腹腔镜肝切除术15例报告

目的:探讨腹腔镜肝切除术的适应证及可行性。方法:回顾分析2010年12月至2013年12月为15例肝占位性病变患者行完全腹腔镜肝切除术的临床资料。结果:13例成功完成腹腔镜肝切除术,2例中转开腹。原发性肝癌5例,肝海绵状血管瘤5例,肝内胆管结石2例,肝囊肿2例,肝血管平滑肌脂肪瘤1例。其中行局部切除术8例,左肝外叶切除术5例,肝囊肿切除2例;合并腹腔镜胆囊切除术2例。手术时间平均(153±53)min,术中出血量平均(412±93)ml,切除病灶最大直径12 cm。肿瘤均完整切除,包膜完整,无破裂。1例术后发生胆漏,保守治疗后痊愈;2例术后出血,经对症治疗后痊愈,无死亡病例,术后平均住院(10±3)d。结论:位于肝脏边缘、右肝表面或肝左外叶(Ⅱ~Ⅵ段)的肝脏占位性病变,行腹腔镜肝切除术是安全、可行的。     

肝癌肝切除术后并发症的处理(附592例报告)

1995年至 1999年期间 ,对 5 92例原发性肝癌(下称肝癌 )病人施行了肝切除术。本文就肝癌病人肝切除术后并发症的处理进行探讨。病例资料本组 5 92例中 ,男性 5 71例 ,女性 2 1例 ,年龄2 6～ 78岁 ,平均 5 2岁。 5 42例 (91 5 % )合并肝硬化。肿瘤直径 2 8～ 2 4ｃｍ。术前肝功能 :Ｃｈｉｌｄ ＰｕｇｈＡ级 5 48例 (92 6 % ) ,Ｂ级 4 4例 (7 4 % )。肿瘤部位及手术方式如表 1所示。表 1　 5 92例手术切除方式手术方式例数右三叶切除 2左三叶切除 1扩大的右半肝切除 18扩大的左半肝切除 9右半肝切除 5 4左半肝切除 2 1中肝叶切除 15尾状叶切…     

肝切除治疗原发性肝癌自发性破裂

目的　探讨肝切除治疗原发性肝癌自发性破裂 (简称肝癌破裂 )的作用。方法　分析两所医院 1970年以来采用肝切除术治疗肝癌破裂 2 1例的临床资料。结果　本组男 17例 ,女 4例。平均年龄 4 2 (2 2～ 6 5 )岁。 19例为急症肝切除 ,2例为 2期切除 ,包括左外叶切除 8例 ,左内叶切除 2例 ,左半肝切除 2例 ,右肝部分切除 5例 ,肿瘤切除 4例。本组中Child Paugh肝功能分级A级的 15例 ,B级 6例 ,B级中 1例术后死于肝衰 ,手术死亡率 4 8%。 2 0例生存者 18例获得随访 ,中位生存时间 16个月 ,1,3,5年生存率分别为 6 4 7% ,11 8% ,5 9%。其中 1例已无瘤生存 2 5年 9个月。结论　肝切除是治疗肝癌破裂的最好方法 ,当有可能时应争取施行。肝切除治疗肝癌破裂可能使病人获得长时间生存。     

腹腔镜手术治疗肝癌128例的疗效评析

目的 探讨腹腔镜手术治疗肝癌的临床价值.方法 回顾性分析2007年3月至2009年10月第三军医大学西南医院采用腹腔镜手术治疗128例肝癌患者的临床资料.其中原发性肝癌116例,转移性肝癌12例.行腹腔镜肝切除术107例,单纯腹腔镜下RFA治疗15例,腹腔镜下门静脉右支结扎降期治疗6例.结果 107例行腹腔镜肝切除术患者中7例中转开腹手术,5例中转手助式腹腔镜肝切除术.规则性肝切除88例,包括左外叶切除21例、左半肝切除15例、超左半肝切除2例、中肝切除1例、右半肝切除11例、右后叶切除9例、单肝段切除29例;两个以上部位联合切除4例;非规则性肝切除15例.肝切除术的平均手术时间(228±92)min,术中平均出血量(393±213)ml,无手术死亡,16例术后出现并发症,术后平均住院时间(8±4)d.126例患者随访1～42个月,12例行腹腔镜肝切除术者于术后3～16个月死亡,术后平均生存时间(118±7)周,平均无瘤生存时间(105±7)周.行腹腔镜下BFA治疗的2例患者分别于术后9个月及11个月死亡;行腹腔镜下门静脉结扎的2例患者于术后行二期根治性切除.结论 腹腔镜手术治疗肝癌安全可行,具有创伤小、恢复快的优点.     

