| Part I Anatomic observation of middle hepatic and its tributaries by ultrasoundObjective:To provide anatomic data for laparoscopic left hemihepatectomy in order to achieve precise resection plane guided by middle hepatic veins (MH V) and deal with its tributaries effectively, this study observed the MHV trunk and its tributaries in people without liver illness by ultrasound.Methods:57adult normal livers (23male and34female, aged20-82, average55.8±13.2) were examined by ultrasound, the anatomic characters about the trunk of MHV and its tributaries detected were surveyed and the data collected were analyzed statistically.Results:1. Observation of the trunk of MHVThe length of trunk was (5.06±1.60)cm; the internal diameter of trunk was (0.65±0.18)cm.35cases (61.4%) of MHV and Left hepatic vein (LHV) jointed together when they went into the inferior vena cava (IVC),21cases (36.8%) of MHV inflowing IVC respectively and1case (1.8%) formed a common trunk both MHV and Right hepatic vein (RHV) before they enter IVC. 2. Observation of the tributaries of MHVThe number of tributaries of MHV was (3.14±1.01). In the left hemiliver, the number of tributaries was (1.70±0.73) and the internal diameter of tributaries was (0.33±0.11) cm. There were25cases (43.8%) which had1branch,25(43.8%) cases which had2branches,6cases (10.6%) which had3branches and1case (1.8%) which had4branches. While in the right hemiliver, the number of tributaries was (1.56±0.66) and the internal diameter of tributaries was (0.33±0.12) cm. There were30cases (52.6%) which had1branch,22cases (38.6%) which had2branches,5cases (8.8%) which had3branches. The distance between tributary nearest to the IVC and the point MHV inflowing to IVC was (3.21±1.67,0.31～6.54)cm in the left and (3.54±2.06,0～7.43) cm in the right.Conclusions:Ultrasonography of MHV and its tributaries had advantages of convenient, non-invasive, real time. In laparoscopic left hemihepatectomy, MHV is always an important reference to select resection plane during liver parenchyma dissection, which could be facilitated by following its tributaries. The number of tributaries detected of MHV was small in left hemiliver, but they were widely distributed. Ultrasound can reveal anatomy of the trunk of MHV and its major tributaries with a certain value of clinical application in laparoscopic left hemihepatectomy. Part II Anatomical observation and surgical strategy of laparoscopic left hemihepatectomyObjective:To summarize the clinical experience of laparoscopic left hemihepatectomy, investigate anatomical characters, recognize the importance of MHV and its tributaries, explore technical points in the operation, two groups of patients classified by different indications were compared for the reasonable surgical strategy.Methods:A retrospective analysis of26cases received left liver resection from January2011to January2013with clinical data, operation videos and anatomical observations was made and people were grouped by intrahepatic bile duct stones and space-occupying lesions in liver.Results:1case with intrahepatic bile duct stones required conversion to open hepatectomy because of postsurgical adhesion.25cases were successfully operated. The operative duration was (205.0±39.3) min. The intraoperative blood loss was (182.5±57.8) ml.1case with intrahepatic bile duct stones had a minor bile leakage which resolved with drainage spontaneously one week later. No severe complications occurred. The duration for hospitalization after operation was (6.8±1.4) day. The group with intrahepatic bile duct stones was shown significant longer regarding operation time than that of group with space-occupying lesions in liver. No significant difference was shown between the groups regarding operative blood loss, the time withdrawing tube, and the duration for hospitalization after operation (P>0.05)Conclusions:Laparoscopic left hemihepatectomy is a minimally invasive technique which can be carried out safely and effective in selected patients. In laparoscopic left hemihepatectomy, a flexible surgical strategy should be taken by intimate knowledge of the relevant anatomical features for patients with intrahepatic bile duct stones or space-occupying lesions in the liver. |
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