Hirokazu Tomishige, Zenichi Morise, Norihiko Kawabe, Hidetoshi Nagata, Hisanori Ohshima, Jin Kawase, Satoshi Arakawa, Rie Yoshida, Masashi Isetani, Department of Surgery, Fujita Health University School of Medicine, Banbuntane Houtokukai Hospital, Nagoya Aichi 454-8509, Japan.
World J Gastrointest Surg. 2013 Jun 27;5(6):173-7. doi: 10.4240/wjgs.v5.i6.173.
To study our novel caudal approach laparoscopic posterior-sectionectomy with parenchymal transection prior to mobilization under laparoscopy-specific view.
Points of the procedure are: (1) Patients are put in left lateral position and posterior sector is not mobilized; (2) Glissonian pedicle of the sector is encircled and clamped extra-hepatically and divided afterward during the transection; (3) Dissection of inferior vena cava (IVC) anterior wall behind the liver is started from caudal. Simultaneously, liver transection is performed to search right hepatic vein (RHV) from caudal; (4) Liver transection proceeds to the bifurcation of the vessels from caudal to cranial, exposing the surfaces of IVC and RHV. Since the remnant liver sinks down, the cutting surface is well-opend; and (5) After the completion of transection, dissection of the resected liver from retroperitoneum is easily performed using the gravity. This approach was performed for a 63 years old woman with liver metastasis close to RHV.
RHV exposure is required for R0 resection of the lesion. Although the cutting plane is horizontal in supine position and the gravity obstructs the exposure in the small subphrenic space, the use of specific characteristics of laparoscopic hepatectomy, such as the good vision for the dorsal part of the liver and IVC and facilitated dissection using the gravity with the patient positioning, made the complete RHV exposure during the liver transection easy to perform. The operation time was 341 min and operative blood loss was 1356 mL. Her postoperative hospital stay was uneventfull and she is well without any signs of recurrences 14 mo after surgery.
The new procedure is feasible and useful for the patients with tumors close to RHV and the need of the exposure of RHV.
研究我们新的经尾部入路腹腔镜后段切除术，在腹腔镜下特定视野下先进行实质切开再进行游离。
手术要点如下：（1）患者取左侧卧位，不游离后段；（2）肝段Glisson 蒂结扎并切断；（3）从尾部开始解剖肝下腔静脉（IVC）前壁；同时从尾部开始行肝实质离断，寻找右肝静脉（RHV）；（4）从尾部向头侧行肝段离断，暴露 IVC 和 RHV 表面；由于残余肝脏下沉，切割面充分暴露；（5）离断完成后，利用重力从后腹膜游离切除的肝脏。该方法用于一名 63 岁女性，肝转移灶靠近 RHV。
为了实现病变的 R0 切除，需要显露 RHV。虽然仰卧位时的切割面是水平的，而重力会阻碍小腹腔内的显露，但利用腹腔镜肝切除术的特定特点，如对肝脏背面和 IVC 的良好视野，以及利用重力进行便于分离的患者体位，使在肝离断过程中能够轻松地完成完整的 RHV 显露。手术时间为 341 分钟，手术出血量为 1356 毫升。患者术后住院期间无并发症，术后 14 个月无复发迹象，恢复良好。
对于靠近 RHV 且需要显露 RHV 的肿瘤患者，新手术方法是可行和有用的。
