肝门区域血管阻断下肝段切除术的要点、扩展和评估

Technical essentials, development, and evaluation of hepatic segmentectomy under regional vascular occlusion at hepatic hilum

目的 总结1987-2008年344例通过肝门H沟中阻断肝叶、肝段或肝亚段入肝血管分支施行肝切除的经验.方法 （1）根据病变部位和大小分别实行大型肝切除（66例）、间隔性多个肝亚段切除（15例）、邻接多个肝亚段切除（216例）和单个肝亚段切除（47例）,其中含肝尾叶切除29例.（2）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.（3）断肝时尽量保护相应的肝静脉主干.结果 （1）术后病死10例（2.9%）,其中死于肝衰8例,出血2例;（2）肝细胞癌病人（n=200）术后生存11～20年10例,7年4例,5年19例,5年生存率18.3%（33/180）.肝内胆管癌（n=13）术后生存1/2～3年.肝门胆管癌（n=14）生存13、6、4年各1例.胆囊癌（n=12）生存1/2～1年.良性肝病（n=92）切肝后皆痊愈.7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）该手术免去了阻断全入肝血流,缩小了术中肝缺血范围,减少了术中失血,提高了大肝癌切除率,减轻了术后肝功能损害,可以满足各种肝病肝切除要求,是一种合理、有效的切肝手术方法.

Objective To summarize the experience of performing a variety of hepatectomies by occluding the branches of the hepatic artery （HA） and portal vein （PV） to the liver lobe, segment or subsegments in hilar H fissure for 344 patients in this hospital from 1987 to 2008. Methods （1） According to the size and location of the liver focus, major hepatectomy （66 cases）, resection of separated hepatic subsegments （15 cases HS）, resection of adjacent HS （216 cases） and resection of single HS （46 cases） were performed. （2） For left lateral HS, the left lateral inferior PV and left lateral superior PV originating from the lateral aspect of the left PV （LPV） were dissected, isolated and severed in umbilical fissure after the LHA was occluded. （3） For left medial HS, the left medial inferior PV and left medial superior PV originating from the medial aspect of the left PV were dissected、isolated and severed in umbilical fissure after the middle HA was occluded. （4） For right anterior HS, the right anterior PV was isolated and occluded in the anteior sulcus of the right longitudinal fissure （RLF） after the RHA behind the main hepatic duct was occluded. （5） For right posterior HS, the right posterior PV was isolated and occluded in the posterior sulcus of RLF after RHA was occluded.（6）The corresponding hepatic venous stem was protected as much as possible during the operation.Results （1） The operative mortality was 2.9% （10/344）. Of these 10 patients, 8 died of liver failure and 2 bleeding. （2） Ten HCC patients （n=200） survived for 11～20 years, 4 for 7years, 19 for 5years and the 5-year survival rate was 18. 3% （33/180）. For patients with hilar cholangiocarcinoma （n= 14）, only 3 survived for 13, 6, 4 years, respectively. The patients with intrahepatic cholangiocarcinoma （n=13） survived for 1/2～3 years. Those with carcinoma of the gallbladder （n=12） survived for 1/2～1 year. All the patients with benign liver diseases （n=92） were cured. In 7 patients with intrahepatic lithiasis, the stones in other locations needed to be managed. Conclusion （1） Separated multiple hepatic subsegmentectctomy is an effective procedure to cure the compacted stones in 2～6 subsegmental hepatic ducts in both right and left lobes. （2） This procedure is reasonable, effective and of low cost for hepatectomy, worthy of being used because of the decrease in the ischemic liver mass and blood loss in operation, increase in the resectability of bulk liver cancer, alleviation of postoperative liver dysfunction and meeting the technical needs of a variety of hepatectomies for various liver diseases fulfilled by regional vascular occlusion at hepatic hilum instead of total hepatic afferent blood flow occlusion.