腹腔镜肝切除术20例临床分析

目的 探讨腹腔镜下肝切除术的可行性及相关技术问题如术中出血的控制、肝实质离断方法和肝断面的处理方法等.方法 自2011年6月至2014年4月共施完全腹腔镜肝切除术20例,对其临床资料进行回顾性分析.结果 20例患者中肝血管瘤10例,肝细胞性肝癌9例,乙状结肠癌肝转移1例.2例位于肝脏第Ⅱ和第Ⅲ段,8例位于第Ⅲ段,7例位于第Ⅵ段,第Ⅳb、Ⅴ、Ⅶ段各1例.平均肿瘤直径（4.7±1.9） cm.肝肿瘤局部切除6例,肝左外叶切除7例,肝右后叶切除2例,肝段切除5例.单独使用超声刀离断肝组织8例,超声刀联合Habib4X射频止血凝固器离断肝组织6例,超声刀联合Endo GIA离断肝组织6例.平均手术时间（196±57） min,术中出血量（380±459）ml,术后出现中等量腹水1例、胆漏1例,顽固性胸腔积液1例,均经保守治疗治愈.术后平均住院时间（9.2±3.5）d.10例恶性肿瘤患者术后随访1～35个月,5例出现肝内复发.结论 在严格掌握手术适应证的前提下,腹腔镜肝切除术是安全可行的;根据肝脏质地的不同,选择不同离断肝实质的器械,可减少术中出血.     

一种理想的腹腔镜下肝实质离断方法：超声刀联合双极电凝

目的探讨腹腔镜下超声刀联合双极电凝实施肝实质离断的可行性。方法自2006年10月至2009年9月,采用上述肝实质离断方法共完成腹腔镜下肝切除（LLR）33例,男21例,女12例,年龄25～80岁,平均（47-3±14．9）岁;所有患者均为单发病灶,术前诊断良性占位20例,恶性占位13例,其中包括复发性肝癌1例;病灶大小2．0—11．0cm,平均（6．1±3．5）cm,位于肝左叶24例,其中20例于肝左外叶,肝右叶9例。结果全组33例手术无一例中转开腹,共行规则性LLR21例,非规则性LLR12例。手术时间45—220min,平均（116．4±63．4）min,术中出血20～700ml,平均（97．3±140．4）ml,术后胃肠恢复时间1—3d,平均（1．1±0．6）d,腹腔引流时间2～8d,平均（3．4±1．8）d,术后住院时间3—10d,平均（4．9±2．1）d。4例发生术后并发症,其中腹水2例,肺部感染1例,少量胆瘘1例（腹腔引流8d后自愈）,所有并发症均通过保守治疗治愈。结论超声刀联合双极电凝在腹腔镜下进行肝实质离断可以充分利用两者的优势,互补各自的缺点,该方法断肝速度快,出血少,显著缩短了手术时间,提高了手术安全性,推荐在当前LLR中常规应用。     

电视腹腔镜肝切除15例报告

目的　探讨腹腔镜下肝切除术。方法　位于肝第Ⅱ、Ⅲ、Ⅳa、Ⅴ、Ⅵ段 ,直径 <10cm的9例原发性肝癌 ,4例肝海绵状血管瘤 ,2例肝局限性增生结节病人 ,在全气腹状态、气腹结合免气腹或腹腔镜加小切口下 ,采用 (1)缝扎切开 ;(2 )钳夹电凝断肝 ;(3)微波固化后断肝 ;(4 )旋吸断肝 ;(5 )超声刀断肝 ;(6 )切割缝合器断肝 ;(7)常规器械切肝多种断肝方法行腹腔镜肝切除术。结果　 15例腹腔镜肝切除均获得成功 ,手术时间 1 5～ 8h ,术中出血 5 0～ 5 0 0ml。术后恢复顺利 ,除 1例胆漏外 ,无其他并发症 ,住院时间为 5～ 4 0d。结论　位于肝第Ⅱ、Ⅲ、Ⅳa、Ⅴ、Ⅵ段 ,直径不超过 10cm ,无周围脏器浸润的肝肿瘤病人行腹腔镜肝切除术是安全可行的。     

