Contents 1 Pinyin 2 English reference 3 Surgery name 4 Category 5 ICD code 6 Overview 7 Indications 8 Preoperative preparation 9 Anesthesia and surgery 10 Surgical steps 11 Postoperative management 12 Complications 1 Pinyin
p>zuǒ bàn gān qiē chú shù 2 English reference
left hemihepatectomy 3 Surgery name
Left hemihepatectomy 4 classification
Pediatric Surgery/ Liver surgery 5 ICD code
50.3
6 Overview
Left hemihepatectomy is more commonly used, especially for liver cancer and intrahepatic stones in the left lobe. The resection limit is about 0.5cm to the left of the median liver fissure, so as not to damage the middle hepatic vein that runs in the middle of the median liver fissure and joins the two middle liver lobes to return blood. The liver is the largest solid organ in the human body and is located in the upper right part of the abdominal cavity, under the diaphragm. Most of them are located in the right quarter rib area, and only a small part transcends the midline and reaches the upper abdominal area and left quarter rib area. The liver consists of liver parenchyma and a series of ductal structures. Intrahepatic ducts include the hepatic artery, portal vein, bile duct system, and independent hepatic venous system. The first three are wrapped in a connective tissue sheath (Glisson's sheath). Generally, the bile duct is in front, the hepatic artery is in the middle, and the portal vein is in the back. They go together and enter and leave the liver parenchyma through the first hepatic portal. The latter travels within the interlobar fissures and intersegmental fissures, collects the return blood flow of the liver, and merges into three hepatic veins: 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 directly merge into the inferior vena cava behind the liver. The number varies in size, with an average of about 14. If it is not handled carefully during liver resection, it can cause massive bleeding, so it is called the third porta hepatis.
Lobation and segmentation of the liver: According to the groove structure on the liver surface, it can be divided into four lobes: left lobe, right lobe, square lobe and caudate lobe, but this is not consistent with the internal structure of the liver. Comply with, but cannot meet the needs of liver surgery. After studying the internal duct system of the liver, it was found that the distribution of intrahepatic blood vessels and bile ducts has a certain segmental nature. There is a certain degree of vascular supply and bile duct drainage in a certain area, and there is also a certain degree of venous drainage. Therefore, the liver lobes were proposed. , new concept of segmentation.
From the liver corrosion specimens, it can be seen that there are obvious fissures between liver lobes and segments. The liver has three main fissures, namely the median fissure, the left interlobar fissure and the right interlobar fissure; there are also two intersegmental fissures and one dorsal fissure. These fissures divide the liver into left and right halves, five lobes and six segments (Figure 12.18.201).
Median fissure: an oblique main fissure. From the middle of the gallbladder fossa, backward and upward to the left edge of the inferior vena cava, the liver is divided into left and right halves. The middle hepatic vein passes through the plane of the median fissure.
Left interlobe fissure: a sagittal fissure. It is located on the left side of the median fissure, starting from the umbilical notch and upward to the point where the left hepatic vein enters the vena cava. It is bounded slightly to the left of the falciform ligament on the diaphragm surface, and the left longitudinal groove is used as a mark on the visceral surface to divide the left hemi-liver into the left Inner and left outer leaves. The interlobar branch of the left hepatic vein passes through the fissure.
Right interlobar fissure: a nearly horizontal oblique fissure. Located on the right side of the median fissure, from the intersection of the middle and outer thirds of the anterior edge of the right liver at the midpoint of the gallbladder notch, backward and upward to the right edge of the inferior vena cava, the right hemi-liver is divided into the right anterior lobe and the right posterior lobe. The right hepatic vein passes through the fissure.
Left intersegmental fissure: located in the left lateral lobe, almost horizontally, from the left hepatic vein to the inferior vena cava, and outwards to the liver through the junction of the middle and posterior 1/3 of the left edge of the liver. On the surface, the left outer lobe is divided into upper and lower segments. The left hepatic vein passes through the fissure.
Right intersegmental fissure: This fissure is located in the right posterior lobe, close to the transverse position. It crosses the right posterior lobe from the right notch to the midpoint of the right edge of the liver, dividing the right posterior lobe into upper and lower parts. Two paragraphs.
