two groups were comparable in terms of preoperative liver function and in the proportion of patients having major hepatectomy. The Pringle maneuver resulted in less blood loss per square centimeter of transection area (12 mL/cm2 vs. 22 mL/cm2, p = 0.0001), a shorter transection time per square centimeter of transection area (2 min/cm2 vs. 2.8 min/cm2, p = 0.016), a significantly higher AKBR in the first 2 hours after hepatectomy, lower serum bilirubin levels in the early postoperative period, and, in cirrhotic patients, higher serum transferrin levels on postoperative days 1 and 8. The complication rate, the hospital mortality rate, and the ICG retention at 15 minutes on postoperative day 8 were equal for the two groups.CONCLUSION: Performing the Pringle maneuver during liver transection resulted in less blood loss and better preservation of liver function in the early postoperative period. This is probably because there was less hemodynamic disturbance induced by the bleeding.