陈氏绕肝双悬吊法联合右半肝血流阻断行右后叶肝肿瘤切除术

目的 评价右半肝阻断技术结合陈氏绕肝双悬吊法在右后叶肝肿瘤切除术中的应用价值.方法 2011年1月至2015年1月,在37例解剖性肝脏右后叶切除术中应用持续右半肝及陈氏绕肝双悬吊法辅助肝切除.右后叶肝肿瘤行右后叶切除时,采取持续右半肝阻断技术并结合陈氏绕肝双悬吊法经下腔静脉右侧放置2根提肝带,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37例肝右后叶肿瘤病人行肝右后叶肿瘤切除术.术中均成功分离出右半肝肝蒂和右后叶肝蒂,游离右肝后均成功放置绕肝提拉带,断肝时行右半肝持续肝门阻断,术中无胆管损伤、肝短静脉、肝右静脉撕裂和大出血等相关操作并发症.肝实质离断时间17～28 min,阻断时间约20～30min,术中出血量60～330 ml.术后第1天丙氨酸转氨酶(ALT) 183～352 U/L,生化指标均在1周内恢复正常,无围手术期死亡.结论 右半肝持续阻断结合陈氏绕肝双悬吊法有助于减少右后叶肝切除术中出血量以及改善手术野,缩短肝实质离断时间,减轻肝脏缺血再灌注损伤,其操作简单、使用安全、适用范围广泛.     

绕肝提拉法的研究进展

绕肝提拉法最早由Belghiti提出,在行前入路右半肝切除时采用止血钳插入肝后下腔静脉前间隙,建立肝后隧道并留悬吊带提拉肝脏的方法.这种方法的难点是建立肝后隧道,其严重并发症是损伤血管引起出血.本文对肝后隧道建立的解剖学基础、手术技巧进行分析总结,为临床医师在肝切除、肝移植及肝外伤等肝脏外科手术中应用绕肝提拉法提供参考,旨在降低采用该方法行手术治疗的并发症,提高其应用的安全性和成功率.     

肝癌肝切除术中肝脏提拉技术的应用

Liver hanging maneuver(LHM)was first performed to assist right hepateetomy by Jacques Belghiti in 2001.During the procedure of hepatectomy,the liver is lifted by a tape which passes between the anterior Surface of the inferior vena cava and the liver.LHM provides effective vascular control and makes the anterior approach safer and easier.As one of the most important innovations in the field of liver resection,LHM has some definite advantages over the classical approach,including less hemorrhage,less tumoral manipulation and rupture,better hemodynamic stability,reduced ischemic damage of the liver remnant and better survival for patients with hepatocellular carcinoma.Moreover,LHM can serve as a guide to the correct analomical transection plane,and help to improve the exposure of the deep parenchymal plane.LHM developed rapidly in the past few years and it has been widely adopted not only in the treatment of liver cancer,but also in living donor liver transplanration,orthotopic liver transplantation and the treatment of benign liver diseases.Furthermore,many surgeons utilize LHM to facilitate various anatomical liver resections.Although the concept of LHM is widely accepted,its limits and contraindications still need to be investigated in the future.     

改良式绕肝提拉法半肝切除的临床应用研究

目的 探讨改良绕肝提拉法(liver hanging maneuver)半肝切除的临床实用性和安全性.方法 将24例行半肝切除术的患者分为两组:改良式绕肝提拉法半肝切除组12例,Pringle's阻断法半肝切除组12例.比较两种半肝切除方法的术中失血量、手术时间、术后肝功能及并发症发生率等指标.结果 两组均顺利完成手术,两组手术时间相比差异无统计学意义.术中平均失血量,改良组为(160±40)ml,Pringle's组为(560±120)ml,差异有统计学意义(P＜0.01).术后第3天和第7天肝功能(ALT、AST、TB)测试数据,改良半肝切除组优于全肝入肝血流阻断组,差异有统计学意义(P＜0.01).术后改良半肝切除组的腹腔引流量、住院时间和并发症均少于全肝入肝血流阻断组,其中腹腔引流量统计两组差异有统计学意义(P＜0.01).结论 改良式绕肝提拉法半肝切除是安全实用的.     

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.     

陈氏双悬吊法在中肝叶肿瘤切除术中的应用

目的探讨陈氏双悬吊法在中肝叶肿瘤切除术中的作用。方法应用陈氏双悬吊法联合区域性入肝血流阻断行中肝叶肿瘤切除26例,术中置入陈氏双悬吊带、肝下下腔静脉阻断带、第一肝门及不同区域入肝血流阻断带。根据切除边界分配阻断带使用,尽量减少阻断带使用数量、阻断时间和残肝缺血时间,最大限度保留功能性残肝体积。结果全组肿瘤最大直径均数为(9.2±2.6)cm。陈氏双悬吊带仅用于肿瘤右侧切开11例,一次性同时使用陈氏双悬吊带和右肝入肝血流阻断带阻断时间为(13.5±3.8)分钟,联合用于肿瘤左右侧切开15例,阻断时间(18.2±6.4)分钟。出血量(425±227)ml,手术时间(153±47)分钟。丙氨酸氨基转移酶、天门冬氨酸氨基转移酶均于术后10天内恢复正常或接近术前值。结论陈氏双悬吊法使中肝叶肿瘤切除出血和肝损伤可控、恢复快。     