Dorsal fissure: Located in the middle of the posterior upper edge of the liver, in front of the caudate lobe, where the hepatic vein flows into the inferior vena cava, it separates the caudate lobe from other liver lobes.
The above clefts divide the liver into 6 segments. Surgeons can perform right hemihepatectomy, left hemihepatectomy, right trilobectomy, left lateral lobe resection and various liver segments based on the above divisions. Resection etc.
For example, if the right half of the liver and the left inner lobe are removed at one time, it is called a right trilobectomy; if the left half of the liver and the right inner lobe are removed, it is called a left trilobectomy; if the left inner lobe and the right front lobe are removed, it is called a middle lobectomy. Due to the different locations of tumor invasion or the different ranges of trauma, in addition to the above regular liver resections, there are also irregular liver resections, which have been on the rise in recent years, and have gradually formed a "left-sided and right-sided" pattern* **knowledge.
In 1954, Couinaud divided the liver into eight segments based on the anatomical distribution of liver fissures and portal veins in the liver, which was gradually accepted by everyone. The eight liver segments are represented by Roman numerals, which are: the caudate lobe is segment I, the left outer lobe is segment II and III, the left inner lobe is segment IV, the right anterior lobe is segment V and VIII, and the right posterior lobe is segment VI and III. Section VII (Figure 12.18.202). Surgical resection of one segment is called segmentectomy; resection of two or more adjacent liver segments at the same time is called combined segment resection; resection of two or more non-adjacent liver segments at the same time is called skip segment resection; resection of only one segment Part of the liver segment is subhepatic segmental or subtotal segmental hepatic resection. In this way, hepatic segmental resection for early-stage lesions limited to a certain segment can not only remove the lesions, but also retain more normal liver tissue, which is beneficial to the recovery of sick children.
Left hemihepatectomy is to remove the left outer lobe and left inner lobe with the median fissure as the boundary (Figures 12.18.21, 12.18.22). 7 Indications
Left hemihepatectomy is suitable for:
1. Liver malignant tumors: Hepatoblastoma is more common in children, and rhabdomyosarcoma is occasionally seen. Primary hepatocellular carcinoma can also occur in older children, often coexisting with cirrhosis. Metastases are common in retroperitoneal neuroblastoma, nephroblastoma, etc. Secondary tumors are only indications for surgery in cases where the tumor is limited to a certain lobe and the primary tumor can be resected.
2. Benign tumors: liver hemangioma, hemangioendothelioma, rare teratoma.
3. Liver cysts: Parasitic cysts are mainly hepatic hydatid, while non-parasitic cysts are common in polycystic liver, and are more common in the right lobe of the liver. Liver resection is only suitable if the cyst is limited to a certain lobe and severely damages the liver.
4. Liver trauma: Those with severe liver damage that cannot be repaired, or those with ruptured liver blood supply disorders are suitable for liver resection.
5. Localized inflammatory lesions, which invade the liver extensively and seriously damage liver tissue, and are ineffective after general treatment, such as chronic bacterial liver abscess, liver tuberculosis, chronic amoebic liver abscess, etc. .
6. Intrahepatic bile duct stones: intrahepatic stones limited to one lobe, with severe lesions, causing liver lobe atrophy.
7. Biliary tract bleeding: When biliary bleeding continues due to malignant tumor erosion, intrahepatic blood vessel rupture or intrahepatic localized infection, liver resection can be performed to remove the cause of the bleeding. 8 Preoperative preparation
1. Before the operation, the heart, lungs, kidneys, liver and other functions should be comprehensively checked to understand the systemic stress ability and liver reserve capacity of the patient. In the medical history, attention should be paid to whether there is low back pain caused by liver cancer metastasis; during physical examination, attention should be paid to whether there is lung metastasis, ascites, cachexia, etc. In addition, necessary preoperative examinations are required, such as liver function tests, ultrasound or CT examinations, radioactive isotope scans, and fetal alpha globulin examinations.
