腹腔镜肝切除术的研究进展课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,腹腔镜肝切除术的研究进展,Research progress of laparoscopic liver resection,1,腹腔镜肝切除术的研究进展 Research progress,主要内容,2,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,主要内容2第一部分,腹腔镜肝切除的发展,3,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3第一阶段朱自满等.腹腔镜肝切除发展历程.,腹腔镜肝切除的发展,1991,年,Reich,（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,腹腔镜肝切除的发展1991年Reich（美国妇产科医生）完成,国际腹腔镜肝切除共识会议,International Consensus 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.,5,国际腹腔镜肝切除共识会议 International Co,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Nguyen KT, et al. Ann,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Nguyen KT, et al. Ann,腹腔镜肝切除的发展,8,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,Conference 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 worldwide. 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 community 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 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 Medicine, 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, Iwate Medical University School of,Medicine, Iwate, Japan,腹腔镜肝切除的发展8The technique of lap,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-Pancreato-Biliary Association,9,Hepato-Pancreato-Biliary Assoc,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,腹腔镜肝切除的发展A total of 448 liverF,11,腹腔镜肝切除的发展,Fig. 3 The number of respondents by country,11腹腔镜肝切除的发展Fig. 3 The number o,腹腔镜肝切除的发展,Fig. 8 The year when laparoscopic liver resection was introduced. LLR, laparoscopic liver resection,腹腔镜肝切除的发展Fig. 8 The year when,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,腹腔镜肝切除的发展 5年完成LLR例数占总LR比例：Fig,腹腔镜肝切除的手术方式,14,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 hepatectomy):,3,个肝段的,肝切除,腹腔镜肝切除的手术方式14 解剖性肝切除 预先处理第一、二,腹腔镜肝切除的类型,15,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术操作指南（,2013,版）,腹腔镜肝切除的类型15 全腹腔镜肝脏切除术(Pure la,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适应征 :,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。,腹腔镜肝切除的适应症与禁忌症禁忌征:,International Consensus Conference 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),International Consensus Confer,腹腔镜肝切除的适应症与禁忌症,International Consensus Conference on LLR: The Morioka 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International Co,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,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禁忌症相对禁忌症:,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,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,recommended during LLR, as in OLR.,低,CVP,（,5cmH2O,）有助于减少术中出血,3. A temporary increase in CO2 pneumoperitoneum pressure (16-20mmHg)can be used to help control bleeding during LLR.,暂时增加气腹压力至,16-20mmHg,可帮助止血,LLR技术观念的更新Bleeding control,LLR,技术观念的更新,Technique for parenchymal transection,What is the best technique for parenchymal transection?,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,Various energy devices appear to be equivalent and,should be left to the surgeons preference and,expertise, as in OLR.,使用氩气刀有潜在的气体栓塞风险,An argon beam coagulator, if used for hemostasis,requires caution to avoid potential gas embolism.,LLR技术观念的更新Technique for parenc,LLR,技术观念的更新,Anatomical LLR,Is anatomical resection preferable for LLR,？,Anatomical resection for HCC is recommended as in the open approach and require continued evaluation of their application to LLR.,解剖性肝切除技术难度大，目前尚难以推广,LLR技术观念的更新Anatomical LLR,LLR,技术观念的更新,Simulation, navigation,What is the role of simulation and navigation in LLR,？,模拟导航在LLR的作用是怎样,?,Preoperative simulation is useful for measuring the remnant liver volume, visualizing the anatomy and tumor location, and planning the resection plane in selected cases,可以有选择的进行术前模拟,对于评估残余肝体积，明确肿瘤位置、解剖关系、规划切除平面具有一定帮助,推荐术中超声导航（建议术中常规使用超声）,LLR技术观念的更新Simulation, navigati,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,2015 年 6月-2016 年 3月期间在我院实施区域血流阻断,全腹腔镜下解剖性肝切除术的12例患者的临床资料,n:,胃瘫,1,胆漏,1,肺部感染,1,中转例数,0,LLR在我院临床应用2015 年 6月-2016 年 3月期,腹腔镜,vs.,开腹,1.,术中输血量 少；,2.,术后并发症 低；,3.,术后疼痛 轻；,4.,围手术期死亡率 无统计学差异；,5.,肝癌患者术后生存期无统计学差异。,腹腔镜 vs. 开腹1.术中输血量 少；,小结,LLR,术者需具备充足的外科手术经验；,LLR,在肝脏外科中的应用越来越广泛 ；,肝实质离断需要使用能量器械，术者应当熟悉器械的特,点、原理，并根据自身情况选择；,Glisson,蒂横断式肝切除术适合于解剖性肝切除，能明显,减少手术时间，减少术中出血，但对术者要求较高；,腹腔镜下进行解剖性肝切除其手术方式尚需进一步标准,化以便推广,小结 LLR术者需具备充足的外科手术经验；,34,THANK YOU,！,34THANK YOU！,Ann Surg,杂志,Annals of Surgery，,中文,外科学年鉴,，英文简写,Ann Surg，,是美国外科协会（,American Surgical Association）、,欧洲外科协会（,European Surgical Association）、,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。,2008,年其影响因子（,Impact Factor，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。,35,Ann Surg杂志Annals of Surgery，中文,国际腹腔镜肝切除共识会议,International Consensus Conference on LLR (ICCLLR),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-Pancreato-Biliary Association,36,国际腹腔镜肝切除共识会议 International Co,