介绍一种简易的区域无血肝切除技术——特制直型肝针区域无血肝切除术

利用特制的直型肝针对13例患者采用肝脏预切区域外的交锁缝扎方法行肝切除，包括肝段或联合肝段切除8例。左或右半肝切除3例，中肝叶切除2例，择期性手术10例，急诊手术3例（2例肝癌破裂腹腔大出血患者急诊手术）。手术出血少，平均241mL，无需输血，急诊手术也相当方便，无需阻断入肝血流，术后均恢复良好。提示该方法为一种简易，快捷的区域无血肝切除方法，容易掌握，费用低廉，患者术后恢复快，值得临床推广应用。     

超声引导下以肝段为本的解剖性肝切除术

目的 探讨超声引导下解剖性肝段或肝叶切除的结果。方法 我们从2001年12月至2004年12月，采用超声引导下以肝段为本的规则性肝切除技术完成120例次的肝段或肝叶切除。结果 120例病人中，1例死于术后肝功能衰竭（死亡率0．9％），术中出血量50～1400ml（平均300m1），25％（30／120）病人需要输血，输血量为200～800ml（平均350ml），术中阻断肝门时间15～30min（平均20min），恶性肿瘤病人切缘全部呈阴性，术后并发症包括：胆漏3例，膈下积液3例。结论 超声引导下以肝段为本的解剖性肝切除术具有操作简单，阻断肝门时间短，术中出血少，术后残肝发生缺血机会少，并发症低以及更加符合肿瘤根治的原则等优点，值得在肝脏外科推广应用。     

肝段血流阻断技术在肝癌患者精准肝段切除中的应用

目的 探讨肝段血管阻断技术在精准肝段切除术中的应用. 方法 回顾性分析在我院行精准肝段切除的67例肝癌患者的临床资料,其中男51例,女16例,年龄45～ 66岁.均经病理学证实为原发性肝细胞肝癌.结果 67例患者均为单发肿瘤,手术均获得成功.肿瘤直径2～6 cm,行肝Ⅲ段切除病例22例,肝Ⅳ段切除病例10例,肝Ⅵ段切除病例35例.手术时间50～120 min,平均时间73 min;术中出血量50 ～ 200 ml,平均出血量86 ml,患者术中术后均未输血;术后出现切口液化6例,经换药后痊愈,患者术后均未发生胆漏、出血、腹腔感染及肝脏衰竭等并发症;术后住院时间6～11d,平均时间7.8d.术后随访3个月,无肿瘤复发患者.结论 肝段血流阻断技术在肝癌患者精准肝段切除中的应用是安全可行的,可有效控制术中出血,减轻了肝脏损伤,可以减少术后并发症的发生,缩短住院时间.     

合理阻断肝脏血流切除累及肝门区肿瘤

目的探讨肝脏血流阻断技术在累及肝门区肿瘤切除中的合理应用。方法对采用第一肝门阻断法（Pringle法）和常温下全肝血流阻断法（THVE）相结合切除14例累及肝门区肿瘤的临床资料进行回顾性分析,统计肿瘤和肝门区血管的毗邻关系、阻断次数、阻断时间、术中出血量、输血量、术后并发症等指标。结果本组Pringle法平均阻断（4.2±2.0）次,第一肝门平均阻断时间（49.6±30.8）min;THVE平均阻断（1.8±0.4）次,平均阻断时间（18.8±7.4）min;术中出血量平均（1100±360）ml,输血量平均（800±220）ml;术中修补下腔静脉4次,主肝静脉2次,门静脉主干2次;术后检测ALT、胆红素有不同程度升高,经治疗2～3周后恢复正常,未发生肝功能衰竭、肝肾综合征等严重并发症。结论Pringle法与THVE法分步结合使用可增加肝门区肿瘤切除的安全性。     

