Tolerance of the liver to intermittent pringle maneuver in hepatectomy for liver tumors.

BACKGROUND: Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during the operation remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but the effect on the metabolic function of hepatocytes is potentially harmful. Although our randomized study showed that an intermittent Pringle maneuver is safe and effective during hepatectomy, the upper limit of the duration of the Pringle maneuver is not known. HYPOTHESIS: The liver can tolerate intermittent Pringle maneuver if the duration is not excessive. DESIGN: From July 20, 1995, to November 25, 1997, 112 patients underwent hepatectomy for liver tumors. The data of 50 patients who had hepatectomy without the Pringle maneuver were compared with those of 62 patients who had a liver transection using a Pringle maneuver for 20 minutes and a 5-minute clamp-free interval. The data were collected prospectively. MAIN OUTCOME MEASURES: The surface area of liver transection was measured, and blood loss during liver transection per centimeter square of transection area was calculated. Routine liver biochemical tests, arterial ketone body ratio (AKBR), and plasma cytokine-interleukin (IL) 1alpha, 1beta, 2, and 6, and tumor necrosis factor alpha--levels were measured before and after the operation. The morbidity and hospital mortality rates were also compared among the patients with different ischemic durations and those without an intermittent Pringle maneuver. SETTING: Tertiary referral center. RESULTS: The cutoff point of accumulated ischemic time that induced substantial liver damage, as shown by the postoperative recovery rate of the AKBR, was found to be 120 minutes. Compared with the control group, the patients whose accumulated ischemic time was shorter than 120 minutes had less blood loss related to transection area (10 mL/cm2 vs 22 mL/cm2; P<.001), less blood transfused (0 L vs 0.6 L; P = .004), a shorter transection time related to transection area (2.0 min/cm2 vs 2.8 min/ cm2; P = .002), a significantly higher AKBR in the first 2 hours after liver transection, an equal recovery rate of the AKBR, and a comparable increase of the plasma level of IL-6 postoperatively. For the patients whose accumulated ischemic time was longer than 120 minutes, blood loss from the transection area was less than for the control group (14 mL/cm2 vs 22 mL/cm2; P<.05), but the transection time related to the transection area and the blood transfusion volume did not differ from those of the control group. Furthermore, they had a significantly lower recovery rate of the AKBR and higher plasma levels of IL-6 postoperatively than the control group.     

Effects of the intermittent Pringle manoeuvre on hepatic gene expression and ultrastructure in a randomized clinical study

BACKGROUND: The intermittent Pringle manoeuvre during hepatectomy results in a better clinical outcome when the accumulated ischaemia time is less than 120 min. The aim of this study was to investigate hepatic gene expression related to microcirculatory modulation and ultrastructural changes in patients having the intermittent Pringle manoeuvre. METHODS: Forty patients who underwent hepatectomy for liver tumours were randomly assigned to liver transection with intermittent Pringle manoeuvre (Pringle group, n = 20) or without the manoeuvre (control group, n = 20). The clinical data and hepatic expression of endothelin (ET) 1 and endothelial nitric oxide synthase (eNOS) combined with liver ultrastructure were compared. RESULTS: The Pringle manoeuvre resulted in less blood loss (8.9 versus 12.4 ml/cm(2); P = 0.034), a shorter transection time (2.7 versus 4.1 min/cm(2); P = 0.015) and a lower serum bilirubin level on postoperative day 2 (26 versus 35 microm/l; P = 0.04). The hepatic messenger RNA content of ET-1 decreased by 38 per cent of the basal level in the Pringle group, whereas it increased by 28 per cent in the control group (P = 0.026). More patients in the control group showed swelling of mitochondria in hepatocytes and disruption of sinusoidal lining cells (12 of 20 patients versus three of 20 in the Pringle group; P = 0.008). CONCLUSION: The intermittent Pringle manoeuvre results in less disturbance of the hepatic microcirculation and better preservation of liver sinusoids after hepatectomy.     

