腹腔镜下刮吸法断肝术在肝脏切除术中的应用(附7例报告)

目的　介绍一种新的腹腔镜下切肝技术———刮吸法断肝术 ,并获 7例肝切除成功的经验和体会。　方法　应用自行设计的可供腹腔镜下使用的多功能手术解剖器 (PMOD)来实施腹腔镜下刮吸法断肝术的肝脏切除术 ,连续 7例。　结果　 7例均手术成功 ,无中转开腹手术 ,无并发症发生。平均手术时间 135分钟 ,术中出血量平均 770ml,切除肝脏体积最大的为 10cm× 9cm× 7cm。术后 2 4小时均能下床活动 ,术后 1周出院。　结论　刮吸法断肝技术应用于腹腔镜下肝脏切除术具有解剖清晰 ,能显露肝内管道结构 ,边操作边吸引 ,切肝速度快 ,止血效果佳 ,术野清晰 ,优于其他切肝方法。     

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目的总结腹腔镜左半肝切除的临床经验。方法2002年1月至1007年2月,广西医科大学第一附属医院对28例原发病灶位于左半肝的病人,应用电刀、超声刀等断肝,肝断面采用腔镜下用肝针缝合并喷洒生物蛋白胶等处理方法,行腹腔镜左半肝切除术28例,其中行解剖性左半肝切除术8例,非解剖性左半肝切除术20例。合并胆囊切除1例。结果28例手术均获得成功。手术时间(251.15±40.94)min,术中出血(422.20±146.01)mL。无并发症,住院时间(5.98±0.73)d。结论腹腔镜左半肝切除安全、可行,具有微创的优点;可作为治疗原发病灶局限于左半肝疾病术式选择。     

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1　临床资料病人女性 ,4 5岁。主因右上腹胀痛不适半年入院。经外院Ｂ超和ＣＴ检查发现左半肝囊性病变 ,诊断为肝囊肿。在我院化验ＣＡ19-9为 14 73ｋＵ/Ｌ ,Ｂ超提示肝左叶囊实混合性病变 ;ＭＲＩ示肝囊性病变 ,约 11ｃｍ× 10ｃｍ ,占据肝脏左内叶位置 ,并向下腹方向突出 ,囊肿内有分隔 ,边缘有占位。初步诊断为左肝囊性病变 :肝囊肿 ,肝囊腺瘤合并癌变待除外。于 2 0 0 2年 8月 2 7日在全麻下行腹腔镜手术。取头高足低左侧稍斜体位 ,脐下缘进气腹针 ,ＣＯ2 气腹压力1 9ｋＰａ ,拔除气腹针 ,经 10ｍｍ 30°腹腔镜置入 12ｍｍｔｒｏ ｃａｒ…     

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目的探讨后腹腔镜胰腺切除术(retroperitoneosco picpancreatectomy,REP)的可行性。方法自2010年2月至2011年4月,中国人民解放军总医院于后腹腔镜下行胰体尾切除、肿瘤剜除4例,前瞻性收集相关资料。结果研究共完成胰岛素瘤剜除2例,保留脾脏的胰体尾切除2例,手术时间30～100min,术中出血10～100mL,术中并发腹膜损伤1例,术后并发A级胰瘘2例,病人术后7d内出院。结论对于部分胰腺体尾处病变,REP安全、可行,具有入路直接、操作简便、术后疼痛轻、切口美容、并发症轻、术后恢复快等潜在优点,本研究为胰腺疾病提供了一种新的手术方式。     

腹腔镜肝脏切除术六例报告

目的 介绍一种新的腹腔镜下断肝技术--刮吸法断肝术。方法 采用特制手术器械--多功能手术解剖器,进行腹腔镜下肝脏切除术,成功地开展了6例肝叶切除。结果 手术顺利,无并发症,术后1～3d可进食,1周左右出院,其中1例肝癌术后2年随访无复发。结论 刮吸法断肝技术较其他断肝方法优越,多功能手术解剖器是开展腹腔镜下肝脏切除术的理想工具。     

