right hepatectomy

The success rate of right hepatectomy is not high, because the liver is rich in blood supply, the structure is complex, and the cut surface is easy to bleed. Therefore, laparoscopic liver resection is slow, only a few large medical institutions have the ability to carry out, and the scope of resection is mostly limited to the left liver. Leaf and liver lesions in segments IV, V, and VI. Because of the difficulty and risk of laparoscopic right hepatectomy, mature laparoscopic hepatectomy and open hepatectomy are required to complete successfully. There are only a few successful reports abroad. Treatment of diseases: liver cancer, liver tuberculosis Indication Applicable to partial necrosis of the right hepatic lobe. Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation Antibiotics are routinely used before surgery. Surgical procedure 1. Position: supine position, the right lower back with a yarn bag, padded high, so that the body and the operating table plane angle of 15 ° ~ 30 °. 2. Incision: Generally, the right upper transabdominal rectus muscle or the right upper right side incision is used for exploration. When the right hepatic resection is decided, because the scope of surgery is large, it can be extended to the upper right side, and the chest and abdomen are combined with the incision, and the diaphragm is cut. When the baby or child underwent right hepatectomy, the chest should not be opened. The right upper abdomen incision or the inferior costal incision should be used. If necessary, the right rib arch cartilage can be cut off. 3. Separate the right hepatic liver: first cut the round ligament and the sacral ligament, gently pull the liver down, and then cut the right triangular ligament and coronary ligament. When cutting the anterior layer of the right triangular ligament (hepatic ligament), do not damage the bare area of the liver. Then, gently invert the right hemi-hepatic inward and upward, and cut the posterior layer of the coronary ligament (hepatic and renal ligament) near the liver. Be careful not to damage the right adrenal gland when cutting. Continue to turn the liver up to reveal the inferior vena cava. When separating the right hepatic liver, there may be more bleeding, careful handling, and attention to prevent tearing of the short and right adrenal vessels that flow into the inferior vena cava. 4. Treatment of the first hepatic hilar venous vasculature, first remove the gallbladder, and use the cystic duct stump to insert the T-shaped tube, the common bile duct fistula, which is beneficial to the intraoperative examination of the liver section without leakage of the gallbladder, but also beneficial to surgery After the biliary decompression. When the cystic duct and the cystic artery are severed, the anatomy of the first hepatic portal can be clearly displayed. Then, the right hepatic duct and the right hepatic artery were separated, ligated, and the right branch of the portal vein was revealed. Because the right branch of the portal vein is shorter, it is separated at the depth of the hepatic hilum, and the position is higher. Therefore, the liver tissue should be carefully separated, and the blood vessels should be ligated and cut. When the right branch of the portal vein is too short or too deep, it can be ligated first, not cut off temporarily, so as to avoid accidental injury. After the right hepatic parenchyma is separated, verify that the right branch of the portal vein is properly ligated, then cut again, and the stump is added for suture. . 5. Ligation and severing of the short hepatic vein: Turn the right posterior lobe of the liver to the left side, carefully separate and cut the residual part of the posterior layer of the right hepatic coronary ligament and the ligament of the liver and kidney, and then the right anterior lobe of the liver can be directly returned to the inferior vena cava. Short veins of the liver. There are generally 4 to 5 branches of small hepatic veins, which are relatively small, thin, and close to the inferior vena cava. It is easy to cause massive hemorrhage after tearing. Therefore, it should be cut as close as possible to the liver parenchyma, and the stump of the inferior vena cava is added as a suture. tie. 6. Treatment of the right hepatic vein of the second hepatic hilum: put the right lobe of the liver back to the original position and pull it downward to reveal the second hepatic hilum. The connective tissue of the second hepatic hilum was separated, the right hepatic vein was exposed, and it was cut after ligation. The right hepatic vein is generally in the right interlobular fissure, opening in the anterior or right wall of the inferior vena cava. The main branch is close to the inferior vena cava. When separated, the inferior vena cava is easily damaged, causing severe bleeding, so when it is difficult to distinguish, The right hepatic vein should be separated and ligated from the parenchyma of the right lobe of the liver. 7. Resection of the right hepatic lobe: After the treatment of the first and second hepatic hilums, the color of the lobe tissue to be resected is darkened, and the boundary of the normal liver tissue is clearly defined. When performing hepatic lobe resection, according to the right hepatic ischemia threshold, the anterior and posterior surface capsules are first cut with a knife, and then the liver tissue is cut slightly to the disease side, and then inserted into the liver tissue with a shank or a finger. Make a blunt separation. When blood vessels or bile ducts are encountered, they should be ligated and cut off one by one. In this way, it is possible to avoid major bleeding when the hepatic lobe is removed. If there is still more bleeding during the liver cutting process, the first hepatic hilum may be temporarily blocked. 8. Treatment section: The bleeding point and the leaking biliary part of the liver section should be carefully sewed separately. Then, 10 to 20 ml of physiological saline was injected from the T-shaped tube to check for the presence or absence of leakage. Then, the wound edge is sutured with silk thread as much as possible, and then the wound is covered with a large omentum, and it is sutured and fixed with a liver capsule by a silk thread. The severed falciform ligament and the round ligament were fixed in place to prevent hepatic sag after surgery. After no bleeding or bile leakage, a cigarette drainage or double lumen drainage was placed under the liver section. For example, a chest and abdomen combined incision was made, and a rubber tube was drained in the chest cavity to suture the incision.