两步分层法腹腔镜半肝切除术的应用价值

Application value of two-step separation approach in laparoscopic hemihepatectomy

目的：探讨两步分层法腹腔镜半肝切除术的应用价值。方法：采用回顾性横断面研究方法。收集2015年1月至2017年12月湖南省人民医院收治的81例行腹腔镜半肝切除术患者的临床病理资料。患者行术前评估后，行两步分层法腹腔镜半肝切除术（肝实质内整体处理肝蒂和肝静脉及其属支，无需鞘内仔细解剖）。观察指标：（1）术前评估、术中及术后恢复情况。（2）随访和生存情况。采用门诊或电话方式进行随访，肝胆管结石病患者术后5～7 d复查腹部CT，观察术后结石残留情况；恶性肿瘤患者常规随访1～3年，随访时间截至2018年2月。正态分布的计量资料以±s表示，计数资料用频数和百分比表示。结果：（1）术前评估、术中及术后恢复情况：81例患者术前均行血生化、肿瘤标志物、影像学检查，其中9例使用三维重建软件测算剩余功能性肝体积及3D打印技术制作肝脏模型。81例患者中，左半肝切除术68例，右半肝切除术13例；77例成功施行两步分层法腹腔镜半肝切除术，4例中转开腹，中转开腹率为4.9%（4/81）。4例中转开腹患者中，1例因肿瘤侵犯门静脉，粘连较为紧密，不易剥离；1例因肝胆管结石腹腔镜下取石困难；2例因肝硬化程度较重，术中大量出血，中转开腹。81例患者中，70例术中采用选择性阻断半肝血流获得明确半肝分界线后，再结合Pringle阻断控制出血；11例直接采用全肝Pringle血流阻断技术。2例患者术中应用了腹腔镜荧光显影技术。81例患者手术时间为（206±42）min，术中出血量为（195±134）mL，术中输血率为11.1%（9/81），术后住院时间为（11.5±2.7）d。81例患者术后胆汁漏发生率为2.5%（2/81），胆汁漏均经保守治疗治愈，术后无出血、肝功能不全、膈下脓肿等严重并发症发生，无围术期死亡及术后30 d无再手术患者。（2）随访和生存情况：55例肝胆管结石病患者术后均获得随访，术后5～7 d复查腹部CT，52例取尽结石；3例结石残留，术后3个月经胆道镜取石后复查未见结石残留。17例恶性肿瘤患者均获得随访，随访时间为12～36个月，中位随访时间为15个月，16例无瘤生存；1例肝细胞癌患者术后1年发生肝内转移，经肝动脉导管内化疗栓塞术治疗后，带瘤生存。9例肝脏良性疾病患者随访期内恢复良好。结论：腹腔镜半肝切除术中合理运用两步分层法肝切除技术流程安全、有效、便捷。

Objective：To investigate the application value of two-step separation approach in laparoscopic hemihepatectomy. Methods：The retrospective cross-sectional study was conducted. The clinicopathological data of 81 patients who underwent laparoscopic hemihepatectomy in the People′s Hospital of Hunan Provincial between January 2015 and December 2017 were collected. Patients underwent laparoscopic hemihepatectomy using two-step separation approach after preoperative assessment. Hepatic pedicle, hepatic vein and branches were processed in the liver parenchyma, without intrathecal anatomy. Observation indicators： （1） preoperative assessment, intra- and post-operative recovery; （2） follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed up to February 2018. Patients with hepatolithiasis received abdominal CT reexaminations at 5-7 days postoperatively for observing postoperative residual stones, and patients with malignant tumor were regularly followed up for 1-3 years. Measurement data with normal distribution were represented as ±s. Count data were described as frequency and percentage. Results：（1） Preoperative assessment, intra- and post-operative recovery： 81 patients underwent preoperative blood biochemistry, tumor biomarker and imaging examinations, and remaining functional liver volume and a liver model in 9 patients were respectively calculated and built using the 3D reconstruction software and 3D printing technology. Of 81 patients, 68 underwent left hemihepatectomy and 13 underwent right hemihepatectomy; 77 underwent successful laparoscopic hemihepatectomy using two-step separation approach, 4 were converted to open operation, with a rate of 4.9%（4/81）. Of 4 patients with conversion to open operation, 1 had difficult tumor separation due to tumor invading port vein induced to close adhesion, 1 had stone removal difficulties under laparoscopy due to hepatolithiasis, and 2 were converted to open operation due to severe liver cirrhosis induced to massive intraoperative bleeding. Of 81 patients, 70 gained dividing line of hemiliver by intraoperatively hemihepatic blood flow occlusion, and then got effectively control of bleeding combined with Pringle blood flow occlusion, and 11 received Pringle blood flow occlusion in whole liver. Laparoscopic fluorescence imaging technology was intraoperatively used for 2 patients. Operation time, volume of intraoperative blood loss, rate of intraoperative blood transfusion and duration of hospital stay in 81 patients were respectively （206±42）minutes, （195±134）mL, 11.1%（9/81） and （11.5±2.7）days. Eighty-one patients were complicated with bile leakage and were cured by conservative treatment, with a bile leakage incidence of 2.5%（2/81）, and without severe complications, such as postoperative bleeding, hepatic dysfunction and subphrenic abscess. There was no perioperative death and reoperation within 30 days postoperatively. （2） Follow-up and survival situations： 55 patients with hepatolithiasis were followed up and underwent CT examinations of upper abdomen at 5-7 days postoperatively, including 52 with depletion of stones; 3 with residual stones received removal of stones by choledochoscope at 3 months postoperatively, without residual stones. Seventeen patients with malignant tumor were followed up for 12-36 months, with a median time of 15 months, 16 had tumor-free survival, and 1 was complicated with intrahepatic metastasis at 1 year after resection of hepatocellular carcinoma, and then underwent transcatheter arterial chemoembolization （TACE） and survived with tumor. Nine patients with benign liver diseases had good recovery during follow-up. Conclusions：Two-step separation approach that is rationally used in laparoscopic hemihepatectomy is safe, effective and convenient.