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1、腹腔镜肝切除术的研究进展 Research progress of laparoscopic liver resection,1,海军安庆医院普外科 李 向 国,2,亨利泰勒博士故居 SINCE 1901,主要内容,3,第一部分 LLR的发展与开展情况 第二部分 LLR技术观念的更新 第三部分 LLR与开腹肝切除在我院临床应用,腹腔镜肝切除的发展,4,第一阶段 起步摸索期（19912003） 第二阶段 交流发展期（20042006） 第三阶段 推广应用期（2007之后）,朱自满等.腹腔镜肝切除发展历程.中华医史杂志，2011，41（3）：173-175,腹腔镜肝切除的发展,1991年Reich
2、（美国妇产科医生）完成世界首例 腹腔镜肝切除术 1993年Wayand(德国)等首先报道腹腔镜肝局部切除 治疗肝癌 1994年周伟平（东方肝胆）等完成我国第一例腹 腔镜下肝癌切除术 1996年Azagra（比利时）等报道第一例腹腔镜 左肝外叶切除术 1997年Huscher等在国际上首先报道腹腔镜下 右半肝切除术 2002年Cherqui首次报道腹腔镜供肝切取 2003年Giulianotti报道第一例机器人辅助肝脏切除术 2006年蔡秀军首先报道腹腔镜下区域血流阻断技术 2014年蔡秀军报道腹腔镜下绕肝带法ALPPS,国际腹腔镜肝切除共识会议 International Consensus
3、Conference on LLR (ICCLLR),1st 2008年, America Louisville宣言, Ann Surg. 2009;250:825830. 国际上指导腹腔镜肝切除的指南。 2nd 2014年, Japan Morioka,Recommendations for Laparoscopic Liver Resection 2014, Ann Surg. 2015;261:619629.,6,腹腔镜肝切除的发展,Nguyen KT, et al. Ann Surg. 2009 Nov;250(5):831-41.,美国匹兹堡大学UPMC,腹腔镜肝切除的发展,Nguy
4、en KT, et al. Ann Surg. 2009 Nov;250(5):831-41.,美国匹兹堡大学UPMC,腹腔镜肝切除的发展,9,The technique of laparoscopic liver resection (LLR) has been greatly improved since the first international consensus conference. Our aim was to evaluate the worldwide spread of LLR prior to the 2nd International Consensus Confe
5、rence on Laparoscopic Liver Resection in Iwate, Japan (46 October 2014). The International Survey on Technical Aspects of Laparoscopic Liver resection was designed to assess dissemination of LLR, indications, and the surgical techniques. The anonymous questionnaire was e-mailed to liver surgeons wor
6、ldwide. A total of 448 liver surgeons responded to the survey. The peak age range of surgeons performing LLR was 4150 years. Japan had by far the largest number of respondents (n = 223), followed by the US (n = 38) and France (n = 20). In Japan, the majority of surgeons performing LLR belonged to co
7、mmunity hospitals, where LLR has been increasingly used since its implementation in 2009 or later, comprising up to 40% of all liver resection cases. In contrast, in North America and Europe, LLR was mostly performed at academic medical centers. LLR has undergone global dissemination after the first
8、 international consensus conference in 2008. Japan has experienced unparalleled, explosive diffusion characterized by the adoption of LLR at middle-tier, regional institutions.,J Hepatobiliary Pancreat Sci (2014),T. Hibi (*) O. Itano Y. Kitagawa Department of Surgery, Keio University School of Medic
