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肝血管瘤外科治疗方式演变及研究进展
Evolution of surgical treatment modalities and research progress of hepatic hemangioma
肝血管瘤的外科治疗理念与技术在过去百余年中持续演进。早期外科治疗以破裂出血后的急诊局部切除为主，20世纪中期随着肝脏解剖学与血流控制技术完善，手术适应证逐步由急诊抢救扩展至以肿瘤直径和症状为主要依据，术式以局部切除和规则性切除为主。20世纪80年代，Alper等提出剥除术并阐明其技术要点。其后大量研究显示，与肝部分切除相比，剥除术可更大程度保留功能性肝组织，具有创伤小、术中出血少、肝功能恢复快等优势，逐渐成为肝血管瘤的标准化术式。进入21世纪后，随着循证医学与多学科诊疗模式发展，手术决策由以肿瘤直径和症状为主，转向基于症状、解剖特征及风险评估的综合判断。近10年来，腹腔镜技术凭借创伤小、恢复快等优势，已被证实可安全用于直径≥10 cm巨大肝血管瘤切除。机器人系统依托三维高清视野、灵活操作臂与震颤过滤功能，在肝门区及中央型病灶等复杂手术中显示出更高操作精度与安全性。随着微创外科持续发展，三维打印、吲哚菁绿荧光导航与术中实时影像融合等技术进一步减少术中出血，缩短阻断时间，并降低并发症发生率。未来，人工智能与多模态影像深度融合将推动肝血管瘤外科治疗向智能化、数据化决策模式转变，为病人带来更高安全性与更优长期获益。
The surgical treatment concepts and techniques for hepatic hemangioma have continuously evolved over the past century. Early surgical treatment was dominated by emergency local resection after rupture and bleeding. In the mid-20th century, with the perfection of liver anatomy and blood flow control techniques, surgical indications gradually expanded from emergency rescue to being primarily based on tumor diameter and symptoms, and the surgical procedures were mainly local resection and regular resection. In the 1980s, Alper et al. proposed enucleation and clarified its technical points. Subsequent numerous studies have shown that compared with partial hepatectomy, enucleation can preserve functional liver tissue to a greater extent, and has the advantages of minimal trauma, less intraoperative bleeding, and fast recovery of liver function, gradually becoming the standardized surgical procedure for hepatic hemangioma. After entering the 21st century, with the development of evidence-based medicine and multidisciplinary treatment models, surgical decision-making shifted from being primarily based on tumor diameter and symptoms to a comprehensive judgment based on symptoms, anatomical characteristics, and risk assessment. In the past decade, laparoscopic technology, with its advantages of minimal trauma and fast recovery, has been proven safe for the resection of giant hepatic hemangiomas with a diameter ≥ 10 cm. Relying on its three-dimensional high-definition field of view, flexible operating arms, and tremor filtration function, the robotic system shows higher operational precision and safety in complex surgeries such as those in the hepatic hilar region and central lesions. With the continuous development of minimally invasive surgery, technologies such as three-dimensional printing, indocyanine green (ICG) fluorescence navigation, and intraoperative real-time image fusion have further reduced intraoperative bleeding, shortened occlusion time, and decreased the incidence of complications. In the future, the deep integration of artificial intelligence and multimodal imaging will promote the shift of surgical treatment of hepatic hemangioma towards an intelligent and data-driven decision-making model, bringing higher safety and better long-term benefits to patients.
肝血管瘤 / 剥除术 / 微创外科 / 精准外科 / 影像导航
hepatic hemangioma / enucleation / minimally invasive surgery / precision surgery / image navigation
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Fifteen patients had hepatic hemangiomas removed with liver resections that ranged in extent from local excision to right trisegmentectomy. There was no mortality and little morbidity. The propriety and feasibility of extirpative treatment of such liver tumors has been emphasized by this experience.