肝细胞肝癌自发性破裂切除术后疗效观察

目的 探讨肝细胞肝癌(HCC)自发性破裂外科切除治疗方法及疗效.方法 分析自1998年3月至2010年3月采用肝切除治疗HCC自发性破裂出血58例的临床资料.结果 58例均行手术治疗,其中左外叶切除17例,左内叶切除5例,左半肝切除2例,尾状叶切除4例,右肝部分切除23例,肿瘤局部切除7例.58例中1个月内死亡3例,占 5.2%,55例生存者全部获得随访,中位生存时间 18.0 个月,1、2、3年生存率分别为 69.1%、20.0%、10.9%.结论 HCC自发性破裂出血早期诊断、早期手术可延长生存期.     

腹腔镜肝癌切除术28例报告

目的探讨腹腔镜肝癌切除术的适应证和可行性。方法回顾性分析2002年3月至2007年10月完成的腹腔镜肝癌切除术28例患者临床资料。结果28例均成功在腹腔镜下完成手术。对于位于肝左外叶的肿瘤，选择规则性肝左外叶切除术；肿瘤位于肝脏边缘或右肝表面时，选择肝脏不规则切除术。平均手术时间95min（60～150min）。平均术中出血345ml（50～800ml）。切除标本最大体积11cm×9cm×7cm。患者术后24h均能下床活动，术后2～3d即能进食。术后平均住院时间8d（5～15d）。术后病理诊断为原发性肝细胞癌24例，结直肠癌肝转移4例。结论对位于肝脏边缘、右肝表面或者左肝外叶的肝癌行腹腔镜肝癌切除术是安全可行的。     

前入路肝切除技术探讨

目的 探讨前入路肝切除术在难切性肝癌肝切除术中的应用价值。方法 对2例用常规手术方法难以切除的肝右叶肝癌和2例肝门部胆管癌用前入路的方法行肝切除,探讨其手术技巧和适应证。结果 2例右半肝切除,1例肝门部胆管加左半肝切除,1例肝门部胆管加尾状叶切除手术均获得成功。术中平均出血量1075ml,手术至出院时间12.5d。无手术死亡。结论 前入路肝切除术对难切性肝癌是一种安全有效的治疗方法。     

腹腔镜肝切除术11例临床报告

目的:探讨腹腔镜肝切除术的适应证和可行性。方法:回顾分析10例病灶位于肝脏边缘及左肝外叶(Ⅱ～Ⅵ段)及1例位于Ⅷ段的肝占位患者的临床资料。其中原发性肝细胞癌8例,肝海绵状血管瘤2例,胆管细胞癌1例,肝功能Child-Pugh评分A级9例,B级2例;AFP(+)7例;位于左肝外叶实质中的肿瘤,行规则性左肝外叶切除;位于肝脏边缘或右肝表面的肿瘤,行肝脏局部切除。结果:11例均成功完成腹腔镜肝切除术,无中转开腹。其中局部切除术7例,左肝外叶切除术4例,腹腔镜脾切除+胆囊切除术2例。平均手术时间105min,术中平均出血220ml,切除病灶最大直径10cm。全部肿瘤均完整切除,肿瘤包膜完整,无破裂。术后未发生胆漏和出血等并发症,恢复良好,术后平均住院8.5d。结论:位于肝脏边缘、右肝表面或左半肝(Ⅱ～Ⅵ段)的肝脏占位,行腹腔镜肝切除术是安全可行的。     

腹腔镜规则性左肝外侧叶切除术15例

目的探讨腹腔镜左肝外侧叶切除术的可行性。方法2004年12月-2006年8月对病灶位于左肝外侧叶原发性肝细胞癌10例，肝海绵状血管瘤3例，结肠癌肝转移2例，腹腔镜下应用电刀或超声刀、线性切割器等切除左肝外侧叶。结果15例均在完全腹腔镜下行规则性左肝外侧叶切除，无中转开腹。手术时间65—120rain，平均100min；术中出血量50—100ml，平均80ml。肿瘤全部完整切除，无破裂，完整取出标本的边界距肿瘤切缘1cm以上，术后病理证实切端未见癌细胞侵犯。术后无出血及胆漏，术后腹腔引流管3—4d。术后住院3—5d。12例肝癌术后随访1-20个月，平均12．5月，未见肝内复发及手术切口肿瘤种植，所有患者均健康存活。结论腹腔镜规则性左肝外侧叶切除可行、安全。     

