肝切除术的超 Glissonian 入路。
Extra-Glissonian approach in liver resection.
机构信息
Hepato-Biliary Surgery Unit, Catholic University of the Sacred Heart, Rome, Italy.
出版信息
HPB (Oxford). 2010 Mar;12(2):94-100. doi: 10.1111/j.1477-2574.2009.00135.x.
BACKGROUND
In this study we analyzed our most recent experience in the use of the extraglissonian approach to the hilar structures in two circumstances: pedicle transection during major liver resections, and selective clamping in minor hepatectomies.
METHODS
The major liver resections study group consisted of 89 cases. Extraglissonian approach and stapler transection of hilar structures was used in 61 (69%). The study group of minor liver resections consisted of 103 cases. Extraglissonian approach and selective clamping was used in 27 cases (26%).
RESULTS
In major hepatectomies pedicle stapling and hilar dissection demonstrated a similar operative time (240 vs. 260 min; P = 0.230); no differences were observed in the amount of haemorrhage (800 ml vs. 730 ml; P = 0.699), number of patients transfused (16 vs. 6; P = 0.418) and volume of blood transfused (4 PRC vs. 4 PRC; P = 0.521). Duration of vascular pedicle occlusion was 35 vs. 30 min respectively (P = 0.293). Major complications (grade >or=3a) occurred in 18 (20%) patients and mortality rates (4.9% vs. 3.5%; P = 0.882) were similar for both group. In minor liver resections there were no differences between Pringle and selective clamping in operative time (240 vs. 240 min; P = 0.321), haemorrhage (435 ml vs. 310 ml; P = 0.575), number of patients transfused (18 vs. 7; P = 0.505) and volume blood transfused (4 PRC vs. 3 PRC; P = 0.423). Major complications (grade >or=3a) occurred in 14 (14%) patients, and mortality (2.6% vs. 3.7%; P = 0.719) were similar for both groups. However, the duration of pedicle clamping was significantly longer in the selective clamping group (26 +/- 21 minutes vs. 44 +/- 18 minutes) (P = 0.001).
CONCLUSIONS
The extraglissonian approach can be extremely useful in liver surgery. Selective clamping with extraglissonian approach avoids ischemia to the other hemiliver. Selective clamping it is also important from the homodynamic point of view because there is no splanchnic stasis and low fluid replacement.
背景
本研究分析了我们最近在两种情况下使用胆囊外入路处理肝门结构的经验：在进行大肝切除时横断肝蒂，以及在小范围肝切除时选择性阻断。
方法
大肝切除研究组包括 89 例患者。61 例（69%）采用胆囊外入路和吻合器横断肝门结构。小范围肝切除研究组包括 103 例患者。27 例（26%）采用胆囊外入路和选择性阻断。
结果
在大肝切除中，肝蒂吻合与肝门解剖的手术时间相似（240 分钟 vs. 260 分钟；P = 0.230）；出血量（800 毫升 vs. 730 毫升；P = 0.699）、输血量（16 例 vs. 6 例；P = 0.418）和输血量（4 PRC vs. 4 PRC；P = 0.521）无差异。血管蒂阻断时间分别为 35 分钟和 30 分钟（P = 0.293）。两组主要并发症（> 或 = 3a 级）发生率为 18 例（20%），死亡率（4.9% vs. 3.5%；P = 0.882）相似。小范围肝切除时，Pringle 与选择性阻断的手术时间（240 分钟 vs. 240 分钟；P = 0.321）、出血量（435 毫升 vs. 310 毫升；P = 0.575）、输血量（18 例 vs. 7 例；P = 0.505）和输血量（4 PRC vs. 3 PRC；P = 0.423）无差异。两组主要并发症（> 或 = 3a 级）发生率为 14 例（14%），死亡率（2.6% vs. 3.7%；P = 0.719）相似。然而，选择性阻断组的血管蒂阻断时间明显较长（26 +/- 21 分钟 vs. 44 +/- 18 分钟）（P = 0.001）。
结论
胆囊外入路在肝外科中非常有用。胆囊外入路选择性阻断可避免对另半肝的缺血。选择性阻断从血流动力学角度来看也很重要，因为没有内脏淤血和低液体替代。
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