How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies

OBJECTIVE: To identify the most efficient parenchyma transection technique for liver resection using a prospective randomized protocol. SUMMARY BACKGROUND DATA: Liver resection can be performed by different transection devices with or without inflow occlusion (Pringle maneuver). Only limited data are currently available on the best transection technique. METHODS: A randomized controlled trial was performed in noncirrhotic and noncholestatic patients undergoing liver resection comparing the clamp crushing technique with Pringle maneuver versus CUSA versus Hydrojet versus dissecting sealer without Pringle maneuver (25 patients each group). Primary endpoints were intraoperative blood loss, resection time, and postoperative liver injury. Secondary end points included the use of inflow occlusion, postoperative complications, and costs. RESULTS: The clamp crushing technique had the highest transection velocity (3.9 +/- 0.3 cm/min) and lowest blood loss (1.5 +/- 0.3 mL/cm) compared with CUSA (2.3 +/- 0.2 cm/min and 4 +/- 0.7 mL/cm), Hydrojet (2.4 +/- 0.3 cm/min and 3.5 +/- 0.5 mL/cm), and dissecting sealer (2.5 +/- 0.3 cm/min and 3.4 +/- 0.4 mL/cm) (velocity: P = 0.001; blood loss: P = 0.003). Clamp crushing technique was associated with the lowest need for postoperative blood transfusions. The degree of postoperative reperfusion injury and complications were not significantly different among the groups. The clamp crushing technique proved to be most cost-efficient device and had a cost-saving potential of 600 to 2400 per case. CONCLUSIONS: The clamp crushing technique was the most efficient device in terms of resection time, blood loss, and blood transfusion frequency compared with CUSA, Hydrojet, and dissecting sealer, and proved to be also the most cost-efficient device.     

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目的探讨肝下下腔静脉(IVC)阻断联合入肝血流阻断(Pringle法)在复杂肝切除术中的应用价值。方法回顾分析第二军医大学东方肝胆外科医院特需治疗一科、肝移植科2010年3月至2011年12月同一手术组收治的91例符合条件的手术病人的临床资料。结果行Pringle法+肝下IVC阻断43例(A组),行Pringle法48例(B组)。两组的术中总出血量分别为50～1150(312.79±267.28)mL和100～1400(471.04±317.80)mL,断肝过程中出血量分别为10～300(80.70±79.77)mL和50～650(200.21±165.09)mL,A组术中总出血量及断肝过程中的出血量均明显低于B组(P<0.05)。两组阻断前的中心静脉压(CVP)无差别[(8.47±2.60)cmH2Ovs.(7.94±2.30)cmH2O(1cmH2O=0.098kPa)],A组阻断后的CVP明显低于B组[(1.81±2.34)cmH2Ovs.(7.21±2.27)cmH2O,P<0.05]。两组术后并发症发生率差异无统计学意义,术前及术后肝肾功能比较差异无统计学意义。结论肝下IVC阻断联合Pringle法应用在复杂肝切除术中可明显降低CVP,显著减少术中失血量。对肝肾功能无不良影响,不增加并发症的发生率和病死率。     

肝下下腔静脉阻断与控制性低中心静脉压在复杂肝切除术中应用的比较

目的:比较肝下下腔静脉(IIVC)阻断与控制性低中心静脉压(CLCVP)技术在复杂肝切除术中应用的安全性及有效性。方法:回顾性分析2016年3月—2017年12月行复杂肝切除术的103例原发性肝癌患者临床资料,术中所有患者均采用Pringle法控制入肝血流,其中56例行IIVC阻断(IIVC阻断组),47例行CLCVP技术(CLCVP组)降低中心静脉压(CVP)。比较两组切肝过程中CVP的变化、切肝过程出血量、手术总出血量、术中尿量、输血率、术后并发症发生率、术后肝功能与肾功能变化。结果:两组患者一般资料差异无统计学意义(均P0.05)。与切肝前对比,两组患者在切肝过程中CVP均明显下降,但IIVC阻断组CVP较CLCVP降低更明显,且IIVC阻断组切肝过程中出血量、手术总出血量、术后第3天ALT和术后第3、7天TBIL均明显低于CLCVP组(均P0.05)。两组患者术中尿量、输血率及术后并发症发生率、肾功能情况差异无统计学意义(均P0.05)。结论:IIVC阻断联合Pringle法操作简单方便,相对于CLCVP技术,其对全身血流动力学影响较小,肝功能恢复更快,且更容易降低CVP,减少术中肝脏断面出血,有利于提高复杂肝切除术的安全性。     

