腹腔镜下肝门部胆管癌根治术中淋巴结廓清方法的探讨

目的探讨腹腔镜下肝门部淋巴结廓清的可行性。方法 2007年6月~2009年6月对35例肝门部胆管癌施行腹腔镜下肝门部胆管癌根治术,探查明确肿瘤可以切除,超声刀将胆总管远端在十二指肠上方离断,远侧断端缝合或圈套线结扎闭合,并将胰腺上方的淋巴结一并切除,将胆总管向前上方分离至肿瘤上方约0.5~1.0 cm,离断,超声刀切开肝十二指肠韧带前包膜,找到肝固有动脉,打开动脉鞘后用冲洗吸引器向近肝侧钝性分离纤维脂肪组织,直至显露左右肝动脉的分叉部,同样处理门静脉,直至显露门静脉左右分叉部,除门静脉和肝动脉外,将肝十二指肠韧带内组织整块切除,完成肝门部肿瘤切除及淋巴结廓清,然后镜下使用腔镜直线切割吻合器(5例)或左上腹3~4 cm切口提出空肠行空肠间吻合后还纳回腹腔,重建气腹行胆管-空肠Roux-en-Y吻合(30例)。结果 35例均在腹腔镜下完成肝门部胆管癌根治术并进行淋巴结廓清。清扫淋巴结8~13枚,平均9.3枚,2例发现淋巴结转移。胆肠吻合在镜下完成,肠间吻合5例在镜下使用腔镜直线切割吻合器完成,30例于腹外吻合后还纳回腹,重新气腹完成胆肠吻合。手术时间3.5~5.8 h,平均4.4 h;术中出血量10~210ml,平均83 ml。术后出现胆汁漏3例,未特殊处理,5~7 d后停止。应激性溃疡1例,抑酸药物治疗后3 d治愈。肝左外叶切除术后第5天出血1例,出血量约300 ml,腹腔镜下探查见肝门处毛细血管出血,圈套线结扎止血,术后10 d出院。35例随访6~30个月,平均16.2月,1例术后12个月因肝转移癌死亡,1例术后15个月因突发心肌梗塞死亡,其余33例存活。结论腹腔镜下进行肝门部胆管癌根治性切除同时进行肝门部淋巴结廓清,是完全可以实现的,但需要严格选择病例以及丰富的腹腔镜手术经验,术后远期效果仍然需要进一步观察。

Laparoscopic Radical Resection of Hilar Cholangiocarcinoma and Lymph Node Dissection

Objective To evaluate the feasibility of laparoscopic portal lymph node dissection. Methods Totally 35 patients with hilar cholangiocarcinoma received laparoscopic resection for hilar cholangiocarcinoma from June 2007 to June 2009 in our hospital.Before the operation the tumor was probed to confirm if it could be removed.During the operation,the distal common bile duct was cut off on the top of the duodenum by scalpel,and the distal stump was sutured or closed by trap-line,and the lymph nodes was removed above the pancreas.The common bile duct was then separated to 0.5-1.0 cm away from the top of the tumor,and cut off.Afterwards,Pre-layer of the hepatoduodenal ligament was separated by scalpel to expose the proper hepatic artery.Then,we opened the arterial sheath and separated the fat and fibrous tissues to the liver by suction cleaning to display the hepatic artery bifurcation.Portal bifurcation was displayed by the same method.Except the portal vein and hepatic artery,the organization within the hepatoduodenal ligament was resected.Finally,tumor and portal lymph node dissection,and endoscopic biliary-enteric anastomosis were completed.Five cases underwent intestinal anastomosis by using the endoscopic stapler,and 30 patients was back on the abdomen after abdominal Roux-en-Y anastomosis for portoenterostomy. Results The procedure was completed by laparoscopy in the 35 cases.A mean of 9.3 lymph nodes were removed（ranged from 8 to 13）.In two cases,lymph node metastasis was detected.Hepatoduodenal anastomosis was completed by laparoscopy in all the cases,and inter-intestinal anastomosis was completed by using endoscopic stapler in 5 cases,in the other 30 patients,portoenterostomy was performed extra-abdominally.The procedure was finished in 3.5 to 5.8 hours with a mean of 4.4 hours.The mean blood loss was 83 ml（10-210 ml）.Three patients developed bile leakage after the operation and was cured spontaneously in 5 to 7 days.Stress ulcer was found in one patients,who was cured by antiacids（3 days）.One patient showed hemorrhage of 300 ml after resection of the left lateral liver lobe,laparoscopic exploration then showed bleeding from the portal capillaries,hemostasis by trap-line was then performed.The patient was discharged from hospital in 10 days afterwards.The 35 patients were followed up for 6 to 30 months with a mean of 16.2 months.One patient died of metastatic liver carcinoma in 12 months,one died of myocardial infarction at month 15,the other 33 patients survived. Conclusions Laparoscopic radical resection of hilar cholangiocarcinoma and hilar lymph node dissection is feasible as long as the cases were selected strictly.Postoperative long-term efficacy of the treatment needs to be further observed.