专家介绍:周乐杜,中南大学湘雅医院主任医师,主要从事肝脏外科方面的研究。 肝脏膜结构再认识及在腹腔镜肝切除术中的应用 肖亮,周乐杜 (中南大学湘雅医院 肝脏外科,湖南 长沙 410008) 摘 要 现代外科学的诞生源于对人体解剖学知识的不断积累,而外科学的飞速发展也促进了对脏器精细解剖的深入认识。肝脏作为人体最大的实质性脏器,其独特的双重血供、复杂的肝内脉管结构,使得手术过程中容易发生难以控制的出血。因此,长期以来肝脏手术都是普通外科难度较大的手术之一,需要较长的学习曲线。近30年来,随着腹腔镜肝切除术(LH)的迅速普及,外科医师发现利用以前未被充分重视的肝脏膜结构能够更便利、精准地解剖肝内、外脉管,定位切肝平面,减少术中出血。目前对肝脏膜结构在LH中应用的系统性阐述不多,笔者针对这一领域进行探讨。 关键词 肝肿瘤;肝切除术;腹腔镜 中图分类号:R735.7 Re-understanding of liver membrane structure and its application in laparoscopic hepatectomy XIAO Liang, ZHOU Ledu (Department of Liver Surgery, Xiangya Hospital, Central South University, Changsha 410008, China) Abstract The birth of modern surgery is attributed to the continuous accumulation of knowledge in human anatomy, and the rapid development of surgery also promotes in-depth understanding of fine organ anatomy. The liver as the largest solid organ in the human body has a unique dual blood supply system and complex intrahepatic vascular structures, make it prone to uncontrollable bleeding during surgery. Therefore, liver surgery has long been one of the most difficult operations in general surgery and requires a longer learning curve. In the past 30 years, with the rapid popularity of laparoscopic hepatectomy (LH), surgeons have discovered that the use of liver membrane structures, to which insufficient attention has been paid previously, can more conveniently and accurately dissect the internal and external vessels of the liver and locate the liver plane, and reduce intraoperative bleeding. At present, there are not many systematic explanations focusing on the application of liver membrane structure in LH. Therefore, the authors address the issues in this field. Key words Liver Neoplasms; Hepatectomy; Laparoscopes CLC number: R735.7 参考文献 [1]蔡云峰, 苏树英, 许卓明, 等. 基于区段肝蒂的肝 切除术在肝胆管结石手术中的应用[J]. 中国普通外科杂志, 2017, 26(8):1001-1006. doi:10.3978/j.issn.1005-6947.2017.08.008. Cai YF, Su SY, Xu ZM, et al. Application of hepatectomy based on pedicles of hepatic segments in treatment of hepatolithiasis[J]. Chinese Journal of General Surgery, 2017, 26(8):1001-1006. doi:10.3978/ j.issn.1005-6947.2017.08.008. [2]温增庆, 严以群, 杨甲梅, 等. 肝尾叶切除治疗尾叶肝癌:附11例报告[J]. 中国普通外科杂志, 2007, 16(3):203-205. doi:10.3969/j.issn.1005-6947.2007.03.001. Wen ZQ, Yan YQ, Yang JM, et al. Caudate lobectomy for liver cancer in candafe lobe:a report of 11 cases[J]. Chinese Journal of General Surgery, 2007, 16(3):203-205. doi:10.3969/j.issn.1005-6947.2007.03.001. [3]Eid EA, Sheta SA, Mansour E. Low central venous pressure anesthesia in major hepatic resection[J]. Middle East J Anaesthesiol, 2005, 18(2):367-377. [4]Chen H, Merchant NB, Didolkar MS. Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality[J]. J Gastrointest Surg, 2000, 4(2):162-167. doi: 10.1016/s1091-255x(00)80052-9. [5]姚磊, 王志明, 欧阳锡武, 等. 不同入肝血流阻断技术在原发性肝细胞癌肝切除术中的应用效果比较[J]. 中国普通外 科杂志, 2019, 28(7):815-824. doi:10.7659/j.issn.1005-6947.2019.07.007. Yao L, Wang ZM, Ouyang XW, et al. Efficacy comparison of using different hepatic inflow occlusion techniques in hepatectomy for hepatocellular carcinoma[J]. Chinese Journal of General Surgery, 2019, 28(7):815-824. doi:10.7659/j.issn.1005-6947.2019.07.007. [6]张贯启, 张志伟, 项帅, 等. 大肝癌手术切除术中不同肝血流阻断方法的临床研究[J]. 