预结扎病侧肝脏入出肝血管切肝术的体会

目的　比较预结扎病侧肝脏入出肝血管切肝术与阻断肝门切肝术的优缺点。方法　 32例病人包括两组 :甲组 2 0例 ,肝切除时阻断肝门。乙组 12例 ,肝切除时预结扎病侧肝脏入出肝血管。对两组病人的术中失血量 ,术后平均出血量和引流量 ,术后肝功能恢复时间和术后并发症等进行比较分析。结果　甲乙两组术中平均出血量分别是 85 0ml和 4 5 0ml (P <0 0 1)。术后平均出血和引流量分别是 30 0ml和 15 0ml(P <0 0 1)。术后ALT恢复正常时间分别为 6～ 35d和 3～ 7d ,AST恢复正常时间分别是 5～ 30d和 4～ 8d ,总胆红素恢复正常时间分别为 7～ 6 0d和 5～ 14d ,两组相比差异显著 (P <0 0 1)。术后并发症发生率分别为 30 %和 0 % (P <0 0 1)。结论　预结扎病侧肝脏入出肝血管切肝术优于阻断肝门切肝术     

Glisson蒂横断法与Pringle法在肝细胞癌肝切除术中的应用效果Meta分析

背景与目的:Glisson蒂横断法与Pringle法在肝细胞癌(简称肝癌)肝切除术中的应用效果目前尚无一致结论,亦无大样本量的多中心研究予以证实.本研究通过Meta分析方法评价两种方法在肝癌肝切除术中的应用效果,以期在肝切除术术中阻断方式的选择上提供参考.方法:计算机检索中、英文数据库,检索时间为数据库建立至2021年...     

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy

Background

Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes.

Methods

A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality.

Results

A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay.

Conclusions

All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.     

Evaluation of Effect of Hemihepatic Vascular Occlusion and the Pringle Maneuver during Hepatic Resection for Patients with Hepatocellular Carcinoma and Impaired Liver Function

Reducing blood loss during resection of hepatocellular carcinoma (HCC) in patients with impaired liver function is important. This study evaluated the effect and safety of inflow occlusion (hemihepatic vascular occlusion and the Pringle maneuver) in reducing blood loss during hepatectomy. A total of 120 HCC patients with impaired liver function (with a preoperative indocyanine green retention rate at 15 minutes > 10%) who underwent hepatectomy were included in this retrospective study. Patients were divided into three groups, no-occlusion (n = 30), hemihepatic vascular occlusion (n = 49), and Pringle maneuver (n = 41). There was one hospital death in each group. Of all three groups, 50 patients (41.7%) had blood loss less than 1000 ml. The three groups were similar in terms of clinocopathological features. All patients underwent minor resection. Blood loss was significantly greater in the no-occlusion group; there was no difference between the hemihepatic group and the Pringle group. Multivariate analysis revealed that risk factors related to blood loss included no inflow occlusion [odds ratios (ORs), 2.93; 95% confidence intervals (CIs) 1.13–7.59], tumor centrally located (ORs, 3.85; 95% CIs, 1.50–9.90), serum albumin level < 3.5 gm/dl (ORs, 5.15; 95% CIs, 1.20–22.07), and serum alanine aminotransferase >120 U/l (ORs, 3.58; 95% CIs, 1.19–10.80). For patients with occlusion time ≥ 45 minutes, postoperative serum total bilirubin and aspartate aminotransferase levels in the Pringle group were significantly higher than those in the hemihepatic and no-occlusion groups (P < 0.05). In HCC patients with impaired liver function undergoing hepatectomy, both hemihepatic vascular occlusion and the Pringle maneuver are safe and effective in reducing blood loss. Patients subjected to hemihepatic vascular occlusion responded better than those subjected to the Pringle maneuver in terms of earlier recovery of postoperative liver function, especially when occlusion time was ≥ 45 minutes.     

The role of the ultrasonically activated shears and vascular cutting stapler in hepatic resection

Hemorrhage and liver failure are the two greatest concerns for patients undergoing major liver resection. Inflow occlusion (Pringle maneuver) is often used to minimize blood loss, but hepatic ischemia results in an increased risk of postoperative hepatic dysfunction. We report our experience with the Harmonic Scalpel ultrasonically activated shears (UAS; Ethicon Endo-Surgery, Cincinnati, OH) and a vascular stapler for hepatic resection as technological advances that aid in minimizing blood loss and thereby reduce the need for inflow occlusion. We retrospectively reviewed liver resections performed from September 1997 through July 1998, in which the UAS and articulating vascular endoscopic linear cutting stapler were used. The vascular stapler was used to divide the appropriate portal vein branch and hepatic vein(s) before parenchymal transection. Parenchymal dissection was performed with UAS to a depth of approximately 2 to 3 cm, and the remainder of the liver parenchyma was divided by a clamp crush and clip and suture ligate technique. Patients underwent segmental resection (n = 12), lobectomy (n = 13), or extended lobectomy (n = 11). Resection was performed for metastatic disease, primary liver tumors, or benign disease in 21, 8, and 7 patients, respectively. A Pringle maneuver was performed in 7 of 36 patients (mean clamp time, 8 minutes). The median required intraoperative blood transfusion was 0 units of packed red blood cells. Major and minor complications occurred in 12 and 3 patients, respectively. Two deaths were related to pneumonia and abdominal infection. The vascular stapler safely and securely divides portal vein branches and hepatic veins. The UAS initiates parenchymal transection with minimal blood loss. These two technologies facilitate the surgeon's aim of liver resection without blood transfusion or Pringle maneuver.     

