切断Arantius韧带暴露左肝静脉背侧43例体会

目的 探讨左肝静脉背侧游离的手术方法.方法 在33例尸肝Arantius导管解剖基础上,切断43例患者的Arantius韧带,显露左肝静脉背侧壁并肝外切断左肝静脉.结果 43例左肝静脉背侧均被显露并成功切断,术后顺利恢复.结论 切断Arantius韧带是显露左肝静脉背侧壁并肝外切断左肝静脉的稳妥方法之一.     

逆行肝切除术及其方法探讨

目的　探索难切性肝癌的切除方法。方法　先离断肝脏,分离被切肝脏与膈肌间的粘连或切除部分被肿瘤侵犯的膈肌,切断相关韧带、取出被切除肝脏。如果邻近脏器与肿瘤紧密粘连或被侵犯则最后分离粘连或一同切除被侵脏器。如邻近脏器之肿瘤侵犯肝脏亦先离断肝脏再将原发肿瘤的器官与肝脏一并切除。结果　１９９４ 年６ 月至１９８８ 年１０ 月,应用该法成功地切除了７４ 例常规肝切除术显露困难或肿瘤与膈肌、相邻脏器紧密粘连以至侵犯的巨大肿瘤（ 甲组） 。同期用常规肝切除术切除１３ 个相似病例（ 乙组） ,二组相比甲组所需手术时间短、术中失血量少、围手术期并发症发生率低（Ｐ＜０－０５） 。结论　逆行肝切除术适合于难切性肝癌的切除。     

逆行肝脏部分切除术

目的为常规方法切除困难的肝脏肿瘤寻找一种新的切除径路。方法手术程序与常规肝切除术相反,即首先离断肝脏,然后分离肿瘤与膈肌间的粘连或切除受累膈肌,切断相应韧带,去除肿瘤。如周围脏器被肿瘤侵犯或有紧密粘连难以分离,则将受累部分器官连同肿瘤一起切除。结果１９９４年６月至１９９６年１月已用该法切除肝脏恶性肿瘤１１例,平均手术时间为１９２ｍｉｎ（１５０～２５０ｍｉｎ）,术中平均失血量１４６０ｍｌ（８００～４２００ｍｌ）,全组无手术死亡,术后均顺利恢复。结论逆行肝脏部分切除术是常规法切除困难肝脏肿瘤的一种良好切除径路     

完全腹腔镜下右半肝切除

切除胆囊后,向左牵拉胆囊管,显露门静脉右支,分离,7号丝线结扎;分离出肝右动脉,结扎切断。显露左右半肝缺血线。游离肝结肠韧带,肝肾韧带,右侧冠状韧带,肝镰状韧带,右半肝充分游离。沿缺血线切开肝脏实质,结扎切断肝中静脉5段支,应用Endo GIA blue reload离断右肝蒂后沿下腔静脉前面结扎切段右侧肝短静脉,继续沿缺血面离断肝组织,结扎切断肝中静脉第8段支,显露肝右静脉,Endo GIA white reload离断。完整切除右肝。装入自制标本袋。取出!     

绕肝提拉法在联合肝脏离断和门静脉切断二步肝切除术中的应用

目的：探讨绕肝提拉法（LHM）在联合肝脏离断和门静脉切断二步肝切除术（ALPPS）中的应用效果。方法：回顾性分析4例原发性肝细胞癌行ALPPS术患者临床资料,其中肝右叶肿瘤3例,肝尾状叶肿瘤1例,均采用LHM法导引的一期左、右肝脏原位劈离,右门静脉切断;二期行肿瘤完整切除。结果：4例均预先游离肝脏,成功安置弹力带,顺利实施二期肝切除术;一期手术时间195~273（232.2±35.3）min,术中失血420~1210（735±344.3）mL,并发胆瘘1例;二期手术时间98~186（139.5±36.6）min,术中失血100~320（197.5±95.3）mL;无手术死亡;术后随访3个月,3例情况良好,1例术后2个月复发死亡。结论：LHM法对于下腔静脉的保护,充分显露左右肝动脉、肝静脉、肝内胆管有较好的效果,可常规适用于肝肿瘤ALPPS二步肝切除术。     

