腹腔镜下不同左肝切除方式治疗左肝胆管结石的对比研究

目的 对比腹腔镜左肝蒂阻断解剖性左半肝切除、腹腔镜左肝蒂阻断左肝部分切除、腹腔镜Pringle法阻断左肝部分切除治疗左肝胆管结石的临床疗效，探讨腹腔镜下三种左肝切除方式治疗左肝胆管结石的合理选择。方法 回顾性分析2015 年5 月至2018 年11 月四川绵阳四0 四医院97 例腹腔镜左肝切除术患者的临床资料，其中腹腔镜左肝蒂阻断解剖性左半肝切除术25 例（区域阻断+解剖性切除组），腹腔镜左肝蒂阻断左肝部分切除术33 例（区域阻断+部分切除组），腹腔镜Pringle法阻断左肝部分切除术39 例（全肝阻断+部分切除组），对比分析三组围手术期结果、术后炎症和肝脏生化指标、术后并发症情况。结果 三组术中失血量、输血率、术后进食时间、术后住院时间、术后炎症指标变化、术后并发症发生率均无统计学差异（P＞0.05）；手术时间区域阻断+解剖切除组最长、区域阻断+部分切除组次之、全肝阻断+部分切除组最短（257.9±66.2）min vs（ 234.6±49.1）min vs（ 216.4±40.2）min]，差异有统计学意义（P＜0.05）。三组白细胞计数、C反应蛋白、谷丙转氨酶、总胆红素及白蛋白均出现术后先升高后降低的趋势，至术后第5 天，除白蛋白外各炎症及肝功能指标区域阻断+解剖性切除组均低于区域阻断+部分切除组和全肝阻断+部分切除组，除C反应蛋白外各炎症及肝功能指标全肝阻断+部分切除组均高于区域阻断+解剖性切除组和区域阻断+部分切除组；采用重复测量的方差分析进一步比较，白细胞计数、C反应蛋白、谷丙转氨酶、总胆红素及白蛋白在各时间点的差异均有统计学意义（P＜0.05），谷丙转氨酶、总胆红素不同手术方式和各时间点存在交互作用（P＜0.05），提示三组谷丙转氨酶、总胆红素随时间改变的趋势存在统计学差异。结论 （1）结石及病灶累及左内叶尤其IVa段时，选择腹腔镜左肝蒂阻断解剖性左半肝切除疗效更佳；（2）结石及病灶限于IVa段以外的左肝区段时，联合术中超声的腹腔镜左肝部分切除更具优势。

Comparative study on different left hepatectomy for left hepatolithiasis under laparoscopy

Objective To compare the clinical effect of laparoscopic anatomical left hemi hepatectomy with left hepatic pedicle occlusion, laparoscopic partial left hepatectomy with left hepatic pedicle occlusion, and laparoscopic partial left hepatectomy with Pringle occlusion in treatment of left hepatolithiasis. To select the reasonable approach from the three kinds of laparoscopic left hepatectomy for treatment of left hepatolithiasis.Methods The clinical data of 97 patients underwent laparoscopic left hepatectomy from May 2015 to Nov. 2018 in Sichuan Mianyang 404 Hospital were analyzed retrospectively. Among them, 25 cases received laparoscopic anatomical left hemi hepatectomy with left hepatic pedicle occlusion (group with regional occlusion+anatomical resection), 33 cases received laparoscopic partial left hepatectomy with left hepatic pedicle occlusion (group with regional occlusion+partial resection), and 39 cases received laparoscopic partial left hepatectomy with Pringle occlusion (group with total occlusion+partial resection group). The perioperative outcomes, postoperative inflammation, liver biochemical parameters, and postoperative complications were compared and analyzed.Results There was no significant difference in blood loss, blood transfusion rate, time of postoperative feeding, postoperative hospitalization time, postoperative inflammatory index changes or postoperative complications among the three groups (P>0.05). The operation time was the longest in the group with regional occlusion+anatomical resection, the second in the group with regional occlusion+partial resection (257.9±66.2)min vs(234.6±49.1)min vs (216.4±40.2)min, P<0.05]. Postoperative WBC, CRP, ALT, TBIL and ALB in the three groups all showed the trend of first increased and then decreased. On the 5th day after operation, except for ALB, the indexes of inflammation and liver function in the group with regional occlusion+anatomical resection were the lowest among three groups; and except for CRP, the indexes of inflammation and liver function in the group with total occlusion+ partial resection were the highest among three groups. The analysis of variance with repeated measurement showed that the difference of WBC, CRP, ALT, TBIL and ALB at each time point was statistically significant (P<0.05). There were interactions of ALT and TBIL among different operation methods and each time point (P<0.05), indicating that there were significant differences among the three groups in the trend of ALT and TBIL changing with time. Conclusion (1) When stone and lesions involve the left inner lobe, especially IVa segment, laparoscopic anatomical left hemi hepatectomy with left hepatic pedicle occlusion is more effective; (2) When stones and lesions are limited to the left liver except for the IVa segment, laparoscopic partial left hepatectomy combined with intraoperative ultrasound is more advantageous.