腹腔镜肝切除技术的优化

目的通过动物实验优化腹腔镜肝切除中入肝血流阻断技术及肝实质离断技术。方法以10头猪为实验动物,以肝门阻断钳或可拆卸肝门阻断钳及鞘内解剖优化腹腔镜下入肝血流阻断技术;在没有任何入肝血流阻断的情况下,分别进行肝脏局部切除、左外侧叶及左内侧叶的序贯切除,肝实质离断采用超声刀、LigaSure、微波刀、双极电凝、外科夹及内镜切割闭合器完成,比较不同器械离断肝实质的效果和安全性。结果肝门阻断钳或可拆卸肝门阻断钳行入肝血流全部阻断或部分阻断后,缺血部分肝脏颜色变化明显;鞘内解剖左半肝入肝血流阻断后,左、右半肝间的缺血线明显;各种常用肝实质离断器械均有其适用范围,对其的优化使用可提高断肝效率,减少出血。结论通过动物实验优化的腹腔镜入肝血流阻断技术以及肝实质离断技术,可为腹腔镜解剖性广泛肝切除的临床应用提供依据。     

腹腔镜解剖性肝切除术:附40例报告

目的 探讨腹腔镜下解剖性肝切除术的可行性及安全性.方法 2008年1月至2012年3月,我院对40例肝良恶性病变患者实施了腹腔镜下解剖性肝切除术.其中原发性肝癌13例、复发性肝癌1例、肝胆管细胞癌1例、转移性肝癌6例、肝胆管结石10例、肝血管瘤7例、肝局灶性结节性增生1例、肝腺瘤1例.术中常规使用腹腔镜超声定位.采用选择性半肝血流阻断技术,应用高频电刀、超声刀或Ligasure等器械离断肝实质.肝断面粗管道用Hemolock夹闭,必要时使用血管切割闭合器离断.实施腹腔镜右半肝切除3例,左半肝切除10例,左肝外叶切除14例,S56切除5例,S5切除3例,S6切除4例,S4b切除1例.结果 全腹腔镜切除34例,中转开腹腔镜辅助切除6例.无围手术期死亡.手术时间(250.21±50.94) min,术中出血(420.20±120.10)ml.术后发生胆漏2例.住院时间(5.68±1.74)d.结论 在严格掌握适应证前提下,腹腔镜解剖性肝切除术是安全、可行的.该法具有创伤小、恢复快的优点,可作为部分肝良恶性病变的标准术式.     

腹腔镜左半肝切除术的技术难点与体会(附34例报告)

目的:探讨腹腔镜左半肝切除模式化手术的可行性及技术难点。方法:选择2013年1月至2017年10月收治的34例左半肝占位患者,均行腹腔镜解剖性左半肝切除术,术中先行入肝血流阻断,再用超声刀、双极电凝等断肝。结果:34例手术均获成功。手术时间平均(164.54±50.32)min,出血量平均(161.67±50.86)mL,无手术并发症发生,术后平均住院(6.30±0.85)d。结论:腹腔镜左半肝切除术的技术越来越成熟,基本上已模式化,可作为治疗左半肝疾病的标准术式。     

伴有重度肝硬化的肝癌腹腔镜肝切除35例分析

目的探讨腹腔镜下微波凝固辅助联合超声刀进行重度硬化肝癌切除术的安全性及有效性。方法回顾性分析我院2010年2月~2012年5月微波治疗仪联合超声刀进行完全腹腔镜下35例伴有重度肝硬化的肝癌手术切除临床资料。结果 35例腹腔镜肝癌切除手术均获成功,无中转手术,术中无需输血;其中21例不规则肝切除,14例肝左外叶切除。手术时间(75~340)分钟,平均(165.5±117.3)分钟。出血量15~300 ml,平均(168.6±147.4)ml;无死亡患者;无肝断面出血、胆漏、肝功能衰竭和腹腔脓肿等术后并发症。术后住院时间5~10天,平均(9.2±2.5)天。结论采用微波凝固辅助联合超声刀对于重度硬化肝癌进行完全腹腔镜切除是一种安全有效的微创治疗方法,可明显降低手术中出血量以及术后并发症发生率。     

