腹腔镜技术在肝脏外科的拓展应用

手术微创化是当今国际外科学发展的一大趋势,腹腔镜作为微创外科的代表已涉及腹腔所有脏器手术.肝脏是腹腔内最大的实质脏器,具有复杂的解剖结构和重要的生理功能,腹腔镜肝脏手术曾被认为是难度和风险较大的手术.近年来,随着腹腔镜技术的进步和器械的改善,腹腔镜手术在肝脏外科的应用范围逐步拓展.该技术已从早期针对肝脏良性病变的边缘性切除和局部切除拓展应用于肝脏各类良恶性病变的大范围肝切除术、肝脏移植物切取、特殊部位肝切除术及解剖性肝段切除术等复杂手术中.我国是肝病大国,肝癌及肝胆管结石病的发病率及术后复发率均较高,部分患者需要接受再次或者多次肝切除术治疗;肝癌患者多合并不同程度肝硬化,肝胆管结石病患者也易并发肝脏萎缩、纤维化及肝门转位等病变,这些因素在一定程度上影响了腹腔镜手术在肝癌及肝胆管结石病外科治疗中的应用.本文结合笔者单位开展800余例腹腔镜肝切除术的临床体会和相关文献,重点探讨腹腔镜技术在解剖性肝段切除术,尤其是特殊部位肝段的解剖性切除术,合并肝硬化等肝脏基础疾病时的肝切除术,以及再次肝切除术等领域的应用现状和最新进展.     

精准右半肝联合尾状叶肿瘤切除术治疗肝尾状叶巨大肿瘤

巨块型肝癌体积较大,其周围组织和重要管道常受到压迫甚至被侵犯,手术切除一直以来是肝脏外科的难题之一.而尾状叶巨大肿瘤因其特殊的位置和复杂的解剖结构,让众多肝脏外科医师望而却步.近年来随着手术技术不断改进,尤其是精准肝脏外科理念的提出,肝脏外科医师开始使用不同手术方式挑战尾状叶巨大肿瘤的切除.2014年4月安徽省立医院对1例58岁男性肝尾状叶巨大肿瘤患者,运用精准肝切除治疗肝癌关键技术,在未阻断入肝血流的情况下,成功施行了精准右半肝联合尾状叶肿瘤切除术,取得了良好疗效.     

仿真手术在肝脏肿瘤外科诊治中的应用

自从有了腹部外科,外科工作者一直梦想在手术前对肝脏、肝脏内部的血管结构,肿瘤的大小、部位、形态及其与周围脏器的关系有直观和立体的了解.但腹部脏器,特别是肝脏内部结构具有较大的复杂性、变异性和缺乏获得人体脏器信息的手段,成为该领域发展的瓶颈.     

第二肝门区难切性肝脏肿瘤手术方式的临床应用

医学影像学技术的快速发展,对肝脏内部脉管结构的深入了解,新手术设备的推广应用,麻醉临床监管水平的提高使得外科治疗肝脏肿瘤的水平有了长足的进展,肝癌切除后5年生存率达50%以上的报告日渐增多。现就第二肝门区难切性肝脏肿瘤手术的临床应用综述如下。1第二肝门区局部应用解     

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…     

简易区域无血肝切除技术的临床应用

肝脏外科的发展和手术中控制出血方法的发展密切相关,术中出血量与手术成败及手术并发症和死亡率有关,出血量越大,并发症和死亡率越高.为减少肝脏手术中出血及简化切肝技术[1-2],笔者设计并对患者施行了一种简易的切肝技术,报道如下.     

离体肝切除术研究进展

对于需要手术切除的肝脏良恶性疾病,由于其位置侵及肝脏重要管道,难以在体切除.在移植技术的基础上,离体(或半离体)肝切除方法可以完成在体切除风险极大的外科手术.鉴于其高度复杂性及安全性问题,离体肝切除术较外科其他手术进展缓慢.近年来,随着肝脏外科手术技术及器官移植学理论的进步,离体肝切除术取得较大进展.但缺乏临床实践规范...     