区域肝蒂阻断技术在肝脏精准切除术中的运用

目的 探讨精准肝脏切除术中运用区域肝蒂阻断技术的临床价值。方法 回顾性分析2014年1月至2017年5月苏州大学附属第一医院58例采用肝蒂横断式技术行肝脏切除术的患者资料。其中解剖性肝段切除46例,占全部手术的79%（46/58）,非解剖性肝切除12例;包括左外叶切除（II+III段）11例,左半肝切除（II+III+IV段）4例,右前叶切除（V+VIII段）1例,右后叶切除（VI+VII段）10例,右半肝切除（V+VI+VII+VIII段）14例,中肝切除（IV+V+VIII段）6例,局部切除12例。结果 全组均顺利完成手术,平均手术时间240（80～430）min,平均失血量420（50～800）mL,术后并发胆瘘2例,腹腔出血1例,均保守治疗后好转。结论 区域肝蒂血流阻断技术能最大限度地减少肝脏热缺血再灌注损伤,保护残余肝功能,有利于术后患者肝脏功能的恢复,具有良好的临床应用前景。     

肝提带配合半肝血流阻断在肝切除术中的应用

目的探讨肝提带配合半肝血流阻断在肝切除手术中的价值。方法回顾64例肝癌肝切除术患者的临床资料,比较行肝提带配合半肝血流阻断（实验组n=24）和半肝血流阻断法（对照组,n=40）在肝切除手术中的应用价值。结果对照组平均手术时间（205.1±55.4）min,实验组平均手术时间（214.3±54.6）min,两者之间无显著性差异（P〉0.05）;对照组平均失血总量（497.3±63.0）ml,无需输血治疗;实验组平均失血总量（203.0±39.4）ml,无需输血治疗;两者之间存在统计学差异（P〈0.05）;术后第1、3 d实验组ALT浓度低于对照组,分别为（232.2±109.2）U/L vs.（434.8±215.7）U/L和（124.8±67.8）U/L vs.（241.6±132.6）U/L（P〈0.05）,术后第1 d实验组TBIL低于对照组分别为（45.2±17.8）μmol/L vs.（55.7±34.1）μmol/L（P〈0.05）。结论肝提带配合半肝血流阻断在肝切除术中是安全可行的,能显著减少术中出血,缩短手术时间,有利于降低手术风险和术后恢复。     

术中介入肝段血管球囊阻断法精准肝切除的临床应用

目的 探讨术中介入肝段血管球囊阻断实现精确肝段动脉、门静脉阻断,实施精准肝段或亚肝段切除的可行性.方法 回顾性分析2011年3月至2011年8月我院肝胆外科施行的6例术中介入肝段血管球囊阻断法精准肝切除术资料,对术中手术时间、出血情况、术中输血、肿瘤情况、术后肝功能情况及术后并发症进行回顾性分析.结果 平均手术时间(270.83±21.31)min,术中失血量中位数800 ml,输血量中位数450 ml,病灶大多位于Ⅴ、Ⅵ、Ⅶ、Ⅷ段,平均病灶直径(5.67±1.03) cm.术后第一天平均丙氨酸转氨酶(570.00±157.76)U/L,平均天冬氨酸转氨酶(410.00±189.94) U/L,平均总胆红素(10.83±1.60)mmol/L,7d内恢复至正常.术后1例发生肠漏、切口裂开,2例发生胸腔积液,其余患者未发生术后并发症,顺利康复出院.结论 肝段血管球囊阻断法是安全有效的控制肝段动脉、门静脉血流的方式,可以达到更加精确的病灶肝段或亚肝段切除以及减少出血、保护剩余肝功能的效果.     

