中国腹腔镜肝癌切除术20年发展、问题与对策

Development,problems and Countermeasures of laparoscopic hepatectomy for liver cancer in recent 20 years in China

我国腔镜肝切除始于上世纪90年代,历经起步摸索、交流发展、推广应用3个阶段。手术指征从起初的肝边缘的小肝癌拓展到尾状叶、Ⅷ、Ⅶ段等各个肝段,肿瘤的大小限定逐渐拓宽。虽然腔镜肝癌切除的理论技术体系日臻成熟,安全性和有效性也渐被证实,但仍面临着较多的问题。主要在手术适应证、术中出血的控制、切缘的保证和疗效评估方面。随着腹腔镜设备的更新换代和技术的进步、经验的积累,目前腹腔镜的适应证已经逐步趋同开腹手术。低CVP法、经肝实质阻断入肝血流等技术的应用大大减少术中出血。腔镜用超声、荧光腹腔镜的出现,能最大限度得保证切缘。在长期疗效评估方面,仍需大型的多中心、前瞻性随机对照研究来验证。

The first laparoscopic hepatectomy(LH)in China was performed in 1990s.Thereafter,the technique of LH has evolved over three stages:the initial exploration,the exchange and development,and the promotion and application period.The indications of LH have been expanded from small liver tumors located at anterolateral segments to larger tumor of all segments(i.e.,caudate lobe,segment VIII,and segment VII).The feasibility,safety and efficacy of LH have been demonstrated by increasing evidence.The techniques of LH has become sophisticated and standardized.And yet,the technique of LH remains challenging in the surgical indications,the control of intraoperative blood loss,the status of resected margins,and long-term outcome in patients with liver malignancies.With the update of laparoscopic instruments,the advancement of techniques,and improved operation skills,the indications for laparoscopic surgery are now very similar to open surgery.The application of new techniques including a low central venous pressure and transhepatic inflow blood ligation without portal dissection can minimize the intraoperative blood loss.Meanwhile,the availability of laparoscopic ultrasound and fluorescent imaging technique maximize the possibility of pursuing a tumor-free margin.Large-scale,multi-centre,prospective,randomized controlled studies are warranted to evaluate the long-term efficacy of laparoscopic hepatoma resection.