中国普通外科杂志, 2015, 24(1):18-22. doi:10.3978/j.issn.1005-6947.2015.01.004. Zhang GQ, Zhang ZW, Xiang S, et al. Comparison of different hepatic inflow occlusion methods in hepatectomy for large liver cancer[J]. Chinese Journal of General Surgery, 2015, 24(1):18-22. doi:10.3978/j.issn.1005-6947.2015.01.004. [7]史惠中, 熊奇如, 夏俊, 等. 控制性低中心静脉压在原发性肝癌伴肝炎后肝硬化患者腹腔镜肝切除中的 应用[J]. 中国普通外科杂志, 2020, 29(1):27-34. doi:10.7659/j.issn.1005-6947.2020.01.004. Shi HZ, Xiong QR, Xia J, et al. Application of controlled low central venous pressure in laparoscopic hepatectomy for patients with primary liver cancer and posthepatitis cirrhosis[J]. Chinese Journal of General Surgery, 2020, 29(1):27-34. doi:10.7659/j.issn.1005-6947.2020.01.004. [8]朱荣涛, 郭文治, 李捷, 等. 控制性低中心静脉压在腹腔镜肝叶切除术中的应用[J]. 中国普通外科杂志, 2018, 27(1):42- 48. doi:10.3978/j.issn.1005-6947.2018.01.007. Zhu RT, Guo WZ, Li J, et al. Application of controlled low central venous pressure in laparoscopic hepatic lobectomy[J]. Chinese Journal of General Surgery, 2018, 27(1):42-48. doi:10.3978/ j.issn.1005-6947.2018.01.007. [9]Reich H, McGlynn F, DeCaprio J, et al. Laparoscopic excision of benign liver lesions[J]. Obstet Gynecol, 1991, 78(5 Pt 2):956-958. [10]肖亮, 方统迪, 龙果, 等. 优先解剖肝实质法在腹腔镜下鞘外肝蒂血流阻断中的应用:附解剖性肝中叶切除1例[J]. 中国普通外科杂志, 2020, 29(7):798-805. doi:10.7659/j.issn.1005-6947.2020.07.003. Xiao L, Fang TD, Long G, et al. Application of liver parenchymal dissection-first method in laparoscopic extra-Glissonian inflow occlusion: a case of anatomical mesohepatectomy[J]. Chinese Journal of General Surgery, 2020, 29(7):798-805. doi:10.7659/j.issn.1005-6947.2020.07.003 [11]Ban D, Tanabe M, Kumamaru H, et al. Safe Dissemination of Laparoscopic Liver Resection in 27,146 Cases Between 2011 and 2017 From the National Clinical Database of Japan[J]. Ann Surg, 2020, 274(6):1043-1050. doi: 10.1097/SLA.0000000000003799. [12]中华医学会外科学分会肝脏外科学组. 腹腔镜肝切除术专家共识和手术操作指南(2013版)[J]. 中华外科杂志, 2013, 51(4):289-292. doi:10.3760/cma.j.issn.0529-5815.2013.04.001. Liver Surgery Group, Society of Surgery of Chinese Medical Association. Expert consensus on laparoscopic hepatectomy and guideline for operative procedure (2013 edition)[J]. Chinese Journal of Surgery, 2013, 51(4):289-292. doi:10.3760/cma.j.issn.0529-5815.2013.04.001. [13]Cristino H, Hashimoto T, Takamoto T, et al. Advanced concept of anatomic resection of the liver: preservation of subsegment during right paramedian sectoriectomy[J]. J Am Coll Surg, 2012, 214(2):e5-7. doi: 10.1016/j.jamcollsurg.2011.10.018. [14]Makuuchi M, Hasegawa H, Yamazaki S, et al. The use of operative ultrasound as an aid to liver resection in patients with hepatocellular carcinoma[J]. World J Surg, 1987, 11(5):615-621. doi: 10.1007/BF01655837. [15]Torzilli G, Montorsi M, Donadon M, et al. 'Radical but conservative' is the main goal for ultrasonography-guided liver resection: prospective validation of this approach[J]. J Am Coll Surg, 2005, 201(4):517-528. doi: 10.1016/j.jamcollsurg.2005.04.026. [16]尤楠, 李靖, 郑璐. 肝实质优先入路的腹腔镜解剖性肝切除技术及应用[J]. 中国普通外科杂志, 2020, 29(7):775-784. doi:10.7659/j.issn.1005-6947.2020.07.001. You N, Li J, Zheng L. Technique and application of laparoscopic anatomical hepatectomy via hepatic parenchymal transection-first approach[J]. Chinese Journal of General Surgery, 2020, 29(7):775-784. doi:10.7659/j.issn.1005-6947.2020.07.001. [17]Takasaki K. Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation[J]. J Hepatobiliary Pancreat Surg,1998, 5(3):286-291. [18]Takasaki K, Kobayashi S, Tanaka S, et al. Highly anatomically systematized hepatic resection with Glissonean sheath code transection at the hepatic hilus[J]. Int Surg, 1990, 75(2):73-77. [19]陈焕伟. 