腹腔镜肝左外叶切除11例报告

目的：探讨腹腔镜下肝左外叶切除术的可行性。方法：直径小于10cm,位于肝左外叶的5例原发性肝癌，4例肝海绵状血管瘤，2例肝局限性增生结节患者，在全气腹状态，气腹结合免气腹或腹腔镜加下切口下，采用微波固化，超声刀，钳夹电凝，旋转刮吸和切割缝合器等多种断肝方法行腹腔镜肝切除术。结果：腹腔镜肝左外叶切除11例均获得成功，手术时间1．5－6h，术中出血50－500ml，术后恢复顺利，住院时间为5－15d，结论：直径小于10cm，无周围脏器浸润的肝左外叶肿瘤行腹腔镜肝切除术是安全可行的。     

手助腹腔镜肝脾联合切除3例

目的探讨手助腹腔镜肝脾联合切除的可行性。方法采用手助腹腔镜（Hand—port）行肝脾联合切除术，选择剑突下正中或右肋缘下手助切口，手助下超声刀分离脾周韧带，Endo-GIA断脾蒂，采用超声刀、生物夹夹闭断肝，肝断面间断缝合闭合。结果3例手术均获得成功，手术时间分别为130、115、145min，术中出血量分别为350、50、150ml。3例术后未发生严重并发症，术后住院日分别为9、7、11d。3例分别随访6、23、5个月，肿瘤无复发。结论手助腹腔镜肝脾联合切除术安全、可行。     

腹腔镜肝切除术肝实质离断技巧及器械选择

肝实质离断技术是决定腹腔镜肝切除术成败的关键。断肝器械较多,选择可因人而异,但目前主流的选择是超声刀和超声外科吸引器(CUSA)。断肝前,肝脏充分游离十分必要,同时预留第一肝门Pringle阻断带是保证手术安全的重要前提。断肝开始时,需要整个团队的稳定配合;肝实质表面血管较少,可以直接用超声刀离断;而肝实质核心部位需要术者利用断肝器械尽量在充分解剖每一束管道后再进行离断,避免大束离断。一旦出血要稳定心态,较小的出血可以用双极电凝或百克钳烧灼止血,较难控制的出血需要缝合止血。     

复发性肝癌的腹腔镜再切除

目的探讨腹腔镜肝切除术(LH)治疗复发性肝癌的安全性及可行性。方法 2003年8月至2008年5月,同一手术组完成大约500例肝癌切除手术,其中LH120例。500例患者中,约有100例复发,我们仔细选择6例病例进行了腹腔镜复发性肝癌再切除术,手术适应证评估指标包括肿瘤位置、大小、转移范围、血管侵犯与否以及肝功能状况等。手术方式包括4例局部切除及2例解剖性左外叶切除。对病例资料进行回顾性分析。结果 6例手术均取得成功,无严重术中及术后并发症发生。平均手术时间为(140.8±35.7)min,平均出血量为(283.3±256.3)ml,术后平均住院日为(5.7±1.6)d。结论对于严格选择的病例,LH是治疗复发性肝细胞癌的一种安全有效的方法,具有创伤小、恢复快的优点。     