Tolerance of the cirrhotic liver to normothermic ischemia. A clinical study of 15 patients

Temporary occlusion of hepatic inflow, namely, the Pringle maneuver, was adopted for 15 patients with liver cirrhosis who underwent partial hepatectomy. The warm ischemia time ranged from 2 to 32 minutes with an average of 19 minutes. The procedure did not cause any harmful effects on systemic hemodynamic and postoperative liver function. The results in our patients were compared with those of 15 comparable control patients who had been operated on over the same period of time without inflow obstruction. The Pringle maneuver significantly diminished the estimated blood loss during surgery, intraoperative and postoperative complications, and suppressed the operative mortality rate from 20 percent to 0.     

肝癌的外科治疗—香港经验

肝细胞肝癌（ＨＣＣ）在香港是居于第二位的致死恶性肿瘤，肝切除是治疗ＨＣＣ最为常用和有效的方法。香港大学玛丽医院在最近９年来，肝切除术技术和围手术期管理已经逐渐形成了一套自己的常规。为了避免不必要的开腹手术，术前仔细地检查和估计肿瘤扩散的范围及病人的肝功能情况十分重要。超声刀和Ｐｒｉｎｇｌｅ技术的采用能够有效地减少术中失血，术后管理和围手术期营养支持也是重要的确保肝切除术成功的因素。玛丽医院肝切除术     

大肝癌手术切除术中不同肝血流阻断方法的临床研究

目的：比较大肝癌手术切除术中3种不同的入肝血流阻断法的临床效果。
　　方法：回顾性分析2011年1月—2013年3月期间218例大肝癌（>5cm）手术患者的临床资料,术中88例采用Pringle法间断阻断全肝血流（肝门阻断组）,51例行选择性的半肝血流阻断（半肝阻断组）,79例行肝下下腔静脉阻断联合Pringle法阻断入肝血流（联合阻断组）。比较3组患者的术中与术后的相关指标。
　　结果：3组患者的术前情况、手术时间、入肝血流阻断时间及肝切除量的差异均无统计学意义（均P>0.05）;半肝阻断组与联合阻断组的术中出血量、输血量、输血率均明显低于肝门阻断组,且联合阻断组的输血量、输血率明显低于半肝阻断组（均P<0.05）;3组患者术后第1天肝功能指标差异无统计学意义（均P>0.05）,但半肝阻断组与联合阻断组第3、7天的转氨酶和总胆红素水平均明显低于肝门阻断组（均P<0.05）;3组术后并发症的发生率差异无统计学意义（P>0.05）。
　　结论：大肝癌切除术术中采用肝下下腔静脉阻断联合Pringle法阻断入肝血流不仅能够有效减少术中失血量,而且有利于术后肝功能的恢复。     

Assessment of Effect of Intraperitoneal Tacrolimus on Liver Regeneration in Major (70%) Hepatectomy Model After Experimental Pringle Maneuver in Rats

AimSmall-for-size grafts have become more important, especially in living donor liver transplants. The Pringle maneuver, used to reduce blood loss, and the immunosuppressive medications used to prevent graft rejection in liver transplants have different side effects on liver regeneration. We researched the effect of situations where tacrolimus and the Pringle maneuver were applied or not on liver regeneration in rats with partial hepatectomy.Material and MethodsThis study was completed with 35 Wistar Albino rats. The subjects were randomly divided into 5 groups: Group 1 had the abdomen opened and no other procedure was performed; Group 2 underwent a 70% hepatectomy; Group 3 underwent a 15-minute Pringle maneuver + 70% hepatectomy; Group 4 underwent a 70% hepatectomy + 5 days of 1 mg/kg/day intraperitoneal tacrolimus; and Group 5 underwent a 150 minute Pringle maneuver + 0% hepatectomy + 5 days of 1 mg/kg/day intraperitoneal tacrolimus. All rats were sacrificed on the seventh postoperative day, remaining liver tissue was weighed, and weight indices created. The remaining liver tissue was stained with phosphohistone H3 and the mitotic index calculated.ResultsThe groups that underwent the Pringle maneuver, 70% hepatectomy, and tacrolimus administration were compared with the control group in terms of mitotic index and weight index, but no statistically significant differences were identified.ConclusionSuppression of regeneration forms a risk after liver transplantation with small-volume grafts. As a result, research on the effect of tacrolimus combined with the Pringle maneuver is important, especially for transplantations using segmented liver grafts. In our study, we showed that the use of tacrolimus had no negative effect on liver regeneration.     

