摘要
目的探讨静脉韧带引导鞘外解剖肝蒂技术在腹腔镜左半肝切除术中的应用价值。方法采用回顾性队列研究方法。收集2015年1月至2018年1月福建医科大学附属第一医院收治的57例行腹腔镜左半肝切除术患者的临床资料;男18例,女39例;平均年龄为57岁,年龄范围为29~75岁。57例患者中,22例采用静脉韧带引导鞘外解剖肝蒂技术行左半肝切除术,设为鞘外解剖组;35例采用常规鞘内解剖肝蒂技术行左半肝切除术,设为鞘内解剖组。观察指标:(1)术中及术后短期疗效情况。(2)术后并发症发生情况。(3)随访情况。采用门诊及电话方式进行随访,了解患者术后疾病复发情况。随访时间截至2018年6月。正态分布的计量资料以Mean±SD表示,组间比较采用t检验;计数资料以绝对数或百分比表示,组间比较采用χ2检验。结果(1)术中及术后短期疗效情况:鞘外解剖组患者手术时间、左肝蒂解剖时间、术中出血量分别为(123±37)min、(14±5)min、(337±169)mL,鞘内解剖组患者上述指标分别为(148±27)min、(22±3)min、(495±203)mL,两组比较,差异均有统计学意义(t=2.992,7.733,3.045,P<0.05)。鞘外解剖组患者术中输血例数、术后胃肠功能恢复时间、术后引流管拔除时间、术后住院时间分别为1例、(1.8±0.9)d、(3.2±0.9)d、(8.2±1.7)d,鞘内解剖组患者上述指标分别为4例、(2.0±0.8)d、(3.6±0.8)d、(10.0±4.0)d,两组比较,差异均无统计学意义(χ^2=0.171,t=1.304,1.857,1.622,P>0.05)。两组患者术中均未发生难以控制的出血及空气栓塞。(2)术后并发症发生情况:鞘外解剖组和鞘内解剖组分别有3例和7例患者发生术后并发症,两组比较,差异无统计学意义(χ^2=0.066,P>0.05)。鞘外解剖组患者中1例肺部感染,1例腹腔感染,1例切口感染(术后并发症均为Clavien-DindoⅠ级);鞘内解剖组患者中2例肺部感染,2例肝脏断面积液,1例膈下脓肿,1例胆汁漏,1例切口感染。术后发生并发症的患者均经对症治疗后治愈出院。两组患者均未出现围术期死亡。(3)随访情况:57例患者均获得随访,随访时间为5~41个月,中位随访时间为23个月。鞘外解剖组患者中2例肝细胞癌复发,1例肝胆管结石病复发,无肝海绵状血管瘤及胆管细胞癌复发;鞘内解剖组患者中5例肝细胞癌复发,无肝海绵状血管瘤、肝胆管结石病及胆管细胞癌复发。鞘外解剖组和鞘内解剖组患者疾病复发率分别为13.6%(3/22)和14.3%(5/35),两组比较,差异无统计学意义(χ^2=0.104,P>0.05)。结论静脉韧带引导鞘外解剖肝蒂技术在腹腔镜左半肝切除术中安全、可行,能快速和精确控制左半肝入肝血流,简化手术流程,缩短左肝蒂处理时间,从而缩短手术时间,减少术中出血量。
Objective To explore the application value of the extra-glissonian pedicle transection approach guided by arantius′ligament in laparoscopic left hemihepatectomy.MethodsThe retrospective cohort study was conducted.The clinical data of 57 patients who underwent laparoscopic left hemihepatectomy in the First Affiliated Hospital of Fujian Medical University from January 2015 to January 2018 were collected.There were 18 males and 39 females,aged from 29 to 75 years,with an average age of 57 years.Of the 57 patients,22 undergoing the laparoscopic left hemihepatectomy with extra-glissonian pedicle transection approach guided by arantius′ligament and 35 undergoing laparoscopic left hemihepatectomy with regular intra-glissonian pedicle transection approach were allocated into the extra-glissonian transection group and intra-glissonian transection group,respectively.Observation indicators:(1)intraoperative situations and postoperative short-term outcomes;(2)postoperative complications;(3)follow-up.Patients were followed up by outpatient examination and telephone interview to investigate postoperative recurrence of diseases up to June 2018.Measurement data with normal distribution were represented as Mean±SD and comparison between groups was analyzed using the t test.Count data were described as absolute number or percentage and comparison between groups was analyzed using the chi-square test.Results(1)Intraoperative situations and postoperative short-term outcomes:the operation time,dissection time of left hepatic pedicle,volume of intraoperative blood loss were(123±37)minutes,(14±5)minutes,(337±169)mL in the extra-glissonian transection group and(148±27)minutes,(22±3)minutes,(495±203)mL in the intra-glissonian transection