经胸腔-膈肌入路的胸腔镜手术治疗转移性肝癌

针对经腹腔手术难于操作的转移性癌，尤其是位于膈下肝段的肿瘤，北京大学第三医院对3例结直肠癌肝转移复发患者采用胸腔镜辅助的经胸腔．膈肌入路进行手术治疗。根据转移癌部位经胸壁的肋间隙放置3根穿刺套管，术中在膈肌表面使用胸腔镜超声确定转移癌的部位并切开相应部位的膈肌，分离膈肌与肝脏间的粘连；经肝脏表面使用术中超声再次确定转移癌的部位并标记；使用电刀、超声刀及血管闭合器切除转移癌，或者行RFA治疗转移癌；完成肝脏手术后缝合关闭膈肌切口。3例患者中1例行手术切除，2例行RFA治疗。3例患者手术时间分别为200、170、220min，术中出血量分别为600、100、10mL，围手术期均未输血。3例患者分别于术后第4、6、3天出院。3例患者随访28、12、7个月，未见肝脏和肝外脏器肿瘤复发。针对位于膈下的转移性肝癌，经胸腔一膈肌入路手术是安全、可行的，术后的近期疗效良好。

Video-assisted thoracoscopic surgery via the thoracic-dia- phragm approach for the treatment of recurrent colorectal liver metastases

Recurrent colorectal liver metastases, espe- cially the lesions located at the subdiaphragmatic liver segments are difficult to manage via the abdominal approach. Three patients with recurrent colorectal liver metastases located at the subdiaphragmatic area received video-assisted thoracoscopic sur- gery via the thoracic-diaphragm approach. Three ports were put into the intercostal space of chest wall surrounding the metasta- sis. The portion of the diaphragm located above the lesions was cut open under the guidance of intraoperative thoracoscopic ultrasonography （IOTU）. The adhesion between the diaphragmand the liver was separated. IOTU was performed on the liver surface to detect and mark the metastasis. Electric knife, har- monic scalpel and Ligasure were used for liver resection, and radiofrequency needle was used for ablation. The incision in the diaphragm was closed after hepatectomy or ablation. Of the 3 patients, 1 received surgical resection, and the other 2 patients received radiofrequency ablation. The operation time and volumes of blood loss were 200 minutes, 170 minutes, 220 minutes, and 600 mL, 100 mL and 10 mL. No patient received perioperative blood transfusion. Three patients were discharged at postopera- tive day 4, 6, 3, and were followed up for 28 months, 12 months and 7 months. No hepatic or extrahepatic metastasis was detected. Video-assisted thoracoscopic surgery via the thoracic- diaphragm approach seems to be promising for the treatment of recurrent colorectal liver metastases in the subdiaphragmatic area. The short-term survival is favorable.