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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2024, Vol. 13 ›› Issue (01) : 21 -26. doi: 10.3877/cma.j.issn.2095-3232.2024.01.005

所属专题： 临床研究；

临床研究

鞘外法和鞘内法Glisson蒂阻断在腹腔镜解剖性肝切除中应用的对比研究
洪汉崟, 陈志坚, 池小斌, 陈剑伟, 俞建达, 陈永标†()   
  1. 350025　福州，福建医科大学福总临床医学院
    350025　福州，第九○○医院肝胆外科
  • 收稿日期:2023-11-01 出版日期:2024-02-10
  • 通信作者: 陈永标
  • 基金资助:
    福建省自然科学基金面上项目(2021J011265)

Comparative study of extrathecal and intrathecal Glisson's pedicle transection in laparoscopic anatomic hepatectomy

Hanyin Hong, Zhijian Chen, Xiaobin Chi, Jianwei Chen, Jianda Yu, Yongbiao Chen†()   

  1. School of Clinical Medicine, Fuzhou General Hospital, Fujian Medical University, Fuzhou 350025, China
    Department of Hepatobiliary Surgery, the 900th Hospital, Fuzhou 350025, China
  • Received:2023-11-01 Published:2024-02-10
  • Corresponding author: Yongbiao Chen
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洪汉崟, 陈志坚, 池小斌, 陈剑伟, 俞建达, 陈永标. 鞘外法和鞘内法Glisson蒂阻断在腹腔镜解剖性肝切除中应用的对比研究[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(01): 21-26.

Hanyin Hong, Zhijian Chen, Xiaobin Chi, Jianwei Chen, Jianda Yu, Yongbiao Chen. Comparative study of extrathecal and intrathecal Glisson's pedicle transection in laparoscopic anatomic hepatectomy[J/OL]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2024, 13(01): 21-26.

目的

比较鞘外法和鞘内法Glisson蒂阻断在腹腔镜解剖性肝切除中的安全性及疗效。

方法

回顾性分析2019年1月至2022年6月在第九○○医院行腹腔镜解剖性肝切除的192例患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男110例，女82例；年龄17～81岁，中位年龄56岁。原发性肝癌（肝癌）96例，其他恶性肿瘤及良性疾病96例。根据Glisson蒂处理方法不同，将患者分为鞘外解剖Glisson蒂（鞘外组，65例）和鞘内解剖Glisson蒂（鞘内组，127例）。观察两组围手术期情况、术后并发症和术后生存复发情况。两组手术时间、术后住院时间比较采用t检验或秩和检验，率的比较采用χ2检验，生存分析采用Kaplan-Meier法和Log-rank检验。

结果

两组患者均手术顺利，均无围手术期死亡。鞘外组平均手术时间、肝蒂处理时间分别为（212±79）、（18±5）min，明显短于鞘内组的（236±68）、（21±5）min（t=-2.097，-3.927；P<0.05）。鞘外组和鞘内组术后并发症发生率分别为7.6%（5/65）、6.3%（8/127），差异均无统计学意义（χ2=0.132，P>0.05）；两组术后住院时间分别为12（10，13）、11（8，14）d，差异亦无统计学意义（Z=1.626，P>0.05）。96例肝癌患者均获得术后随访，随访时间1～42个月，中位随访时间28个月。两组术后总体生存率和无瘤生存率比较差异无统计学意义（χ2=0.894，0.154；P>0.05）。

结论

鞘外法和鞘内法Glisson蒂阻断在腹腔镜解剖性肝切除中均可行且安全，肿瘤学获益方面无明显差异，但鞘外法Glisson蒂阻断可提升手术效率。

关键词: Glisson蒂, 鞘外法, 鞘内法, 腹腔镜, 肝切除术, Laennec膜间隙
Objective

To compare the safety and efficacy of extrathecal and intrathecal transection of Glisson's pedicle in laparoscopic anatomic hepatectomy.

Methods

Clinical data of 192 patients who underwent laparoscopic anatomic hepatectomy in the 900th Hospital from January 2019 to June 2022 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 110 patients were male, 82 female, aged from 17 to 81 years, with a median age of 56 years. 96 patients were diagnosed with primary liver cancer (PLC), 96 cases of other malignant tumors and benign diseases. According to different treatment methods of Glisson's pedicle, all patients were divided into extrathecal anatomical Glisson pedicle (extrathecal group, n=65) and intrathecal anatomical Glisson pedicle (intrathecal group, n=127). Perioperative conditions, postoperative complications and postoperative survival and recurrence were observed in two groups. The operation time and postoperative length of hospital stay between two groups were compared by t test or rank-sum test. The rate comparison was conducted by Chi-square test. Survival analysis was performed by Kaplan-Meier analysis and Log-rank test.

