left hepatectomy

Left hepatectomy is more common in liver cancer and intrahepatic stones, especially in the left lobe. The resection limit is about 0.5cm on the left side of the median fissure of the liver, so that the hepatic vein in which the two hepatic lobes are returned in the median fissure and in the middle of the confluence is not damaged. Treatment of diseases: liver tumor liver abscess Indication Liver tumor Benign tumors (hepatic cavernous hemangioma, hepatic adenoma, hepatic cyst) and malignant tumors (liver cancer, hepatic sarcoma). Liver cancer is divided into primary and secondary. Primary liver cancer only in the early stage of non-diffuse type, no long-distance metastasis, no cachexia, no obvious jaundice, ascites, edema, portal hypertension can be removed, secondary liver cancer can only be cured and metastases in the primary tumor It can only be removed when the single shot is limited. Hepatic trauma Larger blood vessels in the liver rupture, so that part of the liver loses blood supply, large pieces of tissue are broken and broken; liver tissue is severely contused and lacerated, and simple suture repair can not control bleeding or has been seriously infected. Liver abscess Chronic hard-walled liver abscess with severe bleeding and long-term coexistence treatment, liver resection is feasible when conditions permit. Intrahepatic bile duct stones Limited to a leaf of intrahepatic stones, severe lesions, causing liver atrophy. Biliary hemorrhage Hepatic resection hemorrhage and removal of the cause due to malignant tumor erosion, intrahepatic vascular rupture or intrahepatic localized infection caused by biliary bleeding. Contraindications For patients with poor liver function, continuous epidural anesthesia should be used; for patients with liver function or intraoperative chest and abdomen combined incision, general anesthesia can be used for endotracheal intubation. It is estimated that it is necessary to block the hepatic portal blood flow during the operation, and intra-abdominal cooling can be performed during the operation according to specific conditions. Preoperative preparation 1. In the medical history, attention should be paid to the low back pain caused by liver cancer metastasis; during the physical examination, attention should be paid to whether there is lung metastasis, ascites and cachexia. In addition, necessary preoperative examinations such as liver function tests, ultrasound or CT examinations, radioisotope scans, and fetal gamma globulin tests are required. 2. Improve the treatment of the general condition of the patient. In addition to the application of various vitamins, daily intravenous injection of 50% glucose solution 100ml ~ 200ml 1 to 2 weeks before surgery. If there is anemia, iron can be given. It is best to achieve a ratio of albumin to globulin that is not inverted, bilirubin does not exceed 1 mg%, and prothrombin time is not less than 505. A few days before surgery, you can lose 1 or 2 times of fresh blood, 200ml each time, to enhance the body's resistance and improve blood coagulation. 3. From the 2nd day before surgery, take 4-6g of neomycin or 0.2g of metronidazole 3 times a day to prevent postoperative infection or hepatic coma. 4. According to the scope of liver resection, fresh blood is prepared as needed, and it is used in surgery. Surgical procedure 1. Position: supine position. 2. Incision: Generally, the mid-abdominal incision is used. If necessary, it can be extended to the upper left to cut off the xiphoid and rib arch cartilage. The right inferior oblique incision can also be used, and the chest and abdomen combined incision is rarely needed. 3. Separation of the left half of the liver: Before removing the liver, the connective tissue and ligament attached to the left hepatic liver are separated. The liver ligament was first cut and ligated, and the liver was gently pulled down by the liver side stump, and the sacral ligament was cut along the anterior abdominal wall. Push the liver backwards and downwards to better expose and cut the coronary ligament, and ligature and cut the left triangular ligament on the dorsal side of the temporal surface. Then, the liver and stomach ligaments are cut and the hepatoduodenal ligament is cut (not to damage the liver pedicle), and the left half of the liver is separated. 4. Treatment of the hepatic hilum of the first hepatic hilum: After separating the liver, the liver is pulled upward with a large hook to reveal the first hepatic hilum. Sometimes to prevent major bleeding during the removal of the liver. It can be placed in the pedicle with a gauze strip or catheter to control blood flow. There are two common methods for treating hilar vascular: (1) External sheath ligation: the left hepatic duct, the left hepatic artery and the left branch of the portal vein were ligated together outside the Glisson sheath. First, along the left and lower sides of the Glisson sheath, 0.5cm was bluntly separated and penetrated into the liver parenchyma about 1cm. Do not tear the blood vessels that travel inside the sheath when separating. After clear separation, 2 cm from the left side of the main branch of the portal vein, two lines are ligated with thick thread; can not be cut off temporarily, after the left hepatic parenchyma is completely disconnected, then verify whether the left stem is ligated correctly. Then, cut between the two knots, take the left liver, and dry the stump of the vessel for suture. (2) Intrathecal ligation: When the hilar vascular is abnormal, the Glisson sheath should be separated, and the left hepatic duct, the left hepatic artery and the left branch of the portal vein should be ligated. The left hepatic duct and the left hepatic artery need to be cut off first, and the portal vein is not cut off temporarily, as a sign of the subsequent removal of the liver lobe. 5. Treatment of the left hepatic vein of the second hepatic hilum: After the first hepatic hilum treatment is completed, the liver is pulled downward to reveal the second hepatic hilum. At this time, it is necessary to first distinguish the anatomical relationship between the left hepatic vein and the middle hepatic vein. Sometimes the hepatic vein and the left hepatic vein are injected into the inferior vena cava respectively; sometimes the hepatic vein first merges into the left hepatic vein and then into the inferior vena cava. It should also be noted that the left hepatic vein is shorter in the extrahepatic part, and it is often necessary to cut the liver capsule to distinguish it. Slowly separate the left hepatic vein and the middle hepatic vein bifurcation with the back of the knife, retain the middle hepatic vein, and then use the blunt-tipped thick round needle to lead the thick thread, penetrate the liver parenchyma, ligature the left hepatic vein, then cut off and separate the second hepatic hilum. 6. Disengage the left half of the liver: cut the liver capsule 0.5 cm along the left side of the hepatic vein, and bluntly separate the liver parenchyma with the knife back, and then clamp the left hepatic vascular tube with a curved hemostat. Cut and ligature. Do not damage the trunk of the hepatic vein during this procedure. Then from the front edge of the liver to the liver parenchyma blunt separation, and finally cut the left branch of the portal vein, completely disconnected left liver. The blood vessels and liver tubes of the liver section should be ligated or sutured with a thin wire. The oozing can be stopped by hot saline gauze. 7. Omentum covering the liver section: Because the left hepatectomy has removed the hepatic sacral ligament, the section of the liver needs to be sutured with silk suture and covered with a small omentum or omentum suture to prevent intestinal adhesion. Helps stop bleeding. If there is still bleeding, the hemorrhoids should be sutured at the wound edge. After checking for no oozing or leaking bile, a cigarette drainage or double lumen drainage was placed in the left hepatic fossa and the retina hole, and the abdominal wall was sutured layer by layer.