腹腔鏡（補助）下肝切除における肝切離手技の検討

Effective surgical techniques for laparoscopic hepatic resection

◆要旨：腹腔鏡下肝切除を施行した37例の適切な肝切離手技を考察した．肝硬変を伴う原発性肝癌は25例で，21例に肝部分切除，4例に外側区域切除を行った．手術時間は平均199分，出血量は平均147mlであった．また12例の肝硬変を伴わない転移性肝癌と胆囊癌には，9例に肝部分切除，2例に外側区域切除，1例に後区域前背側区域切除を行った．手術時間は平均176分，出血量は平均49mlであった．腹腔鏡下肝切除では，肝硬変の有無や切離部位に応じて適切な肝切離手技が必要で，硬変肝の破砕にはBiClamp^®を，正常肝ではCUSA^®を用いたベッセルシーリングシステムでの切離が有用で，薄い肝実質にはステイプラーによる切離も有用であった．

　To evaluate what techniques and devices were safe and effective, we reviewed clinical profiles of 37 patients who underwent laparoscopic hepatic resection （LHR） between December 2006 and September 2011. Twenty-five patients had hepatocellular carcinomas with liver cirrhosis. Out of them, 21 patients underwent partial resections of the liver, and 4 patients underwent lateral segmentectomy. Hand-assisted laparoscopic surgery was performed in 7 patients. The mean operation time was 199 minutes and the mean blood loss was 147 ml. On the other hand, 12 patients without liver cirrhosis had metastatic liver tumors or gallbladder carcinoma. We performed a partial resection of the hepatic segment in 9, lateral segmentectomy in 2, and right hepatectomy in 1. The mean operation time was 176 minutes and the mean blood loss was 49 ml. According to our LHR experiences, crushing the liver parenchyma with BiClamp^® forceps followed by dissecting with a vessel sealing system was most effective for cirrhotic hard liver resection. To dissect a normal liver, the Cavitron ultrasonic surgical aspirator（CUSA^®） was applicable prior to the vessel sealing system. An endolinear stapler was also applicable for quick dissection of the liver. It was important to adopt appropriate laparoscopic techniques and devices according to the location of tumors and the degree of liver cirrhosis.