腹腔镜肝切除术中肝静脉入路及显露过程中的意外及处理

Accident and treatment of hepatic vein access and exposure during laparoscopic hepatectomy

随着腹腔镜技术的发展,腹腔镜肝切除术已经广泛应用于肝脏手术,其安全性及有效性与开放手术相当,甚至优于开放手术。腹腔镜下循肝静脉解剖性肝切除是以肝静脉为切肝平面的解剖性肝切除,在保证切缘的前提下,尽最大程度保留具有正常功能的肝组织,减少了无血供无效肝组织的残留,降低了术后肿瘤复发及并发症发生率。循肝静脉入路肝切除是目前确定肝内切除平面、实现解剖性肝切除的最佳方法之一。寻找并依循标志性肝静脉走行并判断和修正断面平面对解剖性肝切除至关重要。腹腔镜下循肝静脉操作最大难点在于肝静脉解剖和显露、术中出血控制和处理。循肝静脉腹腔镜解剖性肝切除对于手术视野、操作空间及解剖的显露要求较高,因此,合适的切肝入路对于完成循肝静脉腹腔镜肝切除具有重要意义,目前使用较多的入路为前入路、头侧入路和背侧入路,术者须根据自身操作习惯及不同的肝段切除选择不同的入路方式。肝静脉壁软薄、分支多、易撕裂、回血量大、暴露难度大等因素使得在肝切除过程中易损伤肝静脉。出血和气体栓塞是肝静脉损伤引发的两大并发症。术中出血在肝切除术中难以避免,重在预防,一旦发生出血或气体栓塞,须冷静评估并及时处理,才能更安全地开展腹腔镜肝切除。

With the development of endoscopic technology,laparoscopic hepatectomy(LH)has been widely used in liver surgery.Its safety and effectiveness are equal to or even better than that of open surgery.Laparoscopic anatomic hepatectomy along hepatic vein is an anatomic hepatectomy with hepatic vein as the cutting plane.On the premise of ensuring the cutting edge,the liver tissue with normal function is retained to the maximum extent,reducing the residual of ineffective liver tissue without blood supply,and reducing the incidence of tumor recurrence and complications after operation.Hepatectomy via hepatic vein approach is one of the best methods to determine the resection plane and achieve anatomical hepatectomy.It is very important for anatomic hepatectomy to find and follow the shape of the landmark hepatic vein and to judge and correct the cross-sectional plane.The most difficult points of laparoscopic operation along hepatic vein are the anatomy and exposure of hepatic vein,the control and treatment of intraoperative hemorrhage.Laparoscopic anatomical hepatectomy along the hepatic vein has high requirements for the surgical field,operating space and anatomical exposure.Therefore,an appropriate hepatic resection approach is of great significance for the completion of laparoscopic hepatectomy along the hepatic vein.Currently,more used approaches are the anterior approach,the cephalic approach and the dorsal approach.The operator needs to choose different approaches according to his own operating habits and different liver segment resections.The soft and thin wall of the hepatic vein,many branches,easy to tear,large amount of blood return,and difficult exposure make it easy to damage the hepatic vein in the process of hepatectomy.Bleeding and gas embolism are two major complications caused by hepatic vein injury.Intraoperative bleeding is difficult to avoid in hepatectomy.The emphasis is on prevention.Once bleeding or gas embolism occurs,it must be calmly evaluated and treated in time to carry out laparoscopic hepatectomy more safely.