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Hemangioma is the most common primary tumor of the liver. The widespread use of ultrasonography (USG) and computed tomography (CT) has made the diagnosis more common. Although the vast majority of hemangiomas are diagnosed incidentally and are asymptomatic, treatment is still controversial. Surgery is the treatment of choice, especially in giant, symptomatic hemangiomas and uncertainty of diagnosis. Twenty-two patients (median age: 46 years) underwent resection (n = 12) or enucleation (n = 10) for liver hemangioma from 1989 to 2002. The primary indication for surgery was abdominal pain. Ten patients who were treated by enucleation were compared with twelve patients who were treated by liver resection. Mean tumor size was 90 mm with a range of 40-270 mm. There were no statistically significant differences in tumor size, preoperative liver function tests, hemoglobin levels, and platelet counts between the two groups. Operative time was longer in the resection group, and statistically significant the difference was (p = 0.048). Blood transfusion requirement and blood loss during intraoperative period were higher in the resection group (p = 0.025, p = 0.01, respectively). There were three postoperative complications, 1 in the enucleation group (pleural effusion), 2 in the resection group (liver abscess and wound infection). There was no surgery-related mortality in either group. Although most hemangiomas can be removed by enucleation or liver resection with low morbidity and mortality, if the location and number of hemangiomas are appropriate, enucleation is the choice of the therapy. Hospital stay, blood transfusion requirement, and blood loss can be kept minimal by the selection of enucleation.
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国际肝胆胰协会中国分会肝血管瘤专业委员会. 肝血管瘤诊断和治疗多学科专家共识(2019版)[J]. 中国实用外科杂志, 2019, 39(8):761-765.DOI:10.19538/j.cjps.issn1005-2208.2019.08.01.
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BACKGROUND
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刘允怡, 赖俊雄. 肝癌肝切除手术方式的理论基础及临床价值[J]. 中国实用外科杂志, 2018, 38(4):361-365.DOI:10.19538/j.cjps.issn1005-2208.2018.04.01.
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Over the past 27 years cavernous hemangioma of the liver has been diagnosed in 12 nonoperated patients and in 16 patients who had resection of the lesion at Strong Memorial Hospital. In almost all patients the diagnosis was suggested by an imaging procedure. In the 12 nonoperated patients the average size of the tumor was 4.7 cm (range: 3-8 cm). No problems related to the tumor occurred during the follow-up period. The average size of the resected lesion was 10 cm (range: 4-32 cm). The usual indication for resection was pain, mass, or a combination of these manifestations. Five lobectomies, five left lateral segmentectomies, two trisegmentectomies, two segmentectomies, and two enucleations were performed. There were no postoperative deaths. Review of the literature indicates that although rapid growth of the lesion occurred during pregnancy in one patient, the effects of pregnancy or contraceptive drugs on growth are inconsistent. Spontaneous rupture occurs infrequently, and the potential for rupture should not constitute an indication for resection, which should be performed selectively. Intraoperative blood loss may be appreciable, but a mortality rate near 0% has been reported in all institutional series.
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Haemangioma is the most common liver tumour. Treatment is indicated for symptomatic tumours, rapid increase in size, rupture or doubt in diagnosis. There is continuing debate regarding the ideal method of surgical treatment for liver haemangiomas, with some surgeons favouring enucleation over liver resection.Retrospective analysis of prospectively compiled database of patients who were surgically treated for liver haemangioma.Between 1987 and 2003, we operated on 21 patients with liver haemangioma. Pre-operative diagnosis on imaging was made in 16 patients (13 symptomatic, 3 had progressive increase in size). In five patients, the indication of surgery was uncertain diagnosis. Enucleation was performed in 9 patients and liver resection in 12. The size of the haemangioma was similar in the enucleation and resection groups (8.9 cm versus 10 cm; P = 0.85). The mean intra-operatiive blood loss was significantly less in the enucleation group (400 ml versus 1330 ml; P = 0.004). The mean operative time was significantly less in the enucleation group as compared to the resection group (170 min versus 230 min; P = 0.035). Five patients had major postoperative morbidity in the resection group as compared to none in the enucleation group (P = 0.045). The duration of hospital stay was significantly longer in the resection group.(9.9 days versus 5.6 days; P = 0.005).Enucleation of liver haemangiomas is safer, quicker and associated with less morbidity than liver resection. Except for some situations, such as uncertain diagnosis or total replacement of a lobe, we recommend enucleation as the surgical procedures of choice for the treatment of hepatic haemangiomas.
