第Ⅷ肝段巨大型海绵状血管瘤的手术方法（附4例报告）

第Ⅷ肝段巨大型海绵状血管瘤不必常规进行全肝血流阻断法切除，下腔静脉可预置阻断带，但膈下肝上下腔静脉分离有时较困难，致预置阻断带不成功．本组4例手术顺利完成的关键就在于在常温下间歇阻断第一肝门入肝血流的同时，用剥离法将肿瘤剥除．此种手术方法与行第Ⅶ肝段切除术相比，既简便又安全，值得推广。     

第Ⅰ第Ⅷ肝段巨大型海绵状血管瘤手术治疗4例报告

根据本组手术体会结合近年国内报道的经验，对第Ⅰ及第Ⅷ肝段肿瘤手术，本文提出不必常规进行全肝血流阻断，胆下腔静脉需要预先安置阻断带。手术是在阻断入肝血流情况下进行的，术中如必须阻断下腔静脉时，可采取分步阻断法，以缩短阻断时间，防止由于回心血流骤减所致的血压下降。第Ⅰ肝段的血管瘤用剥除法是困难的，可采用肿瘤根部缝扎后切除的方法，将其切除。如仍残留一部分肿瘤的基底，可用连续褥式缝合法将其缝扎。第Ⅷ肝段的     

紧邻下腔静脉肝癌的外科治疗

目的：总结紧邻下腔静脉肝癌的外科治疗经验。方法：腹内预置下腔静脉阻断带，先在间歇性入肝血流阻断下用彭氏多功能手术剖解器（ＰＭＯＤ）行刮吸法断肝术切除肿瘤；当明确肿瘤侵犯下腔静脉，需作血管修补或切除吻合时行全肝血流阻断。结果：２７例侵犯或发生于肝尾叶的肝癌和６０余例Ⅷ段或Ⅵ段巨大肝癌紧邻下腔静脉者，均得以顺利切除术，仅２在全肝血流阻断下行下腔静脉壁部分切除候补。结论：绝大多数紧邻下腔静脉的肝癌可在腹     

肝静脉主干预置阻断带在高风险肝切除术中的作用和意义

放置肝外肝静脉主干的预置带可结扎准确、可靠 ,使紧邻第 2肝门的肿瘤得以安全切除。此外 ,拉紧预置带阻断肝静脉 ,可作为改良的”无血切肝”———只阻断肝静脉主干和肝蒂而不阻断下腔静脉[1] 。虽然这样未必能达到肝脏的完全无血切除 (肝短静脉仍未阻断 ) ,但却能显著减少肝内血流 ,可以避免全身血流动力学的显著改变。2 0 0 1年以来 ,我们对某些左半肝切除、右半肝切除、右 3叶切除、第Ⅷ段切除、第Ⅳ段切除、第Ⅶ加第Ⅷ段切除等有可能损伤肝静脉的病例 ,有选择地放置肝静脉主干预置阻断带。一方面可防止术中大出血 ,另一方面可用做肝静…     

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目的 探讨紧邻肝内外重要血管的肝血管瘤的安全切除。方法 回顾性分析1996～2003年手术切除的27例紧邻肝内外重要血管的肝血管瘤的临床资料。肝上下腔静脉、肝下下腔静脉、肝右静脉或肝中肝左静脉共干预置阻断带。使用多功能手术解剖器行刮吸法切除肿瘤。结果 27例肝血管瘤均安全切除。肝上下腔静脉、肝下下腔静脉、肝右静脉或肝中肝左静脉共干预置阻断带，成功完成下腔静脉裂口修补2例，肝中静脉修补3例，肝右静脉修补1例。结论 肝上、肝下下腔静脉和主肝静脉预置阻断带有利于复杂情况下的肝血管瘤的安全切除．     

肝脏第Ⅷ区段切除术

本文报道16例肝脏第Ⅷ区段切除手术。16例中原发性肝癌11例,肝转移癌1例,肝血管瘤4例。其中9例合并肝硬化或肝纤维化。手术均在肝上,肝下下腔静脉预置血管阻断带后,常温下阻断第一肝门血流下进行。术后4例发生肝功能失代偿,3例恢复,1例死亡。本文介绍了手术方式,讨论了有关问题。     

