Objective?To approach feasibility, safety, and the application range of pure laparoscopic resection （PLR）, hand-assisted laparoscopic resection （HALR）, and robotic liver resection （RLR） in the minimally invasive liver resection （MILR）. Methods?The clinical data of 128 patients underwent MILR in the Surgical Department of the Shanghai Ruijin Hospital from September 2004 to January 2012 were analyzed retrospectively. According to the different methods, the patients were divided into PLR group, HALR group, and RLR group. The intraoperative findings and postoperative recovery of patients in three groups were compared.?Results?There were 82 cases in PLR group, 3 cases of which were transferred to open surgery；the mean operating time was （145.4±54.4） minutes （range：40-290 minutes）；the mean blood loss was （249.3±255.7） ml （range：30-1 500 ml）；abdominal infection was found in 3 cases and biliary fistula in 5 cases after operation, but all recovered after conservative treatment；the mean length of hospital stay was （7.1±3.8） days （range：2-34 days）. There were 35 cases in HALR group, 3 cases of which were transferred to open surgery；the mean operating time was （182.7±59.2） minutes （range：60-300 minutes）；the mean blood loss was （754.3±785.2） ml （range：50-3 000 ml）；abdominal infection was found in 1 case, biliary fistula in 2 cases, and operative incision infection in 2 cases after operation, but all recovered after conservative treatment；the mean length of hospital stay was （15.4±3.7） days （range：12-30 days）. There were 11 cases in RLR group, 2 cases of which were transferred to open surgery； the mean operating time was （129.5±33.5） minutes （range：120-200 minutes）； the mean blood loss was （424.5±657.5） ml （range：50-5 000 ml）； abdominal infection was found in 1 case and biliary fistula in 1 case after operation, but all recovered after conservative treatment； the mean length of hospital stay was （6.4±1.6） days （range：5-9 days）. The operating time （P=0.001） and length of hospital stay （P=0.000） of the RLR group were shortest and the blood loss （P=0.000） of the PLR group was least among three groups. Conclusions?Minimally invasive resection is a safe and feasible. Different surgical procedures should be chosen according to different cases. The robotic liver resection provides new development for treatment of liver tumor.
【 Abstract 】 Objective To investigate the precautionary effect of fibrin glue on postoperative bleeding and bile leakage when used in partial hepatic resection. Methods House-hold rabbit partial hepatectomy model was prepared and 40 rabbits were divided into sham operation （ SO) group (n=10), control group (n=10) and protocol group (n=20) randomly. The SO rabbits received laparotomy only, while both the control and protocol group received partial hepatectomy. Fibrin glue was used in the protocol group following electric coagulation therapy while the control group received electric coagulation therapy only. The animals’ diet, weight and adverse effects were observed then, and the celiac drainage volume, levels of hemoglobin (Hg), WBC and TBil in celiac outflow and ALT, AST, LDH and TBil in rabbit serum were checked on schedule after operation. Results The average blood loss volume and operation time in the protocol group were (16.0±2.7) ml and (23.7±2.9) min respectively, which were lower than those in the control group 〔 (20.8 ± 3.5) ml and (27.3 ± 2.9) min (P ＜ 0.01) 〕 . The celiac drainage volume, levels of Hg, WBC and TBil in celiac outflow decreased gradually on postoperative days in protocol groups (P ＜ 0.05). The levels of Hg in celiac outflow of the protocol group on the 1st, 2nd and 7th postoperative day were lower than those of the control group (P ＜ 0.05), and the result of TBil was the same on the 1st, 2nd, 3rd, 5th and 7th postoperative day (P ＜ 0.05). The serum ALT, AST, LDH and TBil levels in the control and protocol groups were higher than those in the SO group significantly (P ＜ 0.01), while the serum ALT, AST (except on the 3rd postoperative day) and LDH levels in the protocol group were lower than those in the control group (P ＜ 0.05) in significance.All animals had good appetite, normal weight gain and no adverse reaction and death occurred. Conclusion Application of fibrin glue may effectively prevent and cure the postoperative bleeding and bile leakage in partial hepatectomy without any adverse reaction.
