Clinical application of laparoscopic left hepatectomy

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The Department of hepatobiliary surgery of Ganzhou People's Hospital party Chuanfa Laiyang Xie Yuan Deng Xiaohong Zhang Lei Wang Xiaojun Xia

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The Department of hepatobiliary surgery of Ganzhou People's Hospital party Chuanfa Laiyang Xie Yuan Deng Xiaohong Zhang Lei Wang Xiaojun Xia

Abstract: Objective To summarize the clinical experience of laparoscopic left hepatectomy. Methods totally 22 patients with primary lesions located in the left half of the liver underwent total laparoscopic left hepatectomy. Results all the 19 cases were operated successfully. The operation time was (= + 50) min, and the intraoperative bleeding (= + 150) was mL. There was no serious complication. The hospital stay was (+ + 1.2) d. Conclusion laparoscopic left hepatectomy is safe and feasible, and has the advantages of minimally invasive surgery.

Key words: laparoscopic; left hemi hepatectomy

Laparoscopic left resection: a report liver of22cases

FANG Chuanfa, XIA Laiyang, XIE Yuancai, et

(Department of Hepatobiliary Surgery, The Hospital of city Ganzhou, Ganzhou, Jiangxi, 341000),

AbstractObjectiveTo evaluate the feasibility of laparoscopic left liver rescetion. M ethods with left liver disease 22 cases were used for anatomical left hepatectomy. ResultsLaparoscopic anatomical left hepatectomy was successfully performed in cases. The operative duration was 19 (250 + 50) min; The quantity of blood lost during the operation was (200 + 150) mL. The post-operative recovery was smooth and good. No severe complications occurred. The duration for hospitalization after operation was (6.3 + 1.2) day. ConclusionLaparoscopic left liver resection is a minimally invasive technique which can be carried out safely and effective.

Keywordslaparoscopy; left hepatectomy

Laparoscopic surgery has the advantages of small trauma, quick recovery, beauty, short hospital stay and so on. In recent years, with the improvement of laparoscopic surgery technology continues to mature and laparoscopic instruments, expand the types of operation, increasing the difficulty of operation safety, continuously improve, laparoscopic surgery has penetrated into every field of abdominal surgery. 1991 Reich[1] et al. First reported 2 cases of laparoscopic liver resection (laparoscop-ic hepatectomy, LH), Zhou Weiping et al. [2] completed the first LH in China in 1994. Since then, reports of such surgeries have been increasing. Because the liver is rich in blood supply, laparoscopic portal blood blocking is difficult, bleeding and risk, the existing laparoscopic hepatectomy expensive equipment, hemostatic effect is not ideal, the use process is complicated, the laparoscopic hepatectomy in the clinical practice is still at the exploratory stage of development, only part of the three stage hospital. From January 2004 to December 2009, 22 patients with primary lesions located in the left half of the liver underwent total laparoscopic left hepatectomy. Report as follows.

1 materials and methods

1.1 general data in 22 cases, male in 14 cases, female in 8 cases. Age 27~67 years. The course of disease was 1 months to 20 years. Cases were diagnosed by history, physical examination, B ultrasound, ERCP, CT or MRCP, 3 cases of hepatic hemangioma, intrahepatic bile duct stones in 15 cases, primary liver cancer in 4 cases. All patients had no history of upper abdominal surgery.

1.2 preoperative liver function and liver function child grade A in 20 cases, B grade 2 cases, liver after treatment for Grade A. No ascites, hypoproteinemia and prothrombin time.

2 surgical methods

2.1 laparoscopic hepatic left lateral lobectomy established 12 mmHg pneumoperitoneum, 5 Trocar channels, cut the liver ligament, left lobe liver free; anatomical dissection of the first hepatic portal, hepatic artery and portal vein ligation of the left branch, the lock clamping of the left hepatic artery and portal vein and cut, control blood flow into the liver, visible the left half liver showed ischemic changes (see Figure 2). The anatomy of the second hepatic portal, isolated from the trunk of left hepatic vein after 7 silk suture, the control of hepatic blood flow, if the left hepatic vein anatomy is not ideal, can not wait for temporary treatment, liver resection to left hepatic vein ligation followed by 7 (see Figure 2). According to the anatomical landmarks of the liver lobe, with a variety of instruments such as an electric knife and an ultrasonic knife, the liver parenchyma was cut off on the anterior tangent line. When the diameter of the hepatic duct was greater than 2 mm, the titanium clips were used to clamp the blood vessels, so as to prevent bleeding and bile leakage. Wash the wound, stop bleeding, spray the fibrin glue and / or cover the hemostatic gauze in the liver section, put the abdominal cavity drainage, and take out the specimen with the specimen bag.

3 Results

22 cases of anatomical left liver resection in 19 cases, conversion to open surgery in 3 cases, including cholecystectomy in 2 cases, common bile duct stone removal in 3 cases. The average operation time was 250 min. The average intraoperative bleeding was 250 ml. There were 3 cases of postoperative bile leakage, and the drainage tube was used to drain the bile. The maximum was ml/d D, and the bile leakage after 5~8 was stopped. There were no postoperative complications such as bleeding, infection, bile duct residual stone and so on. Twenty-first days after removal of T tube. Postoperative 6~14 D recovered and discharged. Liver resection specimens were taken from 4 to 13.5 cm x 5 to 6.5 cm in size, and were removed by enlarging the left rib under the rib, stitching the 2-4 needle. No death case.

