瘤体剥除术在紧邻重要血管肝脏海绵状血管瘤中的应用

目的探讨紧邻重要血管的肝脏海绵状血管瘤的安全手术方式并评价其临床应用价值。方法对72例紧邻重要血管的肝脏海绵状血管瘤患者实施剥除术,第一肝门、肝下下腔静脉预置阻断带,剥除过程中遇到不易控制的出血时,行Pringle法加肝下下腔静脉阻断。结果全部肝海绵状血管瘤均被成功剥除,无手术死亡,术中失血(443±128)ml,成功完成肝右静脉破口修补4例,肝中静脉破口修补2例,术后发生右侧胸腔反应性积液和腹腔局限性积液共9例,肝断面胆瘘1例,均经对症治疗后痊愈。结论瘤体剥除术是治疗紧邻重要血管肝脏海绵状血管瘤安全有效的方法,第一肝门、肝下下腔静脉预置阻断带有利于此手术的安全实施。     

第Ⅷ肝段巨大型海绵状血管瘤的手术方法

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Ⅷ肝段切除术相比，既简便又安全，值得推广。     

肝静脉阻断技术在肝切除术中的应用

目的 探讨肝静脉阻断技术在复杂肝脏肿瘤切除术中防止肝静脉破裂大出血及空气栓塞的作用。方法 对71例肝脏肿瘤手术切除病例施行了1根以上主肝静脉阻断。所有肿瘤均位于第二肝门并侵犯或压迫1根以上主肝静脉。肝静脉阻断方法采用绕线结扎、血管带阻断或血管夹及心耳钳夹闭法。结果 71例中无1例肝静脉分离破裂，行肝静脉结扎28例，血管带阻断26例，血管夹阻断17例；阻断右肝静脉34例，右肝静脉＋中肝静脉2例，左、中肝静脉共干24例，左、中肝静脉分干2例，左、中、右三干9例。施行半肝全血流阻断35例（右侧24例，左侧11例）。交替半肝全肝血流阻断4例，第一肝门阻断加部分肝静脉阻断23例。第一肝门阻断加全部肝静脉阻断（不阻断下腔静脉的全肝血流阻断）9例。71例肝肿瘤均顺利切除。结论 肝静脉阻断技术是一种安全、有效的血流阻断技术。不阻断下腔静脉的全肝血流阻断术既能控制术中出血，又能保证全身血流动力学稳定。     

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。     

肝门部海绵状血管瘤18例的外科治疗体会

目的 总结肝门海绵状血管瘤的手术经验。方法 采用改良式全肝血流阻断下包膜外剥离法切除肝门部海绵状血管瘤１８例。其中行下腔静脉和肝右静脉损伤修复,行肝中静脉损伤修复各１例。结果 全组１８例术中平均每位患者输血６６２．５ｍｌ,均痊愈出院,其中下腔静脉及肝静脉损伤修复患者术后两周彩色Ｂ超显示下腔静脉和肝静脉血流通畅。结论 改良式全肝血流阻断下包膜外剥离法是切除肝门部海绵状血管瘤的安全方法。     

解剖第三肝门切除巨大肝脏海绵状血管瘤

目的 为切除紧贴腔静脉的肝脏巨大海绵状血管瘤寻找一种新的安全的手术途径。方法 在患侧肝动脉结扎后,于第三肝门部位逐一分离、结扎、切断肝短静脉,使瘤体与腔静脉分离,在肝门阻断下切除瘤体。结果 全组２７例,行肝右叶及尾叶切除１３例,右半肝切除２例,右肝上段切除３例,右后叶切除２例,左三叶及尾状叶切除５例,尾状叶切除２例。绵未行全肝血流阻断。术中输血平均１１５０ｍｌ,术后随访３￣４８个月,全部情况良好。     

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…     

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。     

间歇性肝门阻断下肝腔静脉结合部肝肿瘤的手术切除及疗效观察

目的 探讨肝腔静脉结合部肝肿瘤手术切除的方法和疗效。方法 在间歇性肝门阻断下行肝切除术，部分病例预置肝下下腔静脉（IVC）阻断带；切肝先易后难，最后处理肝静脉根部；全组68例患者术后随访观察患者生存期。结果 68例肝腔静脉结合部肝肿瘤均在间歇性肝门阻断下得到成功切除，全组无手术死亡，术中因皆得到妥善处理；切除的68例肝肿瘤中65例为原发性肝癌，术后1、2、3和4年生存率分别为64.11％、52.82%、44.90%和36.98%，其中肿瘤有包膜者术后生态率显著高于无包膜者。结论 肝腔静脉结合部肝肿瘤可在简单的间歇性地门阻断下获得安全切除，不必常规作复杂的全肝血流阻断；对该部位边界清楚的原发性肝癌应积极争取手术切除。     