目的探讨间断低氧预适应对大鼠肝大部切除术后残余肝脏合并缺血再灌注引发过氧化损伤的保护作用。 方法78只SD大鼠，用SPSS软件将其随机分为4组：假手术组（SO组，n=6）、肝切除组（PH组，n=24）、肝切除合并缺血再灌注损伤组（IR组，n=24）和间断低氧预适应组（IHP组，n=24）。以无创伤血管夹阻断IR组大鼠入肝血流后切除肝脏的左叶和中叶（约占全肝的70%），20 min后开放入肝血流，残余肝脏发生了缺血再灌注损伤。将IHP组大鼠暴露于10%的低氧环境中，每日持续1 h，连续进行1周，最后1次低氧暴露后行肝切除术（同IR组）。SO组大鼠在术后2 h取材检测，其余各组分别于术后2、6、12及24 h进行检测。检测血清转氨酶（ALT、AST）水平和肝匀浆组织中超氧化物歧化酶（SOD）活性及丙二醛（MDA）含量。 结果术后2 h，PH组、IR组和IHP组大鼠血清ALT和AST水平均高于SO组（P<0.05）。在术后6、12和24 h，IHP组大鼠血清ALT和AST均高于PH组，但低于IR组（均P<0.05）。与IR组相比，IHP组大鼠术后各时间点残余肝脏中SOD活性明显升高，而MDA含量则显著降低（均P<0.05）。 结论间断低氧预适应对残余肝脏缺血再灌注损伤具有保护作用，其机理可能与提高肝脏的抗氧化能力有关。
ObjectiveTo discuss the feasibility, safety, and superiority of da Vinci surgery system (DVSS) in liver tumor resection. MethodThe clinical data of 21 patients who underwent DVSS in the liver tumor resection were analyzed retrospectively. ResultsThere were 12 patients with hepatocellular carcinoma (HCC), 1 patient with cholang-iocellular carcinoma, 1 patient with hepatic cirrhosis regenerative nodule, 2 patients with metastatic adenocarcinoma, 2 patients with leiomyosarcoma, and 3 patients with cavernous hemangioma.The operative time was (156.67±92.19) min (60-480 min), the intraoperative blood loss was (585.71±1 076.12) mL (50-5 000 mL), the time of diet recovery was (3.23±1.26) d (2-6 d), and the hospital stay was (10.10±9.02) d (5-47 d).The hospital mortality and morbidity rates were 0(0/21) and 9.52%(2/21) respectively including 1 patient with biliary leakage and 1 patient with abdominal infection. ConclusionThis study demonstrates the feasibility and safety of DVSS in the liver tumor resection and the system has a wide range of application for patients who are suffering from liver tumor.
ObjectiveTo explore the value of radiofrequency ablation (RFA) in the radical cure for hepatocellular carcinoma (HCC). MethodThe recent literatures about RFA in the treatment for HCC were retrieved and reviewed. ResultsThe liver transplantation, liver resection, and RFA were the three effective treatments in curative intent for early HCC.RFA was more frequently used in downsize therapy prior to liver transplantation in recent years because of its excellent local tumor control.Preoperative RFA extended the average waiting time without increasing the risk of dropout.Even though the controversy about effectiveness of RFA and hepatectomy was not been settled, the liver resection com-bined with RFA extended the operation indication of HCC and improved the effectiveness. ConclusionsRFA plays more and more important roles among the various treatment strategies in HCC.RFA, liver transplantation, and hepatectomy could be complementary to each other in the treatment for HCC and benefit numerous patients.Among these strategies, the key to improve the effectiveness is that minimum reduces residual tumors and suppresses their growth.
ObjectiveTo explore the effect of carbamazepine (CBZ) on liver regeneration following partial hepatectomy (PH) in rats. MethodsSixty male Sprague-Dawley rats were randomly divided into CBZ group and control group, thirty rats in every group, all the rats were underwent 70% hepatectomy. In the CBZ group, all the rats were feed with 5% CBZ at a dose 250 mg/kg at 2 hours before PH, everyday after PH, and the last administration was at 2 hours before sacrifice. In the control group, all the rats were feed with the same quantitative and frequency dimethyl sulfoxide as 5% CBZ of the CBZ group. On day 1 before PH and on day 1, 2, 3, 5, and 8 after PH, the liver to body weight ratio, ALT, hepatocyte growth factor (HGF), and Ki-67 of each group were observed. Results①On day 2, 3, 5 after PH, the liver to body weight ratios of the CBZ group were significantly higher than those of the control group (P < 0.05). On the other time point, there was no significant difference of the liver to body weight ratio between two groups (P > 0.05).②On all the time point, there was no significant difference of the serum ALT level between two groups (P > 0.05).③On day 1, 2, 3 after PH, the serum levels of HGF in the CBZ group were significantly higher than those in the control group (P < 0.05). On the other time point, there was no significant difference of the serum HGF level between two groups (P > 0.05).④On day 2 after PH, the expression of Ki-67 in the CBZ group was significantly higher than that in the control group (P < 0.05). On the other time point, there was no significant difference of the expression of Ki-67 between two groups (P > 0.05). ConclusionThe results suggest that administration of CBZ has a promotive effect on liver regeneration following PH in rats and this effect might be through promotion of hepatocyte proliferation.