Mesohepatectomy as an option for the treatment of central liver tumors

BACKGROUND: Despite substantial improvements in intra- and postoperative management of extended hemihepatectomy as the curative option for treatment of central liver tumors, the high morbidity and mortality rates accompanying the procedure still represent major obstacles. Mesohepatectomy preserves up to 35% more functional liver tissue than extended hepatectomy, but it has not been widely applied, perhaps because of its complexity as a resection method. STUDY DESIGN: Forty-eight consecutive patients (29 men and 19 women) with centrally located liver tumors underwent mesohepatectomy. Peri- and postoperative morbidity and mortality rates were prospectively evaluated and analyzed. Mean age of the patients was 60.7 years. Indications for mesohepatectomy were liver metastasis (n = 29), hepatocellular carcinoma (n = 5), gallbladder carcinoma (n = 4), cholangiocellular carcinoma (n = 4), hemangioma (n = 2), and other benign diseases (n = 4). RESULTS: Mean operative time was 238 minutes (range 65 to 480 minutes) and mean intraoperative blood loss was 1,120 mL (range 100 to 5,000 mL). Mean amount of intraoperative red blood cells and fresh frozen plasma transfusion was 3.6 U (range 1 to 12 U) and 3.8 U (range 2 to 14 U), respectively. Mean postoperative hospitalization was 15.8 days (range 6 to 104 days). Postoperative surgical complications were seen in 18.8% of patients (n = 9) and included liver failure (n = 1), intraabdominal abscess (n = 1), bilioma or bile leakage (n = 4), hemorrhage and hematoma (n = 2), peritonitis because of intestinal perforation (n = 1), and wound infection (n = 1). One patient (2%) died in the early postoperative phase from portal vein bleeding and disseminated intravascular coagulation, followed by liver failure. CONCLUSIONS: Compared with extended liver resection, mesohepatectomy clearly leads to less parenchymal loss. Although it is a technically difficult operation and requires special attention to prevent surgical complications, it is justified in selected patients with centrally located tumors and is a feasible and safe alternative to extended liver resection.     

完全腹腔镜肝Ⅶ段肿瘤切除术10例报告

目的：探讨完全腹腔镜肝Ⅶ段肿瘤手术切除的可行性、安全性和手术技巧。方法回顾性分析2013年6月－2014年3月期间我院行完全腹腔镜下肝Ⅶ肿瘤切除10例患者的临床资料,其中原发性肝细胞癌8例、结肠癌肝转移1例、肝局灶性结节增生1例。术前均进行肝功能评估、CT三维血管成像确定肿瘤肝段位置及周围重要血管情况并进行手术规划,术中均采用超声刀、钛夹或Hem-o-lok 等断肝。结果10例患者均成功实施完全腹腔镜下肝Ⅶ段肿瘤切除术,手术时间105～215 min,失血量50～500 ml,术中未出现严重并发症,术后均康复出院,术后平均住院时间7．0 d。术后随访除1例原发性肝癌破裂患者术后约2月腹膜转移外,其余9例均未见复发。结论术前全面评估及手术规划、术中充分游离暴露肝脏肿瘤及腹腔镜下精准断肝技术是成功施行完全腹腔镜肝Ⅶ段切除术的重要保证。     

Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: initial experience

OBJECTIVE: To prove the feasibility of hand-assisted laparoscopic liver resection for tumors located in the posterior portion of the right hepatic lobe. SUMMARY BACKGROUND DATA: Use of laparoscopic liver resection remains limited due to problems with technique, especially when the tumor is located near the diaphragm, or in the posterior portion of the right lobe. METHODS: Between October 2001 and June 2002, a total of 7 patients with solid hepatic tumors involving the posterior portion of the right lobe of liver underwent hand-assisted laparoscopic hepatectomy with the HandPort system at our hospital. Surgical techniques used included CO2 pneumoperitoneum and the creation of a wound on the right upper quadrant of the abdomen for HandPort placement. The location of tumor and its transection margin were decided by laparoscopic ultrasound. The liver resection was performed using the Ultrashear without portal triad control, with the specimens obtained then placed in a bag and removed directly via the HandPort access. RESULTS: The 5 male and 2 female patients ranged in age from 41 to 76 years (mean 62.3 +/- 14.4). Surgical procedures included partial hepatectomy for 6 patients and segmentectomy for one, all successfully completed using a variant of the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 140.7 +/- 42.2 minutes (90-180). The blood loss during surgery was 257.1 +/- 159 mL (250-500), without any requirement for intraoperative or postoperative transfusion. Pathology revealed hemagioma (n = 2), colon cancer metastasis (n = 2), and hepatocellular carcinoma (n = 3). There were no deaths postoperatively, with 1 patient suffering bile leakage. Mean hospital stay was 5.3 +/- 1.3 days postsurgery. CONCLUSION: The results of this study suggest that laparoscopic liver resection using the HandPort system is feasible for selected patients with lesions in the posterior portion of the right hepatic lobe requiring limited resection. Individuals with small tumors may benefit; because a large abdominal incision is not required, the wound-related complication rate might be reduced.     

