模式化腹腔镜肝切除的临床研究

发布时间：2018-05-23 10:20

  本文选题：腹腔镜 + 微创外科　； 参考：《中国人民解放军医学院》2015年博士论文

【摘要】：目的：1、动物实验研究。A：评价经腹腔镜切取活体猪左半供肝的可行性。B：评价在腹腔镜解剖性肝切除动物模型中应用射频消融技术进行肝段定位、入肝血流阻断以及辅助肝实质离断的可行性、有效性和安全性。2、模式化半肝肝切除。A：建立模式化左半肝切除相关流程并进行临床应用,分析相关结果。B：建立模式化右半肝切除相关流程并进行临床应用,分析相关结果。3、评估对于特殊肝段(S1、S6+S7、S8)腹腔镜肝切除的技术。方法：1、A：建立经腹腔镜切取活体猪左半供肝的动物模型,其技术包括CO2气腹的建立与戳孔布局,解剖肝十二指肠韧带,腹腔镜术中超声辅助确定断肝平面,肝脏的游离,离断肝实质,肝内管道的处理。将切取的左半供肝进行冷灌注及修整,并取少量肝组织块行病理学检查。B：20头猪接受超声引导下肝段门静脉系统定位及射频消融辅助肝段血流阻断下腹腔镜肝段切除(门静脉射频消融辅助组,n=10)与常规腹腔镜肝段切除手术(常规腹腔镜切除组),射频消融辅助肝实质离断腹腔镜左外叶肝切除(射频辅助肝实质离断组,n=10)与常规腹腔镜左外叶切除(常规腹腔镜肝叶切除组)对比研究。2、A：模式化腹腔镜左半肝切除的相关流程首先进行体位的摆放、戳孔的布局,其后左侧肝脏的游离,解剖左侧肝蒂并阻断。在肝实质离断后以切割闭合器离断左侧门静脉和肝静脉,其后进行创面止血和标本的取出、放置引流。B：模式化腹腔镜右半肝切除的相关流程首先将患者摆放左侧45°卧位、戳孔的布局,其后右侧肝脏的游离,解剖右侧肝蒂并阻断。在肝实质离断后以切割闭合器离断右侧门静脉和肝静脉,其后进行创面止血和标本的取出、放置引流。结果：1、A：10头猪接受了手术,除1头因下腔静脉出血后发生气栓死亡外,其余均成功建立模型。手术时间为(208±25)min,热缺血时间为(8±2.3)min,手术出血量为(313±75)ml。供肝切取后,残肝重要结构保留完好；供肝管道结构及组织学形态正常。B：9头猪完成超声引导下肝段门静脉系统消融辅助腹腔镜肝段切除,常规腹腔镜切除组10头猪完成手术。门静脉射频消融辅助组和对照组手术时间为(74±16)min和(104±28)min(t=-2.821,P=0.012),手术出血量(84±20)ml和(114±32)ml(t=2.416,P=0.027).射频消融辅助肝实质离断腹腔镜左外叶肝切除与常规肝叶切除对比,2组手术均顺利完成。射频辅助肝实质离断组和常规腹腔镜切除组手术时间无统计学差异[(136±26)min vs.(124±18)min,t=1.200,P=0.246],术中出血量无统计学差异[(110±36)m1 vs.(164±50)ml,t=-2.772,P=0.013]。2、A：共完成模式化左半肝切除23例,其中恶性肿瘤8例,良性肿瘤15例。平均手术时间95.0±34.6分钟,平均出血量154.0±36.4m1,无术中输血,并发症1例,平均术后住院5.8±1.5天。B：共完成模式化右半肝切除21例,其中恶性疾病15例,良性肿瘤6例。平均手术时间115.0±44.5分钟,平均出血量214.0±56.4m1,无术中输血,并发症2例,平均术后住院6.3±2.4天。3、共完成特殊区域肝切除15例,其中恶性疾病4例,良性肿瘤11例。S1段5例,右后叶(S6+S7)6例,S7段2例,S8段2例。平均手术时间65.0±32.5分钟,平均出血量154.0±43.4m1,无术中输血,并发症1例,平均术后住院4.7±1.8天。结论：1、A：经腹腔镜切取活体猪左半供肝的技术是安全可行的。B：超声引导下肝段门静脉系统消融辅助肝段入肝血流阻断后行腹腔镜肝段切除有助于缩短手术时间和减少术中出血量；射频消融辅助肝实质离断的腹腔镜肝左外叶切除与常规肝叶切除比较在不增加手术时间的基础上可以减少术中出血。2、A：我们进一步发展了新的模式化腹腔镜左半肝切除的技术路线并经临床验证,结果提示该方法简便、安全,可重复性佳,可以作为腹腔镜左半肝切除的范式进行介绍给国内同行。B：模式化腹腔镜右半肝切除虽然对腹腔镜手术技术的要求较高,但对富有腔镜和开腹肝脏手术经验医生仍是能够安全有效地完成。3、涉及S1、S6、S7和S8段的肝脏肿瘤的腹腔镜切除属于非常困难的,但通过精心挑选适合进行腔镜尝试的患者,仔细评估,精心准备后同样可以完成腹腔镜下的肝切除手术。
[Abstract]:Objective: 1, animal experimental study.A: evaluation of the feasibility of laparoscopic removal of left half donor liver in living pigs.B: evaluation of the feasibility, effectiveness and safety of hepatic segment localization, hepatic blood flow blocking and auxiliary hepatic parenchyma disconnection in the laparoscopic anatomical hepatectomy animal model by using radiofrequency ablation technique,.2, and model hemihepatic hepatectomy.A To establish the related process of model left hemihepatectomy and to carry out clinical application, and to analyze the relevant results.B: establish a standardized right hemihepatectomy related process and carry out clinical application, analyze the related results.3, evaluate the technique of laparoscopic hepatectomy for special hepatic segment (S1, S6+S7, S8). Methods: 1, A: to establish a living pig left half donor by laparoscope The animal model of the liver, including the establishment of the CO2 pneumoperitoneum and the layout of the puncture, the anatomy of the hepatic and duodenal ligaments, the ultrasound assisted determination of the liver disconnection, the dissociation of the liver, the parenchyma of the liver, the treatment of the intrahepatic duct in the laparoscopy. The cold perfusion and repair of the left half donor liver were carried out, and a small amount of liver tissue was taken for pathological examination of the.B:20 head. Porcine underwent ultrasound guided hepatic segmental portal system location and radiofrequency ablation assisted laparoscopic hepatic segment resection (n=10) and conventional laparoscopic hepatic segment resection (routine laparoscopic resection group). Radiofrequency ablation assisted hepatic parenchyma dissection laparoscopic left lateral hepatectomy (radiofrequency assisted liver parenchyma) Group n=10) compared with conventional laparoscopic left lateral lobectomy (conventional laparoscopic hepatectomy group) a comparative study of.2, A: the related process of mode laparoscopic left hemihepatectomy was first carried out with the placement of the body position, the layout of the poke hole, then the left liver free, dissecting the left liver pedicle and blocking the left hepatic parenchyma after the liver parenchyma dissociation. The venous and hepatic veins were followed by the bleeding of the wound and the removal of the