体外肝切除联合自体肝移植治疗肝泡型包虫病

Ex-vivo liver resection and liver autotransplantation offers a chance to cure extensive regional liver diseases which are otherwise deemed untreatable in selected cases. A 33-year-old male patient with advanced alveolar echinococcosis (AE) which invaded the right lobes and adjacent retrohepatic inferior vena cava, while the left lobes were free from lesion and had proliferated to over 1200 ml in size except for a 1 cm × 1 cm solid lesion in the segment Ⅳ. No extrahepatic metastases were found in this patient. A lesion with a size of 4300 ml and other small lesions in the right lobes were removed extracorporeally,and the retrohepatic vena cava was repaired, then the remaining AE-free left lobes (more than 700 ml in size) and the retrohepatic inferior vena cava were re-implanted in situ. A temporary end-to-end cavo-caval shunt with interposition of a blood vessel prosthesis and end-to-side portocaval shunt were established to keep the blood flow during the four-hour anhepatic phase. The patient was followed up for six months, and he had no signs of residual liver disease with good hepatic function.     

选择性患侧肝血流阻断下的肝切除术

目的 探讨选择性阻断或结扎患侧肝动脉、门静脉干、及患侧肝静脉并在肝后隧道置阻断带联合阻断进行肝切除术的效果.方法 自2007年3月至2008年2月,对14例肝肿瘤患者采取预先将患侧肝动脉、门静脉和肝静脉阻断或结扎并在肝后下腔静脉隧道置阻断带联合阻断下完成肝切除术.结果 全组14例患者在分离肝右静脉过程发生小破裂口2例,缝合后出血停止.本组患者无下腔静脉或肝短静脉意外损伤.在切肝过程中出血最少100 ml,最多600 ml,平均出血量280ml.并发少最胸腔积液4例,1例通过胸穿抽液治愈,其余3例自行吸收.无肝功能严重损害、胆瘘和腹腔感染以及其他并发症.结论 预先进行患侧肝动脉、门静脉干、及肝静脉阻断或结扎方法 以及利用肝后隧道放置阻断带联合阻断下进行肝切除术可以减少术中出血、及对侧肝再灌注损伤.     

肝血流阻断方法对肝切除术中大出血的影响

目的 分析不同肝血流阻断方法对肝切除术中大出血的影响.方法 回顾性分析1995年1月至2009年8月收治的接受肝切除术的2238例患者的临床资料,分析其中大出血(出血量≥1000 ml)的原因、不同肝血流阻断方法切肝时术中的出血量及大出血的发生率.结果 全组共有215例(9.6%)发生大出血,主要原因依次为门静脉主干取癌栓出血(26.0%)、肿瘤周围广泛粘连出血(24.7%)、肝断面出血(23.7%)、肝血管损伤出血(15.8%)及肿瘤破裂出血(9.8%);无门静脉主干取癌栓的2182例肝切除中,159例(7.3%)发生大出血,1257例(57.6%)出血量≤400 ml.不同肝血流阻断方法下肝切除术中出血量及大出血发生率不同.结论 Pringle联合肝下下腔静脉阻断法和经肝裸区隧道肝脏双悬吊法能更有效减少肝切除术特别是巨大肝肿瘤切除的出血量和大出血发生率.遵循"安全、有效、简便"的原则可根据肝肿瘤大小及位置、肝硬化程度及肝功能代偿情况、术者经验和条件采用不同的切肝方法,能有效减少术中出血量.     

Management of Retrohepatic Inferior Vena Cava Injury during Hepatectomy for Neoplasms

