肝正中裂劈开在肝切除中的应用:附42例

目的 探讨利用肝正中裂劈开的方法来切除较难切除的肝脏肿瘤.方法 先用电刀在肝脏的膈面作一点状虚线,上端起于肝右静脉与肝中静脉之间的静脉陷窝,下端止于胆囊窝的中点,延伸向第一肝门中点,此为肝正中裂标记.然后从胆囊窝起,切开肝实质,上方达第二肝门,下方达第一肝门,完成肝正中裂劈开.根据需要行右半肝、左半肝或尾叶切除.结果 2003年9月至2006年9月,应用肝正中裂劈开方法进行的肝切除共42例,切除最大肿瘤25 cm.手术时间50 min至4 h(平均2.3 h),失血100～3000 ml(平均600 ml),其中有5例失血超过1000 ml,需输血,余37例(88%)不输血.术后再出血1例、2例出现胆漏,经保守治疗治愈,有3例出现肝功能衰竭,治愈2例,另1例在术后2个月死亡,无围手术期死亡.结论 肝正中裂劈开,不需阻断肝门,可以较清楚地显露一二三肝门,应用于一些近肝门的、难切除的大肿瘤,以及肝硬化严重、TACE后等肝功能储备较差情况下,尤其可用于肝周分离困难的肝逆行切除以及尾叶切除.

Hepatic resection by hepatic parenchymal transection along interlobar plane in 42 cases

Objective To investigate the value of a hepatic parenebymal transection along the interlobar plane in un-accessible hepatic tumor. Methods The interlobar plane on the upper surface of liver was marked with electrotome from the crypt between middle and right hepatic vein to fossa of gallbladder. The liver parenehyma was transected from the fossa of gallbladder to the first and second porta with scraping and sucking maneuver. Then the liver was transected on the interlobar plane. The first, second or third porta was dissected and the right, left lobe or caudate lobe resected according to the place of tumors. Results There were 42 cases of hepatic parenchymal transection along the interlobar plane. HCC was in the right lobe in 24 cases, in left one in 10 and in caudate lobe in 4. In 1 case, there was a large hemangioma in the right lobe. Twenty patients underwent right hepatic lobectomy, 5 right three-lobe hepatectomy, 13 left hepatic lobectomy, 4 caudate-lobe hepatectomy and 5 portal vein incision and 3 bile duct incision to pull out cancer emboli. The largest tumor was 25 cm in diameter. The operative duration was 50 min to 4 h (mean= 2.3 h). The blood loss was 1000 -3000 ml (mean=600 ml). In 5 of the 42 cases, the blood loss was beyond 1000 ml and needed perfusion. One patient had bleeding again after the operation, 2 developed bile leakage and cured by non-operative treatment. Three patients developed liver failure and 1 of them died 2 months after the operation. There was no perioperative death. Conclusion It is not necessary to block portal blood flow during hepatic parenchymal transection along the interlobar plane. This technique is safe and effective to resect tumors that are near porta or very large and with poor liver storage function.