腹腔镜下规则性肝切除

肝脏外科实际上是外科手术与肝脏解剖的有机结合。由于对肝解剖缺乏认识,20世纪40年代以前的肝切除均为非规则性的局部切除。50年代中期．Goldsmith和Woodburne强调肝切除应严格遵循肝脏内部的解剖．提出了规则性肝切除术的概念。特别是Couinand提出肝功能性分段以来,规则性肝切除得以迅速发展。欧美国家的肝肿瘤多为转移性、无肝硬化,所以一直沿着这一方向发展。     

腹腔镜肝切除16例临床分析

目的　探讨腹腔镜肝切除手术的解剖基础与技术问题。　方法　选择病灶位于肝脏边缘、右肝表面或左半肝且肝功能Child分级B级以上 1 6例 ,其中原发性肝癌 8例 ,肝血管瘤 3例 ,左肝管胆管癌、肝细胞腺瘤、局灶性结节性增生、肝脓肿和肝囊肿伴感染各 1例。在上腹部放置 4～ 6个Trocar,应用电刀、超声刀和腔内直线形切割钉合器等多种断肝方法 ,采用钛夹夹闭、医用生物蛋白胶粘封等处理肝断面。　结果　对 1 6例在全气腹条件下完成 1 8个病灶的腹腔镜肝切除手术 ,包括左肝规则性切除 8例 ,肝局部切除 8例。手术时间 (2 0 6± 75 )min ,出血量 (35 4± 2 82 )ml,2例出血 1 0 0 0ml,术中输血 80 0ml。腹腔引流管放置时间 2天～ 4天 ,术后未发生胆漏和出血等并发症 ,术后住院 (5 8± 1 6 )天。　结论　腹腔镜肝切除手术的关键是恰当处理要切除肝的蒂部脉管 ,对次级肝门脉管的解剖分离是行肝段或左半肝切除时控制出血的关键     

腹腔镜肝癌切除术11例临床报告

目的　探讨腹腔镜肝癌切除手术的可行性与适应症。方法　 2 0 0 2年 7月～ 11月 ,经临床筛选病灶位于肝脏边缘、右肝表面或左半肝的病例 11例 ,HBs Ag(+ ) 7例 ,HCVAb(+ ) 2例 ,有肝硬变者 10例 ,肝功能 Child分级 A级 6例、B级 5例 ,AFP(+ ) 4例。病灶直径大小 1.8～ 6.0 cm,平均 3 .8± 1.7cm。对于肿瘤位于左半肝实质中的肿瘤 ,选行规则性左肝切除 ;对于肿瘤位于肝脏边缘或右肝表面时 ,选用肝脏局部切除术。结果　全部 11例均成功地在完全腹腔镜下完成肝切除术 ,切除范围包括局部切除 7例 ,左肝解剖性切除 4例 ,左半肝切除 1例、左外叶切除 2例、肝方叶切除 1例。全部肿瘤完整切除 ,肿瘤包膜完整 ,无破裂。手术时间 90～ 3 2 0分钟 ,平均 2 10 .9± 71.9分钟 ,出血量 5 0～ 10 0 0 ml,平均 4 4 3 .6± 3 3 0 .5 m l。切除肝体积最大 12 cm× 8cm× 6cm3、最小 3 cm× 3 cm× 2 cm。术中未出现不能控制的并发症 ,腹腔引流管放置时间 2～ 4天。术后未发生胆漏和出血等并发症 ,术后恢复顺利 ,术后平均住院 6.4天。结论　本组研究表明腹腔镜肝癌切除术是安全可行的 ,腹腔镜肝切除的适应证可适当放宽至右肝表面或左半肝的肝癌的首选的术式     

腹腔镜解剖性肝切除技术研究

目的　介绍完全腹腔镜下解剖性肝切除技术。方法　完全腹腔镜下解剖、阻断相应肝段、肝叶的入、出肝血流,按解剖学标志切除肝段、肝叶共35例,其中原发性肝癌16例、肝脏血管瘤11例、其它8例。结果　35例手术在完全腹腔镜下完成,左半肝切除( 、、段) 7例、左外叶( 、段)切除14例、肝方叶( 段)切除1例、右前叶下段( 段)切除2例、右后叶下段( 段)切除3例、右叶下段( 、段)切除4例、右后叶( 、段)切除3例、右前叶下段并右后叶( 、、段)切除1例。手术时间2 6 7.77±12 2 .6 9m in,出血量4 80 .0 0±5 75 .90 m l。术后住院5 .6 7±2 .0 6天。未发生胆漏、出血、感染等并发症。结论　在现有条件下,腹腔镜解剖性肝切除较好地解决了腹腔镜下肝段以上肝切除时出血、气栓等问题,可安全用于左半肝及肝右叶部分肝段的切除。     

