腹腔镜技术在肝脏外科的拓展应用

Application of laparoscopic techniques in hepatic surgery

手术微创化是当今国际外科学发展的一大趋势，腹腔镜作为微创外科的代表已涉及腹腔所有脏器手术。肝脏是腹腔内最大的实质脏器，具有复杂的解剖结构和重要的生理功能，腹腔镜肝脏手术曾被认为是难度和风险较大的手术。近年来，随着腹腔镜技术的进步和器械的改善，腹腔镜手术在肝脏外科的应用范围逐步拓展。该技术已从早期针对肝脏良性病变的边缘性切除和局部切除拓展应用于肝脏各类良恶性病变的大范围肝切除术、肝脏移植物切取、特殊部位肝切除术及解剖性肝段切除术等复杂手术中。我国是肝病大国，肝癌及肝胆管结石病的发病率及术后复发率均较高，部分患者需要接受再次或者多次肝切除术治疗；肝癌患者多合并不同程度肝硬化，肝胆管结石病患者也易并发肝脏萎缩、纤维化及肝门转位等病变，这些因素在一定程度上影响了腹腔镜手术在肝癌及肝胆管结石病外科治疗中的应用。本文结合笔者单位开展800余例腹腔镜肝切除术的临床体会和相关文献，重点探讨腹腔镜技术在解剖性肝段切除术，尤其是特殊部位肝段的解剖性切除术，合并肝硬化等肝脏基础疾病时的肝切除术，以及再次肝切除术等领域的应用现状和最新进展。

Minimally invasive surgery is the trend of development of modern surgery. As the representative of mini- really invasive surgery, laparoseopy has widely been used in surgeries for visceral diseases. Liver is the biggest solid organ in the abdominal cavity, with complicated anatomical structure and important biological functions. Laparoscopic hepatic surgeries were thought to be difficult and with high risk. In recent years, laparoscopic surgery has been widely applied in the hepatic surgery as the improvement of laparoscopic techniques and instruments. The application of laparoscopy has been extended from marginal and local resection for hepatic benign diseases to major hepatectomy, resection of liver graft, hepatectomy at special location and anatomical segmentectomy. In China, patients with liver cancer or hepatolithiasis have high recurrence rate, and part of the patients had to receive reoperation. Furthermore, patients with hepatic cancer were usually complicated with hepatic cirrhosis, and patients with hepatolithiasis were easily complicated with hepatic atrophy, hepatic cirrhosis or cavoportal transposition, which hinder the application of laparoscopy for the treatment of liver cancer and hepatolithiasis. In this article, we investigate the application and update of laparoscopic techniques in anatomical hepatectomy and re-hepatectomy based on the experiences of 800 cases of laparoscopic hepatectomy.