改良腹腔镜解剖肝切除术：双外科医生技术结合简单的体外普林格尔手法
Summary
在这里，我们提出了一种使用改进的技术和仪器进行改良腹腔镜解剖肝切除术的方案。
Abstract
近年来，腹腔镜解剖肝切除术（LAH）在世界范围内变得越来越普遍。然而，由于肝脏的解剖学特征，LAH仍然是一个具有挑战性的手术，术中出血是主要问题。术中失血是转为开放手术的主要原因;因此，有效管理出血和止血对于成功的LAH至关重要。
建议将双外科医生技术作为传统单外科医生方法的替代方案，在腹腔镜肝切除术期间减少术中出血方面具有潜在益处。然而，仍然缺乏证据来确定哪种模式的双外科医生技术产生更好的患者结局。此外，据我们所知，LAH技术涉及由主外科医生使用cavitron超声手术抽吸器（CUSA），而由第二名外科医生使用超声波解剖器，以前很少有报道。
在这里，我们提出了一种改进的双外科医生LAH技术，其中一名外科医生使用CUSA，而另一名外科医生使用超声解剖器。该技术与简单的体外普林格尔操作和低中心静脉压 （CVP） 方法相结合。在这种改良技术中，初级和二级外科医生同时使用腹腔镜CUSA和超声解剖术来实现精确和快速的肝切除术。采用简单的体外普林格尔手法，结合维持低CVP，以调节肝流入和流出，以尽量减少术中出血。这种方法有助于实现干燥和清洁的手术区域，从而可以精确地结扎和解剖血管和胆管。修改后的LAH程序更简单，更安全，因为它可以有效控制出血以及初级和二级外科医生角色之间的无缝过渡。它为未来的临床应用带来了巨大的希望。
Introduction
近几十年来，肝切除术的安全性显著提高1，随着诊断成像、能量设备和手术技术的快速发展，腹腔镜肝切除术已成为一种广泛实施的手术，可产生良好的临床结果2，3。研究表明，在肝细胞癌4，5 患者中，与非解剖切除术相比，解剖学肝切除术产生更好的结果。因此，腹腔镜解剖肝切除术（LAH）在世界范围内越来越受欢迎6。然而，术中出血仍然是肝切除手术中的主要问题 – 腹腔镜和开放手术涉及解剖和非解剖切除7。此外，术中出血是实质横断面手术从腹腔镜手术转变为开放手术的主要原因8，9。为了有效控制和减少术中出血，广泛建议接受肝切除术的患者将中心静脉压（CVP）保持在5 cmH2O以下10，11.此外，还使用了各种仪器，例如cavitron超声手术吸引器（CUSA）和超声解剖器12，13，并且还记录了许多肝切除技术，包括肝绞痛操作14，Pringle操作15，16和“双外科医生技术”17，18。
Pringle 手法于 1908 年首次报道19，代表了肝流入闭塞最直接的技术，目前在腹腔镜肝切除术中很容易实现，效率很高20，21。
双外科医生技术是作为传统单外科医生方法的替代方案，最初用于开放性肝切除术17。这种方法模糊了初级和二级外科医生之间的分工，两者在实质横断时同时参与，以及使用不同的能量仪器进行止血。研究表明，这种技术可以减少手术时间和术中并发症18，22。Takahisa等人为我们提供了一些执行双外科医生腹腔镜技术的建议23，但不同的中心可能会选择不同的设备来横断肝实质组织，并且仍然缺乏证据证明哪种模式的双外科医生技术产生更好的患者结果。
CUSA是肝切除术中常用的装置，它利用超声波能量破碎和抽吸实质组织，从而实现精确的横切，对血管和胆管的损害最小13。另一个常用的工具是超声波解剖器，它利用两个叶片的振动来破坏氢键并有效切割肝实质，同时凝固直径≤3毫米13的小血管。
2020年7月，我中心首次实施了双外科医生技术。一名外科医生使用CUSA，而另一名外科医生使用超声波解剖。结合简单的体外普林格尔操作和低CVP技术，治疗一名54岁的女性患者，该患者一直出现肝脏肿块，血清甲胎蛋白（AFP）水平升高104ng/mL持续1周。磁共振成像（MRI）（图1A，B）显示位于S5和S8段的肿瘤大小约为2厘米，被认为是原发性肝细胞癌。本文介绍了我们中心在CUSA-超声解剖-体外普林格尔机动技术方面的经验方案。
Protocol
该方案和手术视频演示在手术前获得了患者的知情同意，也获得了中山大学附属第五医院的批准。 1.术前准备 进行实验室检查，包括血液常规检查，肝肾功能检查，消化系统的肿瘤标志物（甲胎蛋白，AFP;癌胚抗原，CEA），凝血酶原时间，国际标准化比值（INR）和15分钟吲哚菁绿保留率（ICG-R15），以评估患者的一般状况。 进行影像学检查，包括胸?…
Representative Results
这名 54 岁的女性患者使用 CUSA 超声解剖-体外普林格尔手法技术成功接受了全腹腔镜解剖肝切除术 （S5 + S8v），获得了良好的围手术期结局。在手术过程中，总共进行了四次体外Pringle操作，以控制和减少术中出血。手术持续约145分钟，估计失血量为150毫升。患者迅速康复，术后第6天出院，无并发症。术后CT影像学检查显示无残留肝肿瘤，病理结果提示原发性肝细胞癌，切?…
Discussion
该协议详细介绍了使用CUSA-超声解剖-体外普林格尔机动技术在我们中心进行的改良LAH。在这种改良的组合技术中，我们同时使用了简单的体外普林格尔操作和低CVP技术来控制和减少术中出血。初级和二级外科医生在实质横断和止血期间分别使用腹腔镜CUSA和超声解剖术，以获得精确和快速的肝切除术。
这位54岁的女性患者是第一个接受我们新的联合技术的患者，其围手术期结?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
这项工作得到了中国国家自然科学基金（第81971773号）的资助。
Materials
| 1.0 absorbable suture | Ethicon Inc | SN2210023642 | Sterile, radiation sterilization, disposable |