group,respectively,showing statistically significant differences between the two groups(t=2.992,7.733,3.045,P<0.05).Cases with intraoperative blood transfusion,time of gastrointestinal recovery,time for postoperative drainage-tube removal,duration of postoperative hospital stay were 1,(1.8±0.9)days,(3.2±0.9)days,(8.2±1.7)days in the extra-glissonian transection group and 4,(2.0±0.8)days,(3.6±0.8)days,(10.0±4.0)days in the intra-glissonian transection group,respectively,showing no statistically significant difference between the two groups(χ^2=0.171,t=1.304,1.857,1.622,P>0.05).There was no uncontrolled hemorrhage or air embolism in the two groups.(2)Postoperative complications:3 patients had complications of Clavien-Dindo classificationⅠin the extra-glissonian transection group including 1 of pulmonary infection,1 of abdominal infection,1 of incisional infection and 7 had complications in the intra-glissonian transection group including 2 of pulmonary infection,2 of liver sectional effusion,1 of subphrenic abscess,1 of biliary leakage,1 of incisional infection,showing no statistically significant difference between the two groups(χ^2=0.066,P>0.05).Patients with postoperative complications were cured and discharged after symptomatic treatment.There was no perioperative death in the two groups.(3)Follow-up:57 patients were followed up for 5-41 months,with a median time of 23 months.Two and 1 patients had tumor recurrence and hepatolithiasis recurrence in the intra-glissonian transection group,without recurrence of hepatic hemangioma or cholangiocarcinoma.Five patients had tumor recurrence in the intra-glissonian transection group,without recurrence of hepatic hemangioma,hepatolithiasis or cholangiocarcinoma.The disease recurrence rate was 13.6%(3/22)and 14.3%(5/35)in the extra-glissonian transection group and intra-glissonian transection group,respectively,showing no statistically significant difference between the two groups(χ^2=0.104,P>0.05).ConclusionsExtra-glissonian pedicle transection approach guided by arantius′ligament in laparoscopic left hemihepatectomy is feasible and effective,which can control hepatic blood inflow of left liver,simplify the surgery procedure and shorten dissection time of left pedicle,in order to save operation time and reduce volume of intraoperative blood loss.
作者
刘国忠
翁山耕
石铮
林间
陈易平
张建斌
林春忠
Liu Guozhong;Weng Shangeng;Shi Zheng;Lin Jian;Chen Yiping;Zhang Jianbin;Lin Chunzhong(Department of Hepatobiliary and Pancreatic Surgery,Trauma Medical Center of Fujian Province,the First Afiliated Hospital of Fujian Medical University,Fuzhou 350005,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2019年第4期387-393,共7页
Chinese Journal of Digestive Surgery
基金
国家临床重点专科建设项目(2013-GJLCZD)
福建省中青年教师教育科研项目(JAT160191).
关键词
肝肿瘤
肝癌
肝血管瘤
肝胆管结石病
鞘外解剖
半肝切除术
静脉韧带
肝蒂
腹腔镜检查
Liver neoplasms
Liver cancer
Hepatic hemangioma
Hepatolithiasis
Extra-glissonian dissection
Hemihepatectomy
Arantius′ligament
Hepatic pedicle
Laparoscopy