Laparoscopic liver resection assisted with radiofrequency

BACKGROUND: Radiofrequency-assisted laparoscopic liver resection is reported. METHODS: Patients suitable for liver resection were carefully assessed for laparoscopic resection. Patient and intraoperative and postoperative data were prospectively collected and analyzed. RESULTS: Eighteen patients underwent laparoscopic liver resection. All operations were performed without vascular clamping and consisting of tumorectomy (n = 9), multiple tumoretcomies (n = 2), segmentectomy (n = 2), and bisegmentectomies (n = 2). Mean blood loss was 121 +/- 68 mL, and mean resection was time 167 +/- 45 minutes. There was no need for perioperative or postoperative transfusion of blood or blood products. One patient developed pneumothorax during surgery as a result of direct puncture of pleura with the radiofrequency probe, and 1 patient had transient liver failure and required supportive care after surgery. The mean length of hospital stay was 6.0 +/-1.5 days. At follow-up, those with liver cancer had no recurrence. CONCLUSIONS: Radiofrequency-assist laparoscopic liver resection can decrease the risk of intraoperative bleeding and blood transfusion.     

腹腔镜肝切除术11例临床报告

目的:探讨腹腔镜肝切除术的适应证和可行性。方法:回顾分析10例病灶位于肝脏边缘及左肝外叶(Ⅱ～Ⅵ段)及1例位于Ⅷ段的肝占位患者的临床资料。其中原发性肝细胞癌8例,肝海绵状血管瘤2例,胆管细胞癌1例,肝功能Child-Pugh评分A级9例,B级2例;AFP(+)7例;位于左肝外叶实质中的肿瘤,行规则性左肝外叶切除;位于肝脏边缘或右肝表面的肿瘤,行肝脏局部切除。结果:11例均成功完成腹腔镜肝切除术,无中转开腹。其中局部切除术7例,左肝外叶切除术4例,腹腔镜脾切除+胆囊切除术2例。平均手术时间105min,术中平均出血220ml,切除病灶最大直径10cm。全部肿瘤均完整切除,肿瘤包膜完整,无破裂。术后未发生胆漏和出血等并发症,恢复良好,术后平均住院8.5d。结论:位于肝脏边缘、右肝表面或左半肝(Ⅱ～Ⅵ段)的肝脏占位,行腹腔镜肝切除术是安全可行的。     

腹腔镜肝癌切除术中应用射频凝血器断肝的价值

目的:评价腹腔镜肝癌切除术中应用射频凝血器断肝的临床效果。方法:回顾性分析2011年7月—2015年12月行完全腹腔镜肝癌切除手术45例患者的临床资料,根据断肝器械不同将患者分为观察组(20例,射频凝血器断肝)和对照组(25例,超声刀断肝),比较两组相关临床指标。结果:观察组与对照组比较,手术时间无统计学差异(P0.05);术中出血量[(325.00±111.80)m L vs.(628.00±119.09)m L)]、输血患者比例(3/20vs.11/25)、术后24 h腹腔引流量[(110.00±57.95)m L vs.(334.40±209.56)m L]均明显降低(均P0.05);术后肝功能指标、住院时间、并发症发生率及住院费用均无统计学差异(均P0.05);术后总生存率(75.0%vs.72.0%)差异无统计学意义(P0.05),但无瘤生存率(75.0%vs.36.0%)明显升高(P0.05)。结论:在腹腔镜肝癌手术中,应用射频凝血器断肝可有效减少出血,减少术后并发症,提高无瘤生存率,近期效果优于术中使用超声刀者。     

