肝后下腔静脉隧道绕肝带提拉法半肝切除19例报告

目的 探讨肝后下腔静脉隧道绕肝带提拉法行半肝切除安全性的作用。方法 回顾性分析2003年11月至2006年6月昆明医学院第一附属医院肝胆外科，在传统经典半肝切除术的基础上加用肝后下腔静脉隧道绕肝提拉法行半肝切除的19例资料。结果 19例均成功放置绕肝带，未发生与该操作有关的并发症，半肝切除时肝正中裂界面内管道显露清楚，处理起来方便、安全可靠，绕肝带具有指示保护肝后下腔静脉的作用。结论 半肝切除时采用肝后下腔静脉隧道绕肝带提拉法，可进一步提高半肝切除的安全性，减少出血，缩短手术时间。保证断肝能在最薄、最小的界面进行。     

双绕肝提拉法在半肝切除中的应用价值

目的 探讨和完善建立肝后隧道的方法及双绕肝提拉在半肝切除术中的应用价值.方法 采用胆道探条代替血管钳建立肝后隧道,并预置2根绕肝带.施行双绕肝提拉前入路法行半肝切除术38例患者为提拉组,用传统方法行半肝切除的89例患者为对照组,比较双绕肝提拉法与传统方法的不同. 结果38例患者均顺利安置双绕肝带,双绕肝提拉切肝时断面无明显出血,断面管道系统显示清晰,肝后下腔静脉与肝脏之间拉开1～2 cm的间隙,以减少肝后下腔静脉及肝静脉、肝短静脉的损伤.与对照组相比,使用双绕肝提拉法的患者术中出血量少(t=4.112,P<0.05),术后肝功能恢复快(x2=11.14,P<0.05),且胆汁瘘发生率低(P<0.05),术后3个月内肿瘤肝内扩散、腹腔种植少(x2=4.239,P<0.05),而两组患者的手术时间比较差异无统计学意义(t=0.007,P>0.05).结论 采用改良后的方法建立肝后隧道成功率高.双绕肝提拉前人路半肝切除术具有减少术中出血量、减轻术后肝功能损害,降低胆汁瘘发生率及肿瘤肝内扩散和腹腔种植等特点.     

绕肝提拉法肝切除术八例体会

目的探讨绕肝提拉法在肝脏切除手术中的应用。方法回顾性分析2007年9月至2009年6月收治的10例在肝切除术中应用绕肝提拉法病人的临床资料。结果本组有8例成功建立了肝后隧道,并放置绕肝带,未出现与绕肝提拉法操作有关的并发症。因为肿瘤侵犯肝后下腔静脉而中止建立肝后隧道2例,改行常规手术。结论绕肝提拉法的出现,大大增加了肝切除的安全性,操作安全简便,切实有效。     

绕肝提拉法前入路肝切除术(附6例临床报告)

目的　绕肝提拉法 (liverhangingmaneuver)进一步提高前入路肝切除术 (anteriorapproach)的安全性。方法　钝性分离肝后下腔静脉前间隙而形成肝后隧道。通过该隧道安放绕肝带 ,前入路肝切除时拉紧绕肝带 ,配合自行设计的止血板 ,完成 6例复杂肝切除术。结果　 6例成功安放绕肝带 ,未发生与该操作有关的并发症 ,前入路肝切除时肝正中裂界面内管道显露清楚 ,绕肝带具有指示作用。结论　复杂肝切除时使用绕肝带和止血板 ,有助于提高前入路肝切除的安全性。保证断肝能在最短的界面上进行。     

绕肝提拉法前人路肝切除术（附6例临床报告）

目的 绕肝提拉法(1iver hanging maneuver)进一步提高前入路肝切除术(anterior approach)的安全性。方法 钝性分离肝后下腔静脉前间隙而形成肝后隧道。通过该隧道安放绕肝带，前入路肝切除时拉紧绕肝带，配合自行设计的止血板，完成6例复杂肝切除术。结果 6例成功安放绕肝带，未发生与该操作有关的并发症，前入路肝切除时肝正中裂界面内管道显露清楚，绕肝带具有指示作用。结论 复杂肝切除时使用绕肝带和止血板，有助于提高前入路肝切除的安全性。保证断肝能在最短的界面上进行。     

