微创外科时代的胆道外科——胆囊切除术尚非平安无事

Present status of biliary surgery in the era of minimally invasive surgery

自从首例在腹腔镜下施行胆囊切除术之后,胆道外科技术经历了革命性的改变。当前,已经有越来越多的传统外科手术方法被腹腔镜外科所取代。然而,腹腔镜胆囊切除术并非平安无事。当前,由于影像学技术的发展,例如对肝内、外胆道的虚拟现实、三维重建等,可以有助于对复杂胆道外科问题如肝内胆管结石和其他肝内病变的手术前评估和手术设计。约占原发性肝癌5%～10%的肝内胆管癌由于其与肝细胞癌有不同的病理-生物学特点,故在治疗措施选择上应得到特殊的关注,一般应该施行广泛的肝切除手术而不是局部切除或消融。关于肝门部胆管癌的治疗,扩大的肝切除术可以改进早期的、无淋巴结转移病变治疗结果。当前,在微创外科时代,许多传统的外科手术将在微创外科理念下重新受到检验。

Since the first case of cholecystectomy conducted under laparoscopy, the technique of biliary surgery has been revolutionized. At the present time, more and more formerly standard surgical procedures had been taken over by laparoscopic method. However, laparoscopic cholecystectomy is still not a procedure without risks. The advances in imaging technology such as virtual reality and 3D reconstruction image of the intra- and extra-hepatic structures may be helpful in the preoperative evaluation and planning of the complicated operative procedures in cases of hepatolihiasis as well as in other intrahepatic leisons. Intrahepatic cholangiocarcinoma, accounted for 5%-10% of the primary hepatic cancer, is a kind of malignancy with distinct patho-biological behavior different from that of hepatic cell carcinoma and should be considered differently from hepatic cell carcinoma as to the treatment of option, extended radical resection instead of local resection or ablation should be adapted as the rule. As to the surgical treatment of hilar cholangiocarcinoma, extended liver resection improved the result in the early, nodal negative patients. At present, many traditional surgical operations will be scrutinized according to the present-day surgical theme of minimal invasiveness.