完全腹腔镜规则性肝切除的解剖基础与技术问题

目的探讨腹腔镜规则性肝切除的解剖基础与技术问题。方法 2 0 0 2年 7月至2 0 0 2年 11月 ,治疗原发病灶位于左半肝但未侵及左肝门的原发性肝癌 4例、肝血管瘤 2例、肝囊肿伴感染 1例。肝切除步骤包括显露第 1肝门 ,游离肝周韧带 ,解剖并离断 2、3级肝门 3管 ,解剖第 2肝门并夹闭肝左静脉 ,离断肝实质和切断肝左静脉。结果 7例完全在腹腔镜下完成手术 ,左半肝切除 2例、左外叶切除 4例、肝方叶切除 1例。均成功地在矢状部对 2至 3级肝门的 3管进行解剖和离断。手术时间为 15 0～ 32 0min ,平均 (2 5 3± 5 9)min。出血量 2 0 0～ 10 0 0ml,平均 (4 5 0± 2 6 1)ml。结论腹腔镜规则性左肝切除术是安全可行的 ,对 2级肝门 3管的解剖和离断是行肝段或左半肝切除时控制出血的关键。     

腹腔镜肝切除技术的综合评价

外科微创化是21世纪外科的发展趋向，而腹腔镜外科是微创外科的重要组成部分。随着技术的逐渐成熟和临床经验的不断积累，目前腹腔镜技术已广泛应用于胆囊切除术、胃肠道和盆腔器官手术。但由于肝脏解剖及生理特点的特殊性和技术器械的局限性，腹腔镜肝切除术(laparoscopic hepatectomy，LH)一直被看作是危险的高技术手术，比传统的开腹肝切除手术更具危险性，因而发展比较缓慢，     

完全腹腔镜肝切除的临床应用价值(附123例经验总结)

目的:探讨完全腹腔镜肝切除(total laparoscop ic hepatectomy,TLH)的临床应用价值。方法:2002年7月~2006年9月,我院完成完全腹腔镜肝切除123例,其中男83例,女39例,平均48.2(22~69)岁。手术方式包括:解剖性切除65例,局部切除58例。结果:手术时间(105~280)m in,平均(201.5±100.5)m in。出血量50~1 500m l,中位数210m l。123例患者中21例输血,输血量400~1 000m l。切除肝体积最大18 cm×16 cm×12 cm,病灶直径1.8~17.0 cm,平均(7.4±2.5)cm。术后平均住院2~14d,平均(4.5±1.5)d。2例出现少量胆漏,经引流,术后第5天愈合。病理报告恶性病变52例,良性病变71例。结论:TLH在一定条件下是治疗某些疾病安全、有效的方法。     

腹腔镜肝切除术的可行性

目的探讨腹腔镜肝切除手术的可行性. 方法 2002年7月～2004年2月行完全腹腔镜肝切除44例,其中原发性肝细胞癌22例、肝血管瘤10例、肝脓肿3例、肝囊肿伴感染1例、肝脏局灶结节性增生3例、肝脏腺瘤1例、胆管囊腺瘤1例、炎性肉芽肿1例、肝门部胆管癌1例、高分化胆管细胞癌1例.肝功能Child分级A级38例,B级6例(均为肝癌病人). 结果腹腔镜下完成肝局部切除17例、左肝规则性切除14例、右肝规则性切除13例.手术时间15～450 min,平均195 min.出血量50～1 500 ml,平均405 ml.输血量0～1 000 ml,平均175 ml.术后恢复顺利,术后住院2～9 d,平均5.6 d.结论腹腔镜肝切除术安全可行,不仅适于肝良性肿瘤,也为肝脏恶性肿瘤提供了切除肿瘤的新途径.     

