liver resection

Since Langenbuch's trial of left hepatic lobe resection in patients with liver tumors in 1888, Lüke and Keen successfully completed the left lateral lobe resection in 1891. Liver surgery has been more than 100 years old. However, due to the complicated structure of the liver and abundant blood supply, it is prone to major bleeding during surgery, postoperative complications, and high surgical mortality. Therefore, liver surgery has developed very slowly for a long time. Until the 1940s, with the advent of antibiotics, the application of blood transfusion techniques, and the improvement of anesthesia techniques, especially the systematic study of liver anatomy, the development of liver surgery was greatly promoted. By the 1950s, not only simple local hepatectomy but also complicated right hepatic resection and even liver transplantation (Starzl, 1963) were performed. Liver surgery in China started late, and there was no report of liver resection in the 1950s. By 1962, only 197 cases of liver resection were performed nationwide. In the 1970s, China's liver surgery was rapidly developed, and liver resection techniques were becoming more and more perfect. Some simpler liver resections were gradually carried out in primary hospitals. At present, China's liver surgery has advanced to the world's advanced level, not only the number of liver resection cases in the world, and the total case fatality rate has dropped below 5%. The unit with the most liver resection was the Eastern Hepatobiliary Surgery Hospital of Shanghai Second Military Medical University. By 2001, there were more than 10,000 cases, and the surgical mortality rate was only 0.62%. Indication At present, the main target of liver resection is liver malignant tumor, followed by benign liver tumor, which accounts for about 80% of liver resection. Other indications include intrahepatic bile duct stones, liver trauma, liver abscess, hepatic cysts, and liver hydatid disease. Contraindications 1. The general condition is poor, and heart, lung and kidney diseases cannot tolerate surgery; 2. Liver function ChildC level; 3. Multiple metastases outside the liver; 4. Multiple lesions in the liver (more than 3) scattered in the liver; tumors invading the hilar or inferior vena cava are not expected to be removed. Preoperative preparation Liver surgery not only affects the normal physiological function of the liver itself, but also affects the normal operation of various organs of the patient's body, especially for the large amount of liver resection (resection of right hepatic lobe), combined with obvious cirrhosis, preoperative Good preparation is especially important. (1) Before performing liver surgery, in addition to detailed medical history and comprehensive physical examination of the patient, the patient's heart, lung and kidney function, as well as the nature, extent, size and quality of the liver should be understood. Wait. Therefore, the heart, lung and kidney function indicators and various biochemical indicators should be examined in detail before surgery to comprehensively evaluate the patient's general condition. (2) The quality of liver function is extremely important for patients with liver surgery. In general, liver function tests are abnormal, reflecting liver damage, or poor liver compensability, and poorer liver function, suggesting that the liver damage is more serious. Therefore, the liver function directly affects the patient's effect after surgery. Hepatic function tests should pay special attention to serum protein content, serum bilirubin, coagulation function and various enzymatic tests. When the liver is severely damaged, serum protein levels decrease and albumin decreases. The ratio of albumin to globulin is inverted and must be corrected before liver resection. Generally, the total protein content is above 60g/L, albumin is above 30g/L, and the white/globulin ratio should be >1. When serum total bilirubin is elevated, it should be identified as hepatic jaundice or obstructive jaundice. Generally speaking, if it is hepatocellular jaundice, it is not suitable for surgery; if it is biliary obstructive jaundice, it should be treated as soon as possible to relieve jaundice. At the time of hepatectomy, the prothrombin time should be more than 50%. If the vitamin K is fully supplied, the prothrombin time is still below 50%, which not only indicates liver dysfunction, but also has a greater tendency to hemorrhage during surgery. In addition, for primary liver cancer with cirrhosis, should also pay attention to the presence or absence of esophagus, gastric varices and splenomegaly and hypersplenism, with or without ascites and lower