活体部分肝移植术肝静脉的重建

本文报告我院开展的１例活体部分肝移植术肝静脉重建的情况。一、临床资料：本例受者为女性,１０岁,因先天性弥漫性肝内胆管囊性扩张症、复发性胆管炎、肝硬变入院。供者为受者之父,４０岁,自愿将其部分肝脏献给女儿。二、手术主要步骤：（１）病肝切除：全身吸入麻醉,取上腹部“屋顶状”切口,用自制的自动拉钩充分显露肝脏,游离肝周韧带,解剖游离出胆总管、门静脉、肝动脉、肝静脉各分支,切断结扎各肝短静脉,待供肝顺利切取时切除病肝;（２）供肝切取：手术按预定切除线在Ｂ超引导下,在供者肝中静脉左侧约１ｃｍ平面用超声刀和…     

后交叉韧带胫骨止点撕脱骨折的早期诊断与手术治疗

目的：探讨后交叉韧带胫骨止点撕脱骨折的早期诊断与手术治疗。方法：回顾性分析1995年1月－2001年10月共收治18例后交叉韧带胫骨止点撕脱骨折的诊断与治疗情况。训练伤1例，车祸伤16例，机器卷伤1例。新鲜骨折16例，陈旧性骨折2例。10例行三维CT重建检查。18例手术均用腓肠肌内侧斜切口显露。采用可吸收钉内固定10例，钢丝2例，螺钉6例。结果：18例均得到随访，时间6个月－2年，平均1．8年。优10例，良6例，中2例，差0例。结论：三维CT重建有利于后交叉韧带胫骨止点撕脱骨折早期诊断；腓肠肌内侧斜切口有利于该损伤的手术显露。     

腹腔镜辅助下低位直肠癌D3根治术(Dixon手术)

手术步骤包括:(1)中央入路法从乙状结肠系膜根部切开进入左Toldt间隙;(2)清扫肠系膜下动脉淋巴结,根部切断IMA;(3)继续分离左Toldt间隙;(4)裁剪乙状结肠系膜及切断IMV;(5)分离直肠后间隙直至骶尾韧带水平;(6)切断右侧直肠侧韧带及左结肠旁沟;(7)切断左侧直肠侧韧带及前壁邓氏筋膜,裸化肠管;(8)直肠切断与吻合。此手术以手控电刀操作为主,其主要优势有:(1)操作精细、快速、安全;(2)烟雾小,利于盆腔深部术野显露;(3)成本低,适合基层医院开展。     

脊髓型颈椎病后路手术疗效分析：（附50例报告）

应用推板切除减压术治疗５０例脊髓型颈椎病，部分病例尚切断齿状韧带。随访时间为７．５～１５４个月，优良率仅６０％。文内分析了后路手术疗效差的原因。术中有否切断齿状韧带。对手术疗效的差别无显著意义。文章最后阐述了后路手术途径的优缺点及选择依据。     

改良颈椎管扩大连体棘突重建术

选择适应于颈后入路的手术患者 ,采取颈后旁正中切口连体棘突重建术式 ,治疗颈椎管狭窄症 9例 ,平均随访期1年 ,疗效满意。现就术式要点及手术步骤初步报告如下 :颈后入路 ,旁正中切口(避开项韧带 ) ,依次显露颈椎手术节段的一侧棘突及椎板 ,在椎板相应的下部刻槽 (做为开门时的绞锁侧 ) ,在棘突根部稍上 ,用电钻钻一小孔 (以备重建棘突固定时用 ) ,在棘突根部 (即小孔的稍下方 )切断棘突 (图 1) ,再将断离的棘突连体推向对侧 (如张力较大 ,将上端及下端的项韧带及棘间韧带切断 ) ,钝行剥离显露对侧椎板 ,自动拉钩撑开 ,充分显露双侧椎板及…     

Successful removal of large adrenal pheochromocytoma on the right side with liver mobilization

We report a case of a large adrenal pheochromocytoma on the right side successfully removed with liver mobilization. Bilateral anterior subcostal incision with a ventral midline incision extending from the xiphoid and subsequent use of self-retraction system provided satisfactory exposure of liver and diaphragm. This incision is useful for easy mobilization of the liver and manipulation of the inferior caval vein in patients with large adrenal tumour on the right side.     

