Division of Transplant and Hepatobiliary Surgery, Henry Ford Transplant Institute, Henry Ford Hospital, Detroit, MI 48202, USA.
Liver Transpl. 2012 Oct;18(10):1188-97. doi: 10.1002/lt.23488.
Minimally invasive procedures are considered to be safe and effective approaches to the management of surgical liver disease. However, this indication remains controversial for living donor hepatectomy. Between 2000 and 2011, living donor right hepatectomy (LDRH) was performed 58 times. Standard right hepatectomy was performed in 30 patients via a subcostal incision with a midline extension. Minimally invasive procedures began to be used for LDRH in 2008. A hybrid technique (hand-assisted laparoscopic liver mobilization and minilaparotomy for parenchymal dissection) was developed and used in 19 patients. In 2010, an upper midline incision (10 cm) without laparoscopic assistance for LDRH was innovated, and this technique was used in 9 patients. The perioperative factors were compared, and the indications for minimally invasive LDRH were investigated. The operative blood loss was significantly less for the patients undergoing a minimally invasive procedure versus the patients undergoing the standard procedure (212 versus 316 mL, P = 0.001), and the operative times were comparable. The length of the hospital stay was significantly shorter for the minimally invasive technique group (5.9 versus 7.8 days, P < 0.001). The complication rates were 23% and 25% for the standard technique and minimally invasive technique groups, respectively (P = 0.88). Patients undergoing minilaparotomy LDRH had a body mass index (24.0 kg/m(2)) similar to that of the hybrid technique patients (25.8 kg/m(2), P = 0.36), but the graft size was smaller (780 versus 948 mL, P = 0.22). In conclusion, minimally invasive LDRH can be performed without safety being impaired. LDRH with a 10-cm upper midline incision and without laparoscopic assistance may be appropriate for donors with a smaller body mass. Laparoscopic assistance can be added as needed for larger donors. This type of LDRH with a 10-cm incision is innovative and is recommended for experienced centers.
微创手术被认为是治疗肝外科疾病的安全有效的方法。然而，对于活体供肝切除术，这一适应证仍存在争议。2000 年至 2011 年间，共施行 58 例活体右半肝切除术（LDRH）。30 例患者采用经肋缘下切口延长中线的标准右半肝切除术。2008 年开始将微创技术用于 LDRH。开发并应用了一种杂交技术（手助腹腔镜肝游离和小切口肝实质离断），19 例患者采用了这种技术。2010 年，创新了一种无需腹腔镜辅助的上中切口（10cm）行 LDRH，9 例患者采用了这种技术。比较了围手术期的各项因素，并探讨了微创 LDRH 的适应证。与行标准术式的患者相比，行微创手术的患者术中出血量明显减少（212 比 316ml，P = 0.001），手术时间相当。微创手术组患者的住院时间明显缩短（5.9 比 7.8 天，P < 0.001）。标准组和微创组的并发症发生率分别为 23%和 25%（P = 0.88）。行小切口 LDRH 的患者体重指数（24.0kg/m2）与杂交技术组患者相似（25.8kg/m2，P = 0.36），但供肝体积较小（780 比 948ml，P = 0.22）。总之，微创 LDRH 可以在不影响安全性的情况下进行。对于体重较小的供者，采用 10cm 上中切口且无需腹腔镜辅助的 LDRH 可能是合适的。对于较大的供者，可以根据需要添加腹腔镜辅助。这种采用 10cm 切口的微创 LDRH 具有创新性，推荐在有经验的中心使用。