extremity edema. (3) According to the preoperative examination results and the comprehensive evaluation of the patient's general condition and liver function tests, positive and targeted treatment, such as patients with malnutrition, should be given high protein, high sugar and high vitamin diet, It is best to give a diet containing 10.46 to 14.64 kJ (2500 to 3500 cal) of calorie daily, especially for liver malignant tumors, cirrhosis with cirrhosis or eating less. For those without diabetes, a certain amount of glucose can be given orally or intravenously daily. Oral or intramuscular injection of vitamins B, C, K. In patients with prolonged prothrombin time or bleeding tendency, large doses of vitamin K should be given to improve coagulation. (4) For those with low plasma protein, appropriate amount of plasma or albumin should be added. If necessary, a small amount of blood transfusion can be used for more than 60g/L of serum total protein and 30g/L of albumin. (5) Antibiotic treatment was given within 1 to 2 days before surgery. However, the patient is in good condition, the lesion is small, the operation is estimated to be easier and simpler, and the antibiotic treatment can be used before surgery. (6) Prepare the skin 1 day before surgery and place the stomach tube in the morning. (7) Prepare whole blood according to the scope of hepatectomy. If you remove more than half of the liver or have cirrhosis or liver dysfunction, you need to prepare fresh blood to avoid complications such as coagulopathy caused by a large amount of blood. (8) Other diseases that may increase the risk of surgery, such as endocrine disorders (diabetes, hyperthyroidism, etc.), cardiovascular diseases (such as hypertension, heart disease, etc.), lung and kidney diseases, portal hypertension, etc. Active and effective treatment should be taken, and appropriate measures should be taken during and after surgery in order to successfully pass the operation period. (9) The ideological work of the patient's family should be done well before the operation, and the close cooperation of the patient and his family should be obtained. Surgical procedure 1. Anesthesia: continuous epidural anesthesia or (and) inhaled general anesthesia. 2. Position and incision: In the supine position, the operating bed is shaken as needed during the operation to tilt the patient to the left or right. Incision under the right costal margin, or as needed, the "human" incision under the double costal margin, combined with the chest and abdomen. 3. Exposure: free tumor and adhesion of the liver to the surrounding tissue, as needed, disconnect the round ligament of the liver, the falciform ligament, the left and right triangular ligaments, or the left and right coronary ligaments, so that the liver is fully free, the palm of the operator can be from behind Hold the liver. 4. Control liver hemorrhage: intermittent hepatic occlusion at room temperature is the most commonly used method, in addition to local hepatic vascular occlusion method (finger hemorrhage controlled by finger press, selective intrahepatic portal vein branching, hepatic sulcus Legitimate), selective hepatic vascular exclusion and bloodless hepatectomy, etc., are selected as needed. 5. Resection: regular liver resection and irregular liver resection. Regular hepatectomy includes segmentectomy, hepatectomy, hepatectomy, and hepatic trifoliate resection; irregular hepatectomy is local hepatectomy. The specific method of resection should be determined according to the size of the tumor, the location, the degree of cirrhosis and the general condition of the patient. The method of clamping the liver with clamp method, finger-pinch method, ultrasonic knife (CUSA) and water knife should be selected according to the conditions and the experience of the surgeon. During the process of liver rupture, the bile duct, hepatic artery and portal vein must be ligated one by one, and the hepatic vein above 1 mm diameter must also be ligated. 6. Treatment of liver section: Larger bleeding points or bile leakage should be done with 8 suture ligation with fine thread; high temperature gas beam generated by argon knife can condense small bleeding point or extensive oozing, which is fast and effective. The purpose of hemostasis; fibrin adhesive, bio-adhesive direct coating or spray cross-section, can play a good role in coagulation and promote wound healing; pedicled omentum or adjacent ligament covering the section, is beneficial for hemostasis and wound healing. It should be emphasized that the section that can be sutured together should be sutured with silk thread as much as possible after the section has stopped bleeding.