腹腔镜肝切除术治疗肝细胞癌的临床体会

目的总结腹腔镜肝切除术治疗肝细胞癌的临床体会。方法选取2008年12月-2015年12月南京医科大学附属淮安第一医院、南京大学附属鼓楼医院、徐州医科大学附属医院收治的肝细胞癌患者临床资料。根据手术方式不同分为腹腔镜肝切除术组(LH组,n=391)和开腹肝切除术组(OR组,n=682)。比较两组手术时间、切口大小、术中出血量、术后恢复情况、术后住院时间、手术费用、住院费用及并发症情况等。计量资料两组间比较采用独立样本t检验;计数资料两组间比较采用χ~2检验。结果LH组与OR组相比,术中出血量[(165.00±79.21)ml vs(457.00±125.00)ml]、切口长度[(4.07±0.31)cm vs(20.48±2.36)cm]、进食时间[(1.50±0.61)d vs(2.43±0.40)d]、术后下床时间[(1.36±0.31)d vs(4.12+0.82)d]、住院时间[(10.09±3.52)d vs(15.36±4.57)d]、手术费用[(9471.00±639.73)元vs(5329.12±461.40)元]及住院费用[(37 315.17±13 194.78)元vs(35 007.6±10 611.20)元]差异均有统计学意义(t值分别为41.64、136.80、30.10、63.98、19.70、122.44、3.13,P值均0.05)。LH组1、3、5年生存率分别为89.42%、64.32%、43.12%,OR组1、3、5年生存率分别为88.11%、61.45%、38.38%,两组生存率比较,差异无统计学意义(P0.05)。结论腹腔镜肝切除术具有创伤小、术中出血少、恢复快的优点,可缩短住院时间,未增加术后并发症,对于周围型和微小肝癌及左外叶肝肿瘤,建议作为首选治疗方法之一。     

腹腔镜肝切除术与开腹肝切除术治疗肝硬化肝细胞癌患者的效果比较

目的探讨肝硬化肝细胞癌患者行腹腔镜肝切除术与开腹肝切除术的临床疗效比较。方法收集2006年1月-2007年12月于临夏市人民医院确诊为肝硬化肝细胞癌的患者136例,分别行腹腔镜肝切除术(LLR组,64例)和开腹肝切除术(OLR组,72例),分析2组患者的近期疗效、病理因素及远期疗效。计量资料组间比较采用t检验,计数资料组间比较采用χ2检验,生存函数的比较采用log-rank进行检验。结果与OLR组患者相比,LLR组在手术时间[(86.43±23.55)min vs(62.31±19.61)min]、术后住院时间[(7.22±3.45)d vs(12.27±5.31)d]方面差异有统计学意义(t值分别为8.539、2.764,P值分别为0.001、0.024),而在患者术中出血量、肝门阻断时间、总病死率方面差异均无统计学意义(P值均0.05)。2组患者的肿瘤数目、有无肝硬化、有无微血管侵犯、有无肝包膜侵犯、切缘范围、最大肿瘤直径等差异亦无统计学意义(P值均0.05)。远期疗效方面LLR组患者1、3、5年无疾病生存率分别为83.30%、48.61%、38.29%,OLR组分别为78.64%、51.26%、43.01%;LLR组患者1、3、5年总生存率分别为97.42%、95.13%、89.23%,OLR组分别为96.41%、94.28%、90.06%,2组比较差异均无统计学意义(P值均0.05)。结论腹腔镜肝切除术治疗肝硬化肝细胞癌患者术后恢复快,且与开腹肝切除术相比远期疗效相当,适合在临床推广及应用。     