Eine adrenale Pseudozyste als Ursache chronischer Rückenschmerzen

We present the case of a 36 year old female patient with a 3 month history of severe lower back pain without improvement after physiotherapy and analgesic drug therapy. X-rays of the spine were normal except for a calcified paravertebral lesion on the right side. A cystic tumor projecting on the posterior area of the right liver lobe was seen using ultrasound. MRI-scan showed an extrahepatic localization of the tumor. Intraoperatively, the tumor was located in the right adrenal gland which was then removed. Histopathology revealed an adrenal pseudocyst, and the pain was gone immediately after surgery.     

A case of exohepatic pedunculated hepatocellular carcinoma suspected of adrenal tumor

A case of exohepatic pedunculated hepatocellular carcinoma that was clinically diagnosed as nonfunctioning adrenal tumor is reported. A 66-year-old man was admitted to our hospital for further examination of unstable angina pectoris. Abdominal echogram and CT scan revealed a large tumor in the right retroperitoneal space. Selective right renal arteriography demonstrated that the tumor was fed by the capsular branch of right renal artery and the right adrenal artery. Adrenal function was normal. Preoperative diagnosis of right nonfunctioning adrenal tumor was made. On operation we found that the tumor was pedunculated from the liver and adhered massively to both right kidney and vena cava. The tumor and right kidney were removed. A histopathological examination demonstrated well differentiated hepatocellular carcinoma (Edmondson's grade II type).     

Laparoscopic Adrenalectomy in a Patient with Situs Inversus

Background:

Situs inversus is a relatively rare congenital disease. A patient with a right adrenal tumor complicated by total situs inversus was treated by laparoscopy.

Case Discussion:

The patient was a 45-y-old male with lower limb weakness. He had been diagnosed with situs inversus during a general health check-up as an infant. His blood pressure was 230/160 mm Hg, and the serum potassium level was 2.0 mEq/L. Abdominal ultrasonography and magnetic resonance imaging showed a mass of about 2cm in diameter in contact with the right adrenal gland. Total situs inversus was simultaneously confirmed. The plasma aldosterone concentration was elevated to 442pg/mL, and renin activity was suppressed, at 0.3ng/mL/hr.

Discussion:

These findings indicated a diagnosis of primary aldosteronism due to an adrenal tumor, and the right adrenal tumor was resected laparoscopically. The right adrenal gland was approached and resected from the lateral side of the spleen, which was located on the right side because of situs inversus. The resected specimen was 4.5cm×1.6cm, and no intraoperative complications occurred. The histopathological examination showed the tumor to be an aldosterone-producing adrenocortical adenoma.     

Ultrasonic spectrum of adrenal masses.

Adrenal masses are amenable to ultrasonic examination. The ultrasonic characteristics of eight adrenal masses in 6 patients are described. In particular, an ultrasonic study of the natural history and progression of a large adrenal adenoma is reported. Adrenal masses on the right side may mimic right posterior liver masses on transverse scans alone. They may compress and displace the liver with expansion. Posterolateral impressions on the inferior vena cava occur. Differentiation from a superior pole renal mass is not always possible.     

Hepatocellular carcinoma with a solitary adrenal metastasis and poor hepatic functional reserve: Report of a case

A 54-year-old man with a 15-year history of liver disease, was found by his family physician to have multiple tumors in the right lobe of the liver and a large right retroperitoneal tumor. He was referred and admitted to our institute where a preoperative diagnosis of liver cirrhosis complicated by hepatocellular carcinoma and probable right adrenal metastasis was made. Because his hepatic functional reserve was so poor, only resection of the right adrenal tumor with a splenectomy for hypersplenism and a cholecystectomy for the prevention of cholecystitis secondary to the scheduled transcatheter arterial embolization was performed. The patient was discharged in good clinical condition 5 weeks after surgery.     

