摘要
治愈性肝切除治疗肝癌的主要目的是切除有足够切缘的肿瘤,同时亦保留足够的余肝体积和功能以支持病人快速康复。近年来,肝脏外科发展迅速,新的切肝技术涌现。概括而言,肝切除手术仅有5个操作步骤,即:(1)分离韧带和游离肝脏。(2)阻断第一肝门的有关分支,即阻断有关切除肝脏部分的入肝血流及胆管。(3)阻断第三肝门的肝短静脉。(4)阻断第二肝门的有关肝静脉。(3)+(4)等同于阻断有关切除肝脏部分的出肝血流。(5)离断肝实质。此外,在关腹前须彻底止血清洗。不同肝切除方法以不同的顺序联合上述5个步骤。部分肝切除可分为解剖性与非解剖性肝切除。理论上,解剖性肝切除比非解剖性肝切除的优点多。因此,非解剖性肝切除只应施行在肿瘤位于数个肝段的交界处,或肿瘤较小并且位于肝脏周边的病人。解剖性肝切除是基于肝内解剖,将肝脏分为两个半肝,4个肝区(或扇区)和8个肝段。解剖性肝切除是根据肝内解剖平面进行,故出血较少且余肝功能较好。手术可在术前或术中计划,而且手术可遵循肿瘤学的原则进行。解剖性肝切除可采取以下方法进行:(1)基于肝脏表面解剖学标志和使用术中超声引导。(2)首先控制Glisson肝蒂供应准备切除的肝段。(3)术中超声引导穿刺供应将要切除肝段的门静脉分支,并注入染料。(4)使用球囊导管通过肠系膜上静脉的属支进行性阻断门静脉或注入染料。最新的三维可视化技术在肝脏领域的应用,使解剖性肝切除手术在术前可进行更好地规划。
Curative liver resection for liver cancer aims to resect the tumor with an adequate safety margin, while at the same time preserve enough volume and function of the remnant liver. Recent developments in liver surgery have allowed different techniques in liver resection to evolve. All the different techniques involve the combination of five surgical steps, although the 5 steps can differ in their order of execution. The 5 steps are mobilization of liver by division of ligaments, interruption of the vasculo-biliary inflow, liver parenchymal transection, interruption of venous outflow from the short hepatic veins and the main hepatic veins. Obviously, adequate haemostasis is required before closure of the abdomen. Liver resection can be divided into anatomical and non-anatomical liver resections. Theoretically, anatomical liver resection has many advantages over non-anatomical resection and the latter should only be carried out for lesions situated at the junction of several liver segments, or at the peripheral edges of the liver. Anatomical liver resection is based on the intrahepatic anatomy of the liver which divides the liver into hemilivers, sections （or sectors） and segments. Liver resection carried out through anatomical planes results in less blood loss and better preserved liver remnant function. The surgery can be well-planned pre- and intra-operatively, and the operation follows oncological surgical principles. Anatomical liver resection can be carried out based on the following methods： （1） based on liver surface anatomy and intraoperative ultrasound guidance; （2） preliminary control of Glissonian pedicle of the liver segment（s） to be resected; （3） ultrasound guided puncture of portal vein branch and injection of dye; and （4） selective portal venous occlusion using a balloon catheter through a branch of the superior mesenteric vein.The recent development of 3D computed tomographic visualization system has made preoperative planning of anatomical liver resection even better.
作者
刘允怡
赖俊雄
LAU WY, LAI ECH.(Faculty of Medicine, the Chinese University of Hong Kong , Sha- tin, New Territories, Hongkong SAR, Chin)
出处
《中国实用外科杂志》
CSCD
北大核心
2018年第4期345-348,共4页
Chinese Journal of Practical Surgery
关键词
肝癌
解剖性肝切除
非解剖性肝切除
肝段
liver cancer
anatomical liver resection
non-anatomical liver resection
liver segment