肝癌解剖性肝切除的初步经验

目的总结行解剖性肝切除的经验及结果。方法2004年1月至2005年6月期间,我们对93例肝细胞癌患者进行解剖性肝切除,对相应外科技术进行改进以减少术中出血、输血及术后并发症。切肝采用血管钳钳夹肝组织,暴露肝内管道后再结扎,选择性阻断出、入肝血流;对13例巨大肿瘤行半肝切除时采用肝脏悬吊法,切肝时采用间断Pringle法阻断肝门。结果93例肝癌患者中82例(88%)伴有不同程度的肝硬变,平均出血量300ml(100~6000ml),71%(66/93)病例不需输血。术后并发症发生率为34%(32/93),膈下积液多发,共8例。术后30d内无手术死亡。结论解剖性肝切除可能提高手术疗效。     

选择性/超选择出入肝血管阻断后解剖性肝切除

目的探讨选择性/超选择性阻断出入肝血管后解剖性肝切除对肝脏疾病患者手术中失血量、术后肝功能、并发症、住院时间等相关因素的影响。方法选择/超选择出入肝血管阻断后解剖性肝切除66例,其中肝段切除22例、右半肝切除12例,左半肝切除6例,Ⅱ Ⅲ段肝切除19例,Ⅵ Ⅶ段肝切除5例,Ⅴ Ⅷ段肝切除2例。观察其对术中失血量、输血量、术后肝功能、术后并发症、术后住院时间等的影响。结果本组切除术中出血量(437±123)m l,所有病例手术中均未输血;术后患者肝功能损伤程度较轻,54例术后1周恢复至术前水平;无肝功能衰竭等相关并发症;术后平均住院时间13.1 d,无围手术期死亡。结论对于适应症明确的肝脏疾病,通过选择性或超选择性出入肝血流阻断后行肝脏解剖性切除可有效减少术中出血、降低术后相关并发症的发生。     

完全腹腔镜肝切除时出血问题的探讨

目的　探讨腹腔镜肝切除手术的出血原因和预防措施。　方法　 2 1例中包括原发性肝癌 13例、肝血管瘤 3例、肝脓肿 2例、肝囊肿伴感染、局灶结节性增生、肝脏腺瘤各 1例。肝功能Child分级 :A级 16例 ,B级 5例 (均为肝癌病人 )。　结果　 2 1例在全气腹条件下完成腹腔镜肝切除手术 ,包括肝局部切除 12例 ,左肝解剖性切除 9例。手术时间 80～ 32 0 (平均 193 8± 78 3)min ,出血量 10 0～ 10 0 0ml (平均 333 1± 2 91 4 )ml,有 2例出血 10 0 0ml,术中输血各 80 0ml。术后恢复顺利 ,术后平均住院时间 6 3± 1 5d ,术后恢复时间较常规开腹方法肝切除患者明显缩短。　结论　本组研究表明在现有的手术器械条件和不阻断肝门血流的情况下 ,可以安全方便地处理术中出血。腹腔镜肝切除微创手术的前景广阔 ,不仅适于对肝良性肿瘤的手术 ,也为肝脏恶性肿瘤患者提供了切除肿瘤的新途径     

Remnant liver injury after hepatectomy with the pringle maneuver and its inhibition by an iNOS inhibitor (ONO-1714) in a pig model

BACKGROUND: Although hepatectomy is often performed with the Pringle maneuver, the problem of remnant liver injury is not fully solved. We examined the remnant liver injury of hepatectomy under the Pringle maneuver and its relation to inducible nitric oxide synthase (iNOS) in a pig hepatectomy model. MATERIALS AND METHODS: Pigs were subjected to a total of eight Pringle maneuvers followed by re-perfusion. The pigs were divided into the following three groups: Control group; only Pringle maneuver, liver resection (LR) group; hepatectomy under the Pringle maneuver, and ONO group; and hepatectomy under the Pringle maneuver with an iNOS inhibitor (ONO-1714). We investigated the changes in serum aminotransferase (AST), lactate dehydrogenase (LDH), NO(2)(-)+NO(3)(-) (NOx), the hepatic tissue blood flow (HTBF), the cellular distribution of endothelial and inducible nitric oxide synthase, nitrotyrosine, infiltration of neutrophils, and thrombocyte-thrombi by immunohistochemistry. RESULTS: The serum AST, LDH, NOx levels in the LR group were significantly higher than those in the Control group. The formation of iNOS, nitrotyrosine, thrombocyte-thrombi, and infiltration of neutrophils were recognized in the LR group. These findings were inhibited in the ONO group. CONCLUSIONS: These results indicate that remnant liver injury appeared after hepatectomy with the Pringle maneuver. iNOS was involved in these injuries and the iNOS inhibitor attenuated the injury.     