ObjectiveTo explore clinical value of 3D printing technology in hepatic resection. MethodsFrom March to May 2015, multidetector-row computed tomography images of 12 patients, including hepatic carcinoma in 6, hepatic hemangioma in 3, intra-and extra-hepatic bile duct stones in 3, were used for 3D hepatic reconstruction, the final segmentation data were converted to stereolithography files for 3D printing, 50%-70% scale of the full-sized liver model was fabricated by polylactic acid to be used to analyze its anatomical structure, design surgical planning, select the optimal operative route and simulate hepatic resection. Hepatic resection was performed by referring to the 3D printing model. ResultsThe hepatic resections were successful without complications by referring to the preoperative 3D printing models, the average blood loss was 340(100-1000) mL. ConclusionHepatic resection is more accurate and safe by 3D printing technology.
ObjectiveTo investigate various methods and strategies of lowering central venous pressure (CVP) during hepatectomy.MethodThrough literature review, the definition, implementation, related complications, and prognosis of low CVP were reviewed and summarized and the most appropriate CVP in the liver surgery was also summarized.ResultsThe low CVP had been widely applied in the different clinical settings. Its effect of reducing hemorrhage and transfusion had been recognized. There were many techniques to intraoperatively reduce the CVP such as the volatile anesthetics, vasoactive agents, fluid restrictive strategy, inferior vena cava clamping, low tidal volume, etc. However, there was no consensus on the best strategy to reduce the CVP and there were no studies focusing on the prognosis of patients underwent the low CVP hepatectomy. Maintaining the CVP between 2.1–3 mm Hg (1 mm Hg=0.133 kPa) intraoperatively might be appropriate, once the section had been made normal hemodynamic state of the patient should be restored immediately.ConclusionsApplication of low CVP could reduce blood loss and transfusion in hepatectomy. Prognosis of patients receiving low CVP is not clear. Application of low CVP in specific population should be cautious.
ObjectiveTo summarize the key operative points and efficacy of ex-vivo ex-vivo liver resection and autologous liver transplantation (ELRA) using various vascular materials for hepatic vein reconstruction in the treatment of end-stage hepatic alveolar echinococcosis (HAE). MethodThe clinicopathologic data of a patient with end-stage HAE who underwent ELRA combined with complex hepatic vein reconstruction were retrospectively analyzed. ResultsThe patient was a 60-year-old male who was admitted to the Sichuan Provincial People’s Hospital due to giant alveolar hydatid in the liver, with a body weight of 60 kg and a standard liver volume of 1 024.5 mL. The imaging showed that the hydatid invaded the first and second hepatic portals, middle hepatic vein, left hepatic vein, and retrohepatic inferior vena cava. The three-dimensional reconstruction of CT showed that the residual liver volume was 1 270.6 mL. The patient received supportive treatment after admission and underwent ELRA following strict evaluation. Intraoperatively, it was found that the multiple hepatic veins and retrohepatic inferior vena cava were widely invaded. The liver was split in vivo and the mass was excised ex vivo by “in vivo first” principle. The hepatic vein was repaired and reconstructed into a wide mouth outflow tract using allogeneic veins, autologous inferior mesenteric vein, and hepatic round ligaments, then performed the autotransplantation by wide mouth outflow-artificial inferior vena cava anastomosis (end to side). The operative time was 16 h, and the intraoperative blood loss was approximately 2 000 mL. FK506 was orally administered after operation, and low-molecular-weight heparin sodium was administered 24 h later for anticoagulation. The patient was returned to the general ward on the 6th day after the operation, and the enhanced CT scan showed that the hepatic outflow tract was unobstructed, without stenosis and thrombosis, and the patient was discharged on day 18 after the operation. The patient was pathologically diagnosed with alveolar echinococcosis. ConclusionsFrom the results of this case, combination of multiple vascular materials to reconstruct the hepatic outflow tract is an optional procedure for ELRA in treatment of end-stage HAE. Strict preoperative evaluation, skillful vascular anastomosis technique, and postoperative anticoagulation are important measures to maintain patency of postoperative reconstruction vessel.