肝门区域血管阻断的肝段切除341例报告

Hepatic Segmentectomy by Regional Vascular Occlusion at Hepatic Hilum--Report of 341 Cases

目的总结从1987～2007年在肝门H沟中阻断各肝叶、肝段或肝亚段的入肝血管分支施行各种类型肝切除341倒的经验。方法（1）对HCC（199例）、肝内胆管癌（13例）、肝门胆管癌（14例）、胆囊癌（12例）、转移性肝肿瘤（15例）、肝血管瘤（32例）、肝内胆管结石（48例）、慢性肝脓肿（3例）和肝包虫病（5例）患者根据肿瘤的部位和大小分别施行大型肝切除（65例）、间隔性多个肝亚段切除（15例）、邻接多个肝亚段切除（215例）和单个肝亚段切除（46例）、其中含肝尾叶切除29例；（2）血管阻断情况：肝左外段切除时在肝门左纵沟外侧游离，切断从门静脉左干矢状部外侧发出的左外上、下分支和肝左动脉。肝左内段切除时游离、切断从门静脉左干矢状部内侧发出的左内上、下分支和肝中动脉。肝右前段切除时游离、阻断肝右纵沟前支中的门静脉右前支和肝总管后方的肝右动脉。肝右后段切除时阻断右纵沟后支中的门静脉右后支和肝右动脉。肝左、右叶切除时在肝门横沟中分别阻断门静脉左干或右干，肝左动脉或肝右动脉；（3）断肝时尽量保护相应的肝静脉主干。结果（1）术后死亡10例，死亡率2．9％，死于肝衰8例，出血2倒；（2）长期疗效：HCC生存11～20年9例，肝内胆管癌术后生存1／2～3年。肝门胆管癌生存12、6、4年各1例。胆囊癌生存1／2～1年。良性肝病切肝后皆痊愈。6例肝内胆管结石尚需处理他处残留结石。结论（1）间隔性多个肝段切除是一次手术治愈多支肝内胆管簇集性结石的有效方法；（2）本手术免去了阻断全入肝血流，缩小了术中肝缺血的范围，有效地减少了术中失血，提高了大肝癌的切除率，减轻了术后肝功能损害，满足了各种肝病各种肝切除的要求，是一个合理、有效、成本低廉的切肝手术方法；（3）术后长期随诊发现按现代观点治疗乙肝对防止合并乙肝的肝癌切除后的转移和复发有效。

Objective Present the experience on a variety of hepatectomy by occluding the branches of hepatic artery（HA） and portal vein（PV） to the liver lobe, segment or subsegments in hilar H fissure for 341 patients from 1987 to 2007. Methods （l）According to the size and location of liver tumor major hepatectomy（65 cases）, resection of separated hepatic subsegments（15 cases, HS）, of adjacent HS（215 cases） and of single HS（46 cases） were performed for patients suffered from HCC（199 cases）, intrahepatic cholangiocarcinoma（13 cases）, hilar cholangiocarcinoma（14 cases）, carcinoma of gallbladder （12 cases）, metastatic liver cancer（l 5 cases）, hepatic haemangioma（32 cases）, hepatolithiasis（48 cases）, chronic liver abscess（3 cases） and liver echinococcosis（5 cases）. （2）Left lateral HS：dissected, isolated and severed the left lateral inferior PV and left lateral superior PV originated from the lateral aspect of left PV（LPV） in umbilical fissure after the LHA occluded. （3）Left medial HS：dissected, isolated and severed the left medial inferior PV and left medial superior PV originated from the medial aspect of left PV in umbilical fissure after the middle HA occluded. （4）Right anterior HS：isolated and occluded the right anterior PV in the anterior sulcus of right longitudinal fissure（RLF） after the RHA behind the main hepatic duct occluded.（5）Right posterior HS：isolated and occluded the right posterior PV in the posterior sulcus of RLF after RHA occluded. （6）Left hepatic Iobectomy（HL） and right HL：isolated and occluded the LPV or RPV in the transverse fissure after the LHA or RHA occluded respectively.（7）Try to prevent the hepatic vein from injury especially transsected at its root except in planning. Results （l）operative mortality rate 2.9%（10/341）,8 for liver failure, 2 for bleeding）.（2）longterm survival：9 HCC patients survived for 11-20 years. 12, 6, 4 years survival for l patient respectively in hilar cholangiocarcinoma.1/2 - 3years survival for intrahepatic cholangiocarcinoma.1/2-1 years survival for carcinoma of gallbladder. All patients of benign liver diseases were cured. Conclusion （1）Separated multiple hepatic subsegmentectomy is an effective procedure in one operation to cure the compacted stones in 2-6 subsegmental hepatic ducts both in right and left Iobes.（2）This procedure is reasonable, effective and low cost for hepatectomy worthing to adopt because of the ischemic liver mass and blood loss in operation decreased, the resectability of bulkliver cancer increased, the postoperative liver dysfunction alleviated, the technical demands of a variety of hepatectomyfor various liver diseases fulfilled by regional vascular occlusion at occlusion.（3）Modern therapy of B hepatitis is essential for preventing with B hepatitis. hepatic hilum instead of total hepatic afferent blood flow metastasis or recurrence after resection of HCC associated