三步断肝法在腹腔镜半肝切除术中的应用价值

The application of the three-step approach based on the regional distribution of hepatic vessel in iaparoscopic hemihepatectomy

目的探讨三步断肝法在腹腔镜半肝切除术中的应用价值。方法2013年8月至2015年10月皖南医学院弋矶山医院肝胆外科采用三步断肝法为32例患者行腹腔镜半肝切除术。所有患者术前均行薄层CT扫描，利用医学影像浏览器模拟半肝切除，观测半肝断面上血管分布的情况。根据血管分布规律，采用三步断肝法行半肝切除，并对患者术中及术后的临床资料进行分析。结果（1）32例患者中肝中静脉长度为（59．1±12．9）mm，至左、右半肝的分支数目分别为（3．07±0．78）、（3．11±0．64）支。肝中静脉出现第一分支处至肝脏膈面的距离为（28．1±3．7）mm，肝中静脉于第一肝门处至肝脏脏面的距离（14．4±4．3）mm。（2）32例患者均顺利完成手术，无中转开腹，其中左半肝切除28例，右半肝切除4例。手术时间：左半肝切除为（165±42）min，右半肝切除为（305±50）min。术中出血量：左半肝切除为（242±65）ml，右半肝切除为（695±122）ml。术后未出现出血、肝衰等严重并发症，3例患者出现胆漏，均通畅引流自愈。术后平均住院（7．96±1．8）d。结论半肝断面上的血管分布呈现区域化的特点，基于这一规律的三步断肝法在腹腔镜半肝切除术中的应用是安全、有效的，可缩短手术时间，降低手术操作难度。

Objective To investigate the clinical significance of the three-step approach in laparoscopic hemihepatectomy. Methods A total of 32 patients received laparoscopic hemihepatectomy with the three-step approach in Yijishan Hospital affiliated to Wanuan Medical College between Aug 2013 and Oct 2015. All patients underwent thin slice CT scan and hemihepatectomy was imitated with the imagic explorer, preoperatively. The vessel distribution was observed at the section and the three-step approach was used in the hemihepatectomy. Pre- and post-operative data were collected and analyzed retrospectively. Results The length of middle hepatic vein （MHV） was （59.1 ± 12.9） mm and the number of branchs to the left and right lobe were 3.07 ± 0.78 and 3.11 ± 0.64 respectively. The distance between the first branch of MHV and the diaphragmatic surface was （28.07 ± 3.74） mm and the distance between MHV and the visceral surface was （14.4 ±4.3） mm. The laparoscopic surgeries （left hemihepatectomy in 28 and right hemihepatectomy in 4） were performed successfully in all cases with the three-step approach, without any conversion to the open surgeries. The operation time was （165 ±42 ） rain in left hemihepateetomy and （305±50） rain in right hemihepatectomy. The intraoperative blood loss was （242 ±65 ） ml in left hemihepatectomy and （695 ± 122） ml in right hemihepatectomy. All the patients recovered well without severe complications except for bile leakage in 3 patients who were cured with drainage. The postoperative hospital stay was （7.96 ± 1.8） d. Conclusions the distribution of vessel is regional at the section of hemihepatectomy and the three-step approach based on this feature is safe and effective in laparoscopic hemihepatectomy, which can shorten the operation time and reduce the difficulty of operation.