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自Langenbuch（1888）报道为肝肿瘤病人试行肝左外叶切除以来，肝脏外科已有百余年历史。从20世纪70年代开始，我国肝脏外科得到迅速发展，许多医院相继开展了肝脏外科手术。目前我国的肝脏外科已居世界领先水平，不仅肝叶切除例数居世界第1位，且手术死亡率已降至5％以下。施行肝叶切除最多的单位是第二军医大学东方肝胆外科医院，     

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目的减少腹腔镜胆囊切除术(LC)的并发症,提高手术安全性。方法回顾分析1993年6月至2004年6月6012例LC资料。结果6012例中胆囊息肉544例,胆囊结石5451例,结石伴胆囊息肉17例。在胆囊结石病人中,慢性胆囊炎急性发作196例,伴胆囊颈或管结石嵌顿126例,慢性萎缩性胆囊炎204例,胆囊癌5例。中转开腹手术218例,占36%。共发生并发症228例,占379%,包括胆管损伤6例,出血31例,胆漏59例,刺口感染38例,术后胆囊床积液36例,术后腹腔内感染5例,其他53例。均治愈出院。结论为了减少并发症,应从严掌握LC手术适应证。肝门部胆管损伤是LC最严重的并发症之一,其对策是预防为主,其关键是在Calot三角的安全区进行解剖,遇到困难时及时中转开腹手术;一旦发生,应当由有经验的医生共同努力才能确保病人的手术一次获得成功。术后必须认真监测生命体征,及时发现各种意外,并给予恰当的处理。     

尾叶原发性肝癌的手术切除(附12例报告)

总结１２例尾叶原发性肝癌手术切除的经验，应用ＰＭＯＤ采取刮吸法断肝，可清楚解剖出管道结构，便于可靠结扎并节省时间；肝正中裂完全切开，有利于尾叶的显露。介绍了左侧尾叶切除、右侧尾叶切除、双侧尾叶切除和单独尾叶切除的操作方法     

腹腔镜肝切除术27例报告

目的探讨腹腔镜肝切除术的可行性。方法采用腹腔镜多功能手术解剖器(LPMOD)刮吸断肝技术行完全腹腔镜下肝切除术27例。包括规则性肝切除13例(其中Ⅱ、Ⅲ段切除3例,Ⅴ段切除1例,Ⅵ段切除7例,Ⅴ、Ⅵ段切除1例,Ⅴ、Ⅵ、Ⅶ、Ⅷ段切除1例),局部切除14例。结果全部顺利完成手术,无中转开腹。手术时间35~360 min,(178.0±78.4)min,术中出血35~1200 ml,(451.7±332.6)ml,术后住院时间2~14 d,(8.4±3.0)d,无严重并发症发生。术后病理:肝海绵状血管瘤15例,肝局灶性增生2例,肝细胞性肝癌伴肝硬化6例,肝胆管结石伴胆管增生2例,肝(血肿)纤维化1例,肝血管平滑肌脂肪瘤1例。27例术后随访1~26个月,(7.9±7.4)月,复查肝B超或CT,无血管瘤复发、肝癌复发及穿刺口种植、肝内胆管结石残留。结论在经过选择的病例中,采用LPMOD行腹腔镜肝切除术是可行的。     

Laparoscopic hepatectomy for hepatolithiasis: a feasibility and safety study in 29 patients