双绕肝提拉在规则性右半肝切除中的应用

目的 介绍我们使用双绕肝提拉法施实规则性右半肝切除术的经验.方法 24例病人施行了双绕肝提拉前入路法右半肝切除,以49例采用传统方法行右半肝切除的病人作为对照组,分析了双绕肝提拉法的优势.结果 27例病人成功建立肝后下腔静脉隧道,其中24例病人通过双绕肝提拉法行规则右半肝切除,3例病人因肿瘤接近正中裂而放弃双绕肝法.与对照组比较,使用双绕肝提拉法的病人术中出血量少(t=3.191,P＜0.05),术后ALT恢复快(t=2.398,P＜0.05)、肝功能Child分级好(χ2=9.31,P＜0.05).两组病人手术时间无明显差异(t=-1.695,P＞0.05).绕肝带提拉肝脏后,由于肝后下腔静脉与肝脏之间产生1～2 cm的间隙,故切肝时无一例损伤肝后下腔静脉及肝静脉.结论 双绕肝提拉前入路法能提高规则右半肝切除的安全性及成功率.     

肝提拉技术在肝切除中的应用

在肝脏切除手术中,由于肝脏本身体积较大、且内部及周围存在众多的管道系统,深部术野显露困难,因此,术中易发生难以控制的大出血及下腔静脉损伤等严重并发症。Belghiti等于2001年首先报道了肝提拉技术（liver hanging maneuver,LHM）,利用肝后下腔静脉前面的间隙建立隧道并留置弹力带,在未游离肝脏情况下通过前入路成功实施右半肝切除,从而有效地保护了下腔静脉。彭淑牖等率先在国内开展这一技术,将其命名为“绕肝提拉法”,并对一些重要步骤进行改进,扩大了手术应用范畴。现在LHM已成为许多复杂肝脏手术的一种安全、可靠的技术方法。     

绕肝提拉法肝后隧道的应用解剖学研究

目的通过解剖学的研究,探讨绕肝提拉法手术的临床解剖学依据。方法选用解剖教学的21例成人尸体的肝后下腔静脉,从腔内观察尸肝组汇入肝后下腔静脉的肝短静脉开口情况,按不同绕肝提拉法的路径和不同肝后隧道宽度(10mm、6mm)统计可能遇到的肝短静脉数。结果绕肝提拉法在肝后隧道宽度6mm时标准路径遇到肝短静脉0～3(中位数=1)支,标准右上方路径(EM路径,肝后下腔静脉右缘距肝下缘1cm)遇到肝短静脉0～2(中位数=0)支,后者小于前者,差异有统计学意义(P=0.003)。结论绕肝提拉法手术建立肝后隧道是可行且安全的。     

绕肝带提拉法在肝切除术中的应用进展

绕肝带提拉法肝切除从2001年被提出之后获得了广泛的应用,前入路肝切除联合绕肝带提拉技术已经成为大肝癌行半肝切除的标准术式.绕肝带放置的安全性问题促使肝后下腔静脉前隧道解剖的深入研究,尾叶静脉与肝右后下静脉之间是建立隧道的安全区域.在肝脏上方三支肝静脉和下方三支主要的Glisson鞘之间放置绕肝带,或通过静脉韧带通道放...     

肝移植中绕肝提拉法肝后隧道的临床应用解剖学研究

目的探讨肝移植中绕肝提拉法手术建立肝后隧道的临床解剖学依据。方法21例成人尸体的肝后下腔静脉和20例背驮式肝移植合并肝硬化的肝后下腔静脉资料,按不同的绕肝提拉法可能的路径和不同宽度肝后隧道(10 mm,6 mm)统计可能遇到的肝静脉。结果绕肝提拉法的标准路径平均可遇到肝短静脉的中位数是1(0~3),标准路径右上方的路径(肝后下腔静脉右缘、距肝下缘1 cm)和标准路径之间存在显著性差异(P<0.05),10 mm肝后隧道在6个路径上多于6 mm隧道(P<0.05),背驮式肝移植病肝组与尸体正常对照组之间无显著性差异(P>0.05)。结论肝移植中绕肝提拉法手术是可行的,6 mm肝后隧道的风险小于10 mm隧道。     