Laparoscopic liver resection for hepatocellular adenoma

AIM:To investigate the role of laparoscopy in the surgical management of hepatocellular adenoma(HA). METHODS:We reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA. RESULTS:Thirteen patients underwent fifteen pure laparoscopic liver resections for HA(male/female:3/10; median age 42 years,range 22-72 years).Two patients with liver adenomatosis required two different laparoscopic operations for ruptured adenomas.Indications for surgery were:symptoms in 12 cases,need to rule out malignancy in 2 cases and preoperative diagnosis of large HA in one case.Symptoms were related to bleeding in 10 cases,sepsis due to liver abscess following embolization of HA in one case and mass effect in one case(shoulder tip pain).Five cases with ruptured bleeding adenoma required emergency admis-sion and treatment with selective arterial embolization. Laparoscopic liver resection was then semi-electively performed.Eight patients(62%)required major hepatectomy[right hepatectomy(n=5),left hepatectomy (n=3)].No conversion to open surgery occurred.The median operative time for pure laparoscopic procedures was 270 min(range 135-360 min).The median size of the excised lesions was 85 mm(range 25-180 mm). One patient with adenomatosis developed postoperative bleeding requiring embolization.Mortality was nil. The median hospital stay was 4 d(range 1-18 d)with a median high dependency unit stay of 1 d(range 0-7 d). CONCLUSION:The laparoscopic approach represents a safe option for the management of HA in a semi-elective setting and when major hepatectomy is required.     

Laparoscopic surgery for benign lesions of the pancreas

Background: Minimally invasive pancreatic surgery, although known to be feasible and safe, is still not considered a standard procedure. We report our experience with laparoscopic pancreatic surgery in a retrospective case series. Materials and Methods: Fifteen consecutive patients (3 male, 12 female) underwent primarily laparoscopic pancreatic surgery from February 2000 to June 2005. Histologically confirmed diagnoses were: neuroendocrine pancreatic tumors (n = 11), adult nesidioblastosis (n = 1), serous cystadenoma (n = 1), and pseudocysts due to chronic pancreatitis (n = 2). Results: Enucleation (n = 3) or left pancreatic resection with spleen preservation (n = 6) was performed laparoscopically in 9 patients. The mean (+/-standard deviation) operative time was 173 +/- 48 minutes (range, 120-250 minutes) and the mean postoperative hospital stay was 5.5 +/- 1.2 days (range, 5-8 days) for the laparoscopic cases. Conversion to open surgery was necessary in 6 patients because of: closeness of the lesion to the portal/mesenteric vein (n = 3), inadequate intraoperative tumor localization (n = 2), or stapler device dysfunction (n = 1). In these patients, open enucleation (n = 1), middle segment pancreatectomy (n = 2), left pancreatic resection (n = 2), and pylorus-preserving Whipple resection (n = 1) were performed. The mean operative time was 268 +/- 74 minutes (range, 150-360 minutes) with a mean postoperative hospital stay of 8 +/- 2 days (range, 6-10 days). Both operative time and hospital stay were significantly longer in patients with secondary open surgery compared to patients with successful laparoscopic operations. Conclusion: Laparoscopic enucleation or distal pancreatectomy with spleen preservation for benign lesions located in the body or tail of the pancreas can be performed safely, with all the potential benefits of minimally invasive surgery. Preoperative tumor localization is of utmost importance to limit pancreatic mobilization and to avoid blind pancreatic resection and conversion to open surgery.     

完全腹腔镜肝部分切除术临床体会

目的总结20例完全腹腔镜肝切除术手术经验,阐述其技术要点和效果。方法回顾性分析2011年4月至2013年11月间我院20例完全腹腔镜肝切除术患者的临床资料。其中肝左叶部分切除15例,肝右叶部分切除5例。术前应用肝功能Child分级、ICGR15评估肝储备功能及cT三维成像评估肝肿瘤周围血管情况,术中根据肝脏病灶部位选择手术径路,应用超声刀、钛夹、LigaSure、Endo—GIA等多种断肝方法行完全腹腔镜肝部分切除。结果20例患者均成功施行完全腹腔镜下肝部分切除术,手术时间105—215min,出血量50～500ml,术中未出现严重并发症,术后均顺利恢复,术后平均住院日为7．5d。除2例原发性肝癌患者分别于术后随访5个月、12个月发现肿瘤复发外,其余原发性肝癌患者尚未见复发,良性病变患者无症状再发。结论术前进行肝功能及影像学评估、术中选择合适的手术入路及灵活应用各种断肝器械是成功施行完全腹腔镜肝部分切除术的保证。