Results

All patients successfully underwent surgery in two groups and no perioperative death was reported. In the extrathecal group, the mean operation time and pedicle treatment time were (212±79) and (18±5) min, which were significantly shorter than (236±68) and (21±5) min in the intrathecal group (t=-2.097, -3.927; P<0.05). The incidence of postoperative complications was 7.6%(5/65) and 6.3%(8/127) in the extrathecal and intrathecal groups, and no significant difference was found between two groups (χ2=0.132, P>0.05). Postoperative length of hospital stay in two groups was 12(10, 13) and 11(8, 14) d, and no significant difference was found (Z=1.626, P>0.05). All 96 PLC patients were followed up for1-42 months, with a median follow-up of 28 months. No significant difference was observed in overall survival and tumor-free survival between two groups (χ2=0.894, 0.154; P>0.05).

Conclusions

Both extrathecal and intrathecal Glisson's pedicle transection are feasible and safe in laparoscopic anatomic hepatectomy. No significant difference is noted in oncology benefits between two procedures. However, extrathecal transection of Glisson's pedicle can improve surgical efficiency.

Key words: Glisson pedicle, Extrathecal approach, Intrathecal approach, Laparoscopes, Hepatectomy, Laennec's capsule
图1 肝切除术中肝蒂解剖注：a为鞘外解剖右前叶肝蒂，b为鞘外解剖左肝蒂，c为鞘内解剖门静脉右支
表1 鞘外组和鞘内组腹腔镜解剖性肝切除术患者术前一般资料比较
组别 例数 性别（例） 年龄（岁，±s） BMI（kg/m2，±s） ALB（g/L，±s） ALT[U/L，M（Q1，Q3）] AST[U/L，M（Q1，Q3）] TB[mmol/L，M（Q1，Q3）]
男 女
鞘外组 65 40 25 56±13 24±3 43±3 24（18，29） 23（18，26） 11（8，16）
鞘内组 127 70 57 55±12 23±3 42±4 22（15，36） 22（16，32） 11（8，15）
统计值   χ2=0.724 t=0.713 t=1.270 t=1.296 Z=0.073 Z=0.500 Z=0.307
P值   0.395 0.477 0.206 0.196 0.942 0.617 0.759
组别 例数 PT[s，M（Q1，Q3）] DSS-ER（例） 病理类型(例)
低难度 中等难度 高难度 肝癌 其他类型恶性肿瘤 良性疾病
鞘外组 65 11（11，12） 22 12 31 36 3 26
鞘内组 127 12（11，12） 39 30 58 60 12 55
统计值   Z=-1.835 χ2=0.695 χ2=1.967
P值   0.066 0.707 0.374
表2 鞘外组和鞘内组腹腔镜解剖性肝切除术患者围手术期指标比较
组别 例数 手术时间（min，±s） 肝蒂处理时间（min，±s） 阻断时间[min，M（Q1，Q3）] 术中出血量[ml, M（Q1，Q3）] 术中输血（例） 术后并发症（例） 术后住院时间[d，M（Q1，Q3）]
鞘外组 65 212±79 18±5 30（20, 45） 150（100, 400） 10 5 12（10, 13）
鞘内组 127 236±68 21±5 27（20, 35） 200（150, 400） 15 8 11（8, 14）
统计值   t=-2.097 t=-3.927 Z=1.530 Z=-1.438 χ2=0.485 χ2=0.132 Z=1.626
P值   0.038 0.000 0.126 0.150 0.486 0.716 0.104
组别 例数 术后ALB（g/L，±s） 术后ALT[U/L，M（Q1，Q3）] 术后AST[U/L，M（Q1，Q3）] TB[mmol/L，M（Q1，Q3）] PT[s，M（Q1，Q3）]
鞘外组 65 37.4±3.0 46（35, 69） 29（22, 37） 15（11, 19） 12（11, 12）
鞘内组 127 37.6±3.1 45（29, 77） 29（22, 49） 16（13, 19） 12 （11, 13）
统计值   t=-0.456 Z=0.704 Z=0.660 Z=-1.249 Z=0.032
P值   0.649 0.481 0.509 0.212 0.975
图2 鞘外组和鞘内组肝癌患者腹腔镜解剖性肝切除术后Kaplan-Meier生存曲线
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