成人间活体右半肝移植供体手术技巧探讨

目的 探讨活体肝移植(living donor liver transplantation,LDLT)的供肝切取技术.方法 对2002年1月至2006年6月期间,我中心进行的47例活体肝移植中不含肝中静脉的右半肝供体切取技术进行回顾性分析.术前CT对供肝管道系统、体积充分评估;术中使用血液回收器回收出血.用超声刀(CUSA)、电刀、滴水双极电凝切取供肝,术中不阻断入肝血流;注意保留＞5 mm的右肝下静脉、肝Ⅴ段(V5)、肝Ⅷ段(V8)静脉以备重建.结果 供体术后无严重并发症和死亡.右半肝切取的中位手术时间为425 min(380～620 min),术中失血250～735 mL,平均345 mL,术中收集自体血并回输0～500 mL,平均263 mL,仅4例输异体血(自2005年供体切取已常规不输血).并发症包括切口脂肪液化2例,乳糜漏1例,门静脉血栓1例,腹腔内出血1例.47例供体中,有31例出现粗大的V5静脉和(或)V8静脉、右肝下静脉,并进行了流出道重建.全部供体术后随访至今,供体生活和工作正常.结论 在切取供肝过程中,CUSA、双极电凝和电刀联合使用,仔细及精良的供肝切取技术值得推广;通过流出道的充分重建,不包含肝中静脉右半供肝可以降低供体的风险,是较为安全的手术方式.

Exploration of Surgical Technique Used to Donor Hepatectomy for Adult to Adult Living Donor Liver Transplantation with Right Liver Lobe Graft

OBJECTIVE: To study the surgical technique of donor hepatectomy for living donor liver transplantation (LDLT). METHODS: From March 2002 to July 2006, the donor hepatectomy was performed to 47 LDLT without middle hepatic vein (MHV) at West China Hospital. The donors were assessed by 3-dimensional computed tomography (CT) preoperatively. Techniques of cut-ultrasound aspiration (cusa) and electrocautery combining with bipolar coagulation were applied to donor hepatectomy. During the parenchymal transection of donor liver, all major (diameter>5 mm) outflows of segment V (V5), segmentV (V8) and inferior right hepatic vein (IRHV) were preserved for future reconstruction. RESULTS: No severe complications and death occurred in all the donors. The median operative time was 425 min (range 380-620 min), the average blood loss during the operation was 345 mL (range 250-735 mL), the average intraoperative self-transfusion was 263 mL (range 0-500 mL), but 4 cases of donors needed the blood transfusion intraoperatively. Since 2004, it has become a routine not to transfuse blood into the donor during grafting operation of liver. Complications of liver graft operation occurred in 4 patients including wound steatolysis (2 cases), chyle leakage (1 case), portal vein thrombosis (1 case), and of all 47 donors, 27 cases with big V5, V8 or IRHV were made the vein outflow ducts reconstructed. All operated donors were followed up until today, and all work and live as usual. CONCLUSION: During the donor operation, it is safe and reliable to the hepatectomy performed by the CUSA and electrocautery combining with bipolar coagulation. And the enough outflow reconstruction for LDLT without MHV have made the donor hepatectomy operation become excellent, which suggests that the surgical operative method should be applied and popularized.