腹腔镜肝左外叶切除治疗左肝外叶胆管结石的体会

目的探讨腹腔镜肝左外叶切除治疗肝左外叶胆管结石的方法及疗效。方法回顾性分析我科2005年5月-2010年5月共12例患者行腹腔镜肝左外叶切除术治疗肝左外叶胆管结石的临床资料,其中2例并发胆囊结石,术中加行腹腔镜胆囊切除术。结果 12例均在腹腔镜下顺利完成手术,术中出血70 mL～370 mL,术后12例均出现一过性转氨酶升高,3例出现肝残面积液,无残留结石、大出血、胆瘘、腹腔脏器损伤等严重并发症发生。结论腹腔镜肝左外叶切除治疗左肝外叶胆管结石是安全可行的。     

双侧肝叶巨大海绵状血管瘤分期切除1例

目的:探讨双侧肝叶巨大血管瘤的外科手术方式并总结治疗经验.方法:对1例罕见的特大双侧肝叶血管瘤患者的临床资料进行完整详细的回顾性分析及术后随访.结果:1例罕见的特大双侧肝叶血管瘤患者因正常肝组织较少无法同时施行左、右侧肝叶血管瘤切除术.该患者接受了二期血管瘤切除术治疗:一期手术切除左侧肝叶巨大血管瘤,术后恢复顺利,残余正常肝组织向左侧增生,但同时右侧肝血管瘤也继续增大;术后3.5年时接受了二期手术切除了右侧肝叶巨大血管瘤,该患者术后逐渐康复.至今已经健康存活4年余.结论:双侧肝叶巨大血管瘤可先切除左侧肝叶巨大血管瘤,使正常肝组织解除压迫,获得生长空间,从而逐渐增生,随后择期二期切除右侧肝叶巨大血管瘤.     

腹腔镜下肝叶切除术14例报告

目的探讨腹腔镜肝切除术的可行性和安全性。方法回顾性分析我院2009年12月至2011年12月行腹腔镜肝切除术的14例肝占位患者的临床资料,其中原发性肝癌8例,肝转移癌1例,肝局灶性结节性增生1例,肝局灶性肝细胞脂肪变性1例,肝血管瘤3例。结果 14例均成功施行腹腔镜肝切除术,无中转开腹。其中8例行腹腔镜辅助肝部分切除术,6例行完全腹腔镜下肝部分切除术。左肝外叶切除3例,左半肝切除1例,肝局部切除10例。手术时间62~276 min,平均124.2 min。术中出血量40~550 ml,平均155.7 ml,住院时间8~15 d,平均10.8 d。所有患者术后均未发生严重并发症。8例原发性肝癌随访5~25个月,在随访超过1年的4例中,1例肿瘤复发后死亡,3例健在,1 a生存率为3/4。结论在掌握好手术指征的情况下,腹腔镜肝切除对于肝脏良恶性肿瘤的治疗是可行和安全的。     

腹腔镜下左肝外叶切除术的手术室护理配合探讨

目的探讨腹腔镜下左肝外叶切除术的手术室护理配合要点及效果。方法选取我院2015年1月至2016年12月收治的行腹腔镜下左肝外叶切除术的45例患者并作为观察组,另选取同期行传统开腹手术进行左肝外叶切除的42例患者作为对照组,观察并记录两组患者手术情况、术后恢复情况、并发症及护理满意度。结果两组患者均顺利完成手术,未发生死亡病例,观察组无腹腔镜中转开腹手术病例。观察组手术时间(192.55±30.40)min明显短于对照组的(223.61±33.78)min(P0.05),且术中出血量(582.51±21.28)m L明显少于对照组(694.83±29.40)m L(P0.05);术后观察组排气时间(30.45±3.75)h、下床活动时间(39.27±6.38)h、住院时间(11.40±3.52)d均短于对照组的(48.61±3.92)h、(65.38±5.84)h、(15.19±3.27)d(P0.05);术后观察组并发症发生率为8.89%,显著低于对照组的28.57%(P0.05);观察组护理满意度为97.78%显著高于对照组的80.95%(P0.05)。结论在实施腹腔镜治疗左肝外叶切除术时给予专业的手术室护理配合,可缩短手术时间,减少术中出血量,并促使患者术后尽快恢复,降低术后并发症率,提高手术室护理满意度,对患者术后尽快康复具有重要价值。     