采用彭氏多功能手术解剖器施行肝Ⅶ、Ⅷ段切除术30例报告

目的总结采用彭氏多功能手术解剖器(PMOD)施行肝Ⅶ、Ⅷ段切除的手术经验。方法2001年1月至2003年12月,共施行了肝Ⅶ、Ⅷ段切除术30例,包括3例右肝内胆管结石和27例肝癌。解剖第Ⅰ、第Ⅱ及第Ⅲ肝门,预置血流阻断带,在分离右段间裂及肝正中裂上部时行入肝血流间歇阻断。结果30例手术均顺利完成,手术平均费时191min,术中平均失血量920ml。全组无术中死亡,术后22例出现右侧胸腔积液,3例胆瘘,3例膈下感染。结论采用彭氏多功能手术解剖器有助于施行肝Ⅶ、Ⅷ段切除。     

肝静脉和下腔静脉血流控制在高难度肝肿瘤切除中的应用

目的评估肝静脉主干和(或)下腔静脉血流控制在高难度肝切除术中的作用和意义。方法对33例位于Ⅳ、Ⅶ、Ⅷ段和左半肝、右半肝、右三叶的肝肿瘤进行了游离下腔静脉和肝静脉主干并加以控制的肝切除术。其中肝细胞性肝癌26例;胆管细胞性肝癌2例;转移性肝癌2例;肝血管瘤3例。32例患者在术中成功预置了下腔静脉和肝静脉的阻断带,必要时控制肝静脉和下腔静脉血流。1例患者预置肝静脉阻断带失败。结果33例全部成功切除肿瘤,术中输血0-1600ml,其中7例没有输血。全组无术中死亡病例。结论熟练掌握和合理控制肝静脉主干和下腔静脉血流,可以提高复杂肝肿瘤切除的安全性和减少输血,有助于完成高难度肝肿瘤的切除。     

常温下全肝血流阻断切除巨大肝海绵状血管瘤八例报告

我院自 1994年至 1996年应用常温下全肝血流阻断 (ＴＨＶＥ)技术切除肝巨大海绵状血管瘤 8例 ,其中男 3例 ,女 5例 ,肿瘤位于肝Ⅷ段 4例 ,Ⅶ、Ⅷ段 3例 ,Ⅴ、Ⅵ、Ⅶ段 1例 ,瘤体最大直径 18ｃｍ ,最小 10ｃｍ ,平均 13ｃｍ。方法是首先游离右半肝 ,解剖肝上下腔静脉(ＩＶＣ)及肝下ＩＶＣ ,分别预置阻断带 ,然后施Ｐｒｉｎｇｌｅ法阻断入肝血流 ,于血管瘤外缘切开肝被膜 ,沿血管瘤包膜外钝性作者单位 :110 0 42　沈阳市 ,辽宁省肿瘤医院肝胆胰外科 (华向东、付庆才 ) ;110 3 0 0　辽宁省新民市人民医院普外科 (刘国生 )剥离 ,遇有通经肿瘤的…     

第Ⅷ肝段切除治疗肝细胞癌

目的评价第们段肝癌切除的手术技术。方法回顾总结９例第Ⅷ段肝癌手术切除的经验,９例患者均伴有肝炎后肝硬化,术前肝功能,ＣｈｉｌｄＡ级７例,ＣｈｉｌｄＢ级２例。肿瘤最大径４—６ｃｍ,４例术中施行全肝血流阻断（ＴＨＶＥ）,阻断时间为６－１４分钟,４例在施行ＴＨＶＥ后成功地修复了损伤的主肝静脉和下腔静脉。结果９例第Ⅷ段肝癌得以顺利切除,术中输血６００～１２００ｍｌ,无手术死亡。术后并发症：右侧胸腔积液２例,胆漏１例。结论第Ⅷ肝段切除是一种十分困难而危险的局限性肝切除,因为很多壁薄如纸的肝静脉在第Ⅷ肝段顶部汇入主肝静脉并进入下腔静脉。虽然第Ⅷ肝段切除技术是困难的,但仍是治疗原发性肝癌的一种选择。而常温下全肝血流阻断是控制术中大出血的重要措施。     

半肝血流完全阻断下无血肝切除术的临床应用:附14例报告

目的探讨半肝血流完全阻断下无血肝切除术的方法及优点。方法膏眭分离肝后下腔静脉壁与肝实质间间隙，建立肝后隧道放置二条阻断带，阻断患侧肝静脉、肝短静脉及肝断面的交通血管，并阻断患侧入肝肝动脉及门静脉，在半肝血流完全阻断下完成14例肝切除术。结果14例均成功建立肝后隧道并放置阻断带，未发生与此相关的并发症。切肝过程中肝断面基本无出血，视野清晰，操作精细，全组病人术后恢复良好。结论半肝血流完全阻断下的肝切除术可显著减少术中出血，避免残肝缺血再灌注损伤，防止术中气栓发生和医源性肿瘤播散，避免胃肠道、肾脏淤血，有效的保护下腔静脉及健侧肝静脉，极大的提高了手术的安全性。     