9、ine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan e-mail address: taizohibiz3.keio.jp D. Cherqui Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France D. A. Geller Liver Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA G. Wakabayashi Department of Surgery,
10、Iwate Medical University School of Medicine, Iwate, Japan,Hepato-Pancreato-Biliary Association,IHPBA: International Hepato-Pancreato-Biliary Association AHPBA: Americas Hepato-Pancreato-Biliary Association E-AHPBA: European-African Hepato-Pancreato-Biliary Association A-PHPBA: Asian-Pacific Hepato-P
11、ancreato-Biliary Association,10,腹腔镜肝切除的发展,A total of 448 liver surgeons responded to the survey,Fig. 2 Geographic distribution of the respondents,12,腹腔镜肝切除的发展,Fig. 3 The number of respondents by country,腹腔镜肝切除的发展,Fig. 8 The year when laparoscopic liver resection was introduced. LLR, laparoscopic liv
12、er resection,腹腔镜肝切除的发展,5年完成LLR例数占总LR比例： 亚洲与欧洲分布情况接近 北美LLR比例最高 大部分亚洲中心LLR比例介于总LR的10-40%,Fig. 11 The proportion of laparoscopic liver resections during the past 5 years 20092013,腹腔镜肝切除的手术方式,15,解剖性肝切除 预先处理第一、二肝门部血管，再行相应部分肝切除的术式 非解剖性肝切除 肝楔形切除 局部切除 病灶剜除 小范围肝切除(minor hepatectomy): 3个肝段的 肝切除 大范围肝切除(major h
13、epatectomy): 3个肝段的 肝切除,腹腔镜肝切除的类型,16,全腹腔镜肝脏切除术(Pure laparoscopic method): 完全在腹腔镜下完成肝切除术 手助腹腔镜肝脏切除术(Hand-assisted laparoscopic method): 将手通过特殊的腹壁切口伸人 腹腔，以辅助腹腔镜手术操作 ，完成肝切除术 腹腔镜辅助肝脏切除术(Laparoscopy-assisted method ): 在腹腔镜或手辅助腹腔镜下完 成肝切除术的部分操作，而肝 切除术的主要操作通过腹壁小于常规的切口完成。 以上3种肝切除术均可在机器人手术系统辅助下完成。 腹腔镜肝切除专家共识与手
14、术操作指南（2013版）,腹腔镜肝切除的适应症与禁忌症,适应征 : 良性疾病包括有症状或最大径超过10 cm的海绵状血管瘤； 有症状的局灶性结节增生、腺瘤； 有症状或最大径超过10 cm的肝囊肿； 肝内胆管结石等； 肝脏恶性肿瘤包括原发性肝癌、继发性肝癌及其他少见的肝脏恶性肿瘤。,腹腔镜肝切除的适应症与禁忌症,禁忌征: 除与开腹肝切除禁忌证相同外，还包括: 不能耐受气腹者；腹腔内粘连难以分离暴露病灶者； 病变紧贴或直接侵犯大血管者；病变紧贴第一、第二或第三肝门，影响暴露和分离者； 肝门被侵犯或病变本身需要大范围的肝门淋巴结清扫者。,International Consensus Confere
15、nce on LLR: The Louisville Statement, 2008,Ann Surg. 2009 Nov;250(5):825-30.,孤立病灶 (Solitary lesions) 5 cm (5 cm or less) 位于 2 到 6段 (Liver segments 2 to 6) 左外叶切除应当常规开展 (lateral sectionectomy should be considered standard practice),腹腔镜肝切除的适应症与禁忌症,International Consensus Conference on LLR: The Morioka
16、Statement, 2014 Major Hepatectomies Extended Major Hepatectomies Central Hepatectomies Posterior Approach (lesions in deep segments 7,8) Single incision Laparoscopic Approaches,腹腔镜肝切除的适应症与禁忌症,腹腔镜肝切除的适应症与禁忌症,禁忌症相对禁忌症: 中央肝段、靠近肝门区、大血管,腹腔镜肝切除的适应症与禁忌症,腹腔镜肝切除的适应症与禁忌症,LLR技术观念的更新,Bleeding control What are the essentials of bleeding control in LLR? 1. Laparoscopic suturing skills are essential for LLR. 良好的腹腔镜下缝合技术是LLR术中止血必备 技能 2. Low central venous pressure (5cmH2O) is recommende
