van Gulik Thomas M, de Graaf Wilmar, Dinant Sander, Busch Olivier R C, Gouma Dirk J
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
Dig Surg. 2007;24(4):274-81. doi: 10.1159/000103658. Epub 2007 Jul 27.
Control of bleeding from the transected liver basically consists of vascular inflow occlusion and control of hepatic venous backflow from the caval vein. Central venous pressure determines the pressure in the hepatic veins and is an extremely important factor in controlling blood loss through venous backflow. Vascular inflow occlusion (Pringle maneuver) involves clamping of the portal vein and the hepatic artery in the hepatic pedicle and gives rise to postischemic, reperfusion injury. Several strategies have been devised to reduce reperfusion injury (pharmacological interventions) or to increase ischemic tolerance of the liver (ischemic preconditioning). Intermittent clamping is recommended in complex liver resections or in patients with diseased livers. The combination of occlusion of vascular inflow and outflow of the liver results in total hepatic vascular exclusion (THVE) and is mainly used in tumors invading the caval vein. During THVE the liver can be cooled by hypothermic perfusion allowing for extended ischemia times. Selective THVE entails clamping of the main hepatic veins in their extrahepatic course, thus preserving caval flow. Safe liver surgery requires knowledge of the regular techniques of vascular occlusion for 'on demand' use when necessitated to reduce blood loss.
控制肝断面出血主要包括血管入流阻断和控制来自腔静脉的肝静脉逆流。中心静脉压决定肝静脉压力，是通过静脉逆流控制失血的极其重要的因素。血管入流阻断（普林格尔手法）包括钳夹肝蒂中的门静脉和肝动脉，会引发缺血后再灌注损伤。已经设计了几种策略来减少再灌注损伤（药物干预）或提高肝脏的缺血耐受性（缺血预处理）。在复杂肝切除术或肝脏疾病患者中推荐间歇性钳夹。肝血管入流和出流阻断相结合导致全肝血管隔离（THVE），主要用于侵犯腔静脉的肿瘤。在THVE期间，肝脏可通过低温灌注冷却，从而延长缺血时间。选择性THVE需要在肝外行程中钳夹主要肝静脉，从而保留腔静脉血流。安全的肝脏手术需要了解血管阻断的常规技术，以便在需要减少失血时“按需”使用。