前入路绕肝提拉法在难切右半肝切除中的应用:附40例

目的 证实前入路绕肝提拉法在难切右半肝切除中的安全性及该技术的临床可行性.方法 自2006年9月至2008年9月间,天津医科大学附属肿瘤医院收治的拟行右半肝切除肝癌病人中选择难切病例40例,配对分成常规肝切除组和前入路绕肝提拉法肝切除组.结果 20例成功安放绕肝带,手术时间、术中出血量、术中输血量、住院时间及术后相关并发症发生率均优于常规组(P＜0.05).结论 在难切的右半肝切除时前入路绕肝提拉法既安全又快捷.     

绕肝提拉法在正中裂劈开肝脏切除中的意义

目的探讨在肝后下腔静脉和肝脏之间建立隧道、放置绕肝带的可行性以及绕肝提拉法在经正中裂劈开断肝中对于下腔静脉的保护和肝内管道显露的作用。方法对47例肝脏切除患者钝性分离肝后下腔静脉前的间隙,建立肝后隧道并且预置绕肝带。必要时放置止血板。切肝时提拉绕肝带使肝脏与下腔静脉之间产生距离,从而有效保护下腔静脉,并且使手术视野暴露更佳。结果47例患者成功建立了肝后隧道并预置绕肝带,未出现与本操作相关的严重并发症,1例因为渗血较多中止建立肝后隧道。结论肝后隧道的建立和绕肝带的放置在解剖和技术上是可行的;绕肝提拉法对于下腔静脉的保护和肝切除术中肝内管道的显露有较好的效果。     

前入路绕肝悬吊解剖性肝右三叶切除术治疗巨大肝癌

前入路肝切除术是指先离断肝实质后游离肝脏的肝切除方法;绕肝悬吊是指在肝后下腔静脉前方放置悬吊带,供在切肝过程中提起肝脏.2011年10月中山大学孙逸仙纪念医院采用前入路、绕肝悬吊、解剖性肝右三叶切除术治疗1例54岁男性肝癌患者.肿瘤位于肝左内叶和右半肝,长径约16 cn.术前肿瘤分期为ⅢA期,T3N0M0;术前评估ICG R15为5.4％,肝左外叶肝脏体积占标准肝脏体积的44％;左肝管受压、轻度扩张.术中首先分离、切断入肝血流,包括肝右动脉、门静脉右支、肝中动脉、门静脉左内叶分支;然后在镰状韧带的右侧离断肝实质,期间在肝后下腔静脉前打隧道并悬吊肝脏;切断右肝管;接着分离、切断肝中静脉和肝右静脉;游离肝周韧带,移出肝右二叶;最后行左肝管、肝总管端端吻合.手术时间为4h,术中出血量为350 mL.患者术后康复顺利,术后4个月复查MRCP示胆管吻合口通畅,肝内未见肿瘤复发.     

体内W型悬吊肝左叶在腹腔镜胃手术中的应用价值

目的探讨体内W型悬吊肝左叶在腹腔镜胃手术中的应用价值。 方法回顾性分析2021年1月至2021年9月行腹腔镜胃相关手术的68例患者的病例资料及手术录像,观察悬吊所用时间及有无相关肝脏副损伤情况（如肝脏撕裂、出血、肝包膜血肿、术后肝功能异常、胆瘘）。 结果68例腹腔镜胃相关手术患者中行腹腔镜全胃切除术17例,腹腔镜下近端胃切除术7例,腹腔镜远端胃切除术25例,腹腔镜胃部分切除术19例。患者平均年龄63.3岁（30~86岁）,平均体重指数24.8 kg/m²（18.6~41.7 kg/m²）。所有手术患者均顺利完成体内肝左叶W型悬吊,用时仅（3.0±1.3）min,术中没有借助特殊器械。通过手术录像观察发现有8例出现壁腹膜穿刺点出血,经电勾完成止血;所有手术患者均未发现有肝脏副损伤发生。 结论在腹腔镜胃相关手术中采用体内W型悬吊肝左叶,是一种操作简单、安全、有效的肝悬吊法。     

Modified liver hanging maneuver with extraparenchymal isolation of the middle hepatic vein in left hepatectomy

Background/purpose  The liver hanging maneuver has been employed mostly for right hepatectomy. After the space between the inferior vena cava and the liver parenchyma is bluntly dissected, a tape is passed through the space, with the upper end of the tape between the right hepatic vein and middle hepatic vein (MHV). We devised a modified maneuver with tape repositioning between the MHV and left hepatic vein (LHV) after extraparenchymal isolation of the MHV, in left hepatectomy with the caudate lobe and without the MHV. Methods  The ligamentum venosum is divided. Traction of the cranial stump of the ligament in the cranial and left direction shows an avascular plane between the LHV and MHV, and enables the taping of each MHV and LHV. Finally, the upper end of the hanging tape is repositioned. Results  This maneuver was successfully performed in three patients. Conclusions  The present maneuver is feasible and useful in left hepatectomy.     