腹腔镜下左肝外叶切除术治疗肝内胆管结石的临床效果

目的探讨腹腔镜下左肝外叶切除术治疗肝内胆管结石的手术方法、安全性及临床疗效。方法选取安徽医科大学附属安庆医院2015年1月-2016年12月收治的肝内胆管结石患者30例,按照手术方式不同分为常规组(n=15)和腹腔镜组(n=15),常规组采用开腹左肝外叶切除术治疗,腹腔镜组采用腹腔镜下微创左肝外叶切除术治疗,观察两组患者各项手术指标情况,比较两组患者术后并发症情况及术后肝功能指标情况。正态分布的计量资料组间比较采用t检验;非正态分布的计量资料组间比较采用Wilcoxon秩和检验。计数资料组间比较采用χ~2检验。结果腹腔镜组患者的肛门排气时间、术后住院时间较常规组明显缩短[(1.02±0.51)d vs(1.98±0.36)d,t=5.956,P0.001;(8.83±0.81)d vs(11.83±0.42)d,t=5.830,P0.001]。腹腔镜组患者术后第5天的ALT水平较常规组降低[(125.8±91.9)U/L vs(214.1±99.6)U/L],血清Alb水平较常规组升高[(33.2±3.7)g/L vs(28.9±4.3)g/L],差异均有统计学意义(t值分别为2.52、2.94,P值分别为0.02、0.01)。结论临床中应用腹腔镜下左肝外叶切除术治疗肝内胆管结石,相对常规开腹手术治疗,具有手术创伤小、患者术后恢复快、肝功能损伤小等特点,疗效显著,值得临床推广。     

肝尾状叶切除术在肝脏外科的应用——附22例肝尾状叶切除报告

目的:探讨肝尾状叶切除治疗肝肿瘤及肝尾状叶结石的适应症及手术方法。方法:分析肝尾状叶切除术的术前评估、手术方式、注意事项和术后并发症。结果:22例中原发性肝癌15例,肝血管瘤4例,肝尾状叶结石2例,肝门部胆管癌1例。肿瘤直径2～18cm。左侧入路9例,右侧入路8例,肝正中裂切开径路5例。行肝尾状突肿瘤切除9例,肝左尾状叶肿瘤切除5例,肝全尾状叶切除术8例。其中,联合行Ⅰ+Ⅸ+Ⅴ+Ⅵ段切除7例,Ⅰ+Ⅱ十Ⅲ+Ⅳ段切除5例,肝门部胆管癌根治术+肝尾状叶切除术1例。肝实质离断时间(20.8±11.6)分钟,出血量(340±250)ml。术后无围手术期死亡,无肝衰、胆汁漏、腹腔内大出血及严重感染,中量胸水3例,肺部感染2例。结论:术前影像检查及正确评估为手术成败关键。术中宜先易后难,争取良好的术野显露,分离肝短静脉时应细致,正确处理肝断面,必要时正确使用术中B超,上述措施可使肝尾状叶切除安全可行。     

两种术式治疗肝巨大血管瘤临床疗效比较

目的探讨肝叶切除术和肝血管瘤包膜外剥脱术治疗肝巨大血管瘤患者的临床疗效。方法 2014年5月～2016年4月我院肝胆外科收治的82例肝巨大血管瘤患者,41例接受肝叶切除术,另41例接受肝血管瘤包膜外剥脱术治疗。随访1年。结果接受肿瘤剥脱和肝叶切除患者的手术时间分别为(2.3±1.1) h和(3.3±1.1) h、术中出血量分别为(885.2±387.5)ml和(1567.5±751.4) ml、术中输血量分别为(928.7±412.4) ml和(1896.4±852.4) ml、肝血流阻断时间分别为(21.4±9.6) min和(27.5±8.2) min,住院日分别为(14.2±3.2) d和(16.5±3.5)d(P均0.05);肿瘤剥脱和肝叶切除患者术后并发症发生率分别为14.6%和34.2%(P0.05);经术后随访1年,肝叶切除患者术后血管瘤复发1例,失访11例,其余29例血管瘤消失,肿瘤剥脱患者复发1例,失访8例,其余32例血管瘤消失。结论肝切除术和肝血管瘤包膜外剥脱术均能有效治疗肝巨大血管瘤,但肝血管瘤包膜外剥脱术具有操作简便、手术创伤小、出血量少、肝血流阻断时间短、术后恢复快和术后并发症少等优点。     

