腹腔镜切除78例肝肿瘤的临床研究

Laparoscopic liver tumor resection of clinical experience in 78 patients

目的探讨腹腔镜肝切除(LH)的安全性、可行性和微创性。方法在2003年11月至2009年3月期间,选择78例患者行腹腔镜肝脏切除术。其中原发性肝癌39例、继发性肝癌10例、肝脏良性肿瘤29例。对其临床资料进行回顾性分析。结果78例肝切除手术在腔镜下全部顺利完成,无中转开腹手术。病灶分别位于Ⅱ(16例)、Ⅲ(24例)、Ⅳ(11例)、Ⅴ(11例)、Ⅵ(9例)、Ⅷ(4例)、Ⅰ(3例)等肝;病灶大小范围0.8～15cm;3个病灶4例、2个病灶8例、其余66例均为单病灶。术前肝功能Child‘A级者52例、Child’B级22例、Child’C级4例。术式包括:左半肝切除7例、左外叶切除14例、肝段切除11例、局部切除39例、腹腔镜直肠癌切除同时行肝转移灶切除7例。断肝方式为超声刀+LigaSure联合分离法,结合内镜下切割缝合器,不阻断第1肝门。仅4例患者需要输血(400～800ml)。术后无创面出血及胆漏等并发症。术后肝功能多在1周左右恢复至手术前水平,无肝功能衰竭发生。结论(1)由于腹腔镜肝切除技术难度大,手术适应证应严格选择,病灶大小和位置是主要的参考指标;(2)腹腔镜肝切除手术对结直肠癌合并局部肝转移和肝功能Child’C级的病例具有较好的微创优势;(3)超声刀+Ligasure联合断肝方法具有止血效果好、解剖结构清晰、术后创面渗出少、肝功能损害轻的优点;(4)手术者应具有丰富的开腹肝切除的经验和娴熟的腹腔镜操作技巧,同时应具备处理肝切除后各种并发症的能力。

Objective To summarize the clinical experiences of laparoscopic hepatectomy. Methods Between November 2003 and March 2009, 78 patients, hepatocellular carcinoma （n=39）, metastatic liver carcinoma （n=10） and benign liver neoplasm （n=29）, underwent laparoscopic hepatectomy in our unit. The lesions located at segment II （n=16）, segment III （n=24）, segment IV （n=11）, segment V （n=11）, segment VI （n=9）, segment VIII （n=4）, segment I （n=3） respectively; lesion size was 0.8-15 cm; lesion number was three lesions （n=4）, two lesions （n=8） and the single lesion （n=66）. Classification of liver function before operation was： Child A （n=52）, Child B （n=22）, Child C（n=4）.The operations included left hemihepatectomy （n=7）, left lateral lobeetomy （n=14）, segmentectomy （n=11）, local resection （n=39） and liver metastatic lesion resection during the laparoscopic surgery of rectal cancer （n=7）. The parenchyma was transected using Laparoscopic ultrosonic scalpel and LigaSure, accomplished with endoscopic linear stapler. Portal pedicles were not blocked. Results Laparoscopic liver resection was successful in all patients, no conversions to open. Only 4 patients received transfusion of blood （400-800 ml）. There was no perioperative Complications such as bleeding and biliary leakage. The liver function of all patients recovered in one week, and no liver failure happened. Conclusions （1）In the cases of local liver metastasis from colorectal cancer and liver function Child C classification, laparoscopic hepatectomy is a safe and feasibility operation with minimal surgical trauma. （2）Indication of laparoscopic hepatectomy should be selected strictly because of the techn!cal difficulity. The size and location of lesions are the major evaluation indicators. （3）Using ultrosonic scalpel and LigaSure to transect liver has the advantage of good hemostatic effect, clear anatomy, less effusion and minor damage to liver function. （4）The surgeon for laparoscopic hepateetomy should have enough experience of open hepatic resection and proficient skill at laparoscopie operation, and also have the ability to deal with the various complications of liver resection.