探讨Kelly钳精细钳夹法切肝技术在肝脏外科中的应用价值。

回顾性研究2010年1月至2012年10月在昆明医科大学第一附属医院肝胆外科接受肝切除的45例患者临床资料。根据术中切肝方法将患者分为Kelly钳精细钳夹法切肝组（精细切肝组）和传统方法切肝组（传统切肝组）。精细切肝组30例，其中男14例，女16例；年龄25~67岁，中位年龄45岁。传统切肝组15例，其中男6例，女9例；年龄30~64岁，中位年龄42岁。所有患者均签署知情同意书，符合医学伦理学规定。精细切肝组采用Kelly钳小范围夹碎肝组织，每次钳夹肝组织的操作范围控制在1 cm左右；暴露肝内的条索状管道，除了极其细微的管道用电凝的方式切断外，其余用小直角钳带线结扎或prolene线予以缝扎。传统切肝组采用大块组织钳夹和缝扎切肝。比较两组患者的术中出血量、手术时间、术后住院时间及术后并发症发生情况。计量资料两组间比较采用t检验或U检验，围手术期并发症发生率比较采用χ²检验。

所有患者均顺利完成手术。精细切肝组术中出血量中位数为350（50~800）ml，明显少于传统切肝组术中出血量625（50~1400）ml，差异有统计学意义（U=6.23，P<0.05）；精细切肝组手术时间为（254±97）min，传统切肝组手术时间为（236±75）min，差异无统计学意义（t=3.21，P>0.05）；精细切肝组术后住院时间为（9.2±0.8）d，明显短于传统切肝组术后住院时间（13.9±3.8）d，差异有统计学意义（t=2.27，P<0.05）。两组患者围手术期均无死亡。精细切肝组患者术后无发生断面出血、胆漏、腹腔感染等并发症；发生胸腔积液5例，经胸腔穿刺抽液后或保守治愈。传统切肝组术后发生胆漏3例，经腹腔引流、对症治疗后治愈；胸腔积液4例，经胸腔穿刺抽液后治愈；肺部感染1例，经抗感染治疗后痊愈。精细切肝组并发症发生率17%（5/30），明显低于传统切肝组发生率53%（8/15），差异有统计学意义（χ²=5.75，P<0.05）。

Kelly钳精细钳夹法切肝技术具有设备要求简单、解剖清晰、术后并发症发生率低等优点，在肝脏外科中有一定的临床应用价值。

To investigate the application value of precise Kelly forceps clamping method in hepatectomy.

Clinical data of 45 patients who received liver resection in Department of Hepatobiliary Surgery, the First Affiliated Hospital of Kunming Medical University from January 2010 to October 2012 were analyzed retrospectively. The patients were divided into 2 groups according to the surgical procedures of liver resection: one group of hepatectomy using precise Kelly forceps clamping(precise hepatectomy group) and the other group of hepatectomy using traditional method (traditional hepatectomy group). There were 30 patients in precise hepatectomy group(14 males and 16 females; the median age of 45 years old, range 25-67 years old). There were 15 patients in traditional hepatectomy group(6 males and 9 females; the median age of 42 years old, range 30-64 years old). The informed consents of all patients were obtained and the ethical committee approval was received. In precise hepatectomy group, the liver tissues were crushed with Kelly forceps in a small range. The crushing range was controlled within 1 cm every time. The intrahepatic streak vessels were exposed and sutured with small right-angle clamps or prolene threads, except for the extremely tiny ones which were cut off by electrocoagulation. For the patients in traditional hepatectomy group, liver resection was performed by using mass tissue clamping and transfixion. Measurement data between two groups was compared by t test or U test. The incidence of perioperative complications between two groups was compared by Chi-square test.

All the operations were successful. The median volume of intraoperative bleeding in precise hepatectomy group was 350(50-800)ml, which was evidently less than that in traditional hepatectomy group [625(50-1400)ml] and significant difference was observed (U=6.23, P<0.05) . No significant difference was observed in the operation duration between precise hepatectomy group and traditional hepatectomy group [ (254±97) min vs. (236±75) min; t=3.21, P>0.05]. The postoperative length of hospital stay in precise hepatectomy group was evidently less than that in traditional hepatectomy group, and there was significant difference between two groups [(9.2±0.8)d vs. (13.9±3.8)d; t=2.27, P<0.05]. No death was observed during the perioperative period in both groups. No liver cross section bleeding, bile leakage, peritoneal infection occurred in patients in precise hepatectomy group after operation but 5 cases of pleural effusion that were cured by thoracentesis or conservative treatment. In traditional hepatectomy group, 3 patients suffered from bile leakage and were cured by peritoneal drainage or symptomatic treatment. Four cases suffered from pleural effusion and were cured by thoracentesis. One case suffered from pulmonary infection and was cured by anti-infection treatment. The incidence of complications in precise hepatectomy group was evidently lower than that in traditional hepatectomy group [17% (5/30) vs. 53% (8/15) ; χ²= 5.75, P<0.05].

Precise Kelly forceps clamping method in hepatectomy has the advantages of simple requirement of equipment, clear anatomy, low incidence of postoperative complications, which has a certain clinical application value in hepatic surgery.