2. Give high protein, high carbohydrate and high fiber diet before surgery. Actively improve anemia, improve the body's resistance, improve coagulation mechanism, and reduce intestinal bacteria in a short period of time.
3. Children with trauma should actively resist shock and correct the imbalance of water, electricity, and acid.
4. From the 2nd day before surgery, take 4 to 8g of neomycin or 0.2g of metronidazole 3 times a day orally to prevent postoperative infection or hepatic coma.
5. Place gastric tube and urinary tube before surgery.
6. According to the scope of liver resection, prepare fresh blood as appropriate for intraoperative use. 9 Anesthesia and ***
Anesthesia should be appropriately selected based on the surgical method, size, and general condition of the patient. General anesthesia with tracheal intubation is commonly used. It is effective and can meet the needs of surgery to the greatest extent. It also facilitates the management of breathing and circulation during the operation and improves the safety of the operation, especially for critically ill children. However, general anesthesia will increase the burden on the liver, and coupled with the impact of the drug itself on the liver, it will be detrimental to children with existing liver function damage. Therefore, the method of combined anesthesia with general anesthesia plus continuous epidural anesthesia is gradually increasing, which provides good muscle relaxation and reduces the use of anesthetic drugs. It has little impact on the whole body of the sick child and has good effects.
Continuous epidural anesthesia should be used for patients with poor liver function; general anesthesia with endotracheal intubation can be used for patients with fair liver function or for whom a combined thoracoabdominal incision may be used during surgery. If it is estimated that it is necessary to block the portal blood flow during the operation, intra-abdominal cooling can be performed during the operation according to specific conditions.
Hypothermic anesthesia has been eliminated because it significantly inhibits liver function and increases post-operative mortality.
***: Supine position 10 surgical steps
1. The commonly used incision is an oblique incision under the right costal margin. If necessary, it can be extended to the right posterior or under the left costal margin to meet the needs. Any form of liver surgery does not require thoracotomy. Straight cuts have been deprecated.
Cut off the round ligament of the liver, left coronary ligament, left triangular ligament, falciform ligament, hepatogastric ligament and part of the right coronary ligament, and fully free the left liver.
2. Cut the hepatoduodenal ligament and dissect out the hepatic artery, portal vein and bile duct. First, the left hepatic artery is double ligated and cut, the Glisson sheath is incised at the transverse groove of the hepatic portal, and the lower edge of the left inner lobe of the liver is bluntly separated 1 to 1.5 cm to expose the left hepatic duct and the left transverse part of the portal vein. The left hepatic duct is located Anterior to the portal vein (Fig. 12.18.23).
3. Use a curved vascular forceps to separate the left branch of the portal vein and the left hepatic duct and ligate and cut them respectively (Figure 12.18.24).
4. At the top of the liver, cut the liver tissue along the left side of the top of the falciform ligament, isolate the left hepatic vein and ligate it, or directly suture the left hepatic vein with a large needle, or cut off the liver during the process , ligate the left hepatic vein from within the liver parenchyma (Fig. 12.18.25). When dealing with the left hepatic vein, it should be noted that the left hepatic vein often merges with the middle hepatic vein and enters the inferior vena cava. In addition, the posterior upper edge of the left hepatic vein often runs within the coronary ligament and is located in the left lateral lobe of the liver. The superficial surface of the hepatic vein can directly enter the inferior vena cava, so it should be clearly distinguished during separation to prevent damage to the middle hepatic vein or inferior vena cava.
5. Left hemihepatectomy: Incise the liver capsule 1cm to the left of the median fissure, bluntly separate the liver tissue with the handle of a knife or your fingers, and cut and ligate blood vessels and bile ducts when encountering them. The middle hepatic vein is located within the median fissure, so do not damage it when incising the liver parenchyma, and do not ligate its main trunk. Only its left branch can be ligated (Figure 12.18.26).