射频止血系统在肝切除术中的应用(附65例报告)

目的介绍一种新的射频止血系统在肝切除术中的应用情况并评估其安全性及有效性。方法 2015年6月至2016年6月间11例病人单独使用射频止血系统行肝切除术,54例病例采用射频止血系统与其他肝切除设备[超声刀、双极电凝钳和超声吸引刀(cavitron ultrasonic surgical aspirator,CUSA)]配合使用行肝切除术。使用射频止血系统解剖第一肝门、离断肝周韧带,使用其他切肝设备离断肝脏实质,肝断面出血点采用射频止血系统止血。结果 11例单独使用射频止血切肝的病人中,有9例没有行肝脏血流阻断,1例左半肝切除病人预先结扎患侧入肝血流,1例左半肝切除术中行陈氏肝血流阻断(第一肝门阻断联合肝下下腔静脉阻断);中位出血量为150 ml(30~300 ml),中位手术时间为200 min(90~250 min)。射频止血系统配合使用其他切肝设备54例病例中:腹腔镜肝切除术33例,开腹手术21例;33例未采用任何血流阻断方法(59.3%),第一肝门联合下腔静脉阻断3例,第一肝门阻断5例,10例半肝切除及3例扩大左半肝切除均预先处理患侧血管;54例中有1例活体肝移植供肝手术未采用任何血流阻断技术;腹腔镜手术无中转开腹;中位出血量为230 ml(50~500 ml),中位手术时间为240 min(90~360 min)。所有病例均未输血,均恢复顺利,无严重术后并发症,无围手术期死亡。结论在肝切除术中使用射频止血系统可减少术中出血量,避免肝血流阻断带来的缺血再灌注损伤,操作简单,值得推广。     

Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study.

OBJECTIVE: To evaluate whether vascular inflow occlusion by the Pringle maneuver during hepatectomy can be safe and effective in reducing blood loss. SUMMARY BACKGROUND DATA: Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during surgery remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but there is a potential harmful effect on the metabolic function of hepatocytes. There has been no prospective randomized study to determine whether the Pringle maneuver can decrease blood loss during hepatectomy, improve outcome, or affect the metabolism of hepatocytes. METHODS: From July 1995 to February 1997, we studied 100 consecutive patients who underwent hepatectomy for liver tumors. The patients were randomly assigned to liver transection under intermittent Pringle maneuver of 20 minutes and a 5-minute clamp-free interval (n = 50), or liver transection without the Pringle maneuver (n = 50). The surface area of liver transection was measured and blood loss during transection per square centimeter of transection area was calculated. Routine liver biochemistry, arterial ketone body ratio (AKBR), and the indocyanine green (ICG) clearance test were done. RESULTS: The two groups were comparable in terms of preoperative liver function and in the proportion of patients having major hepatectomy. The Pringle maneuver resulted in less blood loss per square centimeter of transection area (12 mL/cm2 vs. 22 mL/cm2, p = 0.0001), a shorter transection time per square centimeter of transection area (2 min/cm2 vs. 2.8 min/cm2, p = 0.016), a significantly higher AKBR in the first 2 hours after hepatectomy, lower serum bilirubin levels in the early postoperative period, and, in cirrhotic patients, higher serum transferrin levels on postoperative days 1 and 8. The complication rate, the hospital mortality rate, and the ICG retention at 15 minutes on postoperative day 8 were equal for the two groups.CONCLUSION: Performing the Pringle maneuver during liver transection resulted in less blood loss and better preservation of liver function in the early postoperative period. This is probably because there was less hemodynamic disturbance induced by the bleeding.     