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.     

Hepatic resection using stapling devices

BACKGROUND: The progress and development of stapling devices has been remarkable. They have become indispensable for gastrointestinal diseases and are increasingly utilized in laparoscopic operations. Liver surgery applications for this technique are continuing to emerge, and in this study, we introduced the use of stapling devices to hepatic surgery. METHODS: We examined the operative procedure and efficacy of hepatic resections using stapling devices as follows: transection of Glisson's pedicle and the hepatic vein using endolineal stapling devices in right and left lobectomies; bisegmentectomy II and III en masse using a stapling device; and application of endolineal stapling devices to vessel transections and dissections of the hepatic parenchyma in laparoscopic hepatectomies. RESULTS: It was considered useful to tactfully apply stapling devices to vessel transections and dissections of the hepatic parenchyma in order to simplify the operative procedures of right or left lobectomies and lateral segmentectomies. Furthermore, the use of endoscopic stapling devices was an acceptable alternative to vessel transactions and dissections of the hepatic parenchyma in laparoscopic hepatectomies. CONCLUSIONS: We believe that stapling devices will become utilized in liver surgery hereafter.     

绕肝提拉法联合半肝血流阻断在前入路半肝切除术中的应用

目的探讨绕肝提拉法联合半肝血流阻断在前入路半肝切除术中的应用价值。方法回顾分析2005年1月-2008年12月我院25例各类型肝切除患者实施绕肝提拉法联合半肝血流阻断前入路半肝切除术的资料。结果23例顺利成功实施绕肝提拉法联合半肝血流阻断前入路半肝切除术,2例未能成功实施绕肝提拉法联合半肝血流阻断手术。无重大并发症及死亡。结论绕肝提拉法联合半肝血流阻断前入路肝切除术是安全,可行,有效,值得推广应用。     

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。     

Wedge resection of the portal bifurcation concomitant with left hepatectomy plus biliary reconstruction for hepatobiliary cancer

Background/Purpose: We report our experience performing wedge resection of the portal bifurcation and transverse suture closure in patients undergoing left hepatectomy and caudate lobectomy plus biliary reconstruction for hepatobiliary cancer. Methods: The procedure was performed in three patients with hilar or intrahepatic cholangiocarcinoma. After confirming that tumor invasion of the portal bifurcation was not circumferential, the portal trunk and the right posterior and right anterior portal branches were isolated and clamped. Wedge resection of the portal bifurcation was performed, taking care to secure a clear surgical margin. The edges of the portal vein were approximated, using guy-sutures in the dorsal and ventral edges and a temporary central guy-suture, and portal reconstruction was carried out using a continuous transverse suture. After unclamping, good portal flow was confirmed by color Doppler ultrasonography. Results: The procedure was completed successfully in all three patients; the average time of portal vein occlusion was 15 min. Two patients had postoperative complications: bile leakage and wound infection, but no patient developed postoperative hepatic failure or died. The three patients are alive without recurrence at 2, 11, and 22 months after the operation. Conclusions: Wedge resection of the portal bifurcation is easier and simpler than using a venous patch or performing segmental resection. Received: March 31, 2002 / Accepted: June 10, 2002 Offprint requests to: S. Kondo Presented at the 5th World Congress of the International Hepato-Pancreato-Biliary Association, April 25–29, 2002, Tokyo     

An anatomical study of short hepatic veins,with special reference to delineation of the caudate lobe for hanging maneuver of the liver without the usual mobilization

Abstract. Background/Purpose: The present study was designed to anatomically assess a very recently reported hanging maneuver of the liver without mobilization, in which forceps are inserted blindly between the inferior vena cava (IVC) and liver parenchyma. Methods: We dissected 56 formalin-fixed livers (1) to determine whether preservation of the caudate vein (the largest vein draining Spiegel's lobe) and inferior right hepatic vein (IRHV) was possible and (2) to identify the territories drained by other, non-preserved short hepatic veins. Results: A potential space for insertion of the forceps was found between the openings of the caudate vein and IRHV; however, if preservation of both veins is absolutely necessary, we recommended protecting the IRHV, such as by taping and retracting it. We classified the other short hepatic veins into two categories, i.e., those draining the left portal vein territory and those draining the right territory. The distributions of the openings of the veins in these territories overlapped. Conclusions: Clear delineation of the left caudate lobe according to the drainage veins appeared to be difficult when the liver was divided along a straight line in front of the IVC. Received: March 22, 2001 / Accepted: August 21, 2001     

九例腹腔镜解剖性肝Ⅷ段切除的可行性与策略分析

目的:探讨完全腹腔镜解剖性肝Ⅷ段切除的策略、安全性及近期疗效。方法:回顾分析湖南省人民医院2015年1月至2019年12月行腹腔镜解剖性肝Ⅷ段切除9例患者资料,其中男性6例,女性3例,年龄范围29～67岁,平均年龄53.6岁。观察手术时间、术中失血量、术后住院时间、术后并发症等指标。出院后随访生存和复发情况。结果:9例...