腹腔镜肝尾状叶肿瘤切除术9例临床分析

发布时间：2018-08-09 10:39

【摘要】：研究背景:肝尾状叶位于肝脏后部中央的位置,其局部解剖复杂,该处病变的手术治疗一直是肝胆外科的难点,随着研究的深入,尾状叶肿瘤手术治疗的病例报道逐渐增多,其治疗策略已逐渐达成共识。如今腹腔镜手术技术因其创伤小、切口愈合美观、患者术后恢复快、并发症少等诸多优点在临床上得到广泛运用,然而目前腹腔镜尾状叶肿瘤切除的病例报道非常少,其手术治疗经验匮乏尚未形成规范。本文将对腹腔镜尾状叶肿瘤切除术进行探讨,总结经验,以指导日后临床工作。目的:探讨腹腔镜尾状叶肿瘤切除术的术前诊断、手术入路、手术方式、手术经验及安全性、可行性。方法:2015年6月至2016年12月间,山东大学齐鲁医院开展腹腔镜肝尾状叶肿瘤切除术9例,从术前诊断、手术入路、手术方式、术后恢复等方面对临床资料进行分析。结果:9例均由肝脏外科高级职称医师主刀,手术均顺利完成,将肿物完全切除,均未中转开腹。手术时间75min-285min,平均127.2min。术中失血量为50mL-350mL,平均失血量为133.3mL,术中均未输血。9例手术中4例于第一肝门处预置阻断带,其中3例分别阻断时间为21min、20min、15min。9例病例的入路选择,其中2例为右侧入路,4例选择左右联合入路,3例选择左侧入路。术中未损伤第一肝门、第二肝门、下腔静脉,未出现大出血等并发症。术后病理为4例为中分化肝细胞肝癌,4例为肝海绵状血管瘤,1例为肝局灶性结节状增生。9例患者术后住院时间6天-14天,平均住院天数8.2天。1例原发性肝癌患者术后腹腔引流管出现黄绿色胆汁杨液体,考虑为手术创面存在胆漏,给予持续腹腔引流,带管出院后近2月后痊愈。其余患者术后病情较平稳,无严重并发症,给予抗炎、保肝、抑酸、营养支持治疗,恢复良好后出院。患者住院费用为38241.35 元-82452 元,平均费用 55464.83 元。结论:肝尾状叶肿瘤一般表现为上腹或右上腹痛、腹胀,进食后饱胀不适,部分患者可无症状,由查体时发现。B超、腹部CT、MRI等影响学检查对于尾状叶肿瘤的术前诊断及手术方式的选择具有重要意义。因尾状叶位置特殊,周围解剖关系复杂,行腹腔镜尾状叶肿瘤切除时,应根据肿瘤所在的部位、大小及与周围其他肝段或血管关系,可采用合适的入路及手术方式,通常尾状叶右部的肿瘤,采用右侧或左右联合入路,尾状叶左部肿瘤可以选择左侧入路或左右联合入路,左右联合入路是目前临床应用最多手术入路。腹腔镜尾状叶肿瘤切除术适用于尾状叶病灶较小并局限于尾状叶的肿瘤,若肿瘤瘤体巨大,侵犯其它肝段,或其它肝段存在肿瘤时应选择联合其它肝叶或肝段切除。手术中应在仔细探查尾状叶与下腔静脉的间隙,将肝短静脉逐一夹闭并切断。第一肝门、第二肝门处的重要血管应避免损伤,可于第一肝门预置阻断带,在手术出血较多的情况下进行肝门阻断。手术前对患者进行充分检查并评估患者病情,由高年资经验丰富的外科医师手术,腹腔镜肝尾状叶肿瘤切除术虽然手术过程较复杂,但是安全、可行的,且治疗效果良好。
[Abstract]:Background: the liver caudate lobe is located in the central position of the posterior part of the liver, and its local anatomy is complicated. The surgical treatment of the lesion is always the difficult point in the Department of hepatobiliary surgery. With the further research, the cases of caudate tumor surgery are gradually increasing, and the treatment strategy has gradually reached consensus. However, there are few reported cases of laparoscopic caudate lobe tumor resection, and the lack of experience in surgical treatment has not yet formed a standard. This article will discuss the laparoscopic caudate tumor resection and summarize the experience to guide the future. Objective: to discuss the preoperative diagnosis, surgical approach, surgical approach, operation experience, safety and feasibility of laparoscopic caudate lobe tumor resection. Methods: from June 2015 to December 2016, 9 cases of laparoscopic resection of liver caudate lobe tumor were performed from the Qilu Hospital of Shandong University, from preoperative diagnosis, surgical approach, operation method and postoperative recovery. Results: the clinical data were analyzed. Results: all the 9 cases were performed successfully by the senior professional surgeon of the liver surgery. All the operations were completed successfully. The tumor was completely removed. The operation time was 75min-285min. The average blood loss was 50mL-350mL, the average blood loss was 133.3mL, and 4 of the.9 cases during the operation were not transfusions to the first hepatic portal. There were 3 cases of 21min, 20min, 15min.9 cases, of which 2 were right approach, 4 had left and right approach, and 3 chose left side approach. There were no injuries to the first hepatic portal, second hepatic portal, inferior vena cava and no massive hemorrhage during the operation. The postoperative pathology was 4 cases of medium differentiated hepatocytes. Liver cancer, 4 cases of hepatic cavernous hemangioma, 1 cases of focal nodular hyperplasia of the liver,.9 patients were hospitalized for 6 days after 6 days -14 days, the average hospitalization days were 8.2 days,.1 cases of primary liver cancer were treated with yellow green poplar liquid in the abdominal drainage tube after operation. The patient's condition was more stable and no serious complications. The patients were given anti-inflammatory, liver protection, acid inhibition, nutritional support treatment and good recovery after recovery. The hospitalization expenses of the patients were 38241.35 yuan -82452 yuan, and the average cost was 55464.83 yuan. Conclusion: the liver caudate lobe tumors generally appear to be upper abdominal or right upper abdominal pain, abdominal distention, discomfort after eating, partial patients after eating, some patients. There is no symptom. It is of great significance for the preoperative diagnosis and choice of surgical methods for caudate lobe tumor. The location of caudate lobe is special and the surrounding anatomy is complex. When the tumor is excised, it should be based on the location, size, and other liver segments around the tumor. The right or right side of the caudate lobe can be used in the right or left side of the right part of the caudate lobe. The left tumor of the left caudate leaf can choose the left approach or the left and right combined approach. The combined approach is the most surgical approach at present. The laparoscopic caudate tumor resection is suitable for caudate leaf disease. If the tumor is small and confined to the caudate lobe, if the tumor is huge, the tumor should be removed from the other hepatic segments or other hepatic segments. In the operation, the gap between the caudate and the inferior vena cava should be examined carefully and the short vein of the liver is clipped and cut off one by one. The first porta hepatis, and the important vessels at the second hilum of the liver should be treated. To avoid injury, we can preposition the blockage of the first hepatic portal and block the hepatic portal under the condition of more bleeding. Before operation, the patient is examined fully and the patient's condition is evaluated. The surgery of a highly experienced surgeon and the laparoscopic hepatectomy for the liver caudate lobe tumor are complicated, but safe, feasible, and treated. The effect is good.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7

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