4 discussion

Laparoscopic liver resection is considered as a "forbidden area" due to its anatomical and physiological specificity". The liver with hepatic artery and portal vein double blood supply, blood supply is rich, easy bleeding and intraoperative resection, and not easy to control; laparoscopic liver resection in some parts of difficult exposure, the operation is difficult; cannot use the open surgery of laparoscopic liver resection techniques, such as hepatic portal occlusion, with hand hemostasis and flexible suture hemostasis [3]. Recently, with the improvement of laparoscopic technology and the continuous improvement of equipment, laparoscopic liver resection has made great progress, but it is still in the continuous exploration [4-6].

Generally laparoscopic left liver resection indication: (1) lesions in the liver, Section II III, IV, does not infringe on the other side, not involving the first and the second hepatic portal and inferior vena cava; (2) benign tumor diameter less than 15 cm, malignant tumor diameter less than 10cm; (3) if malignant tumor, with portal vein invasion, intrahepatic metastasis and distant metastasis; (4) no, lung, liver and kidney function of important organs and blood coagulation dysfunction. The contraindications were as follows: (1) the lesions involving the hepatic portal and inferior vena cava; (2) the tumor was larger, the diameter of the benign tumor was >15cm, and the diameter of malignant tumor was >10cm. Because of the tumor, turning difficult exposure. Especially the malignant tumor, even if removed, but inevitably break tumor in operation. There was a history of upper abdominal surgery and severe abdominal adhesion.

Laparoscopic hepatectomy in patients with postoperative recovery was fast, within 24 h bed activity, 1~3 D began to eat. However, attention should be paid to postoperative complications such as blood, bile leakage, hepatic insufficiency, pulmonary infection and so on. There were also some complications such as perforation of small intestine, phlebitis, gas embolism and so on. Gigot et al. [7] reviewed 186 cases of laparoscopic liver resection (in 102 cases of malignant, benign in 84 cases), the incidence of complications was between 16 and 1%, and the incidence of suspected gas embolism occurred in 2 patients. At present, the complications of endoscopic resection of liver decreased. For postoperative complications should be based on prevention, operation should be fine. Because of the bleeding of unknown blind electrocoagulation, hemostatic clamp encountered during operation, should first find out the reason and location for processing later. If the bleeding is unable to control, should be transferred to open surgery. Before the end of surgery, abdominal cavity should be carefully examined, and the wound should be clear without bile leakage, bleeding and intestinal injury. The vital signs and the nature of the drainage fluid were observed after operation.

Preoperative CT or MRCP examination is helpful to understand the situation of the liver, the location of the lesion, and the relationship between the liver and the liver. Control of hemorrhage is the key to successful surgery, especially hepatic vascular occlusion, isolated dissection of left hepatic artery and left hepatic duct and left portal vein ligation and ligation of the distal to the lock, give clipping, cut after the visible left liver black, showed ischemic changes. On whether to block the blood flow of the liver, our approach is generally not blocked, waiting for the cut to the left hepatic vein and then 7 wire ligation. If the left hepatic vein is not shared with the middle hepatic vein in the dissection of the second hepatic hilum, the left hepatic vein and the liver tissue can be treated with suture ligation. Don't force the separation of left hepatic vein, because it is easy to tear and blood vessels, time-consuming, a relatively simple method is left in the left hepatic and falciform ligament on the edge of the [8]. Isolated liver tissue: second difficulties of laparoscopic hepatectomy. The routine use of ultrasound knife to cut the liver tissue, smoke less, familiar with anatomy, our experience is that each clip organization must be less, cut the liver slowly slow basic block, this advantage is less bleeding, less smoke, easy to identify the organizational structure, not easy to injure the bile duct and blood vessels, but cut a long time the need for patience. Ultrasonic knife has patients with cirrhosis of the liver resection combined, the effect is not ideal, we found that the use of high-frequency electric coagulation effect is better, the electric coagulation knife strength to about 80W (Germany ERBE company, transferred to the 4 block), trimming setting, cutting speed, hemostatic effect is satisfied, can reduce the use of ultrasound knife costs, but the disadvantage is the smoke, can be cut appropriately to reduce the impact of smoke exhaust.

As long as the master of laparoscopic liver surgery techniques and technology, and has rich clinical experience and the necessary equipment, laparoscopic liver resection is safe and feasible, with Wang Gang [9] and HironoriKaneko [10] report is consistent. To carry out this kind of surgery on the professional knowledge and professional skills are relatively high requirements, including: (1) unity and cooperation of the team, is an important guarantee for the successful completion of surgery. (2) the spirit of hard work, especially in the early stage of laparoscopic liver resection, the operation time of up to 5-7h. (3) Department of hepatobiliary surgery surgery experienced, surgery must be fine on liver anatomy at. (4) laparoscopic skilled, must have a flexible endoscopic suturing and knotting and cutting technology, also must pay attention to the accumulation of experience and technology. (5) strict indications, as early as possible to select the tumor near the left hepatic lobe, tumor volume is small, no cirrhosis, hepatic atrophy, fibrosis and abdominal surgery history.

In conclusion, laparoscopic hepatectomy has the advantages of less surgical trauma, less bleeding, faster postoperative recovery, less pain, less complication, and less invasive beauty (see Figure 3). Many studies show that laparoscopic surgery on immune system fight with open surgery, laparoscopic liver resection and the curative effect is better than the conventional open hepatectomy for [9], but the long-term effect of control is still a lack of the bulk of cases. With the continuous accumulation of laparoscopic surgical experience and the innovation of laparoscopic surgical instruments, surgical indications will continue to expand.

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