Mutter D, Dallemagne B, Bailey Ch, Soler L, Marescaux J
IRCAD-EITS, University Louis Pasteur, 1 Place de l'Hôpital, 67091, Strasbourg Cedex, France.
Surg Endosc. 2009 Feb;23(2):432-5. doi: 10.1007/s00464-008-9931-y. Epub 2008 Apr 29.
Careful control of haemostasis is particularly important in laparoscopic hepatic surgery, since a bloodless operative field results in safer and smoother procedures. A selective vascular control for a left lateral segmentectomy may be facilitated by the use of three-dimensional (3D) virtual reality.
A 67-year-old male patient presenting with a 3.5-cm hepatocellular carcinoma (HCC) located between segment II and III of the liver was referred for hepatic resection. Transplant was contraindicated due to previous head and neck cancer surgery. Preoperative 3D reconstruction was used for preoperative planning and allowed a virtual resection to be done as well as peroperative simulation.
Five ports were used. The first step was primary control of the hepatic pedicle. 3D virtual-reality reconstruction demonstrated the position of the tumor in the segment and regarding the vessels. The left hepatic artery and the portal vein were successively dissected and controlled. The real anatomy was compared to the virtual-reality reconstruction. Both demonstrated the same anatomy. Vascular section was completed and this resulted in a typical color change of the left lateral segment as well as a small decrease in size. The bisegmentectomy was performed using harmonic dissectors (Autosonix(R), Tyco Healthcare), bipolar cautery, clips, and application of Endo GIA vascular staples (Tyco Healthcare) on the portal pedicles. The procedure was completed following isolation and control of the left hepatic vein. After section, the specimen was placed in a bag and extracted following enlargement of the camera port. Follow-up was uneventful and there was no elevation of hepatic enzymes or postoperative ascites. The patient left the hospital on the fifth postoperative day.
3D reconstruction allowed the procedure to be simulated preoperatively. This facilitated the intraoperative identification of the vascular anatomy and the control of the left lateral segment arteries and veins, thus preventing intraoperative bleeding. The use of this approach in preoperative planning is recommended.
在腹腔镜肝脏手术中，严格控制止血尤为重要，因为无血的手术视野可使手术更安全、更顺利。三维（3D）虚拟现实技术有助于选择性地控制肝左外叶切除术的血管。
一名67岁男性患者，肝Ⅱ段和Ⅲ段之间有一个3.5厘米的肝细胞癌（HCC），前来接受肝切除术。由于既往有头颈癌手术史，肝移植为禁忌。术前采用3D重建进行术前规划，并进行虚拟切除和术中模拟。
使用了5个端口。第一步是对肝蒂进行初步控制。3D虚拟现实重建显示了肿瘤在肝段内的位置以及与血管的关系。依次解剖并控制了肝左动脉和门静脉。将实际解剖结构与虚拟现实重建结果进行比较。两者显示的解剖结构相同。完成血管切断后，肝左外叶出现典型的颜色变化，体积略有缩小。使用超声刀（Autosonix®，泰科医疗）、双极电凝、钛夹以及在门静脉蒂上应用Endo GIA血管吻合器（泰科医疗）进行双段切除术。在分离并控制肝左静脉后完成手术。切除后，将标本放入袋中，扩大摄像端口后取出。随访过程顺利，肝酶未升高，也无术后腹水。患者术后第5天出院。
3D重建可在术前进行手术模拟。这有助于术中识别血管解剖结构并控制肝左外叶动静脉，从而防止术中出血。建议在术前规划中采用这种方法。
