Rotellar Fernando, Pardo Fernando, Benito Alberto, Martí-Cruchaga Pablo, Zozaya Gabriel, Bellver Manuel
HPB and Liver Transplant Unit, Department of General and Abdominal Surgery, University Clinic of Navarre, University of Navarre, Pamplona, Spain,
Ann Surg Oncol. 2014 Jan;21(1):165-6. doi: 10.1245/s10434-013-3298-6. Epub 2013 Oct 1.
Laparoscopic right hepatectomy (LRH) is a complex but feasible procedure. Preoperative portal vein embolization (PVE) can add difficulties that warrant particular technical modifications. A LRH extended to middle hepatic vein after PVE is presented, with special attention paid to specific operative findings and to useful technical modifications.
A 62-year-old female patient with a body mass index of 30.5 kg/m(2) was diagnosed with a 3-cm unresectable centrally located intrahepatic cholangiocarcinoma with infiltration of the retrohepatic vena cava, segment VII portal branch, and adjacent to the middle hepatic vein and portal bifurcation. After four cycles of GEMOX, partial response was observed, disappearing vascular infiltration. PVE was required to perform an extended LRH. Consequently, during pedicle dissection, significant inflammation was found in the vicinity of the right portal vein. Thus, the section of the portal and biliary elements was delayed until the transection of the parenchyma reached the hilum. The opening of the parenchyma improved exposure, allowing the safe management of these structures individually.
The total operative time was 438 min. Three periods of 15-min pedicle occlusion resulted in <100 ml bleeding. Hospital stay was 4 days. Pathological examination revealed residual cholangiocarcinoma with intense posttreatment changes (pT1) and tumor-free margins. After an 18-month follow-up, the patient was alive and free of disease.
LRH is feasible and safe, even after PVE. Nevertheless, periportal inflammation can hinder hilar dissection. In this setting, delaying section of portal and biliary elements until parenchymal transection reaches the hilar region may result in a useful and safe strategy.
腹腔镜右半肝切除术（LRH）是一项复杂但可行的手术。术前门静脉栓塞术（PVE）会增加手术难度，需要进行特殊的技术改良。本文介绍了1例PVE后扩展至肝中静脉的LRH手术，特别关注了具体的手术发现及有用的技术改良。
1例62岁女性患者，体重指数为30.5kg/m²，被诊断为3cm不可切除的肝门部肝内胆管癌，侵犯肝后下腔静脉、Ⅶ段门静脉分支，紧邻肝中静脉和门静脉分叉处。经4周期GEMOX方案化疗后，部分缓解，血管侵犯消失。需行PVE以实施扩大的LRH手术。因此，在肝蒂解剖过程中，发现右门静脉周围有明显炎症。于是，门静脉和胆管结构的离断推迟至肝实质离断到达肝门处。肝实质的切开改善了视野，使这些结构能够被分别安全处理。
手术总时长438分钟。3次15分钟的肝蒂阻断，出血<100ml。住院时间4天。病理检查显示残留胆管癌伴明显的治疗后改变（pT1），切缘无肿瘤。随访18个月，患者存活且无疾病复发。
即使在PVE后，LRH也是可行且安全的。然而，门静脉周围炎症会妨碍肝门部解剖。在此情况下，将门静脉和胆管结构的离断推迟至肝实质离断到达肝门区域可能是一种有用且安全的策略。
