腹腔镜Kasai手术中彻底游离门静脉左右支的技术要点

Technical essentials of thorough mobilization of left and right portal veins during laparoscopic Kasai operation

目的探讨腹腔镜下门静脉左右支彻底游离技术及其在腹腔镜Kasai手术治疗小儿Ⅲ型胆道闭锁中的应用价值。方法回顾性分析2013年6月至2017年6月对28例Ⅲ型胆道闭锁患儿行腹腔镜Kasai手术的临床资料。其中,男20例,女8例;入院年龄为(68.5±16.5)d,范围在30~136 d;其中年龄在30~90 d者24例,90~136 d者4例;体重(4.6±1.5)kg,范围在3.0~7.0 kg。术中根据需要悬吊肝圆韧带,胆囊床残端组织及胆囊颈部。电钩切开肝门前腹膜,充分游离肝左右动脉,结扎并切断肝中动脉,暴露门静脉。彻底游离门静脉左右分支使其与肝门纤维块及肝实质表面分离。用两根弹性牵拉带环绕门静脉左右支及肝左右动脉,牵拉弹性牵拉带暴露肝门,切除肝门纤维块,完成肝门肠吻合手术。结果本组均在腹腔镜下彻底游离门静脉左右支并顺利完成腹腔镜Kasai手术,无手术死亡病例。手术时间为(218.5±15.8)min,范围在194~260 min。其中,游离肝门至彻底游离门静脉左右支时间为(114.0±12.5)min,范围在113~132 min;肝门肠吻合时间为(35.0±4.5)min,范围在28~42 min。术中出血少,无术中输血者,无手术相关的特殊并发症。1例于术后一周死于肺炎呼吸衰竭。27例获得随访24.4个月,范围在6~57个月;3例分别于术后10、16、35个月死于肝功能衰竭。22例获得完全黄疸清除。2例术后黄疸指数已明显下降,还在观察中。结论腹腔镜下门静脉左右支彻底游离技术,可帮助腹腔镜Kasai手术顺利完成,降低手术风险和腹腔镜手术中转率,改善手术疗效。

Objective To explore the technical essentials of thorough mobilization of left and right branches of portal veins for type Ⅲ biliary atresia (BA) during laparoscopic Kasai portoenterostomy (LKPE). Methods The clinical data of 28 children with type Ⅲ BA undergoing laparoscopic Kasai procedure from June 2013 to June 2017 were retrospectively analyzed. There were 20 boys and 8 girls with a mean age of (68.5±16.5)(30-136) days and a mean body weight of (4.6±1.5)(3.0-7.0) kg. And the specific ages were 30-90 days (n=24) and 90-136 days (n=4). Percutaneous suturing was utilized for suspending round ligament and retracting liver. Fundus and neck of gallbladder were sutured to elevate liver for exposing portal hepatis when necessary. Fibrous cord and hepatic vessels were thoroughly mobilized. Then two rubber bands were placed around the branches of portal veins and hepatic arteries. Portal hepatis was exposed by stretching laterally with two elastic rubber bands. Finally fibrous cord was removed. Results All operations were completed successfully. Only two cases were converted into open surgery by a micro transverse incision at right subcostal space. The admission age was (68.5±16.5)(30-136) days. And the distribution was 30-90 days (n=24) and 91-136 days (n=4). Mean laparoscopic duration was (218.5±15.8)(194-260) min, time of thorough mobilizing left & right branches of portal vein (114±12.5)(113-132) min and mean duration of Kasai portoenterostomy (35±4.5)(28-42) min. All cases survived without any intraoperative complication. Intraoperative blood loss was minimal without any necessity for blood transfusion. One case died of respiratory failure at 1 week post-operation. The mean follow-up period after discharge was 24.4 (6-57) months. In 22 cases, total bilirubin returned to normal. In another two cases, bilirubin levels declined markedly and were further monitored. Three deaths occurred due to recurrent cholangitis and liver failure at 10, 16, 35 months postoperatively. Conclusions Laparoscopic thorough mobilization of left and right portal veins for exposing portal hepatis during Kasai portoenterostomy may be performed safely and successfully with encouraging outcomes and a low conversion rate.