Zheng Baijun,Yu Hui,Li Peng,et al.Technical improvements and therapeutic efficacies of laparoscopic liver resection in children[J].Journal of Clinical Pediatric Surgery,2022,21(07):622-626.[doi:10.3760/cma.j.cn101785-202205026-005]
小儿腹腔镜肝切除的技术改进及疗效分析
- Title:
- Technical improvements and therapeutic efficacies of laparoscopic liver resection in children
- 摘要:
- 目的 探索腹腔镜下小儿肝切除的技术改进方案，并观察疗效。方法 以西安交通大学第二附属医院2005年11月至2022年3月收治的42例肝脏肿瘤患儿为研究对象，其中前期组（2005年11月至2019年5月）25例，后期组（2019年6月至2022年3月）17例，两组均采用腹腔镜肝切除（laparoscopic liver resection，LLR）治疗。后期组与前期组相比，主要技术改进包括：①所有病例经术前3-D虚拟手术规划+术中吲哚菁绿（indocyanine green，ICG）导航；②部分病例采用Glisson鞘外解剖、降低中心静脉压技术。记录两组患儿手术相关指标、围手术期并发症发生情况、生化检查结果、是否再手术以及术后随访结果。结果 后期组17例平均手术年龄21个月（2~44个月），其中良性占位3例，肝母细胞瘤（hepatoblastoma，HB）14例；肝脏占位最长径平均为6.2 cm （3.2~14.4 cm）。非解剖性切除2例（S7 1例，S4a 1例），解剖性切除14例（左外叶1例，左半肝7例，右半肝3例，右后叶3例），联合肝脏分隔和门静脉结扎的二步肝切除（associated liver partition and portal vein ligation for staged hepatectomy，ALPPS）1例。后期组平均手术时间234.4 min （70~360min），出血量60.7 mL （20~300mL），中转开放手术1例；术后出现胆漏1例，经引流后自愈。术后肝功能恢复正常时间平均为7 d （5~12 d）。1例术前伴肺转移的HB患儿术后14个月出现肺部病变复发，其余患儿随访期内肿瘤均无复发。经统计学分析，两组手术时间、出血量、中转手术情况、HB切缘及胆漏发生率差异均无统计学意义（P>0.05），但前期组1例严重胆漏患儿共住院4次，总住院时间达11个月，经历4次全麻和3次手术治愈。结论 严格把握手术适应证、术前通过三维重建掌握肝脏肿瘤的空间解剖关系、术中针对不同患儿采用合理的手术入路并应用ICG导航可有效减少小儿腹腔镜肝切除的并发症。
- Abstract:
- Objective To introduce the technical improvements of laparoscopic liver resection (LLR) in children and evaluate its therapeutic efficacies.Methods Clinical data were retrospectively reviewed for 17 children with hepatic masses undergoing LLR from June 2019 to March 2022.There were 8 boys and 9 girls with a median operative age of 21(2-44) months.Patient demographics, perioperative imaging studies, surgical procedures and parameters, postoperative serum biochemical tests, postoperative complications and follow-up data were recorded.The major surgical improvements included preoperative virtual surgical planning based upon three-dimensional reconstruction and routine application of indocyanine green (ICG) navigation during liver parenchyma division and resecting first/econd-class ducts outside Glissonean pedicle or lowering central venous pressure during parenchyma division in selected cases. Results There were benign lesions (n=3) and hepatoblastoma (HB, n=14).The longest average diameter of hepatic mass was 6.2(3.2-14.4) cm.Non-anatomical liver resection was performed for S7 (n=1) and S4a(n=1).Among anatomical liver resections, there were left lateral sectionectomy (n=1), left hepatectomy (n=7), right hepatectomy (n=3) and right posterior sectionectomy (n=3).An associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) was performed in a 3-year-old girl with hepatic mesenchymal hamartoma.The median operative duration was 234.4(70-360) min and the median estimated volume of blood loss 60.7(20-300) ml.One child was converted into laparotomy.The girl undergoing ALPPS developed bile leakage postoperatively and it was cured by drainage.There were no other perioperative complications and all HB cases underwent R0 resection.The average postoperative recovery time of liver function was 7(5-12) days.A child of HB and pulmonary metastasis developed pulmonary recurrence at Month 14 post-operation and there was no other recurrence during follow-ups. Conclusion Surgical complications of LLR in children may be minimized through strictly complying with surgical indications, mastering spatial anatomy of hepatic mass by preoperative three-dimensional reconstruction, selecting a proper surgical approach and routinely applying ICG navigation.
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备注/Memo
收稿日期:2022-05-09。
基金项目:国家自然科学基金（82071692，82170531）
通讯作者:高亚,Email:ygao@mail.xjtu.edu.cn