left lateral lobectomy

The liver is the largest substantial organ of the human body, located in the upper right part of the abdominal cavity, below the diaphragm. Most of them are in the right quarter of the rib area, only a small part of the upper midline and the left quarter of the rib area. The liver consists of liver parenchyma and a series of tubing structures. Intrahepatic ducts include the hepatic artery, the portal vein, the bile duct system, and the independent hepatic vein system. The first three are wrapped in the connective tissue sheath (Glisson sheath), usually the bile duct is in front, the hepatic artery is centered, the portal vein is behind, accompanied by the first hepatic portal. The latter walks in the interlobular fissure and intersegmental fissure, collects the blood flow from the liver, and collects three hepatic veins into the left, middle and right, and flows into the inferior vena cava through the second hepatic portal. In addition, there are some scattered small hepatic veins called short hepatic veins that flow directly into the inferior vena cava directly after the liver, and the number varies from average to 14. In the case of liver resection, if the treatment is inadvertent, it will cause massive bleeding, so it is called the third hepatic hilum. The lobulation and segmentation of the liver: According to the groove structure of the liver surface, it can be divided into four leaves: left leaf, right leaf, square leaf and caudate lobe, but this is inconsistent with the internal structure of the liver and cannot be adapted to liver surgery. Need. After research on the internal tubal system of the liver, it is found that the distribution of intrahepatic vessels and bile ducts has a certain degree of segmentation. There is a certain supply of blood vessels and bile duct drainage in a certain area, and there is also a certain venous drainage. Therefore, a liver lobulation is proposed. New concept of segmentation. From the liver corroded specimens, it can be seen that there are obvious cracks between the liver leaves and the segments. There are three major fissures in the liver, namely median fissure, left interlobular fissure and right interlobular fissure; there are two intersegmental fissures and one dorsal fissure. These fissures divide the liver into left and right hemi-hepatocytes Median split: a split main split. From the middle of the gallbladder fossa, to the upper left of the inferior vena cava, the liver is divided into left and right halves. There is a mid-hepatic vein passing through the median fissure plane. Left interlobular fissure: a sagittal split. Located on the left side of the median cleft, from the umbilical notch to the left hepatic vein into the vena cava, the left side of the sacral ligament is bounded by the left sulcus, and the left side of the spleen is marked by the left longitudinal sulcus. Inside, left and outside leaves. The interlobular branch of the left hepatic vein passes through the fissure. Right interlobular fissure: a nearly horizontal oblique fissure. Located on the right side of the median cleft, the right and left 1/3 intersection of the right hepatic anterior border from the midpoint of the gallbladder incision reaches the right side of the inferior vena cava, and the right hemiliver is divided into the right anterior lobe and the right posterior lobe. There is a right hepatic vein in the fissure. Left intersegmental fissure: located in the left outer lobe, close to the horizontal position, from the left hepatic vein into the inferior vena cava, outward to the left 1/3 junction of the left hepatic lobe to the liver surface, the left outer lobe For the upper and lower sections. There is a left hepatic vein in the fissure. Right interseptal fissure: This fissure is located in the right posterior lobe, close to the transverse position. From the right incision across the right posterior lobe to the midpoint of the right border of the liver, the right posterior lobe is divided into upper and lower segments. Back crack: located in the middle of the upper posterior margin of the liver, in front of the caudate lobe, the hepatic vein flows into the inferior vena cava, separating the caudate lobe from other hepatic lobe. The above division divides the liver into 6 segments. The surgeon can perform right hepatectomy, left hepatectomy, right tricus resection, left lateral resection and various hepatic segment resection according to the above division. For example, the right hepatic lobe and the left inferior lobe are removed once, and the right hepatic resection is called. The left hemisphere and the right inferior lobe are called left tricus resection. The left inferior lobe and the right anterior lobe are removed. Due to the different sites of tumor invasion or the range of traumatic lesions, in addition to the above-mentioned rules of liver resection, there are irregular hepatic resections, and in recent years, it has shown an upward trend, and gradually formed a consensus of "left and right irregularities". . In 1954, Couinaud divided the liver into eight segments based on the anatomical distribution of the hepatic fissure and the portal vein in the liver, and was gradually accepted by everyone. The eight liver segments are represented by Roman numerals, which are: segment I of the caudate lobe, segment II, III of the left outer lobe, segment IV of the left inner lobe, V and VIII segments of the right anterior lobe, and VI of the right posterior lobe. Paragraph VII (Figure 12.18.1-0-4). One of the surgical resections is called hepatic segment resection; at the same time, two or more hepatic segments are removed, which is combined with hepatic segment resection; and two or more non-adjacent hepatic segments are removed for jumping hepatic segment resection; only one resection is performed. A part of the liver segment is a sub-hepatic segment or a sub-hepatic segment. In this way, the removal of the liver segment of the early lesions within a certain segment can not only remove the lesion, but also retain more normal liver tissue, which is beneficial to the recovery of the sick child. Treating diseases: liver cancer Indication Left lateral hepatectomy for: 1. Children with hepatic malignancies are more common with hepatoblastoma, and occasionally rhabdomyosarcoma. Primary hepatocellular carcinoma can also be seen in older children, often with cirrhosis. Metastatic tumors are common in retroperitoneal neuroblastoma, nephroblastoma, and the like. Secondary tumors are surgical indications only if the tumor is confined to a certain leaf and the primary tumor can be resected. 