The aim of this article is to discuss the management of retrohepatic inferior vena cava injury during hepatectomy for neoplasms. Step-by-step hepatic vascular exclusion, digital compression, finger pinching, and surface-to-surface suturing were used in the management of retrohepatic inferior vena cava injury during hepatic resection in 16 cases: 12 patients underwent exclusion of the hepatic artery and portal vein by portal triad clamping (PTC) only; 3 underwent PTC and exclusion of the infrahepatic inferior vena cava (IVC); and 1 underwent PTC together with exclusion of the suprahepatic and infrahepatic IVC. In all cases, bleeding stopped immediately after the management described, with no intraoperative deaths and no postoperative bleeding. The median follow-up was 42.5 months (range 19–60 months) for all patients, and the 5-year survival rate of all patients with malignant tumors was 28.57%. One died of lung metastasis 19 months after operation, one with spontaneous rupture of a hepatocellular carcinoma 19 months after operation, and eight others from recurrence or metastasis 21, 23, 24, 27, 30, 35, 50, or 54 months after operation, respectively. Two patients had a recurrence 4 years and 4 years 6 months after the initial operation, respectively. The recurrent tumors of the liver were resected. The other patients are currently alive without recurrence or metastasis. The techniques described are safe, simple, practical, time-saving, and effective for controlling massive bleeding arising from injury to the retrohepatic inferior vena cava during hepatic resection.     

Distribution of hepatic venous blood in the total cavo-pulmonary connection: an in vitro study

Objectives: The objective of this project was to quantify the effects of geometry on the distribution of hepatic blood to the lungs in patients with a total cavo-pulmonary connection. The basis for this work is the supposition that hepatic blood is necessary for proper lung function. Methods: Plastic models of these connections were made with varying degrees of offset between the inferior and superior vena cava and attached to an in vitro flow loop. Dye was injected into the inferior vena cava and its concentration quantified in each pulmonary artery. These data were converted to percentage concentration and distribution of hepatic blood to each lung. Results: With no offset between the vena cava, hepatic blood distribution and concentration to each lung was similar to normal. For an offset of one or more diameters, hepatic blood tended to flow preferentially towards the nearest pulmonary artery with the opposite pulmonary artery exhibiting a deficit (<10% of normal). Conclusions: Distribution of hepatic blood to each lung was found to be a function of vena cava offset and pulmonary artery flow split. Under normal conditions, 60% of blood towards the right pulmonary artery, the hepatic blood distribution to both lungs could be maintained above 50% of normal if the inferior vena cava was offset towards the left pulmonary artery. Offsetting the inferior vena cava towards the right pulmonary artery jeopardized the delivery of hepatic blood to one lung.     

Balloon Venoplasty for Liver Failure Due to Stenosis of the Left Hepatic Vein After Right Tri-Segmentectomy

A 41-year-old male patient with hepatitis B underwent right tri-segmentectomy and total caudate lobectomy for a huge hepatocellular carcinoma associated with complete occlusion of the inferior vena cava with thrombosis of the infrahepatic inferior vena cava due to tumor compression. Five months later, he was readmitted for ascites and hyperbilirubinemia. Venography revealed stenosis and tortuosity of the left hepatic vein and the inferior vena cava, for which balloon angioplasty of the left hepatic vein and the inferior vena cava was performed using an 8-mm and 10-mm balloon, respectively. The left hepatic venous pressure decreased from 65 mmHg to 25 mmHg after dilatation. The patient made a satisfactory recovery thereafter and remains well with normal liver functions and without ascites. Balloon angioplasty may be useful for liver failure due to hepatic vein stenosis after hepatic resection.     

腹腔镜泌尿外科手术中下腔静脉损伤的处理及探讨(附4例报告)

目的:探讨腹腔镜泌尿外科手术中下腔静脉损伤的处理方法及预防措施.方法:回顾分析4例腹腔镜术中下腔静脉损伤患者的临床资料,其中3例用超声刀分离时损伤下腔静脉,1例为分离钳游离时撕破下腔静脉.损伤发生后,立即采取吸净积血、纱布压迫、增加操作通道等措施,用5-0血管缝线连续缝合破口.结果:4例下腔静脉损伤患者均于镜下修补成功...     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.     

彩色多普勒超声在布加综合征诊断中的应用

目的探讨彩色多普勒超声对布加综合征的诊断价值。方法应用彩色多普勒超声,分析34例布加综合征二维超声及血流声像图特点。结果 34例布加综合征中,直接征象显示下腔静脉膈膜型狭窄7例(20.6%),肝静脉或下腔静脉隧道型狭窄或闭塞18例(52.9%),下腔静脉内血栓或肿瘤4例(11.8%),外压型布加综合征5例(14.7%),均在超声下得到很好的显示;而间接征象主要表现为肝硬化和肝静脉间交通支,发生率分别为76.5%(26例)和91.2%(31例)。结论彩色多普勒超声能够明确显示布加综合征受累血管病变部位、范围、类型,可为临床诊疗提供可靠的诊断信息。而间接征象的出现可为诊断提供辅助证据。