腹腔镜肝切除术肝实质分离和断面处理技术

腹腔镜肝切除术肝实质分离及断面处理技术ParenchymaTransactionandRemnantManagementduringLaparoscopicHepatectomy嵇振岭东南大学附属中大医院普外科东南大学微创外科研究所JiZhen-Ling,MD,PhD.DepartmentofGeneralSurgeryInstituteforMinimallyInvasiveSurgerySoutheastUniversity前言•1991年Reich首先报道腹腔镜肝脏切除术•2009年11月全世界英文文献共计报道2804例•随着经验的不断积累•手术技巧的不断提高•新型器械的不断出现•腹腔镜技术在肝脏外科的应用日渐广泛•1991：Reich报告首例•1994：周伟平报告3例•2004：嵇振岭国外报告22例•2006：李荣报告123例•2007：国内300例左右•2008：蔡秀军200例多•2009：国内文献43篇•2010：国内文献39篇•2011：国内文献33篇02040608010012014016019941995199619971998199920002001200220032004200520062007gapbeginningincreasing我国腹腔镜肝脏切除术的贡献AuthorsInstitutesReportYearsCasenumbersContributions周伟平上海东方肝胆医院19943国内首先报道李朝龙广州南方医院19964林建华广州南方医院200110王存川暨南大学附属医院200210蔡秀军浙大邵逸夫医院200420嵇振岭东南大学中大医院200425首次在国外报道彭承宏上海交大瑞金医院200522肖震宇华中科技同济医院200520微波刀胡三元山东大学齐鲁医院20065李荣北京301医院2006123大综病例蔡秀军浙大邵逸夫医院2008200PMOD1.腹腔镜肝切除技术及进展.中国微创外科杂志.2002;2(1):58-602.腹腔镜超声检查在LC术中的应用.中华肝胆外科杂志.2002;8(10):639-6403.腹腔镜多功能手术解剖器在实验性肝切除术中的医用.实用临床医药杂志.2003;7(5):434-4364.腹腔镜外科中的组织分离技术.实用临床医药杂志.2003;7(5):437-4405.Hepaticresectionformetastasisfromcolorectalcancer.TechColoproctol2004;8(s):47–496.ALaparoscopicMultifunctionalOperativeDeviceinLaparoscopicHepatectomy.ChirurgischeGastroenterologie2004;20:308-3127.腹腔镜肝切除术6例报告.中国微创外科杂志.2005;5(1):23-248.腹腔镜肝切除12例报告.中华消化内镜杂志.2005;22(1):44-459.腹腔镜多功能操作杆：ZL2003201200961.2.实用新型专利.2004年12月1日10.腹腔镜多功能手术解剖器.2009年江苏省科技进步三等奖本组工作国际会议演讲2ndCCIHPBA,Wuhan,Oct14-17,20065thBIC,Wiesbaden,Oct1-5,20073rdIEHS,Stuttgart,Jan16-19,2008CASC2008,HongKong,May12-16,2008精确肝切除(Precisehepatectomy)•肝脏外科:无血解剖性切肝模式时代3DMDCTsimulationforpreoperativeplanning腹腔镜肝脏切除术的关键技术充分游离血流控制实质离断断面处理标本取出肝脏切除断面的形成基于肝切除时肝实质离断的操作方法基于肝切除时肝内管道结构处理方式传统肝切除断面的处理•采用钳夹法或指捏法离断肝脏•断面用镰状韧带或大网膜覆盖处理方法•压迫止血、减少胆漏、减少粘连•促进早期愈合等认识误区•创面粗糙、高低不平•覆盖容易遗留死腔而引流不畅•局部积血积液增加感染机会实际情况良好的肝实质分离和断面处理有助于：控制减少出血防止发生胆漏降低术后感染加快术后恢复降低手术死亡安全腹腔镜肝切除的保证•Forsafelaparoscopichepatectomy,itisimportanttohaveallnecessaryequipment.–theintraoperativelaparoscopicultrasonography–microwavecoagulators–ultrasonicdissection–argonbeamcoagulators–laparoscopiccoagulationshears–endolinearstaplers–TissueLinkmonopolarsealer–KanekoH,etal:ApplicationofdevicesforsafelaparoscopichepatectomyHPB,2008,10(4):219-224肝实质离断的方法•Mono/Bipolarcautery•Ligasure/Biclamp•HabibSealer•PKcuttingforceps•TissueLink•LMOD/PMODRadioFrequencyBasedEnergy•CUSA•HarmonicshearUltrasoundBasedEnergy•Microwave•Laser•Water-jetcutter•LinearCutterOtherBasedEnergyRFBasedEnergy•Mono/Bipolarcautery•Ligasure/ERBEBiclamp•HabibSealer•PKcuttingforceps•TissueLink•LMOD/PMOD1,高频电刀、射频电极•切肝费时•凝固组织厚坏死组织多•继发感染•近肝门