五步法流程化腹腔镜肝右后叶切除(附47例报告)

Five-step procedure of laparoscopic right posterior hepatectomy:a report of 47 cases

目的评估腹腔镜肝右后叶切除的流程化手术方案的安全性和有效性。方法回顾性分析2020年5月至2023年3月武汉大学中南医院肝胆胰外科行腹腔镜右后叶切除手术47例病人的临床资料、手术信息及病理结果,符合正态分布的计量资料以x±s表示,不符合正态分布的计量资料以M(Q_(1),Q_(3))表示。以左侧卧体位、优化处理尾状突及右后肝蒂、吲哚菁绿荧光引导、原位断肝、循下腔静脉前间隙和肝右静脉轴线引导肝实质离断平面的“五步法”为要点,实施流程化手术,并对该术式的临床效果展开分析。结果47例病人均成功完成腹腔镜下流程化右后叶切除手术,其中良性病灶7例,恶性肿瘤40例,包括26例肝细胞癌,肿瘤最大径为12 cm。手术时间为330(138,582)min,肝门阻断时间为60(15,151)min,术中出血量为200.0(100.0,312.5)mL。10例病人出现术后并发症,Clavein-Dindo分级Ⅰ级4例,Ⅱ级6例,无Ⅲ级以上并发症。病人术后住院时间为(8.3±3.0)d。结论“五步法”流程化腹腔镜肝右后叶切除手术改进了手术区的显露,突出了无瘤操作原则,简化了右后肝蒂的处理,优化了肝实质离断平面把握,安全有效,易于推广。

Objective To evaluate the safety and effectiveness of the"five-step"procedure of laparoscopic right posterior hepatectomy.Methods Retrospective analysis was performed for clinical data,surgical findings and pathological results of 47 patients undergoing laparoscopic right posterior hepatectomy from May 2020 to March 2023.For measurement data conforming to a normal distribution,±s was utilized while M(Q_(1),Q_(3))for data not conforming to a normal distribution."Five-step"procedure of laparoscopic right posterior hepatectomy included left supine position,transected caudate process and controlled right posterior liver pedicle,indocyanine green fluorescence guidance,liver transection in situ and guidance of liver parenchyma transection plane along anterior space of inferior vena cava and right hepatic vein.Clinical outcomes were analyzed.Results All 47 patients successfully completed laparoscopic right posterior hepatectomy,including benign lesions(n=7)and malignant tumors(n=40).There were 26 cases of hepatocellular carcinoma.Maximal diameter of tumor was 12 cm,operative duration 330(138,582)min,hilar occlusion time 60(15,151)min and intraoperative blood loss 200.0(100.0,312.5)mL.Postoperative complications occurred in 10 patients,including Clavien-Dindo gradeⅠ(n=4),gradeⅡ(n=6)and gradeⅢor above(n=0).The postoperative hospital stay was(8.3±3.0)day.Conclusion The"five-step"procedure of laparoscopic right posterior hepatectomy may improve the exposure of operative area,highlight the principle of tumor-free operation,simplify the handling of right posterior liver pedicle and optimize the grasp of liver parenchyma disconnection plane.It is safe,effective and easy to learn.