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右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

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Department of General, Visceral, and Transplant Surgery, Tübingen University Hospital

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Cite this Article: 右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

Königsrainer, I., Nadalin, S., Königsrainer, A. Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler. J. Vis. Exp. (35), e1750, doi:10.3791/1750 (2010).

Abstract: 右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

肝切除术的成功，需要深刻的解剖知识和手术技术细腻。 Hemihepatectomies大多执行后，准备在肝十二指肠韧带肝肺门结构，即使在良性肿瘤或肝转移。

Protocol: 右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

外科技术

  1. 病人是床背的位置执行的标准房间条件下，整个腹部desinfected。接下来，病人用无菌床单覆盖。
  2. “反L形”剖腹手术后腹腔探索排除腹膜转移癌。随后韧带大圆和韧带falciforme的划分与连字和电灼。
  3. 腹腔小心双向手动探索肝韧带下探索以排除肝外淋巴结转移。如果中央的肿瘤浸润或淋巴结转移hilus排除，肝肺门结构保持不变。
  4. 肝勘探开始用手动的完整肝脏触诊，后分为肝右三角韧带。其次是术中多普勒声像调查肝内肿瘤的扩散和主要肝内血管结构，尤其是肝中静脉的关系，因此，以确定和标记的横断线。
  5. 如果治疗过程中出现的可能，右半肝完全调动subphrenium和肝后下腔静脉除以之间的片段或缝合后的肝静脉。这一步继续，直到右半肝静脉是免费的。右半肝静脉隔离后，mersilene循环插入后解除肝脏实质横断期间。
  6. 接下来，逆行胆囊切除术。胆囊管钛夹之间的划分。
  7. 随后开始实质清扫。肝脏是轻轻地举行，对称解除和开放两条毛巾。执行的实质横断是一个CUSA剥离（的Valleylab，博尔德- CO，美国）。是密封的小型船只与水灌溉双极钳（ERBE，T图宾根，德国），较大的血管或胆管，绷带，夹子，甚至缝线之间的划分。低中心静脉压CVP（0 5毫米汞柱）切除术，以减少失血。这个阶段一直持续到肝内权蒂是完全免费的。然后，一个mersilene循环插入解除蒂和允许非创伤性血管吻合器（Autosuture TA泰科医疗集团，美国康涅狄格州诺沃克，）的引进。
  8. 正确的蒂是横断订书机，然后用刀在其右侧大幅划分。
  9. 那么剩下的就是完成以前暂停使用先前放置的mersilene循环的肝实质横断。
  10. 随后解剖肝右静脉血管吻合器，右侧肝叶被删除。
  11. 其次是仔细修订切割面和精确的探索，以排除胆汁泄漏。白色的测试可以在这个时候，如果需要的话（7）。
  12. 最后一步是解剖​​固定中断针的残余肝叶，然后封闭运行缝合腹部。
  13. 术后患者对重症监护病房观察一晚常规。如果术后当然是正常的超声检查和肝功能不全患者平静，采取的进一步复苏病房。

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Discussion: 右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

Hemihepatectomies大多执行后，准备在肝十二指肠韧带肝肺门结构，即使在良性肿瘤或肝转移。1-5在各个中心，执行的实质横断是在完成或选择性肝门部血管闭塞。这些程序的主要缺点是复杂的对侧结构受伤的风险和出血门静脉侧分支或胆管受损灌注的可能性hilus准备。

这种权利hemihepatectomy或切除的左外侧段椎弓根与肝内横断的可行的技术叶肝十二指肠韧带完全不变。

这种方法可用于在这些肝肿瘤，淋巴结清扫术是oncologically不必要的，良性的迹象。

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Disclosures: 右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

References: 右右Hemipedicle Suprahilar肝内血管吻合器横断Hemihepatectomy

  1. Belghiti, J., Noun, R., Zante, E., et al. Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg. 224, 155-161 (1996).
  2. Man, K., Fan, ST., Ng, IO., et al. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Ann Surg. 226, 704-711 (1997).
  3. Wu, CC., Hwang, CR., Liu, TJ., et al. Effects and limitations of prolonged intermittent ischaemia for hepatic resection of the cirrhotic liver. Br J Surg. 83, 121-124 (1996).
  4. Figueras, J., Llado, L., Ruiz, D., et al. Complete versus selective portal triad clamping for minor liver resections: a prospective randomized trial. Ann Surg. 241, 582-590 (2005).
  5. Lesurtel, M., Selzner, M., Petrowsky, H., et al. How Should Transection of the Liver Be Performed? A Prospective Randomized Study in 100 Consecutive Patients: Comparing Four Different Transection Strategies. Ann Surg. 242, 814-823 (2005).
  6. Königsrainer, I., Steurer, W., Witte, M., et al. Liver resection without hilus preparation and with selective intrahepatic hilus stapling for benign tumors and liver metastasis. Langenbecks Arch Surg. 392, 485-8 (2007).
  7. Nadalin, S., Li, J., Lang, H., et al. The White test: a new dye test for intraoperative detection of bile leakage during major liver resection. Arch Surg. 143, 402-4 (2008).

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