完全腹腔镜下左肝外叶切除术的手术室护理体会

目的分析完全腹腔镜下左肝外叶切除术的手术室护理方法。方法选择从2015年1月~2017年1月间来我院就诊行完全腹腔镜左肝外叶切除术的52例患者作为本次研究的观察对象,按照不同的护理方法进行随机分组,其中26例患者予以常规护理,作为对比组;另外26例患者在此基础上强调手术室护理配合,作为研究组。比较两组患者各项手术指标以及相关护理情况。结果研究组患者手术时间(147.9±11.2)min明显要比对比组的(189.6±12.5)min短,且下床活动时间(23.8±1.5)h要早于对比组(31.3±2.4)h(P0.05);研究组并发症发生率3.8%要低于对比组23.1%(P0.05)。结论掌握腹腔镜手术室配合流程和特点,加强对完全腹腔镜下左肝外叶切除术患者的手术室护理配合,能够缩短手术用时、促进其术后的尽快康复。     

肝叶切除治疗原发性肝内胆管结石

目的 了解肝叶切除治疗原发性肝内胆管结石的效果.方法 回顾性分析6年来对52例肝内胆管结石行肝叶切除联合其它术式的治疗效果.结果 右半肝切除术2例,右后叶切除术2例,非规则性右肝部分切除术9例,左半肝切除术13例,左外叶切除术26例.术后残石发生7例,经胆道镜取净5例.结论 肝叶切除治疗原发性肝内胆管结石是目前较理想的有效的手术方式.     

腹腔镜射频消融治疗肝海绵状血管瘤的体会

目的探讨腹腔镜射频消融治疗肝海绵状血管瘤的可行性及方法。方法回顾性分析我科2008年1月-2010年12月的8例行腹腔镜射频消融术治疗肝血管瘤的患者,血管瘤直径5～8.2 cm,其中7例为单发病灶、1例为2个病灶,射频消融时间为10～26 min,术后复查超声造影。结果 9个病灶均在腹腔镜下顺利完成手术,术中出血10～60 mL,术后8例患者均出现一过性转氨酶增高、发热,无胆瘘、出血、脏器损伤等严重并发症发生。结论经腹腔镜射频消融治疗肝海绵状血管瘤是安全、有效的治疗方法。     

Safety and Efficacy of Laparoscopic Radiofrequency Ablation for Hepatic Hemangiomas: A Multicenter Retrospective Study

Introduction. Radiofrequency ablation (RFA) is an effective and minimally invasive technique for the management of hepatic hemangiomas (HHs). This study aims to assess the safety and efficacy of laparoscopic RFA for HHs.Material and methods. Forty-four patients with 50 hepatic hemangiomas (5-10 cm in diameter) undergoing laparoscopic RFA from January 2012 to May 2015 at three tertiary hospitals in China were retrospectively analyzed.Results. Thirty-three patients with subcapsular hemangiomas were treated with a laparoscopic approach, and 11 patients with lesions in the liver parenchyma were treated with a combined laparoscopy and an ultrasound-guided percutaneous approach. No conversion to open surgery or two-step surgery occurred during the study period. Patients with small hemangiomas (< 7 cm) required a significantly shorter operating time (71.1 ± 20.18 min vs. 106 ± 23.55 min, p = 0.000) and fewer punctures compared with patients with large hemangiomas (> 7 cm) (4.61 ± 1.09 vs. 6.73 ± 1.01, P < 0.05). According to the Dindo-Clavien classification, 15 patients experienced 34 Grade 1 complications, and two had complications of Grade 3a. All complications were resolved by conservative treatment. Forty-three (86.0%) HHs in 38 patients were completely ablated after RFA, and 7 (14.0%) HHs in 6 patients were incompletely ablated. All patients were followed up for 6-24 months (mean 15 ± 6 months).Conclusion. The data showed that laparoscopic RFA is an effective treatment for small (< 10 cm) HHs. While the incidence of postoperative complications remains high, the majority of complications are minor. Patients undergoing laparoscopic RFA for HHs, even for the small ones, should be carefully selected.     

Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation

AIM: To investigate the possibilities and advantages of laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct compaired with traditional open operation.METHODS: Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation were performed in two groups of patients who had gallstones in the left lobe of liver and in the common bile duct. The hospitalization time, hospitalization costs, operation time, operative complications and post-operative liver functions of the two groups of patients were studied.RESULTS: The operation time and post-operative liver functions of the two groups of patients had no significant differences, while the hospitalization time, hospitalization costs and operative complications of the laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration in the common bile duct group were significantly lower than those in the traditional open operation group.CONCLUSION: For patients with gallstones in the left lobe of liver and in the common bile duct, laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct can significantly shorten the hospitalization time, reduce the hospitalization costs and the post-operative complications,without prolonging the operation time and bringing about more liver function damages compared with traditional open operation. This kind of operation has more advantages than traditional open operation.     

Right hepatic lobectomy for recurrent cholangitis after bile duct and hepatic artery injury during laparoscopic cholecystectomy: report of a case.

A patient is reported who required a right hepatic lobectomy for recurrent cholangitis due to injury of the major bile ducts and the right hepatic artery during laparoscopic cholecystectomy. A 39 year-old woman with acute cholecystitis underwent laparoscopic cholecystectomy. A laparotomy was performed due to a bile duct injury at the hepatic bifurcation. After surgery, she suffered from recurrent cholangitis due to inadequate biliary reconstruction. A right hepatic lobectomy and reconstruction of the left hepatic duct was required because of right hepatic lobe atrophy and recurrent cholangitis. After the 2nd operation, she was active and exhibited no evidence of recurrence at 22 months.     

Hepatic involvement of disseminated actinomycosis

A 35-year-old woman was admitted for weight loss, fatigue, and epigastric and back pain. She had undergone uterine myomectomy 6 weeks previously, and light microscopic examination revealed actinomycosis. Radiologic examination showed 5×4×4 cm and 2×2×2 cm solid lesions in the left liver lobe. Ultrasound-guided fine-needle aspiration biopsy could not exclude the possibility of malignancy. We decided to perform an explorative laparotomy. Frozen sections indicatedEchinococcus alveolaris infection or granulomatous inflammatory disease, and left hepatic lobectomy was performed. Histologic examination revealed hepatic actinomycosis. After 6 months' penicillin treatment, there was no sign of recurrence. This case of hepatic actinomycosis following uterine infection without gross involvement of any other abdominal organ raises questions on the dissemination pathway. The other interesting feature of this case is the short interval from the presumed initiatory event to the presence of the hepatic deposits.     

Traitement chirurgical des hémangiomes hépatiques

Background

Hepatic hemangiomas are the most common benign tumors of the liver and are often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, rapid growth, uncertain diagnosis, and coagulopathy are the main surgical indications. We present our experience with the surgical management of 15 liver hemangiomas to clarify the safety and effectiveness of this treatment.

Methods

There were 15 patients with hepatic hemangiomas who were surgically treated from 2000 to 2008. Indications for the operation were abdominal pain, rapid growth, and uncertain diagnosis. The hemangiomas were located on the left lobe of the liver in nine patients and on the right lobe in three patients. One lesion was located on segment I and one on segment IV. One patient had a liver angiomatosis. Methods for diagnosis included ultrasonography and computed tomography scan, used alone or in combination.

Results

The procedures included five left lobectomies, one left-extended lobectomy, two left-extended hepatectomies, three segmental resections, and three enucleations. There was no death. The postoperative morbidity was minimal and was mainly correlated to a subdiaphragmatic collection and a hemoperitoneum due to a wound of the inferior vena cava. The postoperative hospital stay was 6 days (range, 4–10 days). During the follow-up period, there was no recurrence.

Conclusion

The resection of the hepatic hemangioma is safe. Both anatomic resection and enucleation can be effective in removing these tumors, and the choice of procedure will depend on some factors such as location, size, and morphology of the tumor.     

Laparoscopic vs computerized tomography-guided radiofrequency ablation for large hepatic hemangiomas abutting the diaphragm

