肝实质解剖优先法对比肝蒂优先法在腹腔镜右半肝切除中的应用
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中南大学湘雅医院 肝脏外科,湖南 长沙 410008

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肖亮,中南大学湘雅医院副主任医师,主要从事肝脏外科方面的研究。

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湖南省卫生健康委科研计划项目资助(202104010072)。


Liver parenchyma dissecting-first method versus hepatic pedicle-first approach in laparoscopic right hemihepatolobectomy
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Department of Liver Surgery, Xiangya Hospital, Central South University, Changsha 410008, China

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    摘要:

    背景与目的 腹腔镜右半肝切除术(LRH),是难度较大的微创肝切除手术,需要较长的学习曲线。传统的LRH操作秉承了开放肝切除“肝蒂优先,鞘内解剖”的操作习惯,即在切除胆囊后先游离右肝动脉、右门静脉、右胆管,分别离断后再行肝实质离断。但它耗时费力,如操作不当,有出血风险。笔者在前期临床工作中摸索出了优先解剖肝实质再处理目标肝蒂的入肝血流阻断技术,将其命名为“肝实质解剖优先法”(LPDF)。这一方法未改变手术切除范围,仅调整了操作顺序,初步经验提示其可简化半肝切除手术流程,有利于LRH的推广应用。本研究进一步探讨LPDF相对于肝蒂优先法在LRH中的优势。方法 采用前瞻性研究方法,将2021年8月—2023年8月在中南大学湘雅医院行LRH且符合标准的肝癌患者随机分为观察组和对照组,观察组术中采用LPDF,对照组则采用肝蒂优先法。收集并比较两组患者围术期临床指标。结果 共纳入19例患者,其中观察组10例,对照组9例。两组患者的基线资料差异无统计学意义(均P>0.05)。观察组的手术时间明显少于对照组(224.30 min vs. 267.78 min,P=0.045),两组其余指标包括术中出血量和输血量、中转开腹率、术后排气时间、住院时间、术后第3天肝功能、并发症发生率,以及无复发生存率与总生存率差异均无统计学意义(均P>0.05)。结论 LPDF应用于LRH相较于传统的肝蒂优先法简化了肝蒂处理流程,缩短了手术时间,未增加术后并发症发生率,且一定程度上减少了出血风险,建议行进一步大样本量研究与推广。

    Abstract:

    Background and Aims Laparoscopic right hemihepatectomy (LRH) is a complex minimally invasive liver resection surgery that requires a long learning curve. Traditional LRH procedure adheres to the practice of "pedicle-first and intrathecal dissection" used in open liver resection, which involves first dissociating the right hepatic artery, right portal vein, and right bile duct after removing the gallbladder, then severing them before dividing the liver parenchyma. However, this method is time-consuming and labor-intensive and carries a risk of bleeding if not performed correctly. The authors have developed a technique during prior clinical work that prioritizes liver parenchymal dissection before handling the target hepatic pedicle, named the "liver parenchyma dissecting-first" (LPDF) method. This method does not change the extent of the resection but adjusts the order of the procedure. Preliminary experience suggests that it simplifies the hemihepatectomy process and facilitates the broader application of LRH. This study was peformed to further explore the advantages of LPDF over the pedicle-first method in LRH.Methods Using a prospective study approach, eligible liver cancer patients who underwent LRH in Xiangya Hospital of Central South University from August 2021 to August 2023 were randomly divided into observation group and control group. Patients in the observation group underwent the LPDF method during surgery, while those in the control group used the pedicle-first method. Perioperative clinical variables were collected and compared between the two groups.Results A total of 19 patients were included, with 10 in the observation group and 9 in the control group. There were no statistically significant differences in baseline data between the two groups (all P>0.05). The operative time in the observation group was significantly shorter than that in the control group (224.30 min vs. 267.78 min, P=0.045). Other variables, including intraoperative blood loss and transfusion volume, rate of conversion to open surgery, time to postoperative gas passage, length of hospital stay, liver function on the third postoperative day, and incidence of complications, as well as the recurrence-free survival rate, and overall survival rate, showed no statistically significant differences between the two groups (all P>0.05).Conclusion The application of LPDF in LRH simplifies the pedicle handling process compared to the traditional pedicle-first method, shortens the operative time, does not increase the incidence of postoperative complications, and somewhat reduces the risk of bleeding. Further large-sample studies and promotion are recommended.

    图1 LPDF法术中照片 A:胃钳钳夹右肝蒂;B:电凝钩标记肝表面半肝分界线;C:不解剖右肝蒂,沿半肝分界线离断肝实质;D:肝内沿中肝静脉右侧解剖;E:充分离断肝实质后,金手指分离右肝蒂;F:离断右肝蒂;G:金手指分离右肝静脉;H:离断右肝静脉;I:肝创面可见中肝静脉,右肝蒂断端和下腔静脉Fig.1 Intraoperative photos of the LPDF method A: Clamping the right hepatic pedicle with gastric forceps; B: Marking the Cantlie line on the liver surface with an electrocautery hook; C: Dividing the liver parenchyma along the Cantlie line without dissecting the right hepatic pedicle; D: Dissecting the intrahepatic parenchyma along the right side of the middle hepatic vein; E: Separating the right hepatic pedicle with a Goldfinger dissector after fully dividing the liver parenchyma; F: Severing the right hepatic pedicle; G: Separating the right hepatic vein with a Goldfinger dissector; H: Severing the right hepatic vein; I: Exposed liver surface showing the middle hepatic vein, the severed end of the right hepatic pedicle, and the inferior vena cava
    图2 两组患者术后生存曲线 A:总生存曲线;B:无复发生存曲线Fig.2 Postoperative survival curves of the two patient groups A: Overall survival curve; B: Recurrence-free survival curve
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肖亮,谭盛,龙果,米星宇,莫蕾,杨瀚睿,周乐杜.肝实质解剖优先法对比肝蒂优先法在腹腔镜右半肝切除中的应用[J].中国普通外科杂志,2024,33(7):1035-1042.
DOI:10.7659/j. issn.1005-6947.2024.07.002

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  • 收稿日期:2023-10-10
  • 最后修改日期:2024-05-06
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  • 在线发布日期: 2024-08-10