第Ⅷ肝段切除15例临床体会

目的 总结15例第Ⅷ肝段切除术的临床经验.方法 使用彭氏多功能手术解剖器(PMOD),采取选择性肝血流阻断,对15例第Ⅷ段肝癌进行肝段或联合肝段切除.结果 15例手术均顺利完成,无一例手术死亡.其中13例行第Ⅷ肝段切除,2例行联合第Ⅶ、第Ⅷ肝段切除.术中肝血流阻断1-2次,时间12～25 min,平均(17.3±5.2)min,切肝时间(阻断肝血流至肝脏肿块切除时间)10-23 min,平均(18.3±4.7)min.出血量约(50-700)ml,平均(186±78)ml,2例患者需输血.术后有2例合并胸腔积液,1例胆漏并发膈下感染.结论 使用PMOD在选择性肝血流阻断下,安全快捷地行第Ⅷ肝段的切除是完全可行的.     

区域性肝血流阻断在肝癌切除术中的应用与近期效果

目的:探讨区域性肝血流阻断在肝癌切除术中的应用价值。方法:回顾性分析69例肝癌切除术患者的临床资料,其中行区域性肝血流阻断肝癌切除38例,全肝入肝血流阻断（Pringle法）肝癌切除31例,比较两组患者的手术时间、术中出血量、术中输血率、术后并发症发生率、谷草转氨酶（AST）、引流量、排气时间、术后住院时间和标本切缘满意率。结果:与Pringle法肝癌切除组比较,区域性肝血流阻断肝癌切除组患者术中出血量、术后引流量、术后AST水平及并发症发生率均明显降低（均P<0.05）;标本切缘满意率显著提高（P<0.05）。而术中输血率、术后排气时间、术后住院时间比较,两组间差异无统计学差异（均P>0.05）。结论:用区域性肝血流阻断法行肝癌切除术,具有术中出血少,手术打击小,肿瘤切缘满意率高,术后渗出和并发症少等优点。     

选择性出入肝血流阻断在肝切除手术中的应用

目的进一步改进无血切肝技术,提高肝脏巨大肿瘤患者的切除率和手术耐受性。方法回顾分析16例肝脏巨大肿瘤切除术,讨论选择性出入肝血流阻断方式在肝切除中的应用。结果巨大肝脏肿瘤在肝切除手术中,应用选择性出入肝血流阻断术,术中出血少,患者耐受性好,提高了肝脏手术的切除率。结论应用选择性出入肝血流阻断术可以提高肝脏巨大肿瘤的切除率和手术耐受性,为肝脏手术提供了一个合理安全的术式。     

腹腔镜经肝门板半肝血流阻断在左半肝切除中的应用

目的 评估腹腔镜下经肝门板半肝血流阻断方法在左半肝切除中的安全性和可行性.方法 我院2010年9月至2011年4月采用腹腔镜下经肝门板半肝血流阻断方法行左半肝切除5例患者,分析其术中手术情况及术后并发症及肝功能情况.结果 5例患者均顺利完成手术,无中转开腹.术中出血量100~450 ml,平均(256.0±126.5)ml;手术时间180~255 min,平均(215.0±29.4)min;术后住院时间5~12 d,平均(7.2±2.8)d;术后出现胆漏1例,经腹腔引流后痊愈;无围手术期死亡.患者术后第1 d,ALT、AST及TBIL水平有所升高,ALB水平下降,差异有统计学意义(P<0.01);但术后第4 d,所有肝功能监测主要指标已恢复到术前水平,差异无统计学意义(P>0.05).结论 腹腔镜下经肝门板半肝血流阻断法在半肝切除中安全可行.     

TissueLink技术在肝脏手术中增强止血的作用

目的:采用TissueLink技术进行肝肿瘤切除术,通过提高对肝窦和肝内小血管的凝血和止血功能来提高肝手术的精确性和安全性.方法:采用TissueLink技术进行肝肿瘤切除术40例与传统钳折法进行肝切除术40例对比,观察肝门阻断情况、术中出血量、输血情况、手术时间、住院时间等,对手术的精确性、安全性进行评价.结果:采用TissueLink刀进行肝癌切除组术中仅6例短时间阻断肝门血流,其阻断时间为(8.25±1.78)min,平均失血量(160±80.22)ml,输血8例;而传统钳折法肝癌切除组35例阻断肝门血流,阻断时间为(15.18±3.46)min,平均失血量(500±96,23)ml,输血18例,两组各项对比差异显著(均P＜0.05).TissueLink刀组手术时间要较对照组长,分别为(65±37.77)min和(35±25.33)min,两组对比差异显著,P＜0.05.TissueLink刀组住院日19±3.74,对照组20±3.25,两组对比无显著差异,P＞0.05.结论:用TissueLink技术进行肝肿瘤切除可以在不阻断肝门或者减少阻断时间的情况下减少术中失血及术中输血,从而减少肝脏功能的损害,提高于术的精确性和安全性.     