腹腔镜与开腹肝切除术治疗区域型肝胆管结石病的倾向性评分匹配研究

目的比较腹腔镜与开腹肝切除术治疗区域型肝胆管结石病的临床疗效。方法选取2010年1月-2017年6月咸阳市第一人民医院收治的87例肝胆管结石病患者,其中38例行腹腔镜肝切除术(腹腔镜组),49例行开腹肝切除术(开腹组)。利用倾向性评分匹配,均衡2组患者的混杂因素,比较匹配后的围手术期相关指标。计量资料2组间比较采用t检验,计数资料2组间比较采用χ~2检验或Fisher精确检验。结果共27对患者匹配成功。2组患者的肝切除类型、联合胆总管探查术、术中肝门阻断率、手术时间、术中输血率、术中结石清除率及术后结石清除率﹑术后总并发症及严重并发症发生率比较,差异均无统计学意义(P值均>0.05)。但腹腔镜组患者的手术出血量和住院时间均低于开腹组[(126.4±18.7)ml vs(143.2±24.1)ml;(11.7±2.3)d vs(13.4±1.9)d],差异均有统计学意义(t值分别为2.862、2.961,P值分别为0.006、0.004)。结论腹腔镜肝切除术治疗区域型肝胆管结石病效果与开腹手术相当,且具有术中出血量少、术后恢复快等优势。     

腹腔镜修补术治疗老年十二指肠溃疡合并穿孔的疗效分析

目的探讨腹腔镜与开腹修补术对老年十二指肠溃疡合并穿孔(DUP)患者的疗效。方法选取2014年3月至2017年3月秭归县中医医院普外科收治的老年DUP患者100例,依据治疗方法分为腹腔镜组和开腹组,每组50例。开腹组给予开腹修补术治疗,腹腔镜组给予腹腔镜修补术治疗,比较两组疗效、并发症和胃动素水平。采用SPSS 22.0软件进行数据处理。依据数据类型,组间比较分别采用t检验和χ2检验。结果腹腔镜组下床时间[(28.87±3.07)vs(38.02±4.22)h]、住院时间[(3.69±0.82)vs(5.75±1.03)d]、肛门排气时间[(15.08±1.63)vs(27.36±2.86)h]、肠鸣音恢复时间[(64.58±6.62)vs(81.46±8.36)h]、术中出血量[(52.45±5.27)vs(76.74±8.04)ml]、并发症发生率(10.00%vs28.00%)均显著低于开腹组(P0.05)。腹腔镜组术后1 d[(182.43±19.52)vs(233.59±25.47)ng/L]和2 d[(156.37±16.24)vs(180.42±20.18)ng/L]血清胃动素水平显著高于开腹组,差异有统计学意义(P0.05)。随访3个月,腹腔镜组愈合优良率(96.00%vs 80.00%)显著高于开腹组,差异有统计学意义(P0.05)。结论与开腹修补术比较,腹腔镜修补术可有效减少老年DUP患者手术创伤及并发症的发生,有利于患者术后胃肠功能的恢复,值得临床进一步推广。     

腹腔镜手术治疗胃大部切除术后胆总管结石的效果观察

目的探讨腹腔镜手术治疗胃大部切除术后胆总管结石的安全性和可行性。方法回顾性分析郑州大学附属洛阳中心医院2010年1月-2016年10月收治的46例行手术治疗的胃大部切除术后胆总管结石患者(均合并胆囊结石)的临床资料,其中25例行腹腔镜胆囊切除+胆总管探查术(腹腔镜组),21例行开腹胆囊切除+胆总管探查术(开腹组)。比较2组患者手术相关情况及术后并发症。2组间计量资料比较采用t检验,计数资料比较采用χ~2检验。结果 2组患者均无围手术期死亡病例,腹腔镜组2例(8.0%)中转开腹。腹腔镜组与开腹组相比,术后下床活动时间[(1.2±0.6)d vs(2.4±1.2)d)]、术后肛门排气时间[(1.8±0.5)d vs(2.8±0.8)d]及术后住院时间[(5.2±1.1)d vs(7.5±2.3)d]差异均有统计学意义(t值分别为4.395﹑5.168﹑4.439,P值均0.001)。2组患者的手术时间、手术出血量、住院费用、T管留置和结石残留率比较,差异均无统计学意义(P值均0.05)。腹腔镜组术后2例患者出现并发症,发生率为8.0%,开腹组术后3例患者出现并发症,发生率为14.3%,差异无统计学意义(P=0.495)。结论腹腔镜手术治疗胃大部切除术后胆总管结石是安全可行的,且较开腹手术而言,有明显的微创优势。     

