一种理想的腹腔镜下肝实质离断方法：超声刀联合双极电凝

目的探讨腹腔镜下超声刀联合双极电凝实施肝实质离断的可行性。方法自2006年10月至2009年9月，采用上述肝实质离断方法共完成腹腔镜下肝切除（LLR）33例，男21例，女12例，年龄25～80岁，平均（47-3±14．9）岁；所有患者均为单发病灶，术前诊断良性占位20例，恶性占位13例，其中包括复发性肝癌1例；病灶大小2．0—11．0cm，平均（6．1±3．5）cm，位于肝左叶24例，其中20例于肝左外叶，肝右叶9例。结果全组33例手术无一例中转开腹，共行规则性LLR21例，非规则性LLR12例。手术时间45—220min，平均（116．4±63．4）min，术中出血20～700ml，平均（97．3±140．4）ml，术后胃肠恢复时间1—3d，平均（1．1±0．6）d，腹腔引流时间2～8d，平均（3．4±1．8）d，术后住院时间3—10d，平均（4．9±2．1）d。4例发生术后并发症，其中腹水2例，肺部感染1例，少量胆瘘1例（腹腔引流8d后自愈），所有并发症均通过保守治疗治愈。结论超声刀联合双极电凝在腹腔镜下进行肝实质离断可以充分利用两者的优势，互补各自的缺点，该方法断肝速度快，出血少，显著缩短了手术时间，提高了手术安全性，推荐在当前LLR中常规应用。

A kind of ideal liver parenchyma dissecting method under laparoscope:ultrasonic scalpel combined with bipolar coagulation

Objective To explore the feasibility of the harmonic scalpel combining a bipolar coagulation in laparoscopic liver resection. Methods During Oct 2006 to Sep 2009, 33 cases of laparoscopic liver resection were performed by means of above method in the procedure of liver parenchyma dissection,included 21 cases of male,12 cases of female with mean age of ( 47.3 ± 14.9 ) years old ( range,25-80 years old ),each patient only had one lesion,preoperative diagnosis indicated 20 cases of benign lesions and 13 cases of malignant lesions,included 1 case of recurrent hepatic cellular carcinoma.Mean size of lesions was ( 6.1 ± 3.5 )cm,with a range 2.0-11.0 cm.Twenty-four cases located on the left lobe of liver included 20 cases on the left lateral segment, 9 cases on the right lobe. Results All of 33 cases of laparoscopic liver resection were completed via this method with no conversion to open procedure.Anatomic liver resection and local resections were done in 21 and 12 cases respectively.Mean operation time was ( 116.4 ± 63.4 )min ( range,45-220 min ),mean blood loss was ( 97.3 ± 140.4 )ml ( range,20-700 ml ),postoperative bowel recovery time was ( 1.1 ± 0.6 )d (range,1-3 d),abdominal drainage time was( 3.4 ± 1.8 )d ( range,2-8 d ),postoperative length of stay was( 4.9 ± 2.1 )d ( range,3-10 d ),4 cases of complications occurred,with 2 cases of ascites,1 case of pulmonary infection and 1 case of biliary fistula (cured by delayed drainage time to 8 d).All of complications were cured through conservative treatment. Conclusions Ultrasonic scalpel combined with bipolar coagulation could complement respective weaknesses mutually,and integrate their advantages,and this method could accelerate the speed of liver parenchyma dissection with less blood loss,which obviously reduced the operation time and improved the safety.Thus,in current,ultrasonic scalpel combined with bipolar coagulation is an ideal method of liver parenchyma dissection under laparoscope,which should be commonly used in the procedure of laparoscopic liver resection.