常温下半肝血流阻断后肝叶切除术的临床应用

目的：通过对79例肝癌的回顾性分析研究，讨论选择性半肝血流阻断与全肝血流阻断肝切除术对患者术后肝功能的影响。方法：37例行选择性半肝血流阻断肝切除术、42例行全肝血流阻断肝切除术。术后对两组病例的各项肝功能指标进行比较。结果：79例无手术死亡。94．6％行选择性半肝血流阻断肝切除术的患者和40．4％行全肝血流阻断肝切除术的患者于术后两周肝功能恢复正常或术前水平。两者比较有统计学差异（P＜0．05）。结论：对肝癌伴肝硬变的患者行选择性半肝血流阻断肝切除术可以减轻肝血流阻断对肝功能的损害、术后肝功能恢复较快，是目前较为恰当的入肝血流阻断方法之一。     

半肝缺血预处理在肝硬化肝癌手术中的临床应用价值

目的 探讨半肝缺血预处理（HIP）对肝硬化肝癌患者肝切除的保护作用及临床价值.方法 将60例行开腹手术的肝癌患者按入肝血流阻断方式的不同分为两组,即HIP组（20例）和半肝血流阻断法（HHV）组（40例）,比较两组的临床效果.结果 HIP组术中出血量（自然对数）、术后输血病例数、术后输血量分别为5.7±0.7、3例和（333.3±115.5）ml,均明显少于HHV组的6.1±0.6、18例及（1 433.3±918.4）ml,差异均有统计学意义（t=2.25,P=0.028;x2=5.27,P=0.022;t=4.86,P＜0.001）.两组手术时间、术后住院时间、并发症及肠道通气时间差异均无统计学意义（均P＞0.05）.术后第1、3、5、7天凝血酶原时间活动度HIP组均高于HHV组（均P＜0.05）.HIP组术后一周内有7例丙氨酸氨基转移酶恢复正常,HHV组仅1例（P=0.001）.结论 半肝缺血预处理法可能提高肝硬化肝癌患者手术的安全性,并有助于术后肝功能及早恢复.     

精准肝中叶切除20例临床研究

摘 要：［目的］ 评价精准肝切除手术方式在肝中叶肝细胞癌切除术中的临床价值。［方法］ 回顾性分析辽宁省肿瘤医院2010年6月至2015年6月间施行的原发性肝细胞肝癌肝脏中叶切除的手术病例45例。精准肝切除组20例;Pringle法第一肝门阻断肝脏不规则切除25例。［结果］ 精准肝切除组对肝功能影响小,手术并发症少,术后并发症发生率为5%（1/20）,而对照组术后并发症发生率为36%（9/25）（P＜0.05）。两组1年复发率比较无统计学差异（P>0.05）。［结论］ 精准肝切除手术方式具有更好的手术可控性和手术安全性,对肝功损伤小,在肝脏中叶切除手术中值得推广。     

阻断与不阻断入肝血流切除肝癌

目的:探讨不阻断入肝血流肝切术手术的安全性及技巧,以及对残肝功能的影响和术后并发症的影响.方法:利用病例对照研究,比较阻断与不阻断入肝血流切除肝癌,观察术后并发症发生率、术中输血量等指标.结果:甲组(阻断入肝血流)n=59,乙组(不阻断入肝血流)n=42.甲组和乙组术中估计失血量分别为:892ml±843ml、914ml±894ml.甲组和乙组术后ALT恢复正常时间分别为:17±6天,12±4天,P＜0.05.甲组和乙组术后Tbil恢复正常时间分别为:18±7天,13±5天,P＜0.05.甲组和乙组术后并发症发生率分别为41.3%与12.5%,P＜0.05.结论:本组资料显示应用不阻断入肝血流切肝可行、安全.     