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New laparoscopic instrumentation coupled with standard surgical techniques allows one to perform procedures previously thought impossible via the laparoscope. This report reviews the natural history, the indications for resection, and the technique of laparoscopic resection of hepatic hemangiomata. Two women, 24 and 62 years of age, were first seen with abdominal pain. A diagnosis of hemangioma was made in each case, and both lesions were removed laparoscopically. Operative blood loss was 200 cc in each case, and neither patient required transfusion. Diets were started on the first postoperative day (POD), and the patients were discharged on the second and fourth PODs without narcotic analgesia. If the size and location of the tumor are favorable, laparoscopic resection of liver hemangiomata can be performed safely. Blood loss comparable to that of open procedures and a quicker recovery support an endosurgical approach to resection of liver hemangiomata in selected cases.
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The surgical indications for liver hemangioma remain unclear.
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Severe bleeding remains a significant concern in laparoscopic resection for hepatic hemangioma. It is rarely reported that how the degree of major vessels involvement impacts on severe bleeding. The present study primarily aimed to analyze the impacts of the number of involved major vessels (NIMV) during laparoscopic surgery for hepatic hemangioma and evaluate the risk factors associated with increased bleeding.A database search was carried out for consecutive patients who underwent laparoscopic resection for liver hemangiomas at our department from January 2018 to December 2023. The collected data included demographics, characteristics of the hemangiomas, laboratory data, operation method, surgical and postoperative variables.A total of 72 patients were enrolled in the study. 42 patients were categorized into the group with NIMV < 2, while 30 patients were divided into the group with NIMV ≥ 2. The group with NIMV ≥ 2 demonstrated a significant correlation with special segments, involved multiple segments and diameter of the hemangiomas (P < 0.01). And the perioperative variables including the extent of resection, operative time, blood loss, Pringle maneuver times, postoperative stay, drainage tube duration, and postoperative liver function (ALT, AST) also showed significant differences between the two groups (P < 0.05). Notably, NIMV ≥ 2 was identified as the most important independent risk factor for intraoperative blood loss ≥ 500 ml in laparoscopic surgery for hepatic hemangioma (P = 0.011). For NIMV ≥ 2, the independent risk factor was special segments in multivariate analysis (P = 0.000).The involvement of multiple major vessels (NIMV ≥ 2) was significantly associated with special segments, resulting in increased intraoperative blood loss, operation difficulty, and delayed postoperative recovery. Moreover, it was identified as the single independent risk factor with a considerable risk for increased blood loss during laparoscopic resection for hepatic hemangioma.© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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The use of minimally invasive surgery for the resection of benign liver tumors has increased in recent years as results show decreased abdominal damage and significant cosmetic advantages. Herein, we describe the first reported application of minimally invasive surgery for the removal of a giant symptomatic hemangioma, using robotic surgery, in a Jehovah's Witness (JW) patient.A 32-year-old JW presented with abdominal discomfort and recent episodes of acute abdominal pain due to a giant cavernous hemangioma involving segments VI and VII of the liver. Because of the location and size of the lesion, a right hepatectomy was planned. After a careful preoperative evaluation, a robotic right hepatectomy was performed using the da Vinci Surgical System.The procedure was successfully completed in minimally invasive fashion with an operative time of 310 min and with an intraoperative blood loss of only 300 ml. The postoperative course was uneventful and the patient was discharged on postoperative day 10. At 30-month follow up the patient reported complete relief of symptoms and good esthetic results.In experienced hands, a minimally invasive robotic major hepatic resection is a viable option that can be performed with minimal blood loss in a JW patient. A careful preoperative and intraoperative strategy is required and significant experience in liver and robotic surgery is mandatory.
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Minimally invasive techniques have increasingly been adopted for liver resection. This study aimed to compare the perioperative outcomes of robot-assisted liver resection (RALR) with laparoscopic liver resection (LLR) for liver cavernous hemangioma and to evaluate the treatment feasibility and safety.