及下腔静脉处不宜使用–CurroG，AnnSurg,2009,250(2):229-2332,LigaSure/ERBEBiclamp•BiclampVesselSealing–ERBE安速PTC–ERBEBiclampforceps•LigaSureV–electrothermalbipolarvesseldevice(EBVS)–TycoValleylab3,HabibSealer•thelaparoscopicHabibSealer，LHS,AngioDynamics,Queensbury,NY•thatconsistsofa2×2arrayofneedlesarrangedinarectangleusesbipolarradiofrequency(RF)energy•withaparenchymatransectiontimebeing61±23min.–DulucqJL,SurgLapEnd&PertTech,2007,17(5):413-415–JiaoLR,Surgery2008;144:770-44,PKSystemCuttingForceps•Vaporplasmacoagulationcuttingforceps(PKsystemcuttingForceps,PlasmaKinetic-PKSystem,GyrusMedical,MapleGrove,MN,USA•generatesupto200Wofradiofrequencyoutput，withvariableamplitudebetween320and450kHz.–AbouljoudMS,etal.Newapplicationofthebipolarvaporplasmacoagulationsystemforlaparoscopicmajorliverresections.SurgEndosc,2008,22:426–4295,Tissue-LinkDissectingsealer•saline-enhancedcooledcautery•couplesradiofrequencywithaconductivefluidtoseallivertissuetoprecoagulateparenchymaandisolateintrahepaticstructures.–NissenNN,AmSurg,2007,73(10):987-9906,PMOD/LMOD•集刮碎、钝切、吸除、冲洗与电凝功能于一体•彭淑牖：PMOD•蔡秀军：腹腔镜PMOD•嵇振岭：LMOD万能杆–JiZLetal.ChirGastroenterol2004;20:308-12–CaiXJetal.ChinJMinInvSurg2004;19(2):71-3UltrasoundBasedEnergy•CavitronUltrasonicSurgicalAspirator(CUSA超声分离刀）–anultrasonicdissector–flush4ml/minat23kHzand70-Wcautery•UltrasonicShears–分离、切割、凝血和抓持–3mm以下血管,可先凝后切–频率55.5kHz,振幅50～100μmOtherBasedEnergy•Microwave/Laser•Water-jetcutter•LinearCutter1,Nd:YAGlasers/MicrowaveCoagulator•The1064-nmNd:YAGlaser•1318-nmNd:YAGlaser.–ChopraSS，PhotoMedLaserSurg,2009,27(2):281-286•MicrowaveCoagulator–报道少见2,HydroJet-Cutter•producesapressurizedwaterjet(30–40bar),washesthesoftlivertissue,leavingonlymoreresistantvesselsandbileductthatarethenligatedorclipped.•使用水喷刀时,腹腔内会产生水雾,影响摄像效果•防水腹腔镜(hydrolaparoscope),可在使用水喷刀时清晰摄像,提高了手术的安全性–ERBE螺旋水刀3,LinearCutter/StaplingDevices–HironoriKaneko,etal.Hepaticresectionusingstaplingdevices.AmJSurg,2004,187:280–284肝断面止血的方法直接缝合氩气凝固胶水喷涂止血纤维1,缝合(suturing)•腔镜下缝合同常规开腹肝切除术•困难繁琐且易损伤周围组织•可采用8字缝合法止血•缝合也可以用于阻断肝脏血流2,氩气凝固(ArgonPlasmaCoagulator)•氩气流2～7L/min,喷头距切面1cm以上,在肝切面形成3mm厚焦痂,直径小于2mm血管凝固,快速止血•腔镜下注意防止气栓–ToruIkegami,etal.Argongasembolismintheapplicationoflaparoscopicmicrowavecoagulationtherapy.JHepatobiliaryPancreatSurg(2009)16:394–398–ERBEVIO外科工作站3,黏合剂(sealant)•Tisseel,Baxter,Deerfield,IL,USA生物胶•氰基丙烯酸酯类化学胶本组初步经验•肿瘤定位•肝脏游离•血流阻断•实质分离•断面处理•标本取出体位及套管位置trocarpositionlaparoscopicviewofatumor肝脏游离cavaThirdportahepatisDissectionoftheligaments血流控制RegionalhepaticbloodinflowocclusionAbsorbableclip肝脏实质离断a.transectionbyHarm