腹腔镜下左肝外叶切除术治疗肝内胆管结石的临床效果

目的探讨腹腔镜下左肝外叶切除术治疗肝内胆管结石的手术方法、安全性及临床疗效。方法选取安徽医科大学附属安庆医院2015年1月-2016年12月收治的肝内胆管结石患者30例,按照手术方式不同分为常规组(n=15)和腹腔镜组(n=15),常规组采用开腹左肝外叶切除术治疗,腹腔镜组采用腹腔镜下微创左肝外叶切除术治疗,观察两组患者各项手术指标情况,比较两组患者术后并发症情况及术后肝功能指标情况。正态分布的计量资料组间比较采用t检验;非正态分布的计量资料组间比较采用Wilcoxon秩和检验。计数资料组间比较采用χ~2检验。结果腹腔镜组患者的肛门排气时间、术后住院时间较常规组明显缩短[(1.02±0.51)d vs(1.98±0.36)d,t=5.956,P0.001;(8.83±0.81)d vs(11.83±0.42)d,t=5.830,P0.001]。腹腔镜组患者术后第5天的ALT水平较常规组降低[(125.8±91.9)U/L vs(214.1±99.6)U/L],血清Alb水平较常规组升高[(33.2±3.7)g/L vs(28.9±4.3)g/L],差异均有统计学意义(t值分别为2.52、2.94,P值分别为0.02、0.01)。结论临床中应用腹腔镜下左肝外叶切除术治疗肝内胆管结石,相对常规开腹手术治疗,具有手术创伤小、患者术后恢复快、肝功能损伤小等特点,疗效显著,值得临床推广。     

腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术治疗结直肠癌肝转移

目的探讨腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术治疗结直肠癌肝转移(colorectal cancer liver metastases,CRLM)患者的临床疗效。方法选取2016年5月至2017年3月于普宁市人民医院诊治的105例CRLM患者,按随机数字表法分为对照组(50例)和观察组(55例),对照组行腹腔镜结直肠癌切除术联合肝转移灶切除术,观察组行腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术,采用独立样本t检验比较两组患者相关手术指标(手术时间、术后肛门首次排气、住院时间等),采用χ~2检验比较术后并发症(吻合口狭窄、吻合口出血、切口感染等)、术后复发率及生存率。结果观察组患者手术时间[(254.57±33.41)min vs(290.52±36.42)min;t=5.276,P 0.001]、术中出血量[(187.16±89.52)ml vs(383.63±88.34)ml;t=11.302,P 0.001]、术后肛门首次排气时间[(2.48±0.36)d vs(3.50±0.25)d;t=16.702,P 0.001]、住院时间[(13.25±4.60)d vs(18.73±4.10)d;t=6.419,P 0.001]、治疗费用[(37072±505)元vs(41059±504)元;t=40.442,P 0.001]及术后VAS评分[(4.02±0.26)分vs(7.25±0.63)分;t=34.906,P 0.001]均显著低于对照组。观察组和对照组患者观察组和对照组患者术后切口感染(1.82%vs 12.00%)、吻合口狭窄(1.82%vs 4.00%)、吻合口出血(1.82%vs 4.00%)、输尿管损伤(1.82%vs 4.00%)、吻合口瘘(0%vs 2.00%)、粘连性肠梗阻(1.82%vs 12.00%)、排尿困难(0%vs 2.00%)等并发症发生率差异无统计学意义(P均 0.05)。观察组和对照组患者术后3年局部复发率分别为12.73%(7/55)、20.00%(10/50),差异无统计学意义(χ~2=1.021,P=0.312)。观察组患者术后1年、2年和3年的生存率分别为90.91%(50/55)、85.45%(47/55)、81.82%(45/55),对照组分别为90.00%(45/50)、86.00%(43/50)、84.00%(42/50),差异均无统计学意义(χ~2值分别为0.025、0.006、0.088,P值分别为0.874、0.936、0.767)。观察组患者术后1年、2年和3年的无瘤生存率分别为76.36%(42/55)、72.73%(40/55)、45.45%(25/55),对照组分别为76.00%(38/50)、60.00%(30/50)、40.00%(20/50),差异均无统计学意义(χ~2值分别为0.002、0.062、0.318,P值分别为0.965、0.804、0.573)。结论腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术可显著减少CRLM患者术中出血量,加快术后康复时间,减少术后并发症,近期疗效和安全性良好。     