Outcome using hemihepatic vascular occlusion versus the pringle maneuver in resections limited to one hepatic section or less

Consensus is lacking concerning how to manage afferent vessels during hepatectomy, particularly as to the Pringle maneuver vs. selective hemihepatic clamping. Data for 81 hepatocellular carcinoma patients with chronic hepatitis or liver cirrhosis whose liver resection was limited to one section or less, including intraoperative data and postoperative liver function data, were analyzed retrospectively to compare two strategies. No significant differences of intraoperative data or postoperative clinical course were seen between the two groups, even in patients with chronic hepatitis or liver cirrhosis whose postoperative deterioration of liver function could be expected to be more than patients with a normal liver. The difference was evident only in serum alanine aminotransferase level on postoperative day 10 (mean ± SEM, 64.5±5.1 IU in the Pringle group vs. 51.6±4.4 IU in the selective clamping group; P<0.05). During liver resection limited to one section or less, even with underlying chronic hepatitis or cirrhosis, intermittent use of the Pringle maneuver preserved liver function to the same extent as selective clamping.     

Ischemic preconditioning attenuates portal venous plasma concentrations of purines following warm liver ischemia in man

BACKGROUND/AIMS: Degradation of adenine nucleotides to adenosine has been suggested to play a critical role in ischemic preconditioning (IPC). Thus, we questioned in patients undergoing partial hepatectomy whether (i) IPC will increase plasma purine catabolites and whether (ii) formation of purines in response to vascular clamping (Pringle maneuver) can be attenuated by prior IPC. METHODS: 75 patients were randomly assigned to three groups: group I underwent hepatectomy without vascular clamping; group II was subjected to the Pringle maneuver during resection, and group III was preconditioned (10 min ischemia and 10 min reperfusion) prior to the Pringle maneuver for resection. Central, portal venous and arterial plasma concentrations of adenosine, inosine, hypoxanthine and xanthine were determined by high-performance liquid chromatography. RESULTS: Duration of the Pringle maneuver did not differ between patients with or without IPC. Surgery without vascular clamping had only a minor effect on plasma purine concentrations. After IPC, plasma concentrations of purines transiently increased. After the Pringle maneuver alone, purine plasma concentrations were most increased. This strong rise in plasma purines caused by the Pringle maneuver, however, was significantly attenuated by IPC. When portal venous minus arterial concentration difference was calculated for inosine or hypoxanthine, the respective differences became positive in patients subjected to the Pringle maneuver and were completely prevented by preconditioning. CONCLUSION: These data demonstrate that (i) IPC increases formation of adenosine, and that (ii) the unwanted degradation of adenine nucleotides to purines caused by the Pringle maneuver can be attenuated by IPC. Because IPC also induces a decrease of portal venous minus arterial purine plasma concentration differences, IPC might possibly decrease disturbances in the energy metabolism in the intestine as well.     

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy

Background

Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes.

Methods

A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality.

Results

A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay.

Conclusions

All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.     

单中心腹腔镜下肝癌肝切除术457例分析

目的探讨腹腔镜肝癌肝切除术的切除方式、血流阻断技术应用及临床疗效。方法回顾性分析自2002年1月至2016年12月457例接受腹腔镜肝癌肝切除术病人的临床资料,并予以评价分析。利用软件SPSS 22.0版本进行分析。手术时间、术中出血量采用均数±标准差表示,t检验;术后并发症及其他指标采用频数及%表示,χ2检验。P0.05差异具有统计学意义。结果 15年间共行腹腔镜肝癌肝切除457例,其中解剖性肝切除术183例,切除范围:单肝段15例(8.2%),两肝段112例(61.2%)和大范围肝切除56例(30.6%)。腹腔镜下肝切除采用悬吊法有15例;单用Pringle手法167例;选择性入肝血流阻断65例,其中不解剖肝门的入肝血流阻断10例;Pringle手法联合肝下下腔静脉阻断80例。该组病例总的手术时间为(270.7±91.4)min,术中出血量为(413.2±257.5)ml,中转开腹手术41例。术后并发症发生率为27.8%,术后3个月内死亡率0.65%,术后平均住院时间(7.2±3.1)d。结论腹腔镜肝癌肝切除术在临床已经广泛开展,各类血流阻断技术安全有效的应用到术中出血的控制,并且对大范围和肝段肝切除亦切实可行。     

