疑难部位肝脏占位的手术体会

Clinical Experiences of Surgical Manipulations for Hepatic Masses in Difficult Sites

目的回顾分析疑难部位肝脏占位切除手术的手术经验、手术风险、并发症及处理。方法根据肿瘤邻近位置将47例患者分为第一肝门组、第二肝门组和尾状叶组,所有患者均行肝部分切除术。结果平均手术时间(289.6±62.2)min,平均出血量(602.3±256.4)ml,术中平均输血量(524.0±325.9)ml。3组患者的手术并发症发生率分别为61.5%、26.9%和25%。严重手术并发症为胆漏(27.7%)、出血(6.4%)和术后肝功能衰竭(2.1%)。3例围手术期死亡,原因分别为出血2例、肝功能衰竭1例。结论疑难部位肝脏占位手术中肝脏的游离和重要血管和胆管的显露非常关键,切除肿瘤过程中精细处理肝内的微小管道可以明显减少术后并发症。术前综合评估对判断手术可行性、预测手术风险非常重要,一旦损伤肿瘤邻近的重要血管,不仅导致出血,而且常因为流出道或流入道的梗阻导致相应的肝叶坏死,第二肝门血管的损伤比第一肝门损伤更具致死性。

Objective To summarize the surgical experiences,risks,complications,and managements for hepatic masses in difficult sites.Methods Totally 47 patients were divided into three groups based on the liver tumor sites： primary porta hepatis group,secondary porta hepatis group,and caudate lobe group.All patients underwent different portion of hepatectomy.Results The surgery duration was（289.6±62.2） minutes,intra-operative blood loss was（602.3±256.4） ml,and intra-operative blood transfusion was（524.0±325.9） ml.Incidence of surgical complications in each group was 61.5%,26.9%,and 25%,respectively.Serious complications observed were biliary leakage（27.7%）,bleeding（6.4%）,and post-operative liver failure（2.1%）.Three perioperative deaths were reported： two patients died of bleeding,and one patient died from liver failure.Conclusions Dissection of the liver and exposure of major blood vessels and biliary ducts are of critical importance in the surgeries for hepatic masses in difficult sites,and post-operative complicationsmay be remarkably reduced through delicate manipulations of the small intra-hepatic vessels and biliary ducts during resection.A thorough pre-operative evaluation plays a key role in predicting the feasibility and risks of the surgery.Damage to the major blood vessels adjacent to the tumor,in addition to bleeding,may result in inflow or outflow obstruction and cause necrosis of the corresponding hepatic lobe.Compared with damage to the primary portal area,vascular damage to the secondary porta is generally associated with higher fatality.