Adrenal myelolipoma: a case report

A 51-year old obese man had been followed up for diabetes mellitus and hypertension. Hepatomegaly was noted on routine examination without any complaints in 1981. Through further investigation of the liver, a large hyperechoic mass lesion was shown between right kidney and the liver on ultrasonogram. On admission, diabetes was controlled by diet alone and blood pressure was 160/90 mmHg. without medication. There were no abnormal findings in laboratory data including hormone assays. The mass showed fat density on CT scan and hypovascularity on angiogram. The mass was diagnosed as benign non-functioning right adrenal tumor, most likely myelolipoma. By operation, the tumor was removed through long subcostal incision. The tumor was well defined and encapsulated, 14 X 8 X 8cm. in size and 480g. in weight. Microscopically the tumor was typical myelolipoma with a mixture of hematopoietic and adipose tissue. Postoperative course was uneventful and the patient discharged on 17-th postoperative day. Myelolipoma of the adrenal gland is a rare non-functioning benign tumor consisting of fat cell and bone marrow element. Only 30 resected cases of adrenal myelolipoma have been reported in the world including 7 cases in our country.     

A Child with Adrenocortical Adenoma Accompanied by Congenital Hemihypertrophy: Report of a Case

We report herein the findings of a 7-year-old male child with a ruptured adrenocortical adenoma and congenital hemihypertrophy which was incidentally detected after suffering a trauma. A review of 21 pediatric cases of adrenocortical neoplasms in the literature was made. The patient showed precocious puberty such as pubis and advanced bone age, but an endocrinological examination revealed no definite abnormalities. The right adrenal tumor with hematoma was resected after these evaluations. Adrenocortical adenoma is considered to occur more frequently in female children. However, the incidence of adrenocortical tumors accompanied by congenital hemihypertrophy does not differ between males and females. The outcomes were relatively good, although the observation periods were short in some patients. A large number of patients presented with a tumor and hemihypertrophy on the same side. This finding is of interest when considering the possible association between hemihypertrophy of the organs and tumor proliferation. However, their association in terms of development was unclear. It is necessary for patients with hemihypertrophy to have regular examinations for the possible development of malignant tumors, especially in the kidney, adrenal gland, and liver. Received: November 1, 1999 / Accepted: March 24, 2000     

A case of pedunculated hepatoma suspected of adrenal tumor]

A case of pedunculated hepatoma which was preoperatively diagnosed as non-functioning adrenal tumor is reported. A 48-year-old man presented to our hospital for further examination of remittent fever and leg edema. Abdominal ultrasonography, computed tomographic scan and magnetic resonance imaging showed a right suprarenal mass, its continuity of liver was uncertain. Tumor vessels were visualized on selective right adrenal arteriography and right adrenal function and serum alpha-fetoprotein were normal. Preoperative diagnosis was non-functioning right adrenal tumor. On operation, the dissection between the tumor and the inferior part of liver was easy. Pathological diagnosis was hepatocellular carcinoma with sarcomatous change. Difficulty of preoperative diagnosis of pedunculated hepatoma is discussed.     

腹腔镜手术切除巨大肾上腺肿瘤的临床探讨

目的：探讨腹腔镜手术切除巨大（直径≥8cm）肾上腺肿瘤的可行性。方法：采用经腹途径腹腔镜切除术治疗巨大肾上腺肿瘤患者6例,左侧4例,右侧2例,肿瘤最大径8．5～12cm。结果：6例腹腔镜手术均获得成功,无中转开放手术。手术时间平均120min（90～185min）,术中出血量平均150ml（50～400m1）。术后胃肠功能恢复时间1～2天,术后2～3天拔除引流管,术后住院6～lO天。随访4～24个月,未发现异常。病理检查报告肾上腺嗜铬细胞瘤2例,神经节细胞瘤1例,神经鞘瘤1例,髓性脂肪瘤2例。结论：肿瘤大小并不是选择腹腔镜手术的决定性因素。在技术娴熟的条件下,腹腔镜治疗巨大肾上腺肿瘤是安全、可行的。