Background Hepatolithiasis is a prevalent disease in Southeast Asia. Heaptectomy was considered the best treatment for majority of cases. Laparoscopic hepatectomy is a new procedure for liver lesions that uses a minimal invasive approach. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy for hepatolithiasis by comparing it with open hepatectomy. Methods From November 2002 to March 2006 a total of 30 consecutive patients underwent laparoscopic hepatectomy for hepatolithiasis in Sir Run Run Shaw Hosptial. Twenty-nine were included in this study (a converted case was excluded) and called the laparoscopic hepatectomy group (LH). During the same period 22 patients with hepatiolithiasis who met the inclusion criteria for laparoscopic hepatectomy were selected for open hepatectomy and called the open group (OH). All operations were performed by the authors. There was no significant difference in preoperative data between the two groups. Data were statistically compared. Results Compared with open hepatectomy, those who underwent laparoscopic hepatectomy had a shorter postoperative hospital stay and fasting time, a lower postoperative serum aminotransferase level, and a higher postoperative serum albumin level. Stone clearance rate (intermediate rate, 89.7% vs. 86.4%; final rate, 100% vs. 96.5%), stone recurrence rate (0% vs. 4.5%), operating time, and intraoperative blood loss were similar for the two groups. Six complications occurred, two (6.8%) in LH and four (18.2%) in OH. There was no perioperative mortality in either group. Conclusion Laparoscopic hepatectomy for hepatolithiasis is feasible and safe in selected patients. This work was supported by the Foundation of Science and Technology, Department of Zhejiang Province, No. 2003C33055.     

Laparoscopic hepatectomy by curettage and aspiration

Background This article introduces a new technique for hepatectomy. Its purpose is to describe the details of laparoscopic hepatectomy by curettage and aspiration (LHCA) and develop a new instrument for this technique. Methods We have performed laparoscopic hepatectomy by curettage and aspiration (LHCA) in 62 patients in our institute between 1998 and 2005: 34 men and 28 women, mean age 47.8 years (range: 26–71 years). Their diagnoses included 18 primary hepatic carcinoma, 2 metastatic carcinoma, 19 intrahepatic duct calculus, and 23 benign entities. Results The LHCA operation was completed in 60 patients. In two, the procedure had to be converted to open operation. The mean operative time was 146 min and the mean operative blood loss was 458 ml. Complications occurred in two patients, one with bile leakage and the other with pneumothorax. All the patients were ambulatory within 24 hours of operation. The average length of hospital stay was 1 week. Conclusions Our experience leads us to believe that laparoscopic hepatectomy by curettage and aspiration (LHCA) is a safe and effective technique for resection of liver lesions.     

Glisson蒂横断式腹腔镜左肝外叶切除术八例报告

目的 探讨Glisson蒂横断式腹腔镜左肝外叶切除术的可行性与安全性.方法 显露肝圆韧带根部,自肝圆韧带根部左缘开始,采用腹腔镜多功能手术解剖器(LPMOD)整体解剖左肝外叶Glisson蒂,依次游离左肝外叶Glisson蒂至Ⅱ、Ⅲ段分支,予以夹闭、切断.离断Glisson蒂分支后,可见其支配区域因缺血而变暗,再切除其支配区域的肝组织.如此反复离断约4～6条左肝外叶Glisson蒂至Ⅱ、Ⅲ段分支,同时切断左肝静脉及其属支,完成Glisson蒂横断式腹腔镜左肝外叶切除术.结果 8例均成功完成Glisson蒂横断式腹腔镜左肝外叶切除术,无中转开腹.手术时间L10～190(151.0±35.4) min,其中解剖左肝外叶Glisson蒂分支及切肝时间为70～135(101.0±24.1)min,术中出血100～300(210.0±89.4)ml,均未输血.术后丙氨酸转氨酶(ALT)升高值35～102(75.4±26.5)U/L,恢复正常时间2～6(3.0±1.7)d,术后住院时间6～10(8.2±1.6)d,无并发症发生.结论 Glisson蒂横断式腹腔镜左肝外叶切除术是安全可行的.     

