第Ⅳa肝段肿瘤切除术中肝中及肝左静脉损伤的预防与处理

Prevention and treatment of middle and left hepatic venous injury during hepatic subsegment Ⅳa for hepatic cancer

目的探讨及总结第Ⅳa肝段肿瘤切除术中肝中静脉及肝左静脉主干损伤的预防和处理经验。方法回顾性分析1996年8月至2008年12月47例第Ⅳa肝段肿瘤切除合并肝中静脉及肝左静脉主干损伤患者的临床κ料。切除术式包括:Ⅳa肝段肿瘤局部切除12例、Ⅳa+部分Ⅳb肝段切除(左内叶切除)10例、Ⅳa+部分Ⅳb+Ⅱ+Ⅲ肝段切除(左半肝切除)25例。结果全部病例手术切除及术中止血均获成功,均涉及肝中(左)静脉主干的处理。行肝左静脉主干结扎者27例,肝左静脉主干修补8例;肝中静脉主干结扎者4例,肝中静脉修补者16例。通过术前CT或MRI评估,肝中静脉或肝左静脉损伤发生的符合率97.2%(35/36)。术后并发症发生率10.6%(5/47),其中活动性出血再手术1例,胆汁瘘并膈下感染2例,肝功能代偿不全2例。无围手术期死亡。结论第Ⅳa肝段肿瘤是可以安全切除的。肝中静脉及肝左静脉损伤的预防和处理是手术的重点㈦难点,损伤处理的具体措施包括肝中静脉及肝左静脉结扎和或)修补术。术前CT或MRI可以较准确判断术中肝中静脉及肝左静脉损伤发生的可能性。

Objective To investigate the prevention and treafment of middle and left hepatic venous injury during the resection of tumors in hepatic subsegment Ⅳa. Methods The clinical data of middle and left hepatic venous injury during the resection of tumors in hepatic subsegment Ⅳa for 47 cases from August 1996 to December 2008 were retrospectively analyzed. All cases were received resection successfully, including local excision of tumors in hepatic subsegment Ⅳa（12 cases）, hepatic seginenteetomy for subsegment Ⅳ （hepatectomy in left medial lobe, 10 cases）, hepatectomy in left half（25 cases）. Results The middle hepatic vein and/or left hepatic vein of 47 cases were performed during operation. Twenty-seven cases were received left hepatic venous ligation simultaneously or respectively. Eight cases were received left hepatic venous repairing. Four cases were received middle hepatic venous ligation. Six cases were received middle hepatic venous repairing. Coincidence of middle and left hepatic venous injury was 97.2%（35/36）. Postoperative complications rate was 10.6%（5/47）, reoperation owing to active bleeding（1 case）, bile fistula combined with subphrenie infection（2 cases） and liver function ineompensation （2 cases）. No case died during operation. Conclusions Hepatic segmentectomy for subsegment Ⅳ a is safe. Prevention and treatment of middle and left hepatic venous injury need to be emphasized on. The middle hepatic vein and left hepatic vein should be restored, after judged by preoperative CT or MRI.