When the resection is near the second porta hepatis, there are many short hepatic veins connecting the inferior vena cava and liver tissue to the left segment of the caudate lobe, which should be carefully ligated and cut off one by one during the operation. The liver section was covered with the pedicled omentum and then fixed with interrupted sutures. In order to reduce bleeding, microwave knife, ultrasonic knife, etc. can be used when cutting the liver. If blood oozes from the liver section, warm saline gauze can be used to compress it. If possible, an argon gas knife can be used. Medical biological protein glue, hemostatic gauze, etc. can also be used to help stop bleeding. Cigarette drainage and latex tube drainage were placed under the liver section.
If the tumor in the left lobe of the liver is large or there are extensive adhesions at the porta hepatis, it will be difficult to expose the porta hepatis. At this time, the liver ligaments can be freed first and then the porta hepatis can be blocked at room temperature, and then the porta hepatis can be quickly removed along the The liver was cut 1cm to the left of the median fissure, and the left hepatic duct, left branch of the portal vein and left branch of the hepatic artery were exposed in the liver and ligated and cut. The porta hepatis block generally does not exceed 20 minutes, and when combined with liver cirrhosis, it does not exceed 10 minutes. There should be an interval of 5 minutes between two blocks. 11 Postoperative treatment
The following treatment is required after left hemihepatectomy:
1. After liver lobe resection, liver function is damaged to varying degrees, and the degree is related to the size of the liver resection. , intraoperative blood loss, and the length of time to block the porta hepatis vary. Therefore, liver function damage should be closely monitored after surgery, and sufficient glucose, vitamin C, vitamin K, and vitamin B complex should be supplemented in a timely manner. If there is anemia, blood transfusions should be performed .
2. Supplement sufficient albumin, a small amount of plasma or fresh whole blood within 2 weeks after surgery.
3. Use broad-spectrum antibiotics to reduce intestinal bacteria and prevent incision and abdominal infections.
4. Intermittent oxygen inhalation after surgery to increase the oxygen supply to the liver.
5. Avoid using drugs that damage the liver and drugs that are metabolized in the liver, such as morphine, barbiturates, and hibernating drugs.
6. If there are suspected hepatic coma, elevated blood ammonia, or mental abnormality, and there are signs of hepatic coma, immediately inject arginine or sodium glutamate intravenously to prevent hepatic coma.
12 Complications
1. Intra-abdominal bleeding is mostly caused by the detachment of the knots ligating the blood vessels, incomplete hemostasis of the liver section, or disorders of the coagulation mechanism. Hemostatic drugs should be used after surgery. If hemorrhagic shock occurs or a large amount of fresh blood flows out of the drainage tube, laparotomy should be performed in time to stop the bleeding with active blood transfusion.
2. Upper gastrointestinal bleeding. Stress ulcers may occur after liver surgery. It manifests as bloody or brown gastric juice in the gastric tube. In severe cases, it can cause increased heart rate and decreased blood pressure. Gastrointestinal decompression should be continued after surgery and H2 receptor antagonists should be used. When bleeding is found, antacids and hemostatic drugs can be injected into the stomach tube, and somatostatin can be applied if necessary. Severe bleeding that fails non-surgical treatment should be treated surgically.
3. Hepatic insufficiency: The function of the remaining liver should be carefully evaluated before and during surgery, and liver-protective treatment should be actively performed after surgery.
4. Abdominal infection After liver lobe resection, although the cross section has stopped bleeding, there will still be leakage. If drainage is not smooth, purulent infection will occur. It manifests as high fever and even toxic shock. Treatment consists of systemic application of antibiotics, repeated puncture and extraction of pus under the guidance of B-ultrasound and infusion of antibiotics, and surgical drainage is avoided as much as possible.
5. Biliary fistula is caused by leakage of small bile ducts in liver section, detachment of bile duct ligation or bile duct injury not found during surgery. Poor drainage can cause peritonitis. If the drainage is good, a fistula will form and it will usually heal on its own.
6. Bile peritonitis If a large bile duct ligation falls off or becomes necrotic in the liver wound, bile leakage can occur and cause biliary peritonitis, which is a serious complication. Therefore, liver tissue ischemia should be minimized during surgery, hepatic duct ligation should be secure, and postoperative drainage should be adequate. Once bile leakage occurs, it should be adequately drained.