经脐单孔腹腔镜胆囊切除术与传统三孔法腹腔镜胆囊切除术的疗效比较

目的探讨经脐单孔腹腔镜胆囊切除术与传统三孔法腹腔镜胆囊切除术的效果。方法选取2015年1月-2016年12月延安市人民医院收治的胆囊结石和胆囊息肉患者62例,按住院单双号分为2组,三孔组(n=32)采用三孔法腹腔镜胆囊切除术,单孔组(n=30)采用单孔腹腔镜胆囊切除术。对比分析2组患者手术时间,术中出血量,腹壁美容度评分,术前和术后1、3 d的视觉模拟量表(VAS)评分,镇痛药使用情况,术前和术后24 h肝功能指标ALT、AST、ALP水平,住院费用及随访1个月并发症发生情况。计量资料组内比较采用配对t检验,2组间比较采用t检验,计数资料2组间比较采用χ~2检验。结果单孔组患者术后腹壁美容度评分高于三孔组[(4.89±0.10)分vs(3.15±0.34)分,t=4.910,P=0.039],术后住院时间短于三孔组[(2.58±0.53)d vs(4.35±0.24)d,t=-5.459,P=0.032],手术时间长于三孔组[(78.15±4.21)min vs(50.84±5.12)min,t=4.455,P=0.047],术后1、3 d的VAS评分低于三孔组[(4.72±0.58)分vs(6.37±0.45)分,t=-7.060,P0.001;(3.24±0.83)分vs(5.45±0.94)分,t=-4.644,P0.001],术后使用镇痛药的比例低于三孔组(20.0%vs 37.5%,χ~2=6.768,P=0.009)。2组患者术后24 h的ALT、AST、ALP水平均升高,且单孔组ALT、AST、ALP水平均低于三孔组(P值均0.001)。随访1个月,2组并发症发生率差异无统计学意义(P0.05)。结论单孔腹腔镜胆囊切除术手术创伤小,术后疤痕不明显,患者痛觉感受轻,对手术皮肤外观效果较满意,并且该手术方式不会增加并发症,对肝功能影响较小。但与三孔腹腔镜胆囊切除术相比,所需手术时间较长。     

加速康复外科策略在腹腔镜联合胆道镜行胆总管切开取石Ⅰ期缝合术围手术期的临床应用

目的探讨加速康复外科策略(EARS)在腹腔镜治疗胆总管结石行Ⅰ期缝合术围手术期的临床应用价值。方法选取2015年10月-2016年2月于成都市第二人民医院肝胆外科住院的胆囊结石合并胆总管结石患者64例,按其围手术期处理方式不同分为EARS组(n=32例)和对照组(n=32例),比较两组患者临床观察项目及并发症发生情况。计量资料组间比较采用t检验,计数资料组间比较采用χ2检验。结果 ERAS组患者较对照组引流管拔除时间、住院时间、术后停止输液的时间明显缩短[(1.6±0.9)d vs(2.7±1.0)d,(5.1±1.0)d vs(6.8±1.1)d,(3.8±1.0)d vs(4.9±1.2)d,t值分别为-5.675、-5.910、-3.923,P值均0.01],术后首次下床活动时间及肠道功能恢复时间提前[(1.0±0.3)d vs(1.6±0.7)d,(1.1±0.4)d vs(1.8±0.6)d,t值分别为-4.313、-4.842,P值均0.01],住院总费用降低[(17 433.5±1411.3)万元vs(26 651.6±2945.8)万元,t=-15.942,P0.001],且术后疼痛例数少于对照组[4(12.5%)vs 13(40.6%),χ2=6.490,P=0.011],术后ERAS组患者ALT和TBil明显低于对照组[(105.25±35.34)U/L vs(179.00±48.64)U/L,(50.78±12.60)μmol/L vs(79.70±18.56)μmol/L,t值分别为-5.973、-7.090,P值均0.05]。结论 EARS在腹腔镜手术中的围手术期治疗实用性高,能够促进患者快速康复,在肝胆胰外科的应用前景十分广阔。     