标准残肝体积联合肝纤维化测定在原发性肝癌切除术安全性评估中的价值

[目的]探讨标准残肝体积(SRLV)大小及肝纤维化程度与原发性肝癌切除术后发生肝功能代偿不全间的关系.[方法]对因肝癌行肝切除术的104例病例进行研究.残肝体积=全肝体积-切除肝脏体积;SRLV=残肝体积/体表面积;根据声脉冲辐射力成像(acoustic radiation force impulse,ARFI)评分将所有病例分为A组(中、重度肝纤维化组)和B组(正常或轻度肝纤维化组).通过受试者工作特征曲线(ROC)分析预防发生肝功能代偿不全的SRLV安全临界值.并将术后发生肝功能中度代偿不全患者的术前ARFI评分与术后SRLV进行直线回归分析.[结果]A组病例术后发生肝功能轻度代偿不全、中度代偿不全及重度代偿不全分别为53例、22例、4例.在A组病例中,肝功能中、重度代偿不全发生率为32.9％,(26/79),肝功能轻度代偿不全患者和中、重度代偿不全患者的SRLV[(605.69±1 18.98)ml/m2 vs (470.81±62.59)ml/m2]比较具有显著差异(P＜0.05).ROC曲线分析提示发生肝功能中、重度代偿不全的SRLV的临界值为503ml/m2.B组病例数少,不作统计学分析.将术后发生肝功能中度代偿不全患者的术前ARFI评分及术后SRLV进行直线回归分析,显示呈正相关(R=0.719,P＜0.01),其回归方程为:SRLV(ml/m2)=149.6×A RFI评分(m/s)+194.1.[结论]联合SRLV及肝纤维化程度测定对原发性肝癌术前安全切肝量评估有重要指导价值,对伴中、重度肝纤维化患者安全SRLV临界值为503ml/m2.     

Selective hepatic vascular exclusion and Pringle maneuver: A comparative study in liver resection

Objective

Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.

Methods

From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.

Results

There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.

Conclusion

SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.     

沿肝静脉主干入路的开腹解剖性肝脏切除术治疗原发性肝癌的疗效及安全性

目的:探讨沿肝静脉主干入路的开腹AR治疗原发性肝癌疗效及对患者围术期指标、术后并发症的影响。方法:回顾性分析2016年1月-2022年10月期间在我院就诊并接受开腹解剖性肝切除术的158例原发性肝癌患者临床资料,采用倾向性匹配按照1∶1比例对基线资料进行匹配,共获得52对基线资料差异无统计学意义的样本,其中行沿肝静脉主干入路开腹AR的患者为研究组,行常规入路开腹AR的患者为常规组。比较两组围术期情况及术前、术后7 d检测丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、总胆红素（TBIL）、白蛋白（ALB）、免疫球蛋白（Ig）A、IgG、IgM、CD4+T细胞、CD8+T细胞、白介素6（IL-6）、IL-10和肿瘤坏死因子α（TNF-α）水平以及术后相关并发症情况。结果:研究组术中出血量低于常规组,差异有统计学意义（P＜0.05）,两组手术时间、术中输血患者占比、肝门阻断时间及住院时间差异无统计学意义（P>0.05）。两组术后7 d血清ALT、AST和TBIL水平明显升高（P＜0.05）,血清ALB水平明显降低（P＜0.05）,且研究组血清ALT、AST和TBIL水平低于常规组,血清ALB水平高于常规组,差异有统计学意义（P＜0.05）;两组术后7 d外周血IgA、IgG、IgM和CD8+T细胞水平明显低于术前（P＜0.05）,CD4+T细胞水平明显高于术前（P＜0.05）,且研究组外周血IgG、CD8+T细胞水平高于常规组,CD4+T细胞水平低于常规组,差异有统计学意义（P＜0.05）;两组术后7 d血清IL-6、IL-10和TNF-α水平明显高于术前（P＜0.05）,且研究组血清IL-6、IL-10和TNF-α水平低于常规组,差异有统计学意义（P＜0.05）;两组术后并发症比较差异无统计学意义（P>0.05）。结论:沿肝静脉主干入路的开腹AR治疗原发性肝癌安全可行,可减少术中出血量,减轻肝功能、免疫功能损害和炎症反应,对促进患者康复具有积极作用。     

