腹腔镜活体供肝切除中的意外及处理  

Intraoperative accidents and strategies for them during laparoscopic living donor hepatectomy

作　　者：魏永刚[1] 徐红卫 WEI Yong-gang;XU Hong-wei(West China Hospital of Sichuan University,Chengdu 610041,China)

机构地区：[1]四川大学华西医院肝脏外科,四川成都610041

出　　处：《中国实用外科杂志》2022年第9期997-1001,共5页Chinese Journal of Practical Surgery

基　　金：四川省科技厅重点研发项目(No.2019YFS0372)。

摘　　要：近年来,随着微创外科技术以及设备的迅速进步,极大推动了腹腔镜肝切除术的发展,世界范围的诸多有经验的中心也在逐步扩大腹腔镜肝切除术的适应证,使得腹腔镜下活体供肝切除术成为一种可行的术式选择,促进了供体术后康复过程和生活质量的提高。但由于腹腔镜供肝切取过程相对于普通肝切除更为复杂,术中发生意外的情况更多,处理稍有不当则可能造成中转开放手术。其中术中出血包括了游离肝脏、解剖肝门、离断肝实质以及离断主要管道的各类情形,熟知腹腔镜手术中出血特点、仔细的术前规划、精细的术中操作以及打造默契的团队配合是安全防范和处理术中出血的关键。胆道损伤常常来自于对胆道变异对误判而造成意外,严重者导致供受体恢复不佳甚至移植失败,术前充分的胆道评估和三维重建有助于规避风险,术中离断前后的胆道造影则更是避免胆道损伤的重要环节。此外,由于解剖位置的特殊性,肝静脉的离断可能发生供受体侧的狭窄而影响手术效果,合理的选用仅含单排钉仓的直线切割闭合器则会在很大程度上保护供受体的静脉离断损伤。总之,为减少腹腔镜活体供肝切除术中的意外情况产生,术者应在术前对供体的解剖结构做出充分的评估,并且在术中精细解剖,步步为营,训练打磨良好的扶镜手和一助,打造配合默契的团队是规避风险和安全处理术中意外的关键。With the rapid development of the technique and equipment of minimally invasive surgery during the past decades,the progress of laparoscopic hepatectomy has been promoted dramatically.Many experienced centers from all over the world have gradually expanded the indications of laparoscopic hepatectomy,and adopted the laparoscopic living donor hepatectomy as an alternative operation for living donor liver transplantation,showing the enhanced postoperative recovery course and improved quality of life.However,the laparoscopic living donor hepatectomy is of a more complex nature compared with normal liver resection,and intraoperative accidents appear more common during this surgery and often lead to conversion.Which,intraoperative bleeding may occur during the course of mobilization,hilar dissection,parenchymal dissection,and the division of the vessels and bile duct.A clear notice of the feature of all kinds of bleeding,the meticulous dissection as well as the harmonious cooperation between operators and assistants are all of great significance.Biliary injury may often come from a misunderstanding of the intrahepatic biliary structures and could lead to an unsatisfied outcome for the donor and recipient,even to the failure of the transplantation.Both preoperative and intraoperative evaluation of the biliary structures are important for the safe dissection.Besides,due to the special anatomical location of the hepatic veins,their inappropriate division may sometimes cause relatively stricture for vascular anastomosis.The use of unilateral staplers may have the advantage to protect these veins during division.In conclusion,the operators should make a full evaluation of the anatomical structures before surgery and perform meticulously during the operation,and the harmonious cooperation between operators and assistant is also the key to avoiding accidents and safely addressing them during laparoscopic living donor hepatectomy.

关 键 词：腹腔镜肝切除术 活体供肝切除术 活体肝移植 

分 类 号：R6[医药卫生—外科学]