方扬?何军明?彭建新

【摘要】目的 探討采用腹腔镜经正中裂入路解剖性肝Ⅷ段切除术治疗肝癌的手术效果及可行性，总结相关经验。方法 回顾性分析接受腹腔镜经正中裂入路解剖性肝Ⅷ段切除治疗的22例肝癌患者的临床资料，总结手术效果。结果 22例手术均顺利完成，经正中裂入路不容易压迫肿瘤，术中视野暴露好，操作相对简单，但手术创面偏大。22例均无中转开腹或围术期死亡，手术时间186（92，203）min，术中出血量100（50，200）ml。术中对14例实施了Pringle法阻断入肝血流，肝血流阻断时间为（28±6）min。22例术后住院时间为（12.1±2.2）d。22例术后Clavien-Dindo并发症分级系统分级Ⅰ、Ⅱ、Ⅲ（Ⅲa、Ⅲb）级并发症的发生率分别为13.6%（3/22）、4.5%（1/22）、31.8%（7/22），无腹腔出血、肝衰竭、顽固性腹水等并发症。22例术后病理检查结果均为肝细胞癌，病理切缘均阴性，肝切缘宽度为（1.9±0.4）cm。22例的随访时间为22（14，29）个月，10例患者出现肝内局部复发，复发时间为28（10，31）个月，1年内复发率和3年内复发率分别为18.2%、45.5%。结论 腹腔镜经正中裂入路解剖性肝Ⅷ段切除术的视野暴露好，手术效果尚可，用于肝癌患者具有一定的可行性。但因手术创面偏大，故需要术者熟练掌握腹腔镜肝切除技术，具备较强的损伤控制能力。

【关键词】正中裂入路;腹腔镜;解剖性肝切除;肝Ⅷ段

Application of laparoscopic anatomical resection of segment Ⅷ via separation of median hepatic fissure approach in treatment of hepatocellular carcinoma Fang Yang， He Junming， Peng Jianxin. Guangzhou University of Chinese Medicine， Guangzhou 510405， China

Corresponding author， He Junming， E-mail： 1277155944@ qq. com

【Abstract】Objective To evaluate the surgical efficacy， feasibility and summarize experience of laparoscopic anatomical resection of segment Ⅷ via separation of the median hepatic fissure approach in the treatment of hepatocellular carcinoma. Methods Clinical data of 22 patients with hepatocellular carcinoma undergoing laparoscopic anatomical resection of segmentⅧ via separation of the median hepatic fissure approach were retrospectively analyzed. Surgical efficacy of this technique was evaluated. Results All 22 patients successfully completed the surgery. The median hepatic fissure approach yielded a low risk of tumor compression， better surgical field exposure and simpler operation， whereas it might cause larger wound. No patient was switched to open surgery or died during the perioperative period. The median operation time was 186 （92， 203） min， and the median intraoperative blood loss was 100 （50， 200） ml. The average hepatic blood flow block time was （28±6） min for 14 patients undergoing Pringle method. The average length of  postoperative hospital stay was （12.1±2.2） d. The proportion of postoperative Clavien-Dindo classification Ⅰ， Ⅱ， Ⅲ （Ⅲa， Ⅲb） was 13.6% （3/22）， 4.5% （1/22） and 31.8% （7/22），respectively. No abdominal bleeding， liver failure or refractory ascites was observed. All 22 patients were diagnosed with hepatocellular carcinoma by postoperative pathological examination. All pathological margins were negative， and the average width of liver margin was （1.9±0.4） cm. The follow-up time was 22 （14， 29）months. A total of 10 patients developed intrahepatic local recurrence. The average recurrence time was 28 （10， 31） months. The 1- and 3-year recurrence rates were 18.2% and 45.5%. Conclusions Laparoscopic anatomical resection of segmentⅧ via separation of the median hepatic fissure approach yields good visual field exposure and relatively high surgical efficacy， which is a feasible strategy for hepatocellular carcinoma patients. Nevertheless， it has demanding requirement for the surgeons with skilled laparoscopic hepatectomy and wound control ability.

【Key words】Median hepatic fissure approach;Laparoscopy;Anatomical hepatectomy;Segment Ⅷ

作为全球发病率排名第5的恶性肿瘤，肝癌治疗的首选方案始终是外科手术，外科手术技术的进步使更多的肝癌患者例如肿瘤负荷过大、复杂肿瘤或合并严重肝脏疾病者能够耐受根治性切除术[1]。理想的解剖性肝切除术不仅能保证足够宽的阴性切缘，而且能最大限度地保留正常肝实质，同时能满足快速康复的外科观念，显著改善肝癌患者的生存及预后，5年内生存率可达到60% ～ 65%[2-5]。……