陈氏绕肝提拉法在巨大肿瘤右半肝切除术中的应用

目的 评价陈氏绕肝提拉法在右半肝切除术中的应用价值.方法 右肝巨大肿瘤行右半肝切除时,采取陈氏绕肝提拉法经下腔静脉右侧放置提肝带,离断肝实质的过程中通过牵拉提肝带辅助肝切除.结果 全组共32例右肝巨大肿瘤患者行右半肝切除术,其中前入路肝切除15例,经典入路17例.术中均成功放置提肝带,放置和牵拉过程中无肝短静脉撕裂和大出血等相关并发症.32例肝切除术的肝实质离断时间约25～45 min,肝门阻断时间约20～32 min,术中出血量300～1 300ml.所有患者无围手术期死亡.结论 陈氏绕肝提拉法有助于右半肝切除术中手术野的显露,缩短肝实质离断时间,减少肝实质离断过程中的出血;且其操作简单、使用安全、适用范围广泛.     

Safe Modification of the Liver-Hanging Maneuver by Endoscopic-Assisted Dissection of the Retrohepatic Tunnel

As a safer approach to right hepatectomy, Belghiti et al. (J Am Coll Surg 193:109–11, 2001) described a liver-hanging maneuver. However, this procedure is performed blind, with the risks of damaging the small retrohepatic veins and consequential bleeding. To overcome this problem, we modified the procedure so that, instead of performing blind dissection using a long vascular clamp, we use a flexible choledochoscope to dissect the retrohepatic space filled by loose alveolar tissue anterior to the inferior vena cava (IVC). The avascular path is identified by a combination of saline irrigation and gentle movement of the tip of the choledochoscope. Cotton tape can then be passed around the liver parenchyma to elevate the liver away from the anterior surface of the IVC. This modification of Belghiti's liver-hanging maneuver allows direct vision along the plane anterior to the IVC, thus avoiding injury to the retrohepatic veins.     

经裸区肝脏悬吊法行右肝巨大肿瘤切除术

Belghiti等于2001年首次提出肝脏悬吊法经前入路行右半肝切除术,但由于其在肝后下腔静脉前方盲目建立隧道过程中,易撕裂肝短静脉和肝实质引起出血,难以推广。此后陈孝平等建立一种新的肝脏悬吊技术,即沿腔静脉右侧肝后间隙经肝裸区做隧道置悬吊技术。该方法简单、安全,能充分显露深部肝断面,便于止血,尤其是可有效控制来自肝静脉分支的出血。本文介绍我们应用经裸区肝脏悬吊法行右肝巨大肿瘤右半肝切除的经验,并就其相关的解剖学要点,操作要领以及术中应注意的问题进行讨论。     

Two hundred liver hanging maneuvers for major hepatectomy: a single-center experience

OBJECTIVE: To establish the indications of the liver hanging maneuver for major hepatectomy. SUMMARY BACKGROUND DATA: The liver hanging maneuver, which is a technique of passing a tape along the retrohepatic avascular space and suspending the liver during parenchymal transection, facilitates anterior approach of major hepatectomy. However, the feasibility and limits of this maneuver have never been established in patients with different clinical backgrounds. METHODS: Medical records of 242 consecutive patients considered for major hepatectomy using the hanging maneuver were reviewed. RESULTS: Among 242 patients, 14 patients (6%) were considered to have contraindication for this maneuver preoperatively because of tumor infiltration to anterior surface of retrohepatic inferior vena cava (IVC). It was successful in 201 patients with overall feasibility of 88%. The feasibility increased significantly in the recent years as compared with the initial years (94% in 2003-2005 vs. 76% in 2000-2002, P < 0.0001). Bleeding during the retrohepatic dissection occurred in 5 patients (2%), which was minor due to injury of hepatic capsule in 3 (1%) and major due to injury of short hepatic vein in 2 (1%). In all cases, bleeding stopped spontaneously. The maneuver was abandoned in 27 patients, including 15 related to severe adhesion between liver and IVC. Univariate analysis showed that adhesion between IVC and liver was the only significant negative predictor affecting the feasibility. Cirrhosis, large tumor, preoperative radiologic treatments did not influence on the feasibility. CONCLUSIONS: The liver hanging maneuver has 94% feasibility in recent years. Absolute contraindication is tumor infiltration to the retrohepatic avascular space. Adhesion between the IVC and liver has a negative impact of the feasibility. According to this indication, the hanging maneuver is easily achievable without risk of the major bleeding during the retrohepatic dissection.     