选择性保留健侧肝动脉血流的入肝血流阻断技术在腹腔镜肝切除术中的应用

目的评价选择性保留健侧肝动脉血流的入肝血流阻断技术在腹腔镜肝切除术中的应用价值。方法回顾性分析11例腹腔镜肝切除时采用选择性保留健侧肝动脉血流的入肝血流阻断技术(甲组)及10例腹腔镜肝切除时采用全肝入肝血流阻断技术(乙组)病人资料,比较2组术中出血量、手术时间、入肝血流阻断时间、术后住院时间、术后丙氨酸转氨酶(ALT)升高幅度及恢复正常时间。结果术后ALT升高幅度:甲组(8.16%±7.54%)<乙组(19.72%±13.20%)(t=-2.494,P=0.022);术后ALT恢复正常时间:甲组[(7.0±2.2)d]<乙组[(9.9±1.4)d](t=-3.560,P=0.002)。术中出血量、手术时间、入肝血流阻断时间、术后住院时间差异无显著性(P>0.05)。结论腹腔镜肝切除时选择性保留健侧肝动脉血流的入肝血流阻断技术优于全肝入肝血流阻断技术,有推广价值。     

Laparoscopic hepatectomy: indications and outcomes

We outline the indications, evaluate the degree of invasiveness, and analyze the outcomes of laparoscopic hepatectomy, mainly in the treatment of hepatocellular carcinoma (HCC). The important considerations in determining indications for laparoscopic hepatectomy include tumor size, type, and location. Nodular tumors smaller than 4 cm or pedunculated tumors smaller than 6 cm are suitable candidates. Concerning location, tumors in the lower segment or the left lateral segment are suitable. Regarding operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral segmentectomy is a feasible, less invasive procedure. Operative time in our recent laparoscopic hepatectomy patients has decreased, with less bleeding. Furthermore, laparoscopic hepatectomy is less invasive than conventional hepatectomy on evaluation by the Estimation of Physiolic Ability and Surgical Stress (E-PASS) scoring system. Patients recovered more quickly after laparoscopic hepatectomy, which allowed shorter hospitalization. Both the 5-year survival rate for HCC and the survival rate without recurrence were nearly identical to those of open conventional hepatectomy, although further analysis will be necessary to reach definitive conclusions. In conclusion, laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy in properly selected patients and is beneficial for patient quality of life, because it is a minimally invasive procedure when indications are strictly followed.     

Laparoscopic hepatectomy for hepatocellular carcinoma in cirrhotic patients

Introduction  We have used laparoscopic hepatectomy as a surgical treatment for HCC in patients with cirrhosis. We describe the indications, evaluate invasiveness and analyze the outcomes of laparoscopic hepatectomy. Methods and Results  With respect to operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral sectionectomy is a less invasive procedure in patients with cirrhosis than conventional hepatectomy. Among our laparoscopic hepatectomy cases, operative time was shorter and bleeding was less in recent, as compared to earlier, cases. Furthermore, laparoscopic hepatectomy was less invasive than conventional hepatectomy, as determined by the E-PASS scoring system. Patients also recovered more quickly, which resulted in shorter hospital stays even for patients with cirrhosis. Both the 5-year survival rate and the rate of survival without recurrence of HCC were nearly identical to those of open conventional hepatectomy. Conclusion  These findings indicate that laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy for HCC in properly selected patients with cirrhosis and that its minimal invasiveness improves patients’ quality of life.     

采用彭氏多功能手术解剖器施行肝Ⅶ、Ⅷ段切除术30例报告

目的总结采用彭氏多功能手术解剖器(PMOD)施行肝Ⅶ、Ⅷ段切除的手术经验。方法2001年1月至2003年12月,共施行了肝Ⅶ、Ⅷ段切除术30例,包括3例右肝内胆管结石和27例肝癌。解剖第Ⅰ、第Ⅱ及第Ⅲ肝门,预置血流阻断带,在分离右段间裂及肝正中裂上部时行入肝血流间歇阻断。结果30例手术均顺利完成,手术平均费时191min,术中平均失血量920ml。全组无术中死亡,术后22例出现右侧胸腔积液,3例胆瘘,3例膈下感染。结论采用彭氏多功能手术解剖器有助于施行肝Ⅶ、Ⅷ段切除。