“两步分层法”腹腔镜肝左外叶切除术的临床应用价值

Clinical application value of two-step separation approach in laparoscopic left lateral sectionectomy

目的 探讨“ 两步分层法” 腹腔镜肝左外叶切除术（LLLS） 的临床应用价值.方法 本前瞻性研究对象为2009 年1 月至2014 年9 月在湖南省人民医院收治的156 例采用“ 两步分层法” 行LLLS 患者.其中男76 例,女80 例;年龄18～75 岁,中位年龄56 岁.所有患者均签署知情同意书,符合医学伦理学规定.患者取膀胱截石位或分腿位,均采用四孔法、脐周穿刺建立气腹.采用“两步分层法”切肝,首先沿镰状韧带左侧,超声刀离断肝实质至肝左外叶肝蒂- 肝左静脉平面,其次应用Endo-GIA 切割吻合器,分别离断肝蒂和肝左静脉.结果 本组患者均手术成功,无中转开腹.术中行单纯肝左外叶动脉阻断89 例,未行入肝血流阻断67 例.手术时间的中位数为85（53～150）min,断肝时间17（8～35）min,术中出血量25（10～100）ml.术后住院时间7（5～10）d.本组患者无死亡.术后无严重并发症发生,仅7 例术后发生轻微胆漏,经通畅引流后治愈.结论 “两步分层法”LLLS 安全、易行,适宜作为标准操作广泛推广.

ObjectiveTo investigate the clinical application value of two-step separation approach in laparoscopic left lateral sectionectomy (LLLS).MethodsA total of 156 patients undergoing LLLS with two-step separation approach in Hunan Provincial People's Hospital between January 2009 and September 2014 were included in this prospective study. Among the 156 patients, 76 were males and 80 were females with the age ranging from 18 to 75 years old and the median of 56 years old. The informed consents of all patients were obtained and the local ethical committee approval had been received. The patients were in bladder lithotomy position or straddle position and pneumoperitoneum was established with 4-hole approach and periumbilical puncture. Hepatectomy was performed using two-step separation approach. The liver parenchyma was dissected to the plane of left lateral hepatic pedicle-left hepatic vein using ultrasonic scalpel along the left of falciform ligament. Then, the hepatic pedicle and the left hepatic vein was dissected using Endo-GIA stapler.ResultsAll patients completed the surgery successfully and no case was converted to laparotomy. Eighty-nine patients underwent simple left lateral hepatic artery occlusion and 67 patients did not undergo hepatic inlfow occlusion. The median operation time was 85 (53-150) min and the liver dissection time was 17 (8-35) min. The intraoperative blood loss was 25 (10-100) ml and the postoperative length of stay was 7 (5-10) d. No death case and no serious postoperative complication was observed. Only 7 patients developed mild bile leakage and recovered after effective drainage.ConclusionTwo-step separation approach in LLLS is safe and easy, which can be taken as a standard operation and widely popularized.