Drognitz O, Holzner P, Glatz T, Hopt U T, Neeff H
Abteilung für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg i. Brsg., Deutschland,
Chirurg. 2014 Feb;85(2):139-46. doi: 10.1007/s00104-013-2672-z.
This study compared the technical aspects and results for two different techniques of total laparoscopic anatomical right hemihepatectomy.
From September 2010 to February 2013 a total of 16 patients underwent total laparoscopic right hemihepatectomy at the University Hospital of Freiburg. Of the patients 8 received an intraglissonian approach (IGA) and the other 8 patients an extraglissonian approach (EGA). In the patients of the IGA group, vascular inflow control of the right liver was accomplished by dissection and dividing the right hepatic artery, the right portal vein and the right bile duct separately before parenchymal dissection. In contrast, vascular control for patients in the EGA group was performed by enclosure and transsection of the whole right pedicle using a vascular linear stapler.
Indications for right hemihepatectomy were benign tumors in 2 and malignancies in 14 cases. The average maximum tumor diameter was 5.5 cm (range 1.5-10.0 cm). Adequate tumor-free surgical margins (R0) were confirmed in all patients with malignancies. The perioperative mortality rate was 0 %, surgical complications according to Clavien's classification were grade I (n = 1 trocar site superficial wound infection), grade II (n = 2 cholangitis) and grade IIIb (n = 1 wound dehiscence after conversion to open procedure). The median operating time was 366 min (range 265-422 min) and 313 min (range 247-417 min) in the IGA and EGA groups, respectively. Conversion from laparoscopic to open minimal access procedure was necessary in three patients in the IGA group and two patients in the EGA group. Mean intraoperative blood loss was 644 ml (200-1000 ml) and 518 ml (200-1500 ml) in the IGA and EGA groups, respectively. Transfusion of two units of packed red blood cells was necessary for one patient in group EGA. No patient in either group needed a Pringle maneuver. Mean postoperative hospital stay was 11 days (range 7-23 days) and 13 days (range 7-31 days) in the IGA and EGA groups, respectively.
Total laparoscopic anatomical right hemihepatectomy is a feasible procedure. The extraglissonian technique can provide shorter operating times by correctly facilitating vascular control of the right liver.
本研究比较了两种不同的完全腹腔镜解剖性右半肝切除术的技术要点及结果。
2010年9月至2013年2月，共有16例患者在弗莱堡大学医院接受了完全腹腔镜右半肝切除术。其中8例患者接受了肝门内入路（IGA），另外8例患者接受了肝门外入路（EGA）。在IGA组患者中，在实质解剖前，通过分别解剖和切断右肝动脉、右门静脉和右肝管来实现右肝的血管流入控制。相比之下，EGA组患者的血管控制是使用血管线性吻合器对整个右肝蒂进行包绕和横断。
右半肝切除术的适应证为2例良性肿瘤和14例恶性肿瘤。肿瘤平均最大直径为5.5厘米（范围1.5 - 10.0厘米）。所有恶性肿瘤患者均确认有足够的无瘤手术切缘（R0）。围手术期死亡率为0%，根据Clavien分类的手术并发症为I级（n = 1例套管针部位浅表伤口感染）、II级（n = 2例胆管炎）和IIIb级（n = 1例转为开放手术后伤口裂开）。IGA组和EGA组的中位手术时间分别为366分钟（范围265 - 422分钟）和313分钟（范围247 - 417分钟）。IGA组有3例患者、EGA组有2例患者需要从腹腔镜手术转为开放微创手术。IGA组和EGA组的术中平均失血量分别为644毫升（200 - 1000毫升）和518毫升（200 - 1500毫升）。EGA组有1例患者需要输注2单位浓缩红细胞。两组均无患者需要进行Pringle手法。IGA组和EGA组的术后平均住院时间分别为11天（范围7 - 23天）和13天（范围7 - 31天）。
完全腹腔镜解剖性右半肝切除术是一种可行的手术。肝门外技术通过正确促进右肝的血管控制可缩短手术时间。