2. Benign tumor hepatic hemangioma, hemangioendothelioma, rare teratoma. 3. Hepatic cysts Parasitic cysts are mainly liver hydatid, non-parasitic cysts are usually polycystic liver, and more common in the right lobe of the liver. If the cyst is limited to a certain leaf and the liver is severely damaged, it is suitable for liver resection. 4. Liver trauma The liver is severely damaged, can not be repaired, or the ruptured liver blood vessels are suitable for liver resection. 5. Localized inflammatory lesions, which have a wide range of liver invasion and severe liver tissue damage, such as chronic bacterial liver abscess, liver tuberculosis, and chronic amoebic liver abscess. Preoperative preparation 1. The heart, lung, kidney, liver and other functions should be thoroughly examined before surgery to understand the systemic stress ability and liver reserve capacity of the sick child. 2. Give high protein, high carbohydrate and high cellulose diet before surgery. Actively improve anemia, improve the body's resistance in a short period of time, improve the blood coagulation mechanism, reduce intestinal bacteria, and give broad-spectrum antibiotics before surgery. 3. Children with trauma should actively resist shock and correct the imbalance of water and acid. 4. Place stomach tube and urinary tube before operation. Surgical procedure Incision: The commonly used incision is a right inferior oblique incision. If necessary, it is extended to the right or left rib. It can meet any type of liver surgery without opening the chest. Straight cuts have been abandoned. 1. Free liver Before the hepatic hilum is isolated, the left hepatic liver is first fully freed. Cut the round ligament of the liver, clamp the liver stump with a vascular clamp, and gently pull the liver down. Cut the left coronary ligament, cut off the left triangular ligament, pay attention to protect the stomach and spleen from being torn, and free the left lobe of the liver. 2. The connective tissue was cut in the left longitudinal groove, and the sagittal part of the left portal vein was exposed. The portal vein, hepatic artery and bile duct branch leading to the left outer lobe were separated at the lateral edge, and the ligation was performed. 3. At the top of the liver, cut the liver tissue along the left side of the apex of the falciform ligament, separate the left hepatic vein for ligation, or directly suture the left hepatic vein with a large needle, or ligature the liver from the liver parenchyma during the liver process. Left vein. In the treatment of left hepatic vein, it should be noted that the left hepatic vein is often co-dried with the hepatic vein, and the second vein merges into the inferior vena cava. In addition, the posterior superior margin of the left hepatic vein is often in the coronary ligament, which is shallow in the left outer lobe of the liver. The face can be directly into the inferior vena cava, so it should be clearly distinguished during the separation to prevent damage to the hepatic vein or inferior vena cava. 4. When the blood flow of the left outer lobe is completely controlled, the liver capsule is cut 1 cm to the left of the falciform ligament, and the liver parenchyma is separated by knife or finger pressure or with an ultrasonic scalpel. The intrahepatic duct is exposed, and the clamp is ligated one by one. When sewing. 5. After the hepatic lobe is removed, the cut surface can be hemostatically treated with warm saline, and the gauze can be used to check the presence or absence of bile leakage. The section is covered with the sacral ligament or the liver and stomach ligament, and the suture is interrupted. If the cover is incomplete, the pedicled omentum can be used. Stitched and fixed. A cigarette-type drainage and a latex tube drainage are placed under the liver section and are drawn from the incision. complication Intraperitoneal hemorrhage Most of them are due to the detachment of the knot of the ligated blood vessel, or the hemostasis of the liver section is not complete, or the coagulation mechanism is disordered. After the application of hemostatic drugs, such as hemorrhagic shock, or a large amount of fresh blood in the drainage tube, in the case of active blood transfusion, timely exploration and hemostasis. 2. Upper gastrointestinal bleeding Stress ulcers can occur after liver surgery. It is manifested as bloody or brown gastric juice in the stomach tube. In severe cases, it can cause heart rate to increase and blood pressure to drop. Gastrointestinal decompression should be continued after surgery, and H2 receptor antagonists should be used. When bleeding is found, an antacid and a hemostatic agent can be injected into the stomach tube, and if necessary, somatostatin is applied. Surgical treatment should be performed for patients with major bleeding who are not treated by non-surgical treatment. 3. Liver dysfunction The function of the remaining liver should be carefully evaluated before and during surgery, and the liver should be actively treated after surgery. 4. Abdominal infection After the hepatic lobe is resected, although the section has stopped bleeding, there will still be exudation. If the drainage is not smooth, there will be secondary purulent infection. It is characterized by high fever and even toxic shock. Treatment with systemic antibiotics, repeated B-guided puncture and pus injection and antibiotics, as far as possible without surgical drainage. 5. timid Leakage of the bile duct from the liver section, loss of bile duct ligature or bile duct injury not found during surgery. Poor drainage can cause peritonitis. The drainage is good, and the fistula is formed, which is generally self-healing.