微波固化针在不规则肝脏切除治疗肝癌中的应用

目的:探讨微波固化针在不规则肝脏切除术中的应用价值.方法:回顾性分析我科2011年9月至2013年9月联合微波固化针所施行的68例不规则性肝切除患者的临床资料(微波固化+不规则性肝切除组,A组),与肝切除数据库中同样行不规则肝切除患者进行配对(单纯不规则切除组,B组),并对两组对比分析.结果:两组围手术期均无死亡病例.微波固化在不规则肝脏切除术中无需行肝门阻断,手术时间、出血量、补血量、术后住院时间明显少于单纯行不规则性肝切除术,术后并发症少,恢复快(P＜0.05).而术后肝功能恢复情况两组并无显著差异(P＞0.05).结论:微波固化针在不规则性肝切除术中的应用是安全有效的.在掌握传统方法阻断肝门切肝的基础上,使用微波固化针沿预切除线行微波固化带,可显著减少手术出血量,缩短肝门部阻断及总体时间,且患者术后康复较快.     

不同入肝血流阻断法在肝癌切除术中的应用

目的 探讨选择性Glisson鞘外阻断法和第一肝门阻断(Pringle)法在肝癌切除术中的价值.方法 回顾性分析2012年5月至2021年5月在河池市第三人民医院普通外科收治的93例原发性肝癌患者的临床资料,按照术中入肝血流阻断方式分组,对照组行Pringle法(n=46),观察组行选择性Glisson鞘外阻断法(n=...     

A prospective randomized controlled trial to compare two methods of selective hepatic vascular exclusion in partial hepatectomy

Background and aim

Selective hepatic vascular exclusion (SHVE) has not been widely used because of difficulty in extrahepatic isolation of hepatic veins. This study aims to compare the results of SHVE using tourniquets or Satinsky clamps on major hepatic veins in partial hepatectomy for liver tumors involving the roots of hepatic veins.

Methods

Between June 2008 and March 2012, a randomized controlled trial was performed on patients undergoing liver resection to compare selective hepatic vascular exclusion using tourniquets or Satinsky clamps in partial hepatectomy. In the tourniquet group, the hepatic veins were completely isolated and occluded with tourniquets. In the Satinsky clamp group, the hepatic veins were dissected on the anterior and side walls only and they were clamped directly by Satinsky clamps.

Results

The time for dissecting hepatic veins was significantly shorter in the Satinsky clamp group (7.5 ± 6.6 min vs 21.3 ± 7.4 min) than the tourniquet group. In the tourniquet group, 5 hepatic veins could not be completely isolated and encircled. In 4 additional patients the hepatic vein was slightly torn during dissection. These 9 patients received successful occlusion using Satinsky clamps. In the Satinsky group, all occlusion of the hepatic vein was successful. There was a significant difference in the success rate in hepatic vein occlusion using the Satinsky and the tourniquet groups 60/60 vs 51/60, P = 0.0018.

Conclusions

Both techniques of hepatic vein occlusion were safe and efficacious. As the use of Satinsky clamps is safer, easier and took less time, it is recommended.     

腹腔镜肝切除治疗肝脏恶性肿瘤的临床效果

目的：探讨腹腔镜肝切除治疗肝脏恶性肿瘤的临床效果。方法按照手术方式不同将98例肝脏恶性肿瘤患者分为实验组（腹腔镜手术）50例和对照组（开腹手术）48例,比较2组近期疗效。结果实验组患者术中出血量、术后进食时间及住院时间均明显低于对照组,差异有统计学意义（P＜0．05）;实验组患者术中输血率、术后使用杜冷丁率以及术后并发症发生率均明显低于对照组,差异有统计学意义（P＜0．05）。2组患者术后1 d WBC、ALT、AST水平均显著升高,与同组术前比较,差异有统计学意义（P＜0．05）;2组患者术后5 d WBC、ALT、AST水平均显著下降,与同组术后1 d比较,差异有统计学意义（P＜0．05）;实验组患者术后5 d WBC、ALT、AST水平均显著低于对照组,差异有统计学意义（P＜0．05）。结论腹腔镜肝切除治疗肝脏恶性肿瘤创伤小、术中出血量低、使用杜冷丁率低、术后恢复时间短、并发症少,近期疗效显著,可作为临床优选治疗方案。     

Improvements in hepatocellular carcinoma resection by intraoperative ultrasonography and intermittent hepatic inflow blood occlusion.

