三维可视化技术联合荷瘤门静...腹腔镜解剖性肝切除中的应用_肖亮.pdf

版权归中国普通外科杂志所有http:/2023 年 1 月中国普通外科杂志Vol.32 No.1第 32 卷 第 1 期China Journal of General SurgeryJan.2023三维可视化技术联合荷瘤门静脉流域分析在腹腔镜解剖性肝切除中的应用肖亮，谭盛，米星宇，苏文欣，莫蕾，杨瀚睿，周乐杜（中南大学湘雅医院 肝脏外科，湖南 长沙 410008）摘 要 背景与目的：解剖性肝切除术（AH）是以荷瘤门静脉流域为目标的肝切除，它符合精准肝切除的理念，已经逐步成为肝细胞癌（HCC）患者腹腔镜肝切除的主流。但是，在相当长的一段时间内，学术界对于 HCC 患者行 AH 在肿瘤学获益方面是否优于非解剖性肝切除术（NAH）仍有争议，而产生这种争议的原因可能是由于传统的手术依据Couinaud 肝脏分段法与患者现实肝脏脉管解剖学上的偏差，导致未能完全清除所有的荷瘤门静脉流域。三维（3D）可视化技术的普及可帮助外科医师在术前更加直观和充分地了解患者的肝内脉管走行及变异情况，做出最贴合实际的荷瘤门静脉流域分析，指导制定个体化的精准AH。在本文中，笔者结合临床经验就上述问题进行探讨并介绍腹腔镜下实施AH的步骤与体会。方法：回顾性分析中南大学湘雅医院肝脏外科 2022 年收治的 2 例 HCC 患者的临床资料，2 例患者均为单个肿块，累及相邻2个肝段。术前通过专业软件进行肝脏及肿块的3D成像分析，将荷瘤门静脉及其流域设定为切除范围，同时兼顾手术标本能够满足最小安全切缘（1 cm），否则需要纳入邻近12支门脉分支及其流域，适当扩大切除范围以满足安全切缘。术中采用3D腹腔镜，在低中心静脉压和全入肝血流阻断下，充分利用肝脏膜结构解剖出荷瘤肝蒂（必要时劈开部分肝实质以利肝蒂显露），将其阻断后再恢复入肝血流，在肝表面标记缺血/切除范围，用术中超声再次确定切除范围及切缘是否符合术前规划。结果：2例患者均顺利完成手术，术中解剖出目标肝蒂后，腔镜下超声确认肝表面缺血范围均符合术前规划。术后剖检标本，切缘距离肿瘤至少 1 cm。病理检查确认为高分化 HCC，未见肿瘤微血管侵犯。患者术后随访68个月未见肿瘤复发，生活质量良好。结论：3D 可视化技术联合荷瘤门静脉流域分析可帮助临床医师在术前明确 HCC 患者 AH 的范围，同时兼顾至少 1 cm 的安全切缘，即可达到临床上可接受的最小范围的 AH。该方法尤其适用于同时累及2 个相邻肝段的单个肿块切除。而当肿块贴近肝内大血管（如中肝静脉或右肝静脉）时，可能行更大范围的AH能取得更好的肿瘤学获益。关键词 肝肿瘤；肝切除术；腹腔镜中图分类号：R735.7 专题研究 doi:10.7659/j.issn.1005-6947.2023.01.002China Journal of General Surgery,2023,32(1):30-39.http:/dx.doi.org/10.7659/j.issn.1005-6947.2023.01.002基金项目：湖南省卫健委科研计划基金资助项目（202104010072）。收稿日期：2022-09-16；修订日期：2022-12-10。作者简介：肖亮，中南大学湘雅医院副主任医师，主要从事肝脏外科方面的研究。通信作者：周乐杜，Email:30第 1 期肖亮，等：三维可视化技术联合荷瘤门静脉流域分析在腹腔镜解剖性肝切除中的应用 版权归中国普通外科杂志所有http:/Application of three-dimensional visualization technology combined with tumor-bearing portal territory analysis in laparoscopic anatomical hepatectomy for patients with hepatocellular carcinomaXIAO Liang,TAN Sheng,MI Xingyu,SU Wenxin,MO Lei,YANG Hanrui,ZHOU Ledu(Department of Liver Surgery,Xiangya Hospital,Central South University,Changsha 410008,China)Abstract Background and Aims:Anatomic hepatectomy(AH)is a type of liver resection targeting the tumor-bearing portal territory.It conforms to precise hepatectomy and has gradually become the mainstream laparoscopic hepatectomy for patients with hepatocellular carcinoma(HCC).However,for a long time,the academic community has debated whether AH is superior to non-anatomic hepatectomy(NAH)in terms of oncological benefits for patients with HCC.This controversy may be due to the anatomical deviation of the traditional segmentation method(Couinauds system)from the patients actual liver vascular anatomy,which may fail to remove all tumor-bearing portal territory completely.The popularization of three-dimensional(3D)visualization technology can help surgeons more intuitively and fully understand the patients intrahepatic vascular course and variations before surgery,make the most realistic analysis of the tumor-bearing portal territory,and guide the development of individualized and accurate AH.In this article,the authors discuss the above problems based on clinical experience and describe the procedural steps and experience of implementing AH under laparoscopy.Methods:The clinical data of 2 patients with HCC treated in the Department of Liver Surgery,Xiangya Hospital,Central South University in 2022 were retrospectively analyzed.Both patients had single tumor lesions involving two adjacent liver segments.The 3D imaging analysis of the liver and mass was carried out by professional software before surgery.The tumor-bearing portal territory was set as the resection range while taking into account that the surgical specimen to meet the minimum safe margin(1 cm),otherwise it was necessary to include the adjacent 1-2 portal tributaries and their territories to expand the resection range to achieve the safe margin appropriately.During the operation,3D laparoscopy was used.The liver membrane structure was entirely used to help dissect the tumor-bearing hepatic pedicle under low central venous pressure and temporary total hepatic blood inflow blockade(if necessary,liver parenchyma was split to facilitate the exposure of the liver pedicle).Then the liver blood inflow was restored.The ischemia/resection range was marked on the liver surface.After that,the resection range and the distance between the resection margin and the mass were determined again by intraoperative ultrasound to confirm whether the resection margin was consistent with the preoperative plan.Results:Both patients had successful operations,and after the target liver pedicles were dissected and ligated,the scope of the ischemia area was in line with the preoperative plan,which was confirmed by laparoscopic ultrasound.Postoperative specimen autopsy revealed that the distance between the resection margin and the mass was at least 1 cm.Pathological examination confirmed that both patients had well-differentiated HCC and no tumor microvascular invasion.There was no tumor recurrence during 6-8 months of postoperative follow-up,and their quality of life was satisfactory.Conclusion:3D visualization combined with tumor-bearing portal territory analysis can help clinicians clarify the range of AH in HCC patie