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目的探讨及总结第Ⅳa肝段肿瘤切除术中肝中静脉及肝左静脉主干损伤的预防和处理经验。方法回顾性分析1996年8月至2008年12月47例第Ⅳa肝段肿瘤切除合并肝中静脉及肝左静脉主干损伤患者的临床κ料。切除术式包括:Ⅳa肝段肿瘤局部切除12例、Ⅳa+部分Ⅳb肝段切除(左内叶切除)10例、Ⅳa+部分Ⅳb+Ⅱ+Ⅲ肝段切除(左半肝切除)25例。结果全部病例手术切除及术中止血均获成功,均涉及肝中(左)静脉主干的处理。行肝左静脉主干结扎者27例,肝左静脉主干修补8例;肝中静脉主干结扎者4例,肝中静脉修补者16例。通过术前CT或MRI评估,肝中静脉或肝左静脉损伤发生的符合率97.2%(35/36)。术后并发症发生率10.6%(5/47),其中活动性出血再手术1例,胆汁瘘并膈下感染2例,肝功能代偿不全2例。无围手术期死亡。结论第Ⅳa肝段肿瘤是可以安全切除的。肝中静脉及肝左静脉损伤的预防和处理是手术的重点㈦难点,损伤处理的具体措施包括肝中静脉及肝左静脉结扎和或)修补术。术前CT或MRI可以较准确判断术中肝中静脉及肝左静脉损伤发生的可能性。
Objective To investigate and summarize the prevention and treatment experience of the main hepatic vein and the left hepatic vein in the first Ⅳa tumor resection. Methods A retrospective analysis of 47 patients with stage Ⅳa liver tumor resection from August 1996 to December 2008 in the middle hepatic vein and left hepatic vein were performed. Excision of type Ⅳa hepatic tumors included partial resection in 12 cases, Ⅳa + partial Ⅳb segmentectomy (left endoectomy) in 10 cases, Ⅳa + partial Ⅳb + Ⅱ + Ⅲ hepatectomy (left hepatectomy) in 25 cases. Results All patients underwent surgical resection and intraoperative hemostasis were successful, involving the treatment of the middle (left) vein trunk in the liver. Twenty-seven patients underwent primary ligation of the left hepatic vein and 8 patients underwent primary repair of the left hepatic vein. Four patients underwent primary ligation of the middle hepatic vein and 16 underwent repair of the intermediate hepatic vein. According to the preoperative CT or MRI assessment, the coincidence rate of middle or middle hepatic vein occlusion was 97.2% (35/36). The incidence of postoperative complications was 10.6% (5/47), including 1 case of reoperation after active bleeding, 2 cases of biliary fistula and subphrenic infection, and 2 cases of liver insufficiency. No perioperative deaths. Conclusion Stage IVa liver tumor can be safely removed. The prevention and treatment of the injury of the middle hepatic vein and the left hepatic vein are the key points of the operation. Specific measures of injury include ligation and / or repair of the middle and left hepatic veins. Preoperative CT or MRI can be more accurately determine intraoperative hepatic vein and left hepatic vein injury possibility.