解剖性与非解剖性肝切除术的选择

正周俭,徐泱(复旦大学附属中山医院肝肿瘤外科)在现代"精准外科"的理念下,解剖性肝切除日益受到推崇,其定义是完整切除解剖上相对独立的肝段、亚段或联合肝段的切肝技术。相对于非解剖性肝切除术,解剖性肝切除在切除病灶的同时,一并切除了相应门静脉分支流域的肝段,理论上可以降低肿瘤随门静脉血流在荷瘤肝段播散转移的风险,并可减少术后并发症的发生。但是否精准肝外科必须行解剖性肝切除,非解剖性肝切除就一定是不"精     

腹腔镜解剖性肝叶切除术治疗肝良恶性病变

目的探讨腹腔镜下解剖性肝叶切除术治疗肝良恶性病变的安全性、可行性.方法对2005年1月至2010年2月在我院行腹腔镜下解剖性肝部分切除术的67例患者进行可行性及疗效分析,并对其临床效果进行观察.结果67例完全腹腔镜下解剖性肝叶切除术均获得成功,平均手术时间(50.6±16.2)min;术中平均出血量(220.8±76.5)ml.术中无需阻断肝门血流,术后无并发症发生.术后48 h均能下床活动,术后1～3 d即能进食.术后住院5～7 d,平均(6.6±1.1)d;总住院费用(30767.4±150.1)元.结论对位于肝左叶、右肝表面、肝右叶下段的良恶性病灶,行腹腔镜下解剖性肝叶切除术是安全和可行的,且具有创伤小恢复快的特点,值得临床推广应用.     

腹腔镜解剖性肝叶切除术

自从1987年腹腔镜胆囊切除术开展至今,腹腔镜技术已经涉及腹部外科的所有脏器手术。在肝脏外科,由于腹腔镜器械设备的不断更新,腔镜手术技巧的不断提高,腹腔镜手术范围逐渐从肝脏肿瘤的诊断或活检、肝囊肿开窗引流扩展到肝脏部分切除直至目前的肝叶解剖性切除。近年来,解剖性肝叶切除术仅在少数几个腹腔镜中心开展,现将腹腔镜解剖性肝叶切除术的有关问题做一论述。一、腹腔镜解剖性肝叶切除术适应证的选择对于肝脏原发性恶性肿瘤,肿瘤的部位和大小是能否行腹腔镜解剖性肝叶切除术的关键。一般认为病灶位于左外叶、左内叶前段以及Ⅴ段和Ⅵ段…     

机器人解剖性右肝后叶切除术

目的探讨应用达芬奇机器人行解剖性右肝后叶切除术的可行性、安全性及优势。 方法选取南华大学附属第一医院于2020年12月收治的1例61岁男性肝肿瘤患者，腹部增强CT及MRI提示肝S6、S7段肝细胞癌可能，肿瘤大小约80 mm×60 mm。评估无明显手术禁忌证后，经充分术前准备，拟在全身麻醉下行机器人解剖性右肝后叶切除术，围手术期实施加速康复外科管理模式。 结果手术顺利，手术时间约150 min，术中出血量约100 mL，术后无肝衰竭、出血、感染等并发症，术后7 d出院。术后病理示肝细胞癌，切缘均为阴性，术后4个月和10个月复查CT未见肿瘤复发、转移征象。 结论机器人行解剖性右肝后叶切除术是安全、可行的。     

肝尾状叶切除术

迄今,肝尾状叶切除仍然被许多肝胆外科医生视为禁区。诚然,在缺乏经验和条件之时,不可贸然进行肝尾叶切除,然而尾叶切除却并不神秘。在熟悉其解剖关系、掌握适当的手术器械与技巧和一定的肝手术经验之后,就能够安全地开展尾叶切除。肝尾状叶前面为第一肝门所遮盖,后面则为下腔静脉,其上端紧邻三支肝静脉。可以说,肝尾叶是被第一、第二、第三肝门所包围,因此尾叶的切除难度高,风险大。国内外文献报告累计仅百余例。1994年至今,我们已经施行了52例,其中12例为单独完整的尾叶切除,均获成功。局部解剖肝尾状叶即肝段解剖的Ｉ段,具有独立的管道系…     

解剖性肝切除术研究进展

解剖性肝切除术是目前国际上治疗原发性肝癌的首选手术方式。本文从解剖性肝切除术的理论基础、适应证、实施要点、检验标准、腔镜解剖性肝切除术以及术后近远期疗效几个方面对解剖性肝切除术研究进展进行综述。     

