腹腔鏡肝切除術(shù)課件

1海軍安慶醫(yī)院普外科李向國(guó)2亨利·泰勒博士故居SINCE1901主要內(nèi)容3腹腔鏡肝切除的開(kāi)展4第一階段起步摸索期〔1991—2003〕第二階段交流開(kāi)展期〔2004—2006〕第三階段推廣應(yīng)用期〔2007—之后〕朱自滿等.腹腔鏡肝切除開(kāi)展歷程.中華醫(yī)史雜志，2021，41〔3〕：173-175腹腔鏡肝切除的開(kāi)展國(guó)際腹腔鏡肝切除共識(shí)會(huì)議

InternationalConsensusConferenceonLLR(ICCLLR)1st2021年,AmericaLouisville宣言,AnnSurg.2021;250:825–830.國(guó)際上指導(dǎo)腹腔鏡肝切除的指南。2nd2021年,JapanMorioka,RecommendationsforLaparoscopicLiverResection2021,AnnSurg.2021;261:619–629.6腹腔鏡肝切除的開(kāi)展NguyenKT,etal.AnnSurg.2021Nov;250(5):831-41.美國(guó)匹茲堡大學(xué)UPMC腹腔鏡肝切除的開(kāi)展NguyenKT,etal.AnnSurg.2021Nov;250(5):831-41.美國(guó)匹茲堡大學(xué)UPMC腹腔鏡肝切除的開(kāi)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腹腔鏡肝切除的開(kāi)展Atotalof448liversurgeonsrespondedtothesurveyFig.2Geographicdistributionoftherespondents12腹腔鏡肝切除的開(kāi)展Fig.3Thenumberofrespondentsbycountry腹腔鏡肝切除的開(kāi)展Fig.8Theyearwhenlaparoscopicliverresectionwasintroduced.LLR,laparoscopicliverresection腹腔鏡肝切除的開(kāi)展5年完成LLR例數(shù)占總LR比例：亞洲與歐洲分布情況接近北美LLR比例最高大局部亞洲中心LLR比例介于總LR的10-40%Fig.11Theproportionoflaparoscopicliverresectionsduringthepast5years[2021–2021]15腹腔鏡肝切除的類(lèi)型16腹腔鏡肝切除的適應(yīng)癥與禁忌癥適應(yīng)征:良性疾病包括有病癥或最大徑超過(guò)10cm的海綿狀血管瘤；有病癥的局灶性結(jié)節(jié)增生、腺瘤；有病癥或最大徑超過(guò)10cm的肝囊腫；肝內(nèi)膽管結(jié)石等；肝臟惡性腫瘤包括原發(fā)性肝癌、繼發(fā)性肝癌及其他少見(jiàn)的肝臟惡性腫瘤。腹腔鏡肝切除的適應(yīng)癥與禁忌癥InternationalConsensusConferenceonLLR:

TheLouisvilleStatement,2021AnnSurg.2021Nov;250(5):825-30.孤立病灶(Solitarylesions)≤5cm(5cmorless)位于2到6段(Liversegments2to6)左外葉切除應(yīng)當(dāng)常規(guī)開(kāi)展(lateralsectionectomyshouldbeconsideredstandardpractice)腹腔鏡肝切除的適應(yīng)癥與禁忌癥InternationalConsensusConferenceonLLR:TheMoriokaStatement,2021MajorHepatectomiesExtendedMajorHepatectomiesCentralHepatectomiesPosteriorApproach(lesionsindeepsegments7,8)SingleincisionLaparoscopicApproaches腹腔鏡肝切除的適應(yīng)癥與禁忌癥腹腔鏡肝切除的適應(yīng)癥與禁忌癥禁忌癥——相對(duì)禁忌癥:中央肝段、靠近肝門(mén)區(qū)、大血管腹腔鏡肝切除的適應(yīng)癥與禁忌癥腹腔鏡肝切除的適應(yīng)癥與禁忌癥TechniqueforparenchymaltransectionWhatisthebesttechniqueforparenchymaltransection?

推薦使用能量器械進(jìn)行實(shí)質(zhì)離斷

大的血管推薦使用切割閉合器

能量器械的選擇依照外科醫(yī)生的個(gè)人習(xí)慣選擇Variousenergydevicesappeartobeequivalentandshouldbelefttothesurgeon’spreferenceandexpertise,asinOLR.

使用氬氣刀有潛在的氣體栓塞風(fēng)險(xiǎn)Anargonbeamcoagulator,ifusedforhemostasis,requirescautiontoavoidpotentialgasembolism.LLR與開(kāi)腹肝切除在我院臨床應(yīng)用LLR與開(kāi)腹肝切除在我院臨床應(yīng)用LLR與開(kāi)腹肝切除在我院臨床應(yīng)用LLR在我院臨床應(yīng)用病種例數(shù)左側(cè)肝內(nèi)膽管結(jié)石10肝癌2手術(shù)類(lèi)型例數(shù)左半肝（Ⅱ﹢Ⅲ﹢Ⅳ）9左肝外葉（Ⅱ﹢Ⅲ）2右側(cè)major(Ⅴ﹢Ⅷ﹢Ⅶ)1手術(shù)時(shí)間(min)術(shù)中出血量(ml)肛門(mén)首次排氣(d)術(shù)后住院時(shí)間(d)住院費(fèi)用(rmb)并發(fā)癥n210.75±65.83296.67±373.742.71±0.8413.92±5.9332004±8693.793n:胃癱1膽漏1肺部感染1中轉(zhuǎn)例數(shù)0腹腔鏡vs.開(kāi)腹小結(jié)35AnnSurg雜志AnnalsofSurgery，中文?外科學(xué)年鑒?，英文簡(jiǎn)寫(xiě)AnnSurg，是美國(guó)外科協(xié)會(huì)〔AmericanSurgicalAssociation〕、歐洲外科協(xié)會(huì)〔EuropeanSurgicalAssociation〕、紐約外科學(xué)會(huì)和費(fèi)城外科學(xué)會(huì)的官方雜志，創(chuàng)刊于1885年，全年出版發(fā)行12期。2021年其影響因子〔ImpactFactor，IF〕已高達(dá)8.460，近五年來(lái)其IF一直穩(wěn)定在8.0左右，在SCI所收錄的187種外科學(xué)同類(lèi)期刊中名列第一，也是全球被引頻次最高的外科學(xué)雜志。36國(guó)際腹腔鏡肝切除共識(shí)會(huì)議

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