腹腔镜肝脏切除术的肝门血流阻断及断肝技巧

<正>近20余年来,腹腔镜肝切除术(laparoscopic liver resection,LLR)取得巨大进步,主要表现在技术的革新、术式的发展、手术适应证的拓宽等方面。目前LLR也从最早的局部切除发展到肝段、半肝、尾状叶乃至更大范围的肝切除,而作为LLR的核心环节,腹腔镜下肝脏血流阻断技术及肝实质的离断技术既决定着手术的成败,亦是LLR得以普及     

腹腔镜肝叶切除的纷争

腹腔镜肝切除术(LLR)用于良性肝脏肿瘤及肝癌肝切除术中,手术微创、术后较轻疼痛、消化道功能快速恢复,较传统开腹肝切除术(OLR)具有无法比拟的优势。远期疗效上LLR能够得到与OLR相当的预后和长期生存。同时腹腔镜各种器械的发展可减少LLR手术时间,减少术中出血及术后胆漏等并发症。术者专业知识储备及实践操作技能训练积累可明显减少术中及术后并发症的发生。LLR的纷争极大地促进了微创外科技术的迅速发展。     

腹腔镜肝切除的现状和我们的经验

正自1991年第一例腹腔镜肝脏楔形切除~([1])报道开始,1996年Azagra等~([2])和Kaneko等~([3])同时报道了腹腔镜解剖性肝切除术。此后,腹腔镜肝切除(laparoscopic liver resection,LLR)日益广泛开展。随着手术技术的进步和器械的改进,LLR的复杂性和安全性均明显提高。2008年形成了关于LLR的初步共识即Louisville Statement~([4])。2013年中华医学会肝脏外科学组组长陈孝平院士主持并制定我国第一部《腹腔镜肝切除专家共识与手术操作指南》~([5]),并推行全国。2015年第二届国际腹腔镜肝     

腹腔镜肝切除术前难度评分的研究进展

随着腹腔镜设备的蓬勃发展和微创技术的日益精进,腹腔镜肝切除术（laparoscopic liver resection,LLR）已经成为治疗各种肝脏疾病的最重要手段之一。LLR在世界各地的普及程度越来越高,LLR的适应证也在不断扩大,但由于术中止血、肝实质离断等关键技术尚未完全攻克,LLR仍处在不断探索阶段。因此术前评估手术难度对外科医师来说至关重要,国内外关于LLR难度评分均有报道,但尚未形成统一共识,现就当前LLR难度评分的发展现状作一综述。     

肝内胆管结石的完全腹腔镜下肝切除术

目的 总结肝内胆管结石完全腹腔镜下肝切除术的临床经验.方法 回顾性分析2005年7月至2009年4月间华中科技大学同济医学院附属协和医院腹腔镜外科中心因肝内胆管结石而施行了完全腹腔镜下肝切除术的72例病人临床资料.结果 病人年龄16～65岁,平均(43.8±21.7)岁.72例腹腔镜下肝叶或肝段切除术主要包括左半肝切除术34例,左外叶切除术19例,肝Ⅵ段切除术16例.手术时间125～320 min,平均(262.5±115.5)min.出血量50～400 ml,中位数150 ml.术后并发症发生率12.50%,包括胆漏6例,胃轻瘫1例,术后早期炎性肠梗阻1例,肝包膜下积液1例,均保守治疗成功.结论 微创时代治疗肝内胆管结石应以腹腔镜下肝段或肝叶切除术作为主要方式.     

腹腔镜肝切除术的现状与展望

正1991年,美国妇科医生Reich等~([1])实施了世界首例腹腔镜肝切除术(laparoscopic liver resection,LLR),揭开了微创肝脏外科的序幕。经过近30年的探索与发展,LLR的理论体系日趋成熟,手术适应证不断扩大,其安全性和有效性也被逐一证实。随着器械和技术的进步,精准和微创成为外科手术的两大主题,LLR也逐步取代开腹式肝切除术成为     

腹腔镜肝切除术中出血的防控

正由于肝脏脉管繁多、血供丰富,无论是在传统的开放肝切除术(open liver resection,OLR)还是在腹腔镜肝切除(laparoscopic liver resection,LLR)中,出血及止血一直是肝脏外科医师面临的难题。虽然早在1991年已有腹腔镜下肝脏良性病变切除的报道[1],但因腹腔镜下操作空间受限、暴露困难、止血手段少、缝合打结不便等实际困难,使得LLR的发展迟缓,长期以来滞后于同期的妇科、胃肠外科等专业。随着精准     

术中超声用于机器人辅助肝切除术

机器人辅助肝切除术(RALR)克服了传统腹腔镜肝切除术(LLR)的瓶颈,使之具备完成更大型、更复杂手术的能力。术中超声(IOUS)用于RALR扩展了RALR适应证,提高了肿瘤完整切除率及手术安全性。本文结合笔者经验对IOUS辅助RALR的应用体会进行综述。     

腹腔镜与开腹肝切除术治疗术后复发性肝癌疗效比较的Meta分析

目的:比较腹腔镜肝切除术(LLR)与开腹肝切除术(OLR)治疗复发性肝癌的安全性与疗效.方法:检索PubMed、Embase、Cochrane Library、Web of Science、中国生物医学文献数据库、万方、维普与中国知网,搜索比较LLR与OLR治疗复发性肝癌疗效的队列研究,检索时限从建库至2021年3月3...     

腹腔镜和开腹肝肿瘤切除的病例配对研究和费用效益对比研究

目的探讨腹腔镜肝肿瘤切除治疗肝脏肿瘤的临床疗效和费用效益。方法总结分析2013年1月到2013年12月在上海仁济医院肝脏外科行腹腔镜肝肿瘤切除(Laparoscopic Liver Resection,LLR)的39例患者的临床资料,根据患者年龄、手术方式和肿瘤大小为配对条件,在开腹肝肿瘤切除(Open Liver Resection,OLR)病例库中进行1:1配对抽选,共39例纳入LLR配对组。对行LLR病人和OLR病人进行病例配对研究和费用效益对比研究。结果两组患者在性别、年龄、手术方式、术前Child评分以及病种上的差别无统计学意义(P0.05),在肿瘤个数和大小方面两组患者也无显著的差异(P0.05)。LLR组手术时间和术中出血量分别为123.8±54.9min,171.8±218.5ml,均明显少于OLR组的182.1±50.9min,308.9±208.9ml(P0.05)。LLR组患者术后平均住院日、术后平均进食时间明显少于OLR组,且与OLR组相比,LLR组患者肝功能损伤较小,恢复的更快,差异有统计学意义(P0.05)。在住院费用中,LLR组患者的手术费用和总住院费用与OLR组相差无统计学意义。结论我们的研究不仅证实了腹腔镜肝肿瘤切除术治疗肝肿瘤是安全可行,具有一定的近期优势,而且具有较好的费用效益。     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.