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肝脏三维可视化技术在第二肝门区肿瘤手术切除中的应用

Application of liver visualization technologies in hilar tumor resection at the second hepatic portal area

摘要:

目的 探讨肝脏三维可视化技术在第二肝门区复杂肿瘤切除中的应用.方法 回顾性分析2014年8月至2015年9月在东方肝胆外科医院肝外三科接受手术治疗的80例第二肝门区肿瘤患者资料,男性58例,女性22例,年龄21~ 70岁,中位年龄52岁.肿瘤最大径3.0 ~ 17.0 cm,中位数为7.6 cm.所有患者术前均采用三维可视化技术合成肝脏三维图像,观察肝内血管与肿瘤关系,计算拟切除及剩余肝脏体积,规划手术方案.术中采用合适的肝血流阻断技术完成肝脏切除手术.观察患者肝内血管走行及变异、手术方式、手术时间、肝血流阻断方式及时间、术中出血量、肝切除体积、术后并发症发生情况.结果 应用三维可视化技术对80例患者进行手术风险评估后,23例改变了手术方式.肿瘤压迫1根主肝静脉44例,压迫2根主肝静脉32例,压迫3根主肝静脉4例,同时压迫下腔静脉58例;肝脏6、7段切除12例,肝脏2、3段切除14例,肝脏4、5、8段切除8例,右半肝切除9例,左半肝切除8例,右三叶切除3例,左三叶切除5例,局部肝段切除12例,行联合肝脏分隔和门静脉结扎的二步肝切除术9例.采用全肝血流阻断技术4例,采用选择性肝静脉阻断技术16例.中位手术时间132 min(80~240 min);中位术中出血量580 ml(100~5 000 ml).中位肝切除体积为750 ml(30~2 000 ml).术后出现腹腔出血再手术止血患者1例,术后胆漏14例,需处理胸腔积液患者5例,需处理腹腔积液患者4例,切口感染5例,肺部感染2例,胆道梗阻2例,本组无手术死亡病例.结论 运用肝脏三维可视化技术规划手术方案可保障第二肝门区手术的安全,并能优化手术方案,降低术中出血量及术后肝功能衰竭等并发症发生率.

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abstracts:

Objective To discuss the application of liver visualization technology in complex liver tumor resection at the second hepatic portal area.Methods Clinical data of 80 cases who received surgery at the second hepatic portal area from August 2014 to September 2015 in the Third Department of Hepatic Surgery of Eastern Hepatobiliary Surgery Hospital were analyzed retrospectively.There were 58 male and 22 female patients aged from 21 to 70 years with median age of 52 years.Median maximum diameter of tumor was 7.6 cm (3.0 to 17.0 cm).Before surgery,liver dimensional graphics produced by liver visualization technology were taken on all patients to observe the relationship between intrahepatic vasculars and the liver tumor,and to calculate the intended resection range and the remaining liver volume in order to make a proper surgery plan.Suitable hepatic vascular occlusion was applied in the tumor resection.Intrahepatic vessel shape and variation,surgical operation,surgical operation time,manner and time of hepatic vascular occlusion,blood loss,liver resection volume,postoperative complications were observed.Results There were 23 patients who changed surgery plan after liver visualization technology.There were 44 cases with single main hepatic vein compressed by tumors,32 cases with 2 main hepatic veins,4 cases with 3 main hepatic veins compressed by tumors.And there were 58 cases with both hepatic vein and inferior vena cava compressed by tumor.Hepatic segments 6 and 7 was removed in 12 cases,14 cases,hepatic segments 4,5 and 8 were removed in 8 cases.Right hepatectomy was carried out in 9 patients and left hepatectomy was carried out in 8 patients.Right trisectionectomy was carried out in 3 patients and left trisectionectomy was applied in 5 patients.Local hepatectomy was performed in 12 patients.Nine patients received associating liver partition and portal vein ligation for staged hepatectomy.Four patients underwent total hepatic vascular exclusion,while 16 patients underwent selective hepatic vascular exclusion.The median surgical time was 132 minutes (80 to 240 minutes).Median blood loss volume was 580 ml(100-5 000 ml).Median volume of hepatic resection was 750 ml(30 to 2 000 ml).One patient needed secondary surgery to stop bleeding as a result of postoperative abdominal bleeding.Complication of postoperative bile leakage occurred in 14 cases.Five patients had pleural effusion requiring invasive therapy.Four patients had ascites requiring invasive therapy.Besides,5 patients had incisive infection while 2 patients were found with pulmonary infection after surgery and two patients occurred biliary obstruction.There was no death case occurred a result of surgery.Conclusions Using liver visualization technology to make surgical operation plan can improve surgical safety of the second hepatic portal area and optimize the operation plan.It can also reduce the risk of blood loss and postoperative complications such as liver failure.

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