腹腔镜联合胆道镜胆总管探查一期缝合术治疗胆囊结石合并胆总管结石的临床效果分析

目的探讨腹腔镜联合胆道镜胆总管探查一期缝合术的安全性和有效性。方法回顾性分析2015年7月-2017年7月海南医学院第一附属医院肝胆胰外科收治的76例胆囊结石合并胆总管结石患者,分别行腹腔镜胆囊切除+胆道镜胆总管探查术+一期缝合(PDC组)(n=20)和腹腔镜胆囊切除+胆道镜胆总管探查术+T管引流(TTD组)(n=56),观察2组患者的手术时间、术中出血量、术后胃肠道功能恢复时间、腹腔引流管拔除时间、术后住院天数以及并发症(胆总管残余结石、胆瘘和胆道感染)发生率。术后随访2~12个月。计量资料2组间比较采用t检验,计数资料2组间比较采用χ~2检验。结果所有患者均成功实施腹腔镜手术,无1例中转开腹。PDC组和TTD组患者在手术时间[(106.2±15.8)min vs(147.5±23.2)min]、术后胃肠道功能恢复时间[(32.9±8.1)h vs(49.4±6.5)h]、腹腔引流管拔管时间[(3.5±1.3)d vs(5.7±2.6)d]、术后住院时间[(6.3±1.5)d vs(11.4±2.0)d]进行比较,差异均有统计学意义(t值分别为-2.87、-3.61、-2.64、-26.34,P值分别为0.036、0.021、0.034、<0.001)。2组患者术中出血、术后胆瘘、胆道残余结石和胆道感染方面差异均无统计学意义(P值均>0.05)。结论从有限病例进行初步研究发现,只要选择合适的病例,腹腔镜胆总管探查一期缝合术是安全有效的。     

Outcomes of central hepatectomy versus extended hepatectomy

BackgroundCentral hepatectomy (CH) is more difficult than extended hepatectomy (EH) and is associated with greater morbidity. In this modern era of liver management with aims to prevent post-hepatectomy liver failure (PHLF), there is a need to assess outcomes of CH as a parenchyma-sparing procedure for centrally located liver tumors.MethodsA total of 178 major liver resections performed by specialist surgeons from two Australian tertiary institutions between June 2009 and March 2017 were reviewed. Eleven patients had CH and 24 had EH over this study period. Indications and perioperative outcomes were compared between the groups.ResultsThe main indication for performing CH was colorectal liver metastases. There was no perioperative mortality in the CH group and four (16.7%) in the EH group (P = 0.285). No group differences were found in median operative time [CH vs. EH: 450 min (290–840) vs. 523 min (310–860), P = 0.328], intraoperative blood loss [850 mL (400–1500) vs. 650 mL (100–2000), P = 0.746] or patients requiring intraoperative blood transfusion [1 (9.1%) vs. 7 (30.4%), P = 0.227]. There was a trend towards fewer hepatectomy-specific complications in the CH group [3 (27.3%) vs. 13 (54.2%), P = 0.167], including PHLF (CH vs. EH: 0 vs. 29.2%, P = 0.072). Median length of stay was similar between groups [CH vs. EH: 9 days (5–23) vs. 12 days (4–85), P = 0.244].ConclusionsCH has equivalent postoperative outcomes to EH. There is a trend towards fewer hepatectomy-specific complications, including PHLF. In appropriate patients, CH may be considered as a safe parenchyma-sparing alternative to EH.     

Left hepatectomy

Left hepatectomy is one of the most common types of hepatectomy. In order to perform the procedure, surgeons need to possess all the basic skills for accomplishing any liver resection. The most important points to bear in mind in relation to left hepatectomy are: (1) a precise recognition of the surgical anatomy of the vascular structures of the liver, especially the bile duct, because of the wide anatomic variations; (2) recognition that the procedure consists of the following three parts: hilar dissection, mobilization of the left liver, and liver resection; (3) an understanding that these steps need to be accomplished with great care to control bleeding and to avoid injury to the vessels supplying the right hemiliver.     

Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy

AIM:To assess clinical outcomes of laparoscopic hepatectomy(LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.METHODS:This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery.Of the 80 patients who underwent LH,22 had prior abdominal surgeries,including hepatectomy(n = 12),pancreatectomy(n = 3),cholecystectomy and common bile duct excision(n = 1),splenectomy(n = 1),total gastrectomy(n = 1),colectomy with the involvement of transverse colon(n = 3),and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen(n = 1).Clinical indicators including operating time,blood loss,hospital stay,and morbidity were compared among the groups.RESULTS:Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver.However,there were no conversions to laparotomy in this group.In the 58 patients without a history of upper abdominal surgery,the median operative time was 301 min and blood loss was 150 m L.In patients with upper abdominal surgical history or repeat hepatectomy,the operative times were 351 and 301 min,and blood loss was 100 and 50 m L,respectively.The median postoperative stay was 17,13 and 12 d for patients with no history of upper abdominal surgery,patients with a history,and patients with repeat hepatectomy,respectively.There were five cases with complications in the group with no surgical history,compared to only one case in the group with a prior history.There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history,or with repeat hepatectomy.CONCLUSION:LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.     

Hanging maneuver in left hepatectomy

The liver hanging maneuver in right hepatectomy introduced by Belghiti in 2001, is a safe and effective method for right hepatectomy in cases of large hepatoma and living donor liver transplantation. In this article, we first introduce the hanging maneuver in extended left hepatectomy (left hepatectomy including middle hepatic vein). Extended left hepatectomy is a more difficult procedure than right hepatectomy because in the deeper part of the transection, the plane sharply turns to the left above the caudate lobe. Using the hanging maneuver, the horizontal transection plane becomes vertical, and the extended left hepatectomy can be performed easier and safer. This technique can be applied effectively in all kinds of left-sided hepatectomies.     

Bloodless hepatectomy technique

BackgroundSurgical resection remains the gold standard in dealing with liver tumours. Blood loss, biliary leak and postoperative liver function are still the main concerns of surgeons operating on the liver, even though different techniques have been developed to allow safer liver resection. A novel concept for liver resection is described using a radiofrequency energy (RF) assisted technique.MethodA patient with a large colorectal liver metastasis located in segments VI, VII, VIII underwent a right hepatectomy using this technique. At laparotomy the tumour was staged with intraoperative ultrasonography, and a ‘cooled tipped’ radiofrequency probe was used to achieve a ‘zone of desiccation’ in the liver parenchyma 2 cm away from the edge of the tumour. Liver parenchyma was subsequently divided with a surgical scalpel.ResultsThe resection time was 80 min with a blood loss of 30 ml. The patient was discharged on the ninth postoperative day without complications.DiscussionLiver resection assisted by RF energy is feasible and safe. This technique could offer a new method for ‘transfusion-free’ resection without the need for sutures, ties, staples, tissue glue or admission to the intensive care unit.     

腹腔镜肝切除术与开腹肝切除术治疗肝内胆管细胞癌患者短期临床疗效研究

目的 研究腹腔镜肝切除术(LH)与开腹肝切除术(OH)治疗肝内胆管细胞癌(ICC)患者的短期临床疗效。方法 2018年2月～2021年2月我院诊治的122例ICC患者,被随机分为对照组61例和观察组61例,分别接受OH或LH治疗,随访观察半年。采用ELISA法检测血清C反应蛋白(CRP)、皮质醇(Cor)和白细胞介素-6(IL-6)。结果 LH组手术时长、术中失血量、肛门首次排气和术后住院日分别为(232.2±50.4)min、(592.3±164.7)ml、(2.1±0.8)d和(6.5±1.3)d,显著短于或少于0H组【分别为(321.1±69.7)min、(995.5±321.4)ml、(2.7±0.7)d和(8.2±1.7)d,P<0.0 5】;在术后3 d时,LH组血清CRP、Cor和IL-6水平分别为(25.1±4.0)mg/L、(529.6±75.4)mmol/L和(83.5±7.2)pg/ml,均显著低于0H组【分别为(39.8±5.1)mg/L、(654.7±78.1)mmol/L和(97.3±10.2)pg/ml,P<0.05】;在术后7 d时,LH组血...