中南大学湘雅医院 胆道外科，湖南 长沙 410008
Department of Biliary Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
背景与目的 肝胆管结石是常见的消化系统疾病之一，容易导致肝硬化、胆道感染、积脓，甚至引起胆管癌。肝切除是彻底治疗肝胆管结石的主要手段，近年来随着技术的进步，腹腔镜手术因在近期手术效果方面的优越性，逐步取代了开腹手术。但是，相比于肝胆管肿瘤而言，肝胆管结石造成的炎症水肿和粘连使手术更加困难，因此寻找简便可靠的手术方法是有必要的。近来随着对肝脏解剖的再认识，腹腔镜下鞘外解剖性肝切除在肝脏肿瘤中得到广泛应用，且有报道证实结合吲哚菁绿（ICG）荧光反染技术可使手术更加高效和精准，但是在肝胆管结石中的应用鲜有报道。在本文中，笔者总结和归纳近期实施腹腔镜下鞘外解剖性肝切除结合ICG荧光反染在肝胆管结石治疗中的应用体会。方法 回顾性分析中南大学湘雅医院胆道外科2022年2月—2023年4月收治的7例肝胆管结石患者的临床资料，根据患者病史、临床体征和术前影像学资料，患者均有肝切除的指征，其中6例行左半肝切除，1例行右肝后叶切除术。术中应用荧光腹腔镜，在低中心静脉压和全肝入肝血流阻断下，充分利用肝脏表面的解剖标志（Arantius板、脐板、胆囊板、尾状突的Glisson蒂）和Laennec膜解剖出目的肝蒂，将其阻断后再向外周静脉注射ICG，使肝脏表面显示出缺血/切除标记线，术中再结合肝静脉的显露，使解剖性肝切除的实施得以完成。部分患者需要行胆道切开及术中胆道镜取石，提高结石清除率。结果 7例患者均顺利完成肝切除手术，术后解剖标本，检查确认切除肝脏的肝胆管结石情况。5例患者切除肝脏后行胆总管切开取石及术中胆道镜探查。术中出血量100~600 mL，平均（314.3±211.6）mL，无严重并发症（Clavien-Dindo分级Ⅲ~Ⅳ级）发生，除1例患者因术后胆汁漏、伤口感染住院24 d外，其余患者术后住院时间7~9 d，平均（8.5±0.8）d。术后通过腹部B超和T管造影或者MRCP检查，6例患者的结石清除干净，1例患者行1次术后胆道镜后将结石清除干净。病检回报均示肝胆管结石及胆管炎，未见癌变。结论 腹腔镜下鞘外解剖性肝切除结合ICG荧光反染技术在肝胆管结石患者中的应用是安全和可行的。其有效性和优越性还有待扩大样本量、丰富临床数据的对照研究来进一步验证。
Background and Aims Hepatolithiasis is one of the most common digestive system diseases, which can progress to liver cirrhosis, biliary tract infection, liver abscess, and even cholangiocarcinoma. Hepatectomy remains the thorough treatment method for hepatolithiasis. In recent years, with the advancement of technology, laparoscopic surgery has gradually replaced open surgery due to its superiority in short-term therapy effects. However, compared to hepatobiliary tumors, the inflammation, edema, and adhesion caused by hepatobiliary stones make the surgery more difficult. Therefore, it is necessary to find a simple and reliable surgical approach. Recently, with a renewed understanding of liver anatomy, laparoscopic extra-Glissonean anatomic hepatectomy has become widely used in liver tumors, and there have been reports confirming that its combination with indocyanine green (ICG) fluorescence negative staining technique can enhance the efficiency and precision of surgery. However, its application in hepatolithiasis has been rarely reported. Here, the authors summarize and compile their recent experiences applying the extra-Glissonean approach combined with ICG fluorescence-negative staining in treating hepatolithiasis.Methods The clinical data of seven patients with hepatolithiasis treated in the Department of Biliary Surgery of Xiangya Hospital, Central South University, from February 2022 to April 2023, were retrospectively analyzed. Based on the medical history, clinical symptoms, and preoperative imaging data, all patients exhibited indications for liver resection. Six patients underwent left hepatectomy, and one underwent right posterior lobectomy. Intraoperatively, fluorescence laparoscopy was employed. Under low central venous pressure and total hepatic inflow occlusion, anatomical landmarks on the liver surface (including the Arantius plate, cystic plate, umbilical plate, and Glissonean pedicle of the caudate process) and the Laennec's capsule were utilized to dissect the target hepatic pedicle anatomically. After occlusion, ICG was injected into the peripheral veins, resulting in ischemia/resection demarcation lines on the liver surface. Then, an anatomic hepatectomy was completed with intraoperative exposure of the hepatic vein. In some patients, bile duct incision and intraoperative cholangioscopy were additionally performed to enhance stone clearance rates.Results All seven patients successfully underwent liver resection surgery, and postoperative specimens were dissected to examine and confirm the status of the removed stones. Five patients underwent choledocholithotomy and intraoperative choledochoscopy after liver resection. Intraoperative blood loss ranged from 100 to 600 mL, with an average of (314.3±211.6) mL. No severe complications (Clavien-Dindo grade Ⅲ-Ⅳ) occurred. Except for one patient who was hospitalized for 24 d due to postoperative bile leakage and wound infection, the length of postoperative hospital stay in the remaining patients ranged from 7 to 9 d, with an average of (8.5±0.8) d. Postoperative abdominal ultrasonography, T-tube cholangiography, or MRCP examination revealed complete stone clearance in 6 patients, and in 1 patient, the stones were completely removed after an additional postoperative choledochoscopic lithotomy. Pathological examination results for all cases indicated hepatolithiasis and cholangitis, with no evidence of canceration.Conclusion The application of laparoscopic extra-Glissonean anatomic hepatectomy combined with ICG fluorescence-negative staining in patients with hepatolithiasis is safe and feasible. Its effectiveness and superiority still require further validation through controlled studies with expanded sample sizes and enriched clinical data.