腹腔镜解剖性肝Ⅶ段切除术的难点与应对策略

Challenges and tactics of laparoscopic anatomical hepatectomy of segment 7

腹腔镜解剖性肝Ⅶ段切除术是被公认难度较大的肝段切除手术方式之一。肝Ⅶ段因其位置与解剖特点,行解剖性肝切除术时存在显露不佳、操作困难、肝蒂解剖复杂、切除平面难以确定和断肝容易出血等问题。笔者在行腹腔镜解剖性肝Ⅶ段切除术时病人常规采取左侧半卧位,将Trocar布局整体向右季肋区偏移,根据术前三维重建个体化选择适宜的肝Ⅶ段肝蒂解剖方式,由肝Ⅵ和Ⅶ段间平面开始离断肝脏,以垂直方向寻找和显露肝右静脉主干,然后以肝右静脉作为肝内路标指引肝实质离断。笔者临床经验表明:通过选择合适手术策略能有效降低腹腔镜解剖性肝Ⅶ段切除术难度、提高手术安全性和可控性,同时保证肿瘤根治性效果。

Laparoscopic anatomical hepatectomy of segment 7 is recognized as one of the most difficult hepatectomies.Because of its location and anatomic characteristics,the resection of hepatic segment 7 has the difficulties of poor surgical view,instrumental accessibility,hepatic pedicle anatomy,confirmation of dividing line and secure hemostasis.When performing laparoscopic anatomical hepatectomy of segment 7,the authors routinely put patient at left semi-decubitus position,set all trocars at the right upper quadrant of the abdomen,and select proper approach for hepatic pedicle anatomy according to the results of individualized preoperative three-dimensional reconstruction.The authors use to transect the liver parenchyma at the plane between hepatic segment 6 and segment 7,with the direction perpendicular to the right hepatic vein,and then finish parenchymal dissection using right hepatic vein as the intrahepatic landmark.According to the authors experiences,choosing appropriate tactics can effectively reduce the difficulty of laparoscopic anatomical hepatectomy of segment 7,improve the safety and controllability of operation,and ensure the oncological radical effects.