腹腔镜解剖性肝切除术

虽然全球第一例开腹肝切除术始于1949年,直至1967年Gauinand的肝脏功能性分区和分段的问世,才为肝脏手术发展奠定了解剖学基础[1]。而腹腔镜肝切除术（laparoscopic hepatectomy,LH）尽管始于很晚的1991年,国内则1994年后才相继开展,但由于早年先驱学者的研究成果,以及影象学、     

完全腹腔镜下肝外Glisson鞘内解剖性肝切除术

目的探讨肝外Glisson鞘内解剖选择性阻断入肝血流在完全腹腔镜解剖性肝切除术中的应用价值。方法回顾性分析2018年1月~2019年7月34例完全腹腔镜下解剖性肝切除的临床资料。于肝外解剖Glisson鞘,鞘内解剖出肝动脉及门静脉,预先阻断预切除肝脏入肝血流。结果均在腔镜下完成手术,行右半肝切除12例,左半肝切除12例,右后叶切除3例,左肝外侧叶切除7例,无中转开腹。手术时间(2.7±0.6)h,术中出血量(414.7±194.0)ml,9例(26.5%)输血,术后常规不留置胃管,肛门排气时间(3.3±0.6)d,术后住院时间(8.2±3.4)d,无死亡。并发症包括腹水2例,肺部感染1例。34例随访时间1~18个月,平均8.8月,无肿瘤及结石复发。结论肝外Glisson鞘内解剖选择性阻断入肝血流操作相对简单、安全,可常规应用于完全腹腔镜下解剖性肝切除。     

“门理论”在微创解剖性肝切除术中的应用与展望

“门理论”由Atsushi Sugioka基于Laennec膜解剖结构提出,目前在肝胆外科领域得到了广泛的关注和应用。该理论通过定位肝蒂的“门”,并在此基础上实现肝蒂的快速、精准、安全的阻断,从而显著提高了肝切除手术的效率,并提升了手术的安全性和有效性。但由于生理和解剖的个体差异以及临床需求的多元性,经典的"门理论"在具体实施中难免存在一定的局限性。为此,南方医科大学南方医院肝胆外科团队提出了“泛门理论”该理论强调在遵循个体差异的基础上,以手术需求为导向,灵活设定并贯通“所想所需”的“门”,从而实现更精准的、个体化的微创解剖性肝切除（MIALR）。该理念在实践中得到了有效的验证,特别是在处理右侧肝蒂的解剖和手术中,表现出了较好的效果和优势。“门理论”为MIALR提供了重要的理论基础和技术支持,但仍需在实践中不断完善和发展,以适应不断变化和发展的外科新技术和新理念,实现真正意义上的精准医疗。     

解剖性和非解剖性肝切除对肝细胞癌患者预后的影响

目的：探讨解剖性肝切除和非解剖性肝切除对肝细胞癌患者预后的影响。方法62例肝细胞癌患者,其中33例采用解剖性肝切除术进行治疗（AH组）,29例采用非解剖性肝切除术进行治疗（IH组）;记录手术情况和血红蛋白（Hb）损失量。术后采取患者空腹静脉血,检测肝细胞癌AFP mRNA表达;并记录复发率、死亡率及并发症情况。结果 AH组的平均手术时间显著高于IH组,但术中出血量和手术Hb损失量显著低于IH组（P＜0．05）;两组患者的AFP mRNA表达水平和术后复发率差异无统计学意义（P ＞0．05）,AH组的近期死亡率稍低于IH组（P＜0．05）,但远期死亡率与IH组相仿（P ＞0．05）;在并发症方面,总发生率差异无统计学意义（P ＞0．05）,但AH组以肝功能障碍为主,多发于肝硬化或肝纤维化患者,IH组以腹腔内出血和感染为主,多发生于中心性肿瘤患者。结论解剖性切除术能够有效保护肝细胞癌血管,可改善患者预后,但对于肝脏存在严重病理性损伤患者,存在一定风险,可考虑非解剖性切除术。     

Role of artificial intelligence in hepatobiliary and pancreatic surgery

Over the past decade, enhanced preoperative imaging and visualization, improved delineation of the complex anatomical structures of the liver and pancreas, and intra-operative technological advances have helped deliver the liver and pancreatic surgery with increased safety and better postoperative outcomes. Artificial intelligence (AI) has a major role to play in 3D visualization, virtual simulation, augmented reality that helps in the training of surgeons and the future delivery of conventional, laparoscopic, and robotic hepatobiliary and pancreatic (HPB) surgery; artificial neural networks and machine learning has the potential to revolutionize individualized patient care during the preoperative imaging, and postoperative surveillance. In this paper, we reviewed the existing evidence and outlined the potential for applying AI in the perioperative care of patients undergoing HPB surgery.     