肝三叶切除术治疗肝脏巨大肿瘤29例

目的 探讨肝三叶切除术治疗肝脏巨大肿瘤的可行性及疗效。方法 自1993年7月-1999年10月间行肝三叶切除术治疗肝脏巨大肿瘤29例,其中包括原发性肝癌23例,胆囊癌肝浸润、结肠癌肝转移、肝血管肉瘤和肝神经纤维瘤各1例及肝巨大囊肿2例,共行肝右三叶切除术26例,肝左三叶切除术3例。所有手术均采用常温下一次性肝门阻断法,阻断时间为15-40min。结果 本组肝三叶切除术取得较好疗效,原发性肝癌患者的1、3、5年生存率分别为63.6%、36.4%和27.3%,胆囊癌肝浸润和结肠癌肝转移患者的生存期均为6个月,肝血管肉瘤、肝神经纤维瘤和2例肝巨大囊肿患者至最近随访止已分别生存35、26、25和40个月,5例出现明显的并发症,手术病死率为3.4%(1/29)。结论 如能掌握好手术适应证（肝储备功能好）和手术技巧（肝门阻断技术）,肝三叶切除术治疗肝脏巨大肿瘤是安全和有效的。     

Patterns of failure after surgical cure of large liver tumors: A change in the proximate cause of death and a need for effective systemic adjuvant therapy

During a period of 7 years, we have aggressively treated liver tumors whether primary or metastatic. Our experience after 43 curative major liver resections has shown an excellent overall survival: 34 of 43 patients still alive a median of 12 months after liver resection (patient ages ranged from 21 to 85 years, median 57 years). Nineteen patients underwent right hepatic lobectomy, 9 trisegmentectomy, 5 left hepatic lobectomy, 5 extended left hepatic lobectomy, 4 right lobectomy plus left lobe wedge resection, and 1 patient underwent a major hilar wedge resection. Two patients died from sepsis and hepatic failure on or before the 60th postoperative day. One patient with no evidence of recurrent colorectal cancer was lost to follow-up after 2.5 years. One patient died without cancer 12 months after left hepatic lobectomy for colon cancer metastases. Cumulative survival for the entire series and for patients after resection of colorectal cancer metastases was the same: 1 year survival 90 percent; 2 year survival 75 percent, and 3 year survival 65 percent. Seventeen of 30 patients remain disease-free after resection of liver metastases. Of the 13 who had recurrence, 8 are still alive. Ten recurrences were outside of the residual liver (predominantly multiple pulmonary metastases). One recurrence was in the right hemidiaphragm, and only three were in the residual or regenerated liver. Serial carcinoembryonic antigen analysis was the best indicator of recurrence in these 13 patients, 12 of whom were asymptomatic. These data confirm that major liver resection can be performed with minimum postoperative mortality (4.7 percent in this series). More importantly, the majority of patients were cured of their liver metastases. The next goal should be the initiation of adjuvant systemic therapy trials after liver resection in such patients.     

联合肝叶切除治疗肝门部胆管癌

目的研究联合肝叶切除术治疗肝门部胆管癌的手术方式、并发症及疗效。方法回顾性分析2000年1月至2011年3月67例肝门部胆管癌患者临床资料。联合左半肝切除23例,右半肝切除9例,尾状叶切除3例,右三叶、右前叶切除各4例,姑息性切除15例,内引流术4例,经皮肝穿刺胆道引流外引流术5例。结果死亡1例,手术并发症发生率37．31％（25／67）。联合肝叶切除组术后中位生存时间为31．1个月,高于姑息性切除组（15．8个月）。联合肝叶切除组的1、3、5年存活率为78．5％、48．3％和29％,姑息性切除组的1、3、5年存活率为43．5％、6．8％、0。术后随访率67．16％（45／67）。结论肝门部胆管癌应积极手术切除治疗,对无明显手术禁忌证的患者行包括肿瘤切除的联合肝叶切除的扩大根治术可延长患者存活期;围手术期正确处理是减少术后并发症,提高患者生活质量和延长存活期的关键。     

肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌

目的 总结应用肝部分切除联合肝十二指肠骨骼化治疗肝门部胆管癌的临床经验。方法回顾1999年1月～2001年12月手术治疗67例肝门胆管癌的临床资料。结果67例患者中65例手术切除,49例根治性切除(22例肝十二指肠韧带骨骼化切除,27例联合部分肝切除)。根据Bismuth分型,Ⅰ、Ⅱ型行骨骼化切除,Ⅲa型行右半肝加右尾叶切除,Ⅲb型行左半肝加左尾叶切除,Ⅳ型中行右半肝加全尾叶3例切除,左半肝加全尾叶9例切除,方叶切除者2例。2例外院曾行部分肿瘤切除加肝门胆管空肠吻合术者,我们再次行左半肝加全尾叶切除加右肝管空肠吻合术根治肿瘤。8例患者行肿瘤部分切除加肝内胆管支撑加肝门胆管空肠吻合。13例患者行门静脉部分切除,27例患者切除肝动脉。24例患者术后无并发症发生,加例发生了严重并发症。后者中14例经治疗后康复,余6例患者术后7、12、14、42、57、89d死于肝功能衰竭、心源性休克、腹内大出血、消化道大出血。术后30d病死率4、5％,根治性手术后患者中位生存期16个月(1个月～41个月),姑息治疗者为7个月(1个月～16个月)。结论 肝部分切除联合肝十二指肠韧带骨骼化可用以根治肝门部胆管癌,尾叶切除可提高根治性切除率。     

Surgical resection and chemotherapy improve survival rate for patients with hepatoblastoma

BACKGROUND: The authors reviewed retrospectively their experience in 30 children with hepatoblastoma (HB). Despite an increased trend in the incidence of HB during the last 2 decades, an encouraging cure rate has been achieved with complete resection of the tumor and chemotherapy before or after surgery with cisplatin plus doxorubicin (Adriamycin) or cisplatin plus vincristine plus 5-Fluorouracil. RESULTS: There were 10 female and 20 male patients. For the period from 1963 to 1980 there were 8 patients, and for the period from 1981 to 1998 there were 22 patients. Their mean age at surgery was 16 months (range, 3.5 months to 5.5 years). Tumors were localized to the right lobe in 10 (42%), to the left lobe in 7 (29%), and in both lobes in 7 (29%) of the resected patients. Tumors were greater than 10 cm in size in 16 (67%) of these patients. Twenty-four patients (80%), underwent liver resection before or after chemotherapy. One patient (3%) with an unresectable tumor received chemotherapy and a liver transplant. In 5 patients (17%) the hepatic involvement was too extensive for resection. The types of resection performed were right lobectomy in 7, left lobectomy in 6, right trisegmentectomy in 8, left trisegmentectomy in 2, and middle hepatectomy in 1. The overall survival rate for 35 years of the study was 60% (18 of 30). With the association of surgery and chemotherapy (1981 through 1998) survival rate is 82% (14 of 17). Overall median follow-up in our study is 8 years (range, 2.5 to 24 years). CONCLUSIONS: There has been a dramatic improvement in the results of treatment of hepatoblastoma. Formerly, only 25% to 30% of patients were cured, whereas today, with combination of chemotherapy and surgery, 75% to 80% may be cured.     

肝叶切除术在肝门胆管癌手术中应用的价值

目的探讨联合肝叶部分切除在肝门部胆管癌根治术中的应用价值.方法对42例行手术治疗的肝门部胆管癌患者的临床资料进行回顾性分析.结果42例患者中有34例行肿瘤切除术,其中局部切除15例,右半肝切除8例,左半肝切除3例,左半肝切除联合尾叶切除4例,左肝外叶切除联合尾叶切除1例,方叶切除3例,总体手术切除率为81%.其中25例根治性切除,包括8例局部切除,及17例联合肝叶部分切除,根治性切除率为60%.根治性切除组的中位生存期28个月,姑息性手术组的中位生存期14个月,根治性切除术的1年生存率为90%,2年生存率73%,4年生存率28%,姑息性手术1年生存率为57%,2年生存率27%.结论根治性切除的生存率比姑息性手术显著提高,联合肝叶部分切除能明显提高根治性手术的切除率.     