左肝蒂横断式腹腔镜左半肝切除术的新方法介绍[J]. 国际外科学杂志, 2018, 45(2):128-129. doi:10.3760/cma.j.issn.1673-4203.2018.02.015. Chen HW. Introduction of a new method of laparoscopic left hemihepatectomy with left hepatic pedicle transection[J]. International Journal of Surgery, 2018, 45(2):128-129. doi:10.3760/cma.j.issn.1673-4203.2018.02.015. [20]谭新华, 张文兴, 刘鹏, 等. 腹腔镜下Glisson蒂横断式解剖性肝切除的应用价值[J]. 中国内镜杂志, 2018, 24(2):90-93. doi:10.3969/j.issn.1007-1989.2018.02.018. Tan XH, Zhang WX, Liu P, et al. Application of transection of glissionean sheath for laparoscopic anatomic liver resection[J]. China Journal of Endoscopy, 2018, 24(2):90-93. doi:10.3969/j.issn.1007-1989.2018.02.018. [21]晏益核, 卢榜裕, 蔡小勇, 等. 经Glisson鞘路径腹腔镜肝切除术的临床研究[J]. 中华普通外科杂志, 2013, 28(3):205-207. doi:10.3760/cma.j.issn.1007-631X.2013.03.011. Yan YH, Lu BY, Cai XY, et al. Laparoscopic hepatectomy trans-Glissoni capsula fibrosa approach[J]. Zhong Hua Pu Tong Wai Ke Za Zhi, 2013, 28(3):205-207. doi:10.3760/cma.j.issn.1007-631X.2013.03.011. [22]陈曦, 周存才, 周红兵, 等. 肝蒂横断式肝切除在解剖性肝中叶切除术中的应用[J]. 中国普通外科杂志, 2012, 21(7):791-795. doi: 10.7659/j.issn.1005-6947.2012.07.003. Chen X, Zhou CC, Zhou HB, et al. Anatomic central hepatectomy using Glissonean pedicle transection method[J]. Chinese Journal of General Surgery, 2012, 21(7):791-795. doi: 10.7659/j.issn.1005-6947.2012.07.003. [23]余德才. 肝脏膜性解剖及Laennec入路解剖性肝切除[J]. 中华腔镜外科杂志: 电子版, 2019, 12(6):332-336. doi:10.3877/cma.j.issn.1674-6899.2019.06.005. Yu DC. Hepatic membranous dissection and Laennec approach for anatomic hepatectomy[J]. Chinese Journal of Laparoscopic Surgery: Electronic Edition, 2019, 12(6):332-336. doi:10.3877/cma.j.issn.1674-6899.2019.06.005. [24]Sugioka A, Kato Y, Tanahashi Y. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec's capsule: proposal of a novel comprehensive surgical anatomy of the liver[J]. J Hepatobiliary Pancreat Sci, 2017, 24(1):17-23. doi: 10.1002/jhbp.410. [25]Hanzawa S, Monden K, Hioki M, et al. How-I-do-it: laparoscopic left medial sectionectomy utilizing a cranial approach to the middle hepatic vein and Laennec's capsule[J]. Langenbecks Arch Surg, 2021, 406(6):2091-2097. doi: 10.1007/s00423-021-02282-x. [26]肖亮, 周乐杜. 腹腔镜解剖性肝切除手术入路选择[J]. 中国普通外科杂志, 2021, 30(1):9-15. doi:10.7659/ j.issn.1005-6947.2021.01.002. Xiao L, Zhou LD. The choice of surgical approach in anatomic laparoscopic hepatectomy[J]. Chinese Journal of General Surgery, 2021, 30(1):9-15. doi:10.7659/j.issn.1005-6947.2021.01.002 [27]中国研究型医院学会肝胆胰外科专业委员会. 腹腔镜肝切除术治疗肝细胞癌中国专家共识(2020版)[J]. 中华消化外科杂志, 2020, 19(11):1119-1134. doi:10.3760/cma.j.cn115610-20201029-00682. Chinese research hospital association, Society for Hepatopancreatobiliary Surgery. Chinese expert consensus on laparoscopic hepatectomy for hepatocellular carcinoma (2020 edtion)[J]. Chinese Journal of Digestive Surgery, 2020, 19(11):1119-1134. doi:10.3760/cma.j.cn115610-20201029-00682. (本文编辑 姜晖) 本文引用格式:肖亮, 周乐杜. 肝脏膜结构再认识及在腹腔镜肝切除术中的应用[J]. 中国普通外科杂志, 2022, 31(1):1-7. doi:10.7659/j.issn.1005-6947.2022.01.001 Cite this article as: Xiao L, Zhou LD. Re-understanding of liver membrane structure and its application in laparoscopic hepatectomy[J]. Chin J Gen Surg, 2022, 31(1):1-7. doi:10.7659/j.issn.1005-6947.2022.01.001 中国普通外科杂志 微信号:ZGPTWKZZ |
|