猪到猴异位辅助性肝移植模型的建立

目的建立长白小家猪到恒河猴异位辅助性肝移植模型,总结手术操作要点。方法以健康雄性长白小家猪和健康恒河猴各5只建立猪到猴异位辅助性肝移植模型。以长白小家猪作为肝移植供体,以恒河猴作为受体。保留长白小家猪的右后叶和部分右前叶作为供肝,移植到受体的左肾窝和左结肠旁沟处。短暂阻断受体的腹主动脉和下腔静脉血流后,将移植肝的门静脉和肝下下腔静脉分别与受体的腹主动脉和下腔静脉行端侧吻合。结扎移植肝的肝动脉,不予重建。术后观察受体的一般情况和生存时间。结果成功建立4对肝移植模型,供肝切取时间24～35min、（30±5）min,供肝修整时间31～51min、（40±10）min,受体下腔静脉阻断时间23～36min、（30±6）min,受体腹主动脉阻断时间22～38min、（30±8）min,肝移植手术时间130～310min、（220±80）min,术中失血35～48mL、（42±6）mL。术后均无吻合口血栓形成及胆漏发生。4只受体分别于术后48、54、88及96h死亡,死亡原因均为排斥反应及术中失血过多。结论猪到猴异位辅助性肝移植模型的可重复性强、手术易操作、移植器官灌注良好,可用于猪到非人类灵长类动物肝移植的进一步研究。     

下腔静脉膈上段解剖特征及毗邻关系的尸体研究

目的:明确腹腔镜手术中下腔静脉膈上段的解剖特点及毗邻关系。方法:2018年12月于南方医科大学基础医学院选取成人尸体、新鲜尸体各2例。对冰冻尸体进行解剖。沿双侧锁骨中线打开胸腔,翻开心包前壁,解剖分离上腔静脉、下腔静脉。沿腹正中线打开腹腔,翻左、右肝叶,显露肝后段下腔静脉、第二肝门,剖开腔静脉裂孔进入心包,观察下腔静脉...     

Osteoiliacography as diagnostic method of vena cava inferior circulation failure in liver cirrhosis

Hypertension developing in the vena cava system under conditions of cirrhosis results in the formation of collateral blood outflow into vena cava superior (VCS) and inferior, at the same time the carrying capacity of vena cava inferior (VCI) might be limited due both to its fixation in the rigid diaphragm ring and to the fact that the hepatic segment of VCI is compressed by regenerated nodes. The increased volume of blood outflow via VCI with a simultaneous constriction of its hepatic segment results in the development of caval hypertention which even more complicates the transhepatic blood flow. Increased pressure in the VCI system with the formation of suprahepatic postsinusoidal block creates additional considerable barriers for blood outflow from the liver aggravating the failure of portal circulation, creating vicious circle that leads to decompensation of both regional visceral and common venous hemodynamics. The author describes the method of diagnosing cava-caval crossflows from VCI to VCS. The condition of VCI and cava-caval crossflows under liver cirrhosis is an important component in complex diagnostics.     