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??Application of LAVA CE-MRA in hepatectomy for huge hepatic tumor WU Jian-wei*, QU Xian-li, GAO Hong, et al. *Department of Radiology, the 81st Hospital of PLA, Nanjing 210002,China
Corresponding author??WU Jian-wei, E-mail??wujianwei81@163.com
Abstract Objective To discuss the application of liver acquisition volume acceleration??LAVA??contrast-enhanced magnetic resonance angiography (CE-MRA) in hepatectomy for huge hepatic tumor. Methods From January 2011 to October 2012, the hepatectomy was performed in 31 patients with hepatic tumors in 81st Hospital of PLA. The LAVA CE-MRA was performed before operation. The reconstruction of hepatic vasculature with multiplanar reconstruction (MPR) and measurement of remnant liver volume were performed to assess the feasibility of surgery. The results of liver function test before and after operation were also analyzed. Results CE-MRA showed the hepatic artery, portal veins, hepatic veins and their main branches as well as their relationship with the tumors clearly in all patients. The right and left hepatectomy were performed in 10 patients, lobectomy in 7??segmentectomy in 9 and wedge resection in 5. The remnant liver volume was 38%??84% in 10 patients with hemibepatectomy. All patients were survival after operation. The recovery of liver function occurred 7 days postoperatively in 93.5% of patients. Conclusion Combining with volumetry of remnant liver, LAVA CE-MRA which showed the vasculature of liver and their relationship with tumors clearly can play an important role in preoperative planning of liver resection.     

Major liver resection for hilar cholangiocarcinoma.

Between 1968 and 1984 liver resection with curative attempt was performed in 22 patients with hilar cholangiocarcinoma. Right lobectomy was performed in 4 patients, extended right lobectomy in 7, left lobectomy in 8, and excision of the median segment segment of the left lobe (segment IV) in 3. Bilio-enteric continuity was restored by hepatocholedochostomy in 17 patients and hepatojejunostomy in 4. (One patient had external transhepatic catheter drainage and no internal bile drainage.) Operative mortality rate was 27% and caused by excessive intraoperative bleeding, sepsis, or liver insufficiency. Postoperative complications occurred in 57% of patients surviving the operation and were due mainly to leakage from the hepatocholedochostomy. Median survival was 6 months, and one third of the patients survived 1 year. Three patients survived 10 years and were among the four patients in whom a tumor-free resection margin was obtained (one of them died in the postoperative phase). It is concluded that resection of hilar cholangiocarcinoma may give long-term survival if a free resection margin is obtained. The importance of a free resection margin indicates that surgery should be aggressive and include liver resection.     

Laparoscopic liver resection for hepatocellular adenoma

AIM:To investigate the role of laparoscopy in the surgical management of hepatocellular adenoma(HA). METHODS:We reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA. RESULTS:Thirteen patients underwent fifteen pure laparoscopic liver resections for HA(male/female:3/10; median age 42 years,range 22-72 years).Two patients with liver adenomatosis required two different laparoscopic operations for ruptured adenomas.Indications for surgery were:symptoms in 12 cases,need to rule out malignancy in 2 cases and preoperative diagnosis of large HA in one case.Symptoms were related to bleeding in 10 cases,sepsis due to liver abscess following embolization of HA in one case and mass effect in one case(shoulder tip pain).Five cases with ruptured bleeding adenoma required emergency admis-sion and treatment with selective arterial embolization. Laparoscopic liver resection was then semi-electively performed.Eight patients(62%)required major hepatectomy[right hepatectomy(n=5),left hepatectomy (n=3)].No conversion to open surgery occurred.The median operative time for pure laparoscopic procedures was 270 min(range 135-360 min).The median size of the excised lesions was 85 mm(range 25-180 mm). One patient with adenomatosis developed postoperative bleeding requiring embolization.Mortality was nil. The median hospital stay was 4 d(range 1-18 d)with a median high dependency unit stay of 1 d(range 0-7 d). CONCLUSION:The laparoscopic approach represents a safe option for the management of HA in a semi-elective setting and when major hepatectomy is required.     

腹腔镜肝切除术中出血的处理

目的探讨腹腔镜肝切除术中出血的处理方法。方法对22例肝脏病变实施腹腔镜肝切除术。其中原发性肝癌5例,肝血管瘤16例,肝转移癌1例。15例肿瘤位于左外叶,1例位于肝尾状叶,2例位于第Ⅳ段,4例位于肝脏第Ⅵ段;肿瘤平均直径为4 cm（2～10 cm）。手术方式包括腹腔镜肝左外叶切除术15例,不规则肝部分切除术6例,肝尾状叶左半切除术1例。结果 22例均在腹腔镜下完成手术,无中转开腹,无手术死亡。平均手术时间为115 min（65～142 min）,平均术中出血量为450 mL（270～780 mL）,平均术后住院时间为6.5 d（3～11 d）。结论控制肝脏断面出血是腹腔镜肝切除术的技术关键。