| 1.0 non-absorbable suture | Ethicon Inc | SF1AN | Sterile, radiation sterilization, disposable |
| 10-mm trocar | Hangzhou Optoelectronic Equipment Medical Co., LTD | 121-01715 | Sterile, ethylene oxide sterilized, disposable |
| 12-mm trocar | Hangzhou Optoelectronic Equipment Medical Co., LTD | 121-01715 | Sterile, ethylene oxide sterilized, disposable |
| 5-mm trocar | Hangzhou Optoelectronic Equipment Medical Co., LTD | 121-01715 | Sterile, ethylene oxide sterilized, disposable |
| 7.0 non-absorbable suture | Ethicon Inc | SF7AN | Sterile, radiation sterilization, disposable |
| Aspirator | Hangzhou Kangji Medical Instrument Co., LTD | 20172080644 | Sterile,dry heat sterilized, reusable |
| Cordless Ultrasonic dissector | Covidien llc | SCD396 | Sterile, ethylene oxide sterilized, disposable |
| CUSA | INTEGRA | HDA1902805IE | Sterile,dry heat sterilized, reusable |
| Electric coagulation hook | Zhejiang Shuyou Instrument Equipment Co., LTD | IIIA-D003-SG842 | Sterile, ethylene oxide sterilized, disposable |
| Endo-GIA stapler | Jiangsu Guanchuang Medical Technology Co., LTD | GCJQB-160 | Sterile, ethylene oxide sterilized, disposable |
| Endoscopic specimen bag | Qingdao Huaren Medical Product Co., LTD | 20192060113 | Sterile, ethylene oxide sterilized, disposable |
| Hem-o-lok | Zhejiang Wedu Medical Instrument Co., LTD | JY1004-2012003 | Sterile, ethylene oxide sterilized, disposable |
| Laparoscopic ultrasound | BK medical | flex Focus 800 | Sterile,dry heat sterilized, reusable |
| Lumir device (modified Pringle maneuver) | Shanghai Chester Medical Technology Co., LTD | 016651477 | Sterile,dry heat sterilized, reusable |
| Surgicel(absorbable hemostat) | Ethicon Inc | LAB0011179V3 | Sterile, radiation sterilization, disposable |
| Veress needle | Hangzhou Kangji Medical Instrument Co., LTD | 20172080644 | Sterile, ethylene oxide sterilized, disposable |
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Tags
Modified Laparoscopic Anatomic HepatectomyTwo-surgeon TechniqueSimple Extracorporeal Pringle ManeuverCUSAUltrasonic DissectorLow Central Venous PressureHepatocellular CarcinomaLiver ResectionPreoperative PreparationImaging ExaminationsCT VolumetryFuture Liver RemnantInclusion CriteriaExclusion Criteria
Cite This Article
Zeng, G., Chen, J., Zhuo, W., Zou, B., Li, P., Lin, E., Li, D., Cai, C., Li, J. Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver. J. Vis. Exp. (196), e63555, doi:10.3791/63555 (2023).