specimen, and drainage of the.B: the related process of the mode laparoscopic right hemihepatectomy first placed the patient in the left 45 degree position, the layout of the poke hole, then the right liver was free, and the right hepatic pedicle was dissected and blocked. The right portal vein was dissected with a cutting closure after the liver parenchyma dissociation. The result: 1, A:10 head pigs were operated on. Except for 1 cases of hemorrhage after hemorrhage of the inferior vena cava, the rest were successfully established. The operation time was (208 + 25) min, the time of thermal ischemia was (8 + 2.3) min, and the amount of bleeding was (313 + 75) ml. after the liver resection. The important structure was well preserved; the hepatic duct structure and histology of normal.B:9 head pigs were treated with ultrasound guided hepatic segment portal venous system ablation assisted laparoscopic liver resection, and 10 pigs were operated by conventional laparoscopic resection group. The operation time between the portal vein radiofrequency ablation assisted group and the control group was (74 + 16) min and (104 + 28) min (t=-2.821, P=0.). 012) the amount of bleeding (84 + 20) ml and (114 + 32) ml (t=2.416, P=0.027). Compared with conventional lobectomy, the 2 groups were successfully completed by radiofrequency ablation assisted hepatic parenchyma resection and conventional lobectomy. There was no statistical difference between the radiofrequency assisted hepatic parenchyma dissection group and the conventional laparoscopic excision group [(136 + 26) min vs. (124 + 18) min, t=1.20 0, P=0.246], there was no significant difference in the amount of bleeding during the operation [(110 + 36) M1 vs. (164 + 50) ml, t=-2.772, P=0.013].2, A: 23 cases of complete mode left hemi hepatectomy, including 8 malignant tumors and 15 benign tumors. The average operation time was 95 + 34.6 minutes, average bleeding was 154 + 36.4m1, no intraoperative blood transfusion, complication 1 cases, average postoperative 5.8 + 1.5 days after operation. .B: 21 cases of right hemi hepatectomy were completed. Among them, there were 15 cases of malignant disease and 6 cases of benign tumors. The average operation time was 115 + 44.5 minutes, the average bleeding amount was 214 + 56.4m1, no intraoperative blood transfusion, 2 cases had complications, and the average postoperative hospitalization was 6.3 + 2.4 days.3. 15 cases were completed in special area liver resection, among them, 4 cases of malignant diseases and 11 cases of benign tumor 11 segment 5, There were 6 cases of right posterior lobe (S6+S7), 2 cases of S7 segment and 2 cases of S8 segment. The mean operation time was 65 + 32.5 minutes, the average bleeding amount was 154 + 43.4m1, no intraoperative blood transfusion, 1 cases of complications, and average postoperative hospitalization 4.7 + 1.8 days. Conclusion: 1, A: the technique of laparoscopic removal of living pig left half donor liver by laparoscopy is a safe and feasible.B: ultrasound guided hepatic portal venous system ablation assistant under the guidance of ultrasound Laparoscopic hepatic resection is helpful to shorten the operation time and reduce the amount of bleeding in the hepatic segment of the liver after occlusion of the liver. The laparoscopic liver left excision with radiofrequency ablation assisted liver parenchyma disconnection and conventional lobectomy can reduce intraoperative bleeding.2 on the basis of no increased operation time, A: we further developed a new model. The technical route of laparoscopic left hemihepatectomy and clinical validation showed that the method was simple, safe and reproducible, and could be used as a paradigm for laparoscopic left hemihepatectomy to be introduced to domestic.B. The experience of visceral surgery is still safe and effective to complete.3. Laparoscopic resection of liver tumors in the S1, S6, S7 and S8 segments is very difficult, but carefully selected patients who are suitable for endoscopic attempts are carefully evaluated, and the hepatectomy under the celioscope can be completed after careful preparation.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R657.3
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本文编号：1924340