完全腹腔镜下肝切除60例手术经验

腹腔镜肝切除术具有创伤小,术后恢复快的优点,本研究行完全腹腔镜下肝切除术60例,59例手术获成功,1例因门静脉分叉处牵拉破裂致大出血中转开腹。腹腔镜肝切除术要具有熟练的腹腔镜下操作基本技术,开展单位要有精良可靠的腹腔镜下手术操作器械,助手的配合及正确合理选择使用恰当的手术器械也很重要。     

经腹腔镜左肝切除五例

目的 探讨腹腔镜解剖性左肝切除手术的临床经验。方法 经临床筛选病灶位于左半肝的病例5例，其中原发性肝癌3例、肝囊肿伴感染1例、肝血管瘤1例。应用电刀、超声刀和腔内直线形切割缝合器等多种断肝方法，采用钛夹夹闭、医用生物蛋白胶粘封等肝断面处理方法，在全气腹条件下经腹腔镜行左半肝切除2例，左外叶切除2例，肝方叶切除1例。结果 5例均在腹腔镜下完成肝切除手术，对各肝段的脉管先进行解剖分离，然后进行处理是手术控制出血的关键。使用垃圾袋将标本取出。术中未出现不能控制的并发症，腹腔引流管放置时间2～4d。术后未发生胆漏和出血等并发症，恢复顺利，术后平均住院7d，术后恢复时间较常规开腹方法肝切除病人明显缩短。结论 对位于左半肝的病灶，采用多种方法相结合行腹腔镜解剖性左肝切除手术是安全可行的手术方式，特别是创伤小的优点给伴有严重肝硬化而不能耐受开腹手术者提供了切除肿瘤的新途径。     

ONE HUNDRED LIVER RESECTIONS INCLUDING COMPARISON TO NON-RESECTED LIVER-MOBILIZED PATIENTS

Background : Factors of liver resection associated with postoperative recovery and survival, the modalities that affect survival with resected colorectal carcinoma liver metastases, the comparison of liver function of liver-resected to liver-mobilized but not resected patients, and observation of early liver regeneration volume over time have not been studied prospectively. This study aimed to prospectively analyse these factors. Methods : Data were collected prospectively on 100 consecutive liver resections, and 10 liver-mobilized but not resected patients by the Hepatobiliary Unit, University of Melbourne, Austin Campus. Follow-up of patients was 100%. Results : The factors associated with blood loss were the type of liver resection (P= 0.0001), the length of the operation (P= 0.0001) and a central venous pressure greater than 5 cm of water (P= 0.0008). An inverse correlation existed between blood loss and long-term survival (P= 0.003). The only predictor for a postoperative complication was the length of the operation (P= 0.03): a correlation of moderate significance existed between blood loss and a complication (P= 0.052; confidence interval 0.19–1.17). The 5-year cumulative survival for hepatic resection for colorectal carcinoma Dukes A + B was 55%; there was a significantly better survival of Dukes A + B compared to Dukes C (P= 0.03) and also for those 50 years or older, but this did not depend on whether there were one or more lesions present. Resected patients had a significantly higher alanine transaminase (ALT), total bilirubin and international normalized ratio than non-resected patients, but not albumin, total protein, alkaline phosphatase or aspartate aminotransferase. The serum albumin fall was similar in both groups, which indicated that loss of liver tissue was not the cause. The re-resection rate was 8% without mortality and with low morbidity. Liver volume was restored by 64% (510± 170cc) by 7 days postoperatively. Conclusions : Major hepatic resection can be performed with low mortality, morbidity and short hospital stay, with a 5-year survival for colorectal carcinoma better than 50%. Resection needs to be considered more frequently for curative management. Serum albumin fall is not caused by loss of liver tissue and blood loss can be controlled by central venous pressure manipulation and vascular isolation. Re-resection is a safe and rewarding treatment and needs to be planned at the first resection.     

AN INITIAL EXPERIENCE WITH A POSTERIOR INTRAHEPATIC APPROACH FOR LIVER RESECTIONS

This is a report of an initial experience using a recently devised posterior approach to the intrahepatic Glissonian sheaths of the liver, for the purpose of hepatic resections. Between February 1991 and October 1903. 22 patients. median age 58 years (range 36–77) underwent either a right or a left hepatectoiny or a segmentectomy procedure of the liver using this technique. Seventeen of these patients underwent this operation for malignant disease of the liver. Median operating time was 930 min (range 100–285) with nine of the 22 patients requiring an intra-operative blood transfusion. There was one postoperative death, from liver failure, and 17 of the patients were alive at the early time of reporting. It is concluded that this technique is a useful addition to the surgeon's armamentarium for operating on the liver.     