Assessment of Effect of Intraperitoneal Tacrolimus on Liver Regeneration in Major (70%) Hepatectomy Model After Experimental Pringle Maneuver in Rats

AimSmall-for-size grafts have become more important, especially in living donor liver transplants. The Pringle maneuver, used to reduce blood loss, and the immunosuppressive medications used to prevent graft rejection in liver transplants have different side effects on liver regeneration. We researched the effect of situations where tacrolimus and the Pringle maneuver were applied or not on liver regeneration in rats with partial hepatectomy.Material and MethodsThis study was completed with 35 Wistar Albino rats. The subjects were randomly divided into 5 groups: Group 1 had the abdomen opened and no other procedure was performed; Group 2 underwent a 70% hepatectomy; Group 3 underwent a 15-minute Pringle maneuver + 70% hepatectomy; Group 4 underwent a 70% hepatectomy + 5 days of 1 mg/kg/day intraperitoneal tacrolimus; and Group 5 underwent a 150 minute Pringle maneuver + 0% hepatectomy + 5 days of 1 mg/kg/day intraperitoneal tacrolimus. All rats were sacrificed on the seventh postoperative day, remaining liver tissue was weighed, and weight indices created. The remaining liver tissue was stained with phosphohistone H3 and the mitotic index calculated.ResultsThe groups that underwent the Pringle maneuver, 70% hepatectomy, and tacrolimus administration were compared with the control group in terms of mitotic index and weight index, but no statistically significant differences were identified.ConclusionSuppression of regeneration forms a risk after liver transplantation with small-volume grafts. As a result, research on the effect of tacrolimus combined with the Pringle maneuver is important, especially for transplantations using segmented liver grafts. In our study, we showed that the use of tacrolimus had no negative effect on liver regeneration.     

不阻断肝门的大肝癌切除术

目的 研究不阻断肝门的肝切除术在大肝癌切除手术中的价值。方法 回顾性分析30例不阻断肝门的大肝癌切除术，并与同期98例采用肝门阻断的大肝癌切除术做对比。采用单因素和多因素分析的方法，研究与大肝癌术后并发症有关的因素。结果 不阻断肝门组术后并发症率低于阻断肝门组(10．0％vs32．7％，P＝0．02)。单因素分析显示年龄、肝门阻断、术中出血量、输血量以及手术时间等与并发症发生有关，进一步通过多元逐步回归模型分析发现，年龄、肝门阻断、输血量以及手术时间是决定术后并发症发生的4个独立的预测指标。结论 大肝癌切除手术中有选择性地采用不阻断肝门的肝切除技术是安全可行的。     

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Liver Resections: Prospective Study

Selective hepatic vascular exclusion (SHVE) and the Pringle maneuver are two methods used to control bleeding during hepatectomy. They are compared in a prospective randomized study, where 110 patients undergoing major liver resection were randomly allocated to the SHVE group or the Pringle group. Data regarding the intraoperative and postoperative courses of the patients are analyzed. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group, and postoperative liver function was better in that group. Although there was no difference between the two groups regarding the postoperative complications rate, patients offered the Pringle maneuver had a significantly longer hospital stay. The application of SHVE did not prolong the warm ischemia time or the total operating time. It is evident from the present study that SHVE performed by experienced surgeons is as safe as the Pringle maneuver and is well tolerated by the patients. It is much more effective than the Pringle maneuver for controlling intraoperative bleeding, and it is associated with better postoperative liver function and shorter hospital stay.