下腔静脉滤器开放手术取出的安全性与可行性分析

背景和目的：下腔静脉滤器（IVCF）在预防致死性肺栓塞（PE）中广泛应用,通常经过腔内介入手段取出。对于腔内取出失败或超回收时间窗的滤器,可考虑手术取出。本研究目的是评价开放手术取出IVCF的安全性及可行性。方法 回顾性分析2019年2月—2022年8月在北京积水潭医院血管外科收治的27例IVCF置入后行开放手术取出的患者临床资料。所有患者开放手术前行介入尝试取出的中位次数为1（1~2）次。结果 所有滤器均全部取出,技术成功率为100%,滤器置入中位时间为20（5~48）个月。其中,Aegisy滤器8例（29.6%）,Denali滤器1例（3.7%）,Cordis滤器10例（37.0%）,Simon滤器1例（3.7%）,Celect滤器3例（11.1%）,Tulip滤器4例（14.8%）。1例（3.7%）滤器位于肾静脉上下腔静脉,1例（3.7%）位于肝后下腔静脉,25例（92.6%）滤器位于肾静脉下下腔静脉。术中,2例（7.4%）于滤器回收钩处留置荷包缝合线,未阻断下腔静脉血流,通过直接钳夹回收钩取出,取出后进行荷包缝合;2例（7.4%）未阻断下腔静脉血流,将滤器直接回收至血管鞘后行荷包缝合;1例（3.7%）阻断双肾静脉及滤器远近端下腔静脉血流,1例（3.7%）分别阻断滤器远端下腔静脉、第一肝门及第二肝门血流,21例（77.8%）阻断滤器远近端下腔静脉血流,然后通过切开下腔静脉前壁进行滤器取出,取出后进行血管壁连续缝合。手术平均时间为（224.15±23.85）min。围手术期无下肢深静脉血栓或症状性PE发生,无心肺系统并发症,无伤口感染。1例（3.7%）出现腹痛伴血性胃液,1例（3.7%）出现血尿,均保守对症治疗后缓解。术前血红蛋白平均为（128.59±15.05）g/L,术后为（110.56±22.15）g/L,6例（22.2%）术后输入悬浮红细胞400 mL,未见致命性大出血及休克。中位术后住院时间9（8~12）d。结论 尽管开放手术滤器取出手术难度较大、技术十分复杂,但滤器取出是安全可行的。术前充分利用CT判断滤器及其回收钩的位置,采用合适的手术方式,通过熟练的手术技巧可以极大地提高开腹手术的安全性和成功率。     

A case of membranous obstruction of inferior vena cava at the hepatic associated with hepatocellular carcinoma and liver cirrhosis

A case of inferior vena cava obstruction at the hepatic portion associated hepatocellular carcinoma with and liver cirrhosis is reported, which was treated with lateral segmentectomy of the liver after transcatheter angioplasty. A 36-year-old male, who had noticed venous dilatation in the abdominal wall and legs from his childhood, visited a doctor complaining of right upper quadrate pain and was diagnosed liver cirrhosis. One year later ultrasonography revealed a liver tumor, which was diagnosed as hepatocellular carcinoma by ultrasonically guided aspiration cytology. Inferior and superior vena cavography revealed complete membranous obstruction of inferior vena cava at the hepatic portion with marked collateral circulation through azygos, hemiazygos and phrenic veins. The caval pressure difference between above and below the obstruction was 16.5 cm H2O. The membranous obstruction was perforated and dilated by transluminal angioplasty using Dotter's balloon catheter. The obstructive segment of inferior vena cava changed into 8mm in diameter after the second angioplasty, and the caval pressure difference between above and below the stenosis decreased to 10 cm H2O. Lateral segmentectomy of the liver was performed. Histopathologic diagnosis was clear cell type hepatocellular carcinoma with liver cirrhosis. Marked postoperative liver damage was observed and transcatheter caval dilatation was performed again. The pressure of inferior vena cava below the stenosis decreased to 8 cm H2O. One year and 8 months after the operation, the patient is healthy without recurrence of cancer.     

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.     

Correlation between the prostatic vein and vertebral venous system under various conditions.

In dogs, the venous blood from the prostate gland was observed under X-ray fluoroscopy to drain into the vertebral venous system under conditions of abdominal compression, the addition of various intraabdominal pressures, and occlusion of the inferior vena cava by a balloon catheter. Pressure in the inferior vena cava and abdominal cavity were measured simultaneously. The venous blood draining from the prostate gland started to flow from the inferior vena cava into the vertebral veins at more than 25 mmHg of intraabdominal pressure with the animal in the supine position. The average pressure of the inferior vena cava draining into the vertebral veins was 12.8 +/- 1.3 mmHg in the supine position and 21.1 +/- 2.7 mmHg in the standing position. The average intraabdominal pressures were 35.5 +/- 3.9 mmHg and 30.1 +/- 2.8 mmHg, respectively. Under conditions of abdominal compression and balloon occlusion of the inferior vena cava, the materials flowed into the vertebral venous system from various routes, such as the internal iliac vein, common iliac vein, and inferior vena cava. It was suggested that the inferior vena caval blood easily enters the vertebral venous system in the standing position by adding high intraabdominal pressure, and that the vertebral venous system may be useful for experimental study of drug administration in bone metastasis of prostate cancer.     

Tape-guided living donor left hepatectomy

A procedure of tape-guided living donor left hepatectomy is described. A tape was placed along the anterior wall of the inferior vena cava for left liver with caudate lobe, and along Arantius' ligament for left liver without caudate lobe. The final step of liver transection was applied by dividing the liver parenchyma under tape guidance. This procedure contributed to safe and accurate anatomic procurement of left liver grafts in living donor hepatectomy.