肝尾状叶肿瘤切除的技术难点与对策

由于肝尾状叶独特的形态和解剖学结构特点,肝尾状叶肿瘤切除术仍是肝脏外科的难点.安徽医科大学第一附属医院于2011年5月对1例38岁男性肝尾状叶巨大复发性肝癌患者,在阻断第一肝门和肝下下腔静脉情况下施行肝尾状叶肿瘤切除术,但由于术中出血量达1000 ml,被迫中断手术,采取输血、保温等治疗后,施行腔静脉钳阻断下腔静脉右侧壁,完成肝尾状叶肿瘤的完整切除.患者术后恢复良好,随访14个月肿瘤无复发.该例患者的疗效证明:术者需做好充分而准确的术前评估和判断,明确手术适应证,娴熟掌握肝脏外科各项手术技巧,才能安全实施手术.     

根据术前肝脏储备功能选择肝切除术式

近年来肝脏外科取得了快速发展,在大的肝脏外科中心肝切除死亡率＜3%,其主要死因是术后肝功能衰竭[1,2].因此,必须重视对肝切除术前的肝脏储备功能的评估.基于此,对于肝癌合并明显肝硬化、肝脏大块切除术以及大于10 cm的巨大肝癌的切除等[3]复杂肝切除术均要求术前必须提供准确的肝储备功能评估以降低手术后肝衰的风险,并根据术前评估的肝脏储备功能状况,确立肝癌病人的个体化手术治疗方案.     

肝切除断肝器械的选择

肝脏外科的发展,始终面临着如何控制术中出血的困难和挑战.手术死亡率的下降标志着肝脏外科的发展,然而,术中出血仍然是威胁患者生命的主要危险因素之一.对于肝脏恶性肿瘤的患者,术中出血不仅增加死亡风险,同时增加输血需求,输血量的增加可能通过抑制患者免疫状态而导致术后的肿瘤复发风险增加[1].精准肝切除理念的提出并在临床上得到认可,其核心问题仍然是在不影响疗效的前提下最大限度地减少手术创伤和术中出血以及手术并发症,最终使患者从康复中最大获益[2].“工欲善其事,必先利其器.”肝脏外科的发展,离不开切肝器械的发展.令人高兴的是,近年来,新的切肝器械不断涌现,在临床上发挥巨大作用,推动着肝脏外科发展的同时,又给肝脏外科医师带来困惑.如何更好地选择和利用现有的切肝器械?哪种切肝器械临床效果最好?可以说仁者见仁,智者见智.无论选择哪种切肝器械或者不同切肝器械的联合使用,其根本目的都是为了快速的断肝,尽可能使断肝过程的出血量达到最少,封闭切断肝创面的血管和胆管,以减少术后并发症[3].指捏和钳夹法最早用于肝脏实质的分离,成为肝实质离断的最基本的技术.近20年来,新的切肝器械得到快速发展,主要包括超声刀,CUSA,水刀,百克钳,Ligasure,彭氏多功能手术解剖器以及Tissue-Link等.同时,肝脏血流阻断技术以及低中心静脉压麻醉技术的发展,使肝切除术中出血进一步减少,手术安全性得到进一步提高.笔者根据现有的文献以及多年来肝脏外科的经验,对常用的切肝方法和器械进行总结,希望能给读者以借鉴.     

Anatomy of the liver

Over the past decades, great progress has been made in surgery on the liver. Technical achievements and the strict application of anatomical knowledge to surgical practice have added a new dimension to the field of liver surgery. In some cases, new facts about the anatomy of the liver needed considerable time before being implemented. Surgery of liver metastases, primary tumours of the liver and not least liver transplantation have focussed the interest of visceral surgeons more and more on this organ. Segment-orientated liver anatomy, a knowledge and consideration of vascular structures, and the observance of anatomical landmarks are the prerequisites for successful surgery on the liver.     

腹腔镜肝切除术的应用与进展

肝切除一直是肝脏良恶性肿瘤的主要治疗方法,随着微创技术在外科领域的普及,腹腔镜肝切除术(LH)的应用也得到了快速发展,腹腔镜肝切除术具有局部创伤小、全身反应轻及术后恢复快等优点,同时能达到与开腹手术相同的疗效,但也存在着操作复杂、器械昂贵、止血效果不理想的问题.本文就有关腹腔镜肝切除术的发展历程、现状、存在问题及疗效评...     

