腹腔镜肝切除术课件

1海军安庆医院普外科李向国2亨利·泰勒博士故居SINCE1901主要内容3腹腔镜肝切除的开展4第一阶段起步摸索期〔1991—2003〕第二阶段交流开展期〔2004—2006〕第三阶段推广应用期〔2007—之后〕朱自满等.腹腔镜肝切除开展历程.中华医史杂志，2021，41〔3〕：173-175腹腔镜肝切除的开展国际腹腔镜肝切除共识会议

InternationalConsensusConferenceonLLR(ICCLLR)1st2021年,AmericaLouisville宣言,AnnSurg.2021;250:825–830.国际上指导腹腔镜肝切除的指南。2nd2021年,JapanMorioka,RecommendationsforLaparoscopicLiverResection2021,AnnSurg.2021;261:619–629.6腹腔镜肝切除的开展NguyenKT,etal.AnnSurg.2021Nov;250(5):831-41.美国匹兹堡大学UPMC腹腔镜肝切除的开展NguyenKT,etal.AnnSurg.2021Nov;250(5):831-41.美国匹兹堡大学UPMC腹腔镜肝切除的开展9Thetechniqueoflaparoscopicliverresection(LLR)hasbeengreatlyimprovedsincethefirstinternationalconsensusconference.OuraimwastoevaluatetheworldwidespreadofLLRpriortothe2ndInternationalConsensusConferenceonLaparoscopicLiverResectioninIwate,Japan(4–6October2021).TheInternationalSurveyonTechnicalAspectsofLaparoscopicLiverresectionwasdesignedtoassessdisseminationofLLR,indications,andthesurgicaltechniques.Theanonymousquestionnairewase-mailedtoliversurgeonsworldwide.Atotalof448liversurgeonsrespondedtothesurvey.ThepeakagerangeofsurgeonsperformingLLRwas41–50years.Japanhadbyfarthelargestnumberofrespondents(n=223),followedbytheUS(n=38)andFrance(n=20).InJapan,themajorityofsurgeonsperformingLLRbelongedtocommunityhospitals,whereLLRhasbeenincreasinglyusedsinceitsimplementationin2021orlater,comprisingupto40%ofallliverresectioncases.Incontrast,inNorthAmericaandEurope,LLRwasmostlyperformedatacademicmedicalcenters.LLRhasundergoneglobaldisseminationafterthefirstinternationalconsensusconferencein2021.Japanhasexperiencedunparalleled,explosivediffusioncharacterizedbytheadoptionofLLRatmiddle-tier,regionalinstitutions.JHepatobiliaryPancreatSci(2021)T.Hibi(*)·O.Itano·Y.KitagawaDepartmentofSurgery,KeioUniversitySchoolofMedicine,35Shinanomachi,Shinjuku-ku,Tokyo160-8582,JapanD.CherquiHepatobiliaryCenter,PaulBrousseHospital,Villejuif,FranceD.A.GellerLiverCancerCenter,UniversityofPittsburghMedicalCenter,Pittsburgh,PA,USAG.WakabayashiDepartmentofSurgery,IwateMedicalUniversitySchoolofMedicine,Iwate,JapanHepato-Pancreato-BiliaryAssociationIHPBA:

InternationalHepato-Pancreato-BiliaryAssociationAHPBA:AmericasHepato-Pancreato-BiliaryAssociationE-AHPBA:European-AfricanHepato-Pancreato-BiliaryAssociationA-PHPBA:Asian-PacificHepato-Pancreato-BiliaryAssociation10腹腔镜肝切除的开展Atotalof448liversurgeonsrespondedtothesurveyFig.2Geographicdistributionoftherespondents12腹腔镜肝切除的开展Fig.3Thenumberofrespondentsbycountry腹腔镜肝切除的开展Fig.8Theyearwhenlaparoscopicliverresectionwasintroduced.LLR,laparoscopicliverresection腹腔镜肝切除的开展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比例最高大局部亚洲中心LLR比例介于总LR的10-40%Fig.11Theproportionoflaparoscopicliverresectionsduringthepast5years[2021–2021]15腹腔镜肝切除的类型16腹腔镜肝切除的适应症与禁忌症适应征:良性疾病包括有病症或最大径超过10cm的海绵状血管瘤；有病症的局灶性结节增生、腺瘤；有病症或最大径超过10cm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InternationalConsensusConferenceonLLR:

TheLouisvilleStatement,2021AnnSurg.2021Nov;250(5):825-30.孤立病灶(Solitarylesions)≤5cm(5cmorless)位于2到6段(Liversegments2to6)左外叶切除应当常规开展(lateralsectionectomyshouldbeconsideredstandardpractice)腹腔镜肝切除的适应症与禁忌症InternationalConsensusConferenceonLLR:TheMoriokaStatement,2021MajorHepatectomiesExtendedMajorHepatectomiesCentralHepatectomiesPosteriorApproach(lesionsindeepsegments7,8)SingleincisionLaparoscopicApproaches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TechniqueforparenchymaltransectionWhatisthebesttechniqueforparenchymaltransection?

推荐使用能量器械进行实质离断

大的血管推荐使用切割闭合器

能量器械的选择依照外科医生的个人习惯选择Variousenergydevicesappeartobeequivalentandshouldbelefttothesurgeon’spreferenceandexpertise,asinOLR.

使用氩气刀有潜在的气体栓塞风险Anargonbeamcoagulator,ifusedforhemostasis,requirescautiontoavoidpotentialgasembolism.LLR与开腹肝切除在我院临床应用LLR与开腹肝切除在我院临床应用LLR与开腹肝切除在我院临床应用LLR在我院临床应用病种例数左侧肝内胆管结石10肝癌2手术类型例数左半肝（Ⅱ﹢Ⅲ﹢Ⅳ）9左肝外叶（Ⅱ﹢Ⅲ）2右侧major(Ⅴ﹢Ⅷ﹢Ⅶ)1手术时间(min)术中出血量(ml)肛门首次排气(d)术后住院时间(d)住院费用(rmb)并发症n210.75±65.83296.67±373.742.71±0.8413.92±5.9332004±8693.793n:胃瘫1胆漏1肺部感染1中转例数0腹腔镜vs.开腹小结35AnnSurg杂志AnnalsofSurgery，中文?外科学年鉴?，英文简写AnnSurg，是美国外科协会〔AmericanSurgicalAssociation〕、欧洲外科协会〔EuropeanSurgicalAssociation〕、纽约外科学会和费城外科学会的官方杂志，创刊于1885年，全年出版发行12期。2021年其影响因子〔ImpactFactor，IF〕已高达8.460，近五年来其IF一直稳定在8.0左右，在SCI所收录的187种外科学同类期刊中名列第一，也是全球被引频次最高的外科学杂志。36国际腹腔镜肝切除共识会议

InternationalConsensusConferenc