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Meta-analysis was used to compare the difference between 3D reconstruction technology and 2D computed tomography (CT) before surgery for primary hepatic carcinoma (PHC) and to systematically evaluate the application value of 3D vascular reconstruction and 3D navigation technology in guiding precise liver resection for PHC. However, there are still many controversies in this aspect, and there are no clear conclusions on the effectiveness and safety of three-dimensional vascular reconstruction combined with three-dimensional navigation in laparoscopic hepatectomy. Therefore, it is necessary to systematically review the results of previous studies with meta method in this study to determine their clinical efficacy and complications and guide clinical treatment.We used the Cochrane Library, PubMed, Embase, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodicals Full-Text Database (VIP), and Wanfang database to conduct an online search for data from randomized controlled trials of preoperative 3D reconstruction versus conventional CT in hepatectomy published up to October 2021. Relevant literature was selected based on the inclusion criteria, data was extracted, and quality evaluation of the included literature was carried out. I test was used to evaluate heterogeneity among the studies, and Cochrane risk of bias 2.0 was used to evaluate the studies.A total of 16 studies were included in this study. Meta-analysis showed that there were statistically significant differences between the 3D vascular reconstruction group and conventional surgery group in operation time [mean differences (MD) =-40.10, 95% confidence interval (CI): -74.94, -5.26, P=0.02, I=78%, Z=2.26] and intraoperative blood loss (MD =-50.40, 95% CI: -62.93, -37.86, P<0.00001, I=9%, Z=7.88), but no statistically significant difference was found in total days in hospital (MD =-0.39, 95% CI: -1.81, 1.03, P=0.59, I=76%, Z=0.54), and postoperative complications rate (OR =0.98, 95% CI: 0.64, 1.50, P=0.91, I=0%, Z=0.11).Preoperative 3D reconstruction plays an important role in preoperative evaluation and surgical planning, which improves the operation time of PHC and reduces the intraoperative blood loss, but no effect to length of stay in hospital or complication rate comparing to conventional 2D techniques.2022 Journal of Gastrointestinal Oncology. All rights reserved.
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To evaluate the effectiveness of preoperative 3D reconstruction combined with intraoperative augmented reality fluorescence guidance system in laparoscopic liver surgery by establishing a retrospective cohort study.A retrospective cohort study was conducted from March 2023 to December 2024, with patients' data from the medical record system. Patients were divided into two groups according to their surgical protocols: 46 cases in the control group (conventional laparoscopic liver surgery) and 50 cases in the observation group (preoperative 3D reconstruction combined with intraoperative augmented-reality fluorescence guiding system in laparoscopic liver surgery). We compared perioperative indexes (operation time, intraoperative bleeding, time to first flatus, drainage tube removal time, hospitalization time), preoperative and postoperative liver function indexes [alanine aminotransferase (ALT), albumin (ALB), total bilirubin (TBIL)], stress indexes [angiotensin II (AT II), norepinephrine (NE), epinephrine (AD)], and complication rates between the two groups.The operation time of patients in the observation group was shorter than that of patients in the control group (110.75 ± 20.56 vs. 122.35 ± 20.48 min, 95% CI of difference: 2.52-20.68 min, p = 0.013), and the amount of intraoperative bleeding was less (300.80 ± 32.70 vs. 320.76 ± 35.84 mL, 95% CI of difference: 7.62-32.30 mL, p = 0.002). There was no statistically significant difference in the comparison of time to first flatus, drain removal time, hospitalization time and complication rate between the two groups (p > 0.05). Preoperatively, the comparison of ALT, ALB, TBIL, AT II, NE, AD levels of patients in the two groups were not statistically significant (p > 0.05); postoperatively, the AT II, NE, AD levels of patients in the observation group were lower than those of patients in the control group, with statistically significant differences (p < 0.001), while the differences in ALT, ALB, TBIL levels were not statistically significant (p > 0.05). For malignant cases, the R0 resection rate was similar between groups (92.3% vs. 89.5%, p = 0.724).Preoperative 3D reconstruction combined with intraoperative augmented reality fluorescence guidance system is potentially beneficial for laparoscopic liver surgery, which can modestly shorten the operation time, reduce intraoperative bleeding, and alleviate postoperative stress reactions.© 2025. The Author(s).
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