中国基层医院如何开展腹腔镜肝切除术:术前规划、术中技巧和术后管理

Practice of laparoscopic hepatectomy in primary care facilities in China:surgical planning,surgical techniques and postoperative management

目前,随着腹腔镜肝切除术在各大医疗中心广泛发展和应用,国内外有指南总结了手术的适应症、技术要点和操作流程等。但是,基层医院在具备一定硬件设备的基础上,仍处于开展例数较少、进展缓慢的阶段,其原因在于手术思想观念未转变、腔镜切肝的解剖理论知识欠缺、腔镜切肝围手术期多学科合作不紧密以及腹腔镜技术水平不足等。本文针对腹腔镜肝切除术的术前规划、术中技巧以及术后管理3个方面进行阐述:术前充分了解肝脏解剖结构,并根据手术难度和自身条件选择合适的病例;术中做到选择合适的体位和戳卡布局,与麻醉科紧密合作控制良好中心静脉压,掌握肝脏悬吊牵拉技术以及超声刀使用技巧,选择正确的出血处理技巧和出入肝血流控制技术;术后采用加速康复外科管理。基层医院可通过借鉴上述经验,加速腹腔镜肝切除术的推广和应用。

With the development and application of laparoscopic hepatectomy in major medical centers,domestic and foreign guidelines have summarized the indications,surgical techniques and operational procedures of the surgery.But in primary care facilities,where the surgical equipment are available,laparoscopic hepatectomy is performed only in a small number of cases and the progress of its application remains slow.The reasons possibly lie in the failure of a full understanding of the surgery,the lack of anatomical knowledge of laparoscopic hepatectomy,the lack of close multidisciplinary cooperation in the perioperative period and insufficient training of laparoscopic technology.In this review,we elaborate on three aspects of laparoscopic hepatectomy:preoperative planning,surgical techniques and postoperative management.Before the operation,the surgeons should fully understand the anatomical structure of the liver and select appropriate cases considering both the difficulty of operation and the surgical experience of the surgeons.During the operation,the position of the patient and the layout of the stamping card should be appropriate,and the central venous pressure needs to be well controlled in close cooperation with the anesthesiologist.The surgeons should be proficient at the techniques of liver suspension and pulling and at the use of ultrasonic knife,and select correct techniques for management of bleeding and the control of blood flow in and out of the liver.The patient should receive postoperative management with standard enhanced recovery after surgery(ERAS)protocols.These experiences may help to improve the practice of laparoscopic hepatectomy in local hospitals or primary care facilities.