AIM: To compare safety and therapeutic efficacy of laparoscopic radiofrequency(RF) ablation vs computed tomography(CT)-guided RF ablation for large hepatic hemangiomas abutting the diaphragm.METHODS: We retrospectively reviewed our sequential experience of treating 51 large hepatic hemangiomas abutting the diaphragm in 51 patients by CT-guided or laparoscopic RF ablation due to either the presence of symptoms and/or the enlargement of hemangioma.Altogether, 24 hemangiomas were ablated via a CTguided percutaneous approach(CT-guided ablation group), and 27 hemangiomas were treated via a laparoscopic approach(laparoscopic ablation group).RESULTS: The mean diameter of the 51 hemangiomas was 9.6 ± 1.8 cm(range, 6.0-12.0 cm). There was nodifference in the diameter of hemangiomas between the two groups(P 0.05). RF ablation was performed successfully in all patients. There was no difference in ablation times between groups(P 0.05). There were 23 thoracic complications in 17 patients: 15(62.5%, 15/24) in the CT-guided ablation group and2(7.4%, 2/27) in the laparoscopic ablation group(P 0.05). According to the Dindo-Clavien classification,two complications(pleural effusion and diaphragmatic rupture grade Ⅲ) were major in two patients. All others were minor(grade Ⅰ). Both major complications occurred in the CT-guided ablation group. The minor complications were treated successfully with conservative measures, and the two major complications underwent treatment by chest tube drainage and thoracoscopic surgery, respectively. Complete ablation was achieved in 91.7%(22/24) and 96.3%(26/27) in the CT-guided and the laparoscopic ablation groups,respectively(P 0.05).CONCLUSION: Laparoscopic RF ablation therapy should be used as the first-line treatment option for large hepatic hemangiomas abutting the diaphragm.It avoids thermal injury to the diaphragm and reduces thoracic complications.     

Giant hemangiomas of the liver: surgical strategies and technical aspects

The incidence of hemangiomas is 2-7% in the general population. We evaluated more than 300 patients with hepatic hemangiomas. Surgical removal of hepatic hemangiomas was performed in 48 cases due to uncertain diagnosis (2 cases), intractable symptoms (26 cases), size increase (18 cases), and liver failure in 2 cases that were treated by hepatic transplantation. In all, 26 patients underwent enucleation of hemangiomas or segmentectomies, while the remaining 20 patients underwent right lobectomies or left lateral segmentectomies. Blood transfusions were required in four cases (including two liver transplants); mean post-resection hospital stay was 6.3 days. We observed no perioperative mortality and only two cases of major morbidity (bile leaks not requiring reoperation). Our experience confirms that, after adequate patient selection, surgical treatment of hepatic hemangiomas is a very effective therapeutic choice with no mortality and low morbidity.     

Hepatic hemangiomas: pitfalls in scintigraphic detection

The evaluation of solitary hepatic lesions detected on scintiscans is a common clinical problem. It is usually assumed that radionuclide rapid sequence flow studies and blood pool images are reliable and accurate methods of demonstrating the vascularity of hepatic lesions. Our recent experience with 3 patients with angiographically proven hepatic hemangiomas indicates that radionuclide techniques may fail to detect the vascularity of hemangiomas. We speculate that blood flow within a hepatic hemangioma may be sluggish and its vascularity may be appreciated only by arteriography. Therefore, we alert the clinician to assess the vascularity of solitary hepatic tumors by angiography before percutaneous liver biopsy and thereby avert the possibility of life-threatening exsanguination, as occurred in one of our patients.     

Enucleation of Centrally Located Giant Hepatic Hemangioma: Report of Two Cases

Two centrally located giant hepatic hemangiomas were referred with severe pain, one of which had a protruding abdominal mass was listed for transplantation at another center. Tumors were 35 and 30 cm at their longest diameter. One was centrally located involving the hilum and segments VI/VII and II/III were partially spared. Volumetric analysis and imaging suggested enucleation is feasible if the left lateral segment and the right posterior sector are left intact. Operation was straightforward except few breaks in enucleation technique in an effort to secure the venous drainage of the remnant liver. She had an uneventful recovery except a biliary fistula through the operatively severed left hepatic duct, which was repaired over a stent. This was managed by lateral segmentectomy and resection of the fistula after the enlargement of the right posterior sector was confirmed volumetrically. The other tumor-involved segments II, III, IV, V, and VIII and the hilum were totally hemangiomatic. Enucleation and postoperative recovery was uneventful. The era of liver transplantation enhanced our knowledge about complex liver surgery and these cases are good examples about the feasibility of enucleation even in extremely complicated liver hemangiomas saving both the patients and a donor liver.     

肝脏恶性血管外皮瘤误诊为肝转移癌1例

肝脏恶性血管外皮瘤是一种罕见的肿瘤,本例患者为男性,57岁,有中上腹胀痛不适,CT发现左肝占位,2年前曾因食管癌行手术治疗.术前被误诊为转移性肝癌,经手术行左肝肿瘤切除及胆囊切除术后行病理检查,最终确诊为肝脏恶性血管外皮瘤.