From September, 1989, to December, 1990 (late period), intraoperative ultrasonography (IOU) and intermittent hepatic inflow blood occlusion were introduced in hepatectomy. Compared with the early period from January, 1983, to August, 1989, the resectability of hepatocellular carcinoma (HCC) increased from 12.1 to 62.1% (P less than 0.0001). More resections on cirrhotic patients (P less than 0.05) and more combined resections with other organs (P less than 0.005) were carried out. Although the operation time was longer (P less than 0.01), less blood loss during surgery and fewer perioperative blood transfusions (P less than 0.001) were found during the late period. Since the rate at which classical resections were performed has reduced (P less than 0.001), postoperative morbidity has also decreased (P less than 0.05). Although the surgical mortality did not differ between the two periods, most deaths in the early period were caused by postoperative hepatic failure which was not found in the late period. Since IOU can clarify the intrahepatic vasculature and identify impalpable and invisible tumors, more precise resections can now be carried out. Intermittent hepatic inflow occlusion reduces blood loss during surgery without increasing risk. We suggest both techniques should be mandatory in hepatectomy for HCC in order for the safety range of resections to be broadened.     

控制性低中心静脉压联合肝血流阻断在肝癌切除术中的应用

目的:观察控制性低中心静脉压（controlled low central venous pressure,CLCVP ）联合肝血流阻断对肝切除术中出血及血流动力学变化的影响。方法:选取天津医科大学肿瘤医院2014年6 月至2014年12月60例肝叶/ 段切除术患者,随机分成肝血流阻断组（Ⅰ组）和肝血流阻断联合CLCVP 组（Ⅱ组）。 Ⅰ组在肝切除过程中只应用肝血流阻断技术,采用常规液体管理,维持中心静脉压（central venous pressure,CVP ）为6～12cmH2O;Ⅱ组在肝切除过程中联合应用肝血流阻断和CLCVP 技术。CLCVP 包括:限制液体输入和输注硝酸甘油,即从手术开始到肝实质分离完成时,液体输注速度控制在1～3 mL/（kg · h）左右,并以输注晶体液为主,必要时输注硝酸甘油,维持CVP ≤ 5 cmH2O;在肝切除后,快速输入乳酸钠林格氏液和羟乙基淀粉130/ 0.4 氯化钠注射液,恢复正常 CVP 。记录两组患者基本情况和手术信息,记录术前、气管插管后 5 min、肝切除开始、肝切除 20min、肝切除后 5 min、手术结束时的平均动脉压（mean arterial pressure ,MAP ）、心率（heartrate ,HR）、CVP 、脑电双频谱指数（bispectral index,BIS）等。结果:与Ⅰ组相比,Ⅱ组手术时间、出血量、输血量均明显减少（P < 0.05）,两组尿量无显著性差异（P > 0.05）。 两组患者术前各项指标比较无显著性差异（P > 0.05）。 术中不同时点,两组患者MAP 、HR也无显著性差异（P > 0.05）。 与Ⅰ组相比,Ⅱ组CVP 在肝切除开始及肝切除20min时显著下降（P < 0.05）,BIS值在肝切除开始、肝切除20min及肝切除后5 min显著降低（P < 0.05）。 结论:肝血流阻断联合应用CLCVP 技术能够有效降低肝切除术的术中出血量和减少输血。      

肝海绵状血管瘤二种手术方式的选用体会

Objective: To investigate the optimizing of operative techniques on cavernous hepatic hemangioma by compar-ing the effective of the two approaches (enucleation and hepatectomy). Methods: From May 1994 to September 2006, forty-three patients underwent the surgical removal of the cavernous hepatic hemangioma were analyzed retrospectively. Enucle-ation was used for 16 cases and hepatectomy for 27 cases. The relative clinical data and operative factors between the two operative techniques were compared. Results: Statistically significant differences in tumor size, location and intraoperative blood lose between the two groups were observed (P < 0.05 ). Although enucleation was associated with less intraoperative bleeding and transfusion requirement but no significant differences in postoperative liver functional parameter, complication and length of hospital stay were observed. Conclusion: With proper choice, enucleation and hepatectomy both are effective treatments for cavernous hepatic hemangiomas.