肝内双向血流阻断与肝门血流阻断肝切除的临床比较

目的：对不同肝血流阻断法比较,探讨肝切除时肝血流阻断法合理选用。方法：本文对肝内双向阻断法与肝门阻断法肝切除术病人术前病变大小,位置,术前及术后肝功能,术中出血量及术后平均出血量和引流量,术后上消化道出血及死亡等严重并发症进行比较分析。结果：68例肝切除中肝内双向阻断法28例,肝门阻断法40例,肝内双向阻断法肝切除术后转氨酶升高程度是65-560U/L,恢复正常时间是3-8d,胆红质恢复正常时间是4-14d,术后Child A/B/C分级是3/8/17,术中平均出血量650ml,术后总平均出血和引流量780ml,术后无上消化道出血和死亡病例。肝门阻断法肝切除术后转氨酶升高程度是470-9780U/L,恢复正常时间是5-38d,胆红质恢复正常时间是7-52d,术后Child A/B/C分级中0/2/38,术中平均出血量950ml,术后总平均出血量和引流量1200ml,术后上消化道出血4例,出血1例,死亡4例。结论：肝切除时肝血流阻断方法的选用应用根据病变的位置,范围大小及手术类型和肝硬化等综合考虑而定。肝内双向阻断法较肝门阻断法肝切除肝损伤小,利于术后病人恢复,肝内双向阻断法更适用于肝硬变病人的肝切除。     

持续肝动脉阻断预防破裂性肝癌肝切除术中大出血

目的 探讨应用持续肝动脉阻断技术对预防破裂性肝癌肝切除术中大出血的价值.方法 回顾性分析2006年5月至2010年4月第三军医大学西南医院收治的36例应用Pringle法+持续肝动脉阻断技术对破裂性肝癌患者(研究组)行肝切除术的临床资料.在肝癌数据库中配对选取同期36例采用纱布压迫止血的肝癌破裂出血手术患者(对照组).对两组患者术中和术后的相关指标采用方差分析、x2检验、Fisher确切概率法进行对比分析.结果 研究组患者动脉持续阻断中位时间为58 min(36～98 min);术中中位出血量为400ml,明显少于对照组的750ml(F=16.47,P＜0.05);研究组78%(28/36)的患者未进行输血治疗,明显优于对照组的53%(19/36),两组比较,差异有统计学意义(x2=6.01,P＜0.05).两组患者围手术期AST、TBil均在术后第2天达到最高值,然后逐渐下降,1周左右降至正常范围.两组患者的术后并发症发生率和并发症分级比较,差异无统计学意义(x2=1.83,0.89,P＞0.05).结论 应用持续肝动脉阻断技术可明显减少破裂性肝癌肝切除术的术中出血量,且不会对肝功能产生明显的不良影响.     

Hepatectomy using an ultrasonically activated scalpel for hepatocellular carcinoma

BACKGROUND: The first retrospective studies were performed to compare the efficacy of the ultrasonic cavitational aspirator (aspirator group) and the ultrasonically activated scalpel (scalpel group) for hepatic resection in patients with hepatocellular carcinoma. PATIENTS AND METHODS: The aspirator group consisted of 8 patients (6 with liver cirrhosis and 2 with chronic hepatitis in the nontumorous liver), and the scalpel group of 7 patients (6 with liver cirrhosis and 1 with chronic hepatitis). All patients underwent limited hepatic resection, and the intermittent Pringle maneuver was applied during hepatic transection. RESULTS: There were no significant differences in preoperative hepatic function, type of hepatectomy, tumor size and maximum cross-sectional area of the resected specimen between the 2 groups. The amount of intraoperative blood loss was significantly less in the scalpel group than in the aspirator group (684 versus 1,859 ml, p < 0.05). The operation time was significanly shorter in the scalpel group than in the aspirator group (176 versus 262 min, p < 0.05). There were no significant differences in postoperative liver function and morbidity between the 2 groups. CONCLUSIONS: The ultrasonically activated scalpel is effective in reducing blood loss and in shortening the time of operation, and can be employed during limited resection of the liver with cirrhosis or chronic hepatitis.     

Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Liver Resections: Prospective Study

Selective hepatic vascular exclusion (SHVE) and the Pringle maneuver are two methods used to control bleeding during hepatectomy. They are compared in a prospective randomized study, where 110 patients undergoing major liver resection were randomly allocated to the SHVE group or the Pringle group. Data regarding the intraoperative and postoperative courses of the patients are analyzed. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group, and postoperative liver function was better in that group. Although there was no difference between the two groups regarding the postoperative complications rate, patients offered the Pringle maneuver had a significantly longer hospital stay. The application of SHVE did not prolong the warm ischemia time or the total operating time. It is evident from the present study that SHVE performed by experienced surgeons is as safe as the Pringle maneuver and is well tolerated by the patients. It is much more effective than the Pringle maneuver for controlling intraoperative bleeding, and it is associated with better postoperative liver function and shorter hospital stay.     

第二肝门区域肿瘤切除中两种肝血流阻断方法的比较

目的比较入肝血流加肝静脉血流阻断术与单纯第一肝门阻断术在第二肝门区域肿瘤切除中的作用。方法从2000年1月至2005年10月,共施行2100例肝脏肿瘤切除术,其中235例肿瘤紧贴或压迫1根以上主肝静脉,根据肝血流阻断方法的不同,将235例患者分为两组：选择性肝血流阻断组（SHVE组,125例）和第一肝门阻断组（Pringle组,110例）。分析两组患者的术中及术后情况。在SHVE组,完全SHVE（阻断第一肝门和所有主肝静脉）25例,部分SHVE（阻断第一肝门和部分主肝静脉）100例。肝静脉阻断方法有3种：丝线结扎肝静脉,止血带阻断和辛氏钳阻断。结果两组间年龄、性别、肿瘤大小、肝硬化发生率、HBsAg阳性率、术中热缺血时间和手术时间的差异均无统计学意义（P〉0．05）。SHVE组的术中失血量及输血量明显少于Pringle组（P〈0．05）。Pringle组有17例发生主肝静脉破裂,其中大出血14例,空气栓塞3例。而SHVE组无1例肝静脉破裂、大出血或空气栓塞发生。Pringle组术后再出血、再次手术和肝功能衰竭等并发症发生率高于SHVE组,ICU时间和住院时间长于SHVE组（P〈0．05）。结论SHVE较Pringle法能更有效地控制术中大出血,防止肝静脉破裂导致的大出血和空气栓塞,降低术后并发症和手术病死率。用辛氏钳阻断肝静脉较结扎法和止血带阻断法更安全和简便。     

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??Laparoscopic hepatectomy: Pringle maneuver versus tourniquet method ZHANG Deng-ming, ZHEN Zuo-jun, CHEN Huan-wei, et al. Department of Hepatobiliary Surgery, the First People's Hospital of Foshan City, Foshan 528000, China
Corresponding author??ZHEN Zuo-jun??E-mail??zzjun@fsyyy.com
Abstract Objective To evaluate the feasibility of tourniquet method in laparoscopic hepatectomy compared with Pringle maneuver. Methods Sixty-two patients performed laparoscopic hepatectomy between January 2003 and January 2011 in the Department of General Surgery, the First People’s Hospital of Foshan City were divided into Pringle group (30 patients) and tourniquet group (32 patients) randomly. The changes of preoperative and postoperative liver function, intraoperative blood loss, complications, operation time and hospital stay between the two groups were compared. Results No significant difference was found in operative blood loss, perioperative complications, the TBIL and ALB before operation and on the first, third and seventh day after operation between two groups (P>0.05). There was significant difference in ALT and AST before operation and on the first, third and seventh day after operation between two groups (P??0.05). Patients in tourniquet group had significantly faster recovery of liver function than those in Pringle group (P??0.05). The postoperative hospital stay of tourniquet group was significantly shorter than that of Pringle group (P??0.05). Conclusion Tourniquet method can limit operative blood loss effectively with quicker recovery and shorter hospital stay, which is safe, efficient and feasible for patients performed laparoscopic hepatectomy.