手助腹腔镜左肝大肝癌切除22例

目的探讨手助腹腔镜左肝大肝癌切除的可行性和安全性。方法对病变位于左肝的22例大肝癌病人,肝细胞癌19例,肝内胆管细胞癌2例,肝转移性鳞癌1例。采用手助腹腔镜行规则性左半肝或肝左外叶切除术。结果22例手助腹腔镜肝切除均获得成功,肝左外叶切除18例,左半肝切除4例,术中13例行肝门阻断,平均阻断时间15.5 min,平均手术时间为103.2 min,平均出血量106 ml,瘤体大小平均7.8 cm,切除的肝组织最长径平均10.2 cm,术后无严重并发症发生,术后平均进食时间为2.5 d,术后平均住院日为8 d。结论只要病例选择得当,手助腹腔镜左肝大肝癌切除是安全可行的。     

RESECTION OF ANATOMICAL SEGMENTS OF THE LIVER

The aim of this report is to review recent experience of removal of anatomical segments of the liver. Resection of one or more segments of the liver was undertaken in 49 patients; in 32 patients, the resection was for malignant disease and in the remainder it was for benign disease. Operating time was 130 (60–600) min and the median transfusion requirement was 0 (0–15) units, with 31 patients having a resection without the need for a blood transfusion. There was no postoperative or in-hospital mortality. The removal of anatomical segments of the liver is a very useful technique for the safe removal of benign and malignant lesions.     

肝部分切除结合囊肿开窗术治疗严重成人多囊肝的疗效分析

目的 探讨肝部分切除结合囊肿开窗术治疗严重成人多囊肝的疗效.方法 回顾性分析近期2例严重成人多囊肝的临床、影像学资料及手术疗效.结果 2例多囊肝采用肝部分切除结合囊肿开窗术治疗术后即时及远期疗效良好.结论 肝部分切除结合囊肿开窗术治疗严重成人多囊肝安全有效,远期疗效好,可作为该类疾病的首选治疗方法.     

腹腔镜肝癌切除术28例报告

目的探讨腹腔镜肝癌切除术的适应证和可行性。方法回顾性分析2002年3月至2007年10月完成的腹腔镜肝癌切除术28例患者临床资料。结果28例均成功在腹腔镜下完成手术。对于位于肝左外叶的肿瘤,选择规则性肝左外叶切除术;肿瘤位于肝脏边缘或右肝表面时,选择肝脏不规则切除术。平均手术时间95min（60～150min）。平均术中出血345ml（50～800ml）。切除标本最大体积11cm×9cm×7cm。患者术后24h均能下床活动,术后2～3d即能进食。术后平均住院时间8d（5～15d）。术后病理诊断为原发性肝细胞癌24例,结直肠癌肝转移4例。结论对位于肝脏边缘、右肝表面或者左肝外叶的肝癌行腹腔镜肝癌切除术是安全可行的。     

Laparoscopic hepatectomy, a systematic review

This systematic review was undertaken to assess the published evidence for the safety, feasibility and reproducibility of laparoscopic liver resection. A computerized search of the Medline and Embase databases identified 28 non-duplicated studies including 703 patients in whom laparoscopic hepatectomy was attempted. Pooled data were examined for information on the patients, lesions, complications and outcome. The most common procedures were wedge resection (35.1%), segmentectomy (21.7%) and left lateral segmentectomy (20.9%). Formal right hepatectomy constituted less than 4% of the reported resections. The conversion and complication rates were 8.1% and 17.6%, respectively. The mortality rate over all these studies was 0.8% and the median (range) hospital stay 7.8 days (2-15.3 days). Eight case-control studies were analysed and although some identified significant reductions in-hospital stay, time to first ambulation after surgery and blood loss, none showed a reduction in complication or mortality rate for laparoscopically carried out resections. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by appropriately skilled surgeons. Further work is needed to determine whether these conclusions can be generalized to include formal right hepatectomy.     

急诊手助式腹腔镜肝切除治疗原发性肝癌破裂出血

目的 分析总结原发性肝癌破裂出血时急诊行手助式腹腔镜肝切除的方法和经验.方法 回顾性分析15例急诊行手助式腹腔镜肝切除手术治疗的原发性肝癌破裂出血病例的临床资料.结果 15例原发性肝癌破裂出血的病例均顺利完成手术,无手术死亡.13例获得随访,生存时间11～56个月.1、3年生存率分别为84.6%(11/13)、53.8%(7/13).结论 在经过临床选择的病例中,急诊手助式腹腔镜肝部分切除术治疗原发性肝癌破裂出血是安全可行的,疗效显著,如患者的病情允许可作为首选.