The preliminary experience of Belghiti's liver hanging manoeuvre in right hepatectomy with anterior approach

Aim: To summarize the experience of Belghiti's liver hanging manoeuvre in right hepatectomy. Methods: Nine cases of right hepatectomy were performed with Belghiti's liver hanging manoeuvre from June 2002 to May 2005. They included seven cases of large hepatocellular carcinoma located in the right liver lobe with diameters from 8 to 12 cm (two have encroached diaphragm and lateral peritoneum) and two cases of recurrent pyogenic cholangitis with hepatolithiasis fully packed in the right liver lobe. The key step of this manoeuvre was to develop a retrohepatic tunnel between the anterior surface of the inferior vena cava and the liver parenchyma. A tape was then passed though the tunnel and the liver was resected under tape suspension. Results: The retrohepatic tunnel was established and the suspending tape was passed though the tunnel successfully in all cases. The mean time for this procedure was 21 min. Mean intraoperative blood loss was 380 mL. The middle hepatic veins were protected from damage in eight cases. There were no operative deaths or morbidity, except one case that developed postoperative bile leakage, which was cured by drainage. Conclusion: Belghiti's liver hanging manoeuvre is a preferred surgical method for right hepatectomy, with its reliable anatomic background and satisfactory primary clinical results.     

经前路改良式绕肝提拉法在右半肝切除术中的应用

目的：评价改良式绕肝提拉法前入路在右半肝切除术中的临床应用价值。
方法：细致解剖分离肝后与下腔静脉前间隙,建立肝后隧道,置弹力带提拉肝脏,绕肝提拉法前入路在仅阻断病肝侧血流的情况下,进行右半肝切除术。
结果：全组10例,包括肝癌5例,肝血管瘤2例,肝胆管结石2例,严重肝损伤1例,手术均获得成功,未发生与本术式相关的并发症。
结论：改良式绕肝提拉法进行右半肝切除术仅阻断病肝侧血流,手术从容且安全可靠。此法适用于肝良、恶性病变及严重肝损伤的右半肝切除术,是值得推荐的一种手术方式。

     

前入路绕肝提拉法半肝切除在肝硬化患者中的应用

目的：探讨前入路绕肝提拉法半肝切除在肝硬化患者中应用的安全性及可行性。方法：2008年1月—2011年6月间笔者从拟行半肝切除的肝硬化患者中选择45例,随机分成前入路组和常规组。前入路组22例,使用前入路绕肝提拉法行半肝切除;常规组23例,使用常规法半肝切除。比较两组的手术时间、术中失血量、输血例数、住院时间、并发症等以及围手术期肝功能指标。结果：两组患者均成功施行手术治疗。前入路组行右半肝切除17例,左半肝切除5例,患者均成功建立肝后隧道;常规组行右半肝切除19例,左半肝切除4例。与常规组比较,前入路组术中出血量及输血例数少、手术时间短、并发症少、术后谷丙转氨酶（ALT）和谷草转氨酶（AST）恢复较快（均P<0.05）,两组患者住院时间及术后总胆红素（TBIL）变化无明显差异（均P>0.05）。结论：在肝硬化患者中施行前入路绕肝提拉法半肝切除可减少术中出血,缩短手术时间,有利于肝功能恢复,临床应用是安全可行的。     

Hanging maneuver in right hepatectomy for recurrent metastases with diaphragmatic infiltration after radiofrequency ablation: a new indication

The liver hanging maneuver is a safe technique to prevent bleeding during transection when a right hepatectomy by an anterior approach, without previous mobilization of the liver, is required. This article proposes a new indication for this technique. The liver hanging maneuver may be useful during right hepatectomy for local recurrence of liver metastases previously treated by radiofrequency ablation (RFA). In these cases, necrosis or fibrosis induced by RFA and local recurrence may cause strong adhesions between liver parenchyma and the diaphragm, thus increasing the risk of bleeding during liver mobilization. Between January 2003 and March 2006, seven patients with recurrent colorectal liver metastases of the right hemiliver, after previous treatment by RFA, underwent right hepatectomy. Liver resection was feasible with the proposed technique in all patients. In four cases, a limited diaphragmatic resection was associated. There was no mortality. Postoperative morbidity was 42.8 per cent. An anterior approach with the liver hanging maneuver for recurrent liver metastases after RFA should be recommended when the metastases are located posteriorly, are not detachable from the diaphragm, and the preliminary mobilization of the right liver may be difficult.