腹腔镜低位直肠癌手术精准筋膜解剖的原则与意义

近年来，膜解剖理念被广泛应用于结直肠癌手术，该理念将器官切除、肿瘤根治、血管神经解剖及功能保护与“膜”相关联，显著促进了结直肠癌微创手术的进一步发展。然而，目前学界对膜解剖结构的定义、膜平面的建立及手术层面，尤其是直肠癌手术层面的选择，仍存在较大争议。本文对低位直肠癌手术相关筋膜，包括直肠固有筋膜、盆筋膜、Denonvilliers筋膜、Waldeyer筋膜及壁筋膜等概念及结构进行梳理，并结合筋膜解剖对直肠癌手术层面入路的原则进行探讨，以进一步规范和提高低位直肠癌微创手术治疗效果，达到“肿瘤根治”与“功能保护”兼顾的最佳结果。     

Virtual reality applied to hepatic surgery simulation: the next revolution.

OBJECTIVE: This article describes a preliminary work on virtual reality applied to liver surgery and discusses the repercussions of assisted surgical strategy and surgical simulation on tomorrow's surgery. SUMMARY BACKGROUND DATA: Liver surgery is considered difficult because of the complexity and variability of the organ. Common generic tools for presurgical medical image visualization do not fulfill the requirements for the liver, restricting comprehension of a patient's specific liver anatomy. METHODS: Using data from the National Library of Medicine, a realistic three-dimensional image was created, including the envelope and the four internal arborescences. A computer interface was developed to manipulate the organ and to define surgical resection planes according to internal anatomy. The first step of surgical simulation was implemented, providing the organ with real-time deformation computation. RESULTS: The three-dimensional anatomy of the liver could be clearly visualized. The virtual organ could be manipulated and a resection defined depending on the anatomic relations between the arborescences, the tumor, and the external envelope. The resulting parts could also be visualized and manipulated. The simulation allowed the deformation of a liver model in real time by means of a realistic laparoscopic tool. CONCLUSIONS: Three-dimensional visualization of the organ in relation to the pathology is of great help to appreciate the complex anatomy of the liver. Using virtual reality concepts (navigation, interaction, and immersion), surgical planning, training, and teaching for this complex surgical procedure may be possible. The ability to practice a given gesture repeatedly will revolutionize surgical training, and the combination of surgical planning and simulation will improve the efficiency of intervention, leading to optimal care delivery.     

倡导精准肝脏外科重现普罗米修斯神话

From ancient to present,liver has always been a mystery and magical organ.As the largest glandular organ of the body,liver has many vital functions.Its regenerative capabilities and functional reservation allow major resection of up to 80%of its volume.Many diseases,such as liver cancer,cirrhosis and hepatolithiasis Can affect liver,and the mainstay of curative treatment is liver resection.Technological advances play an important role in modern surgery,and a new surgical paradigm characterized by precision has evolved.Recently,we haveadvocated the concept of"precise hepatectomy"on the basis of modem anatomy,physiology,oncology,imaging and surgical techniques,which is characterized by minimal invasion,liversaving and maximally restoration of liver function.Related subjects,including computer sciences,imaging and information are needed to be combined to create a new alliance of treatment.Although,there are still many theoretical and technical problems about liver resection and liver function preservation.With the development of science and technology,precise hepatectomy will further improve the outcomes of liver surgery.     

Treatment of the liver cross section following hepatectomy

The incidence of complications after hepatectomy has been considerably reduced over the last 20 years. Better knowledge of liver anatomy and liver regeneration, and methods preventing bleeding during surgery have resulted in morbidity rates below 20% and mortality rates less than 5%. The treatment of the liver cross section remains controversial. Experimental studies have reported convincing biological effects of fibrin sealants or compresses when applied on the liver to decrease hemorrhagic or biliary complications. However, clinical studies are very heterogeneous, providing conflicting results compromising recommendations for routine use.     

腹腔镜解剖性肝切除手术入路选择

腹腔镜解剖性肝切除术(ALH)是普通外科难度较大的手术之一,这是由于腹腔镜下操作空间有限,肝脏作为人体内最大的实质性脏器,较难翻动和显露.另外,肝脏的血供丰富,肝内脉管结构纵横交错,肝实质解剖过程中容易发生难以控制的出血,从而被迫中转开腹,也因此导致ALH需要较长的学习曲线.虽然历经近30年的发展,目前国内较大的医疗机...