Hepatocyte growth factor: clinical implications in hepatobiliary pancreatic surgery

Hepatocyte growth factor (HGF), originally identified as the most potent mitogen for hepatocytes, is now known to be a cytokine with numerous functions in a wide variety of cells. HGF transduces its various activities via a receptor encoded by the c-met proto-oncogene and coupled to a number of transducers integrating the HGF signal inside the target cells. Extensive investigation has revealed that HGF has various beneficial effects, especially for liver. HGF significantly stimulates regeneration in damaged, as well as in normal liver, ameliorates hepatic fibrosis/cirrhosis; and attenuates various types of liver dysfunction in animals. Moreover, the fascinating data on HGF in experimental liver and islet transplantation suggest that the use of HGF may represent a breakthrough for reducing the shortage of donor livers, and increasing the success rate of insulin independence after islet transplantation. Further understanding of the biological significance of HGF, including that in carcinogenesis, will undoubtedly have important clinical implications in hepatobiliary pancreatic surgery. Received: April 14, 2000 / Accepted: July 20, 2000     

吲哚菁绿荧光成像技术在肝胆外科的应用进展

吲哚菁绿(indocyanine green,ICG)是一种水溶性花青染料,在近红外光激发下可发出荧光。近年来,ICG荧光成像技术在肝胆外科手术中得到广泛应用,尤其在肿瘤检测识别、肝切缘界定、肝段染色定位、胆道显像及胆漏检测等方面具有广阔的前景。此文通过回顾分析PubMed、Embase和Medline数据库中吲哚菁绿荧光成像技术在肝切除术的最新临床研究,结合作者单位实际操作经验,阐述吲哚菁绿荧光成像技术在肝胆外科手术中的应用及研究进展。     

BBT-UT-3300型超声刀在肝胆手术中的应用

目的探讨超声刀在复杂肝胆手术中的临床应用效果。方法对2008年7月至2009年8月60例行肝切除术、胆道探查术、脾切除联合贲门周围血管离断术病人,随机分为超声刀组和对照组,各30例,超声刀组运用超声刀行分离止血及脏器切除,对照组运用常规方法施行手术。两组均观察术中出血量、手术输血量、并发症发生率等。结果超声刀组与对照组相比,术中出血量显著减少[（107±115）ml与（354±3.76）ml,P〈0．05];手术输血量显著减少[{102±123）ml与（356±131）ml,P〈0．01];手术时间显著缩短[（170±36）min与（221±54）min,P〈0．05];并发症发生率低（16．7％与26．7％,P〈0．05）。结论运用超声刀行复杂肝胆手术可有效提高手术安全性,降低手术风险。     

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

INTRODUCTION

The terms ‘enhanced recovery after surgery’, ‘enhanced recovery programme’ (ERP) and ‘fast track surgery’ refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery.

METHODS

A MEDLINE® literature search was undertaken using the keywords ‘enhanced recovery’, ‘fast-track’, ‘peri-operative’, ‘surgery’, ‘pancreas’ and ‘liver’ and their derivatives such as ‘pancreatic’ or ‘hepatic’. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate.

RESULTS

Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study.

CONCLUSIONS

The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.     

门静脉动脉化在肝胆外科中的应用现状与展望

自首次将门静脉动脉化(PVA)用于门静脉高压症患者治疗以来,PVA的概念一直受到关注.在某种特殊形式下,PVA技术在肝胆外科中仍有一定的应用价值.然而,PVA毕竟改变了正常的人体生理解剖关系,对于它在肝胆外科中应用也存在较多争议.文中综述门静脉动脉化在肝动脉切除和(或)损伤、急性肝功能衰竭以及肝移植中的应用现状,并对以后的研究进行初步的展望.

Abstract：

Since portal vein arterialization(PVA) was firstly introduced as a treatment in patients with portal hypertension due to liver cirrhosis, the concept of PVA has drawn much attention. In special situations, in hepatobiliary surgery, this procedure remains useful. However, PVA is unphysiological and there is much controversy on its use.This article reviews the current status of PVA in hepatic artery resection or injury, in acute liver failure and in liver transplantation, and suggests future directions in research in PVA.     

腹腔镜解剖性肝切除手术切面确定原则

精确确定手术切面是规范实施腹腔镜解剖性肝切除的技术难点。与开腹手术相比，腹腔镜肝切除由于缺乏开放手术的触感、操作空间限制等原因，在如何确定解剖性肝切除的手术切面方面，有其特殊性。本文就腹腔镜解剖性肝切除确定手术切面的常用的方法，进行小结。目前主要方法有：(1)循肝脏表面解剖标志；(2)循肝静脉路径；(3)预先控制目标肝段肝蒂，循缺血界面；(4)目标肝段门静脉穿刺染色。这些方法各有优缺点，适用于不同的肝段切除。临床实践应根据实际情况，综合应用。