中国实用外科杂志

中国实用外科杂志 ›› 2024, Vol. 44 ›› Issue (03): 312-319.DOI: 10.19538/j.cjps.issn1005-2208.2024.03.16

• 论著 • 上一篇    下一篇

可视化技术辅助腹腔镜肝切除治疗胆道术后肝胆管结石研究

曾小军，李馨慈，陶海粟，王俊锋，祝    文，项    楠，曾    宁，胡浩宇，方驰华，杨    剑   

  1. 南方医科大学珠江医院肝胆一科 广东省数字医学临床工程技术研究中心，广东广州 510280
  • 出版日期:2024-03-01 发布日期:2024-04-07

  • Online:2024-03-01 Published:2024-04-07

摘要： 目的    探讨可视化技术辅助下的腹腔镜肝切除术在治疗既往胆道手术史肝胆管结石病的安全性和有效性。方法    回顾性收集2022年1月至2023年6月南方医科大学珠江医院收治的50例接受肝切除治疗的胆道术后肝胆管结石病人的临床资料，根据手术方式分为腹腔镜组（n=22）和开腹组（n=28）。两组在术前通过三维可视化技术规划手术方案，腹腔镜组在可视化技术[吲哚菁绿（ICG）荧光影像联合增强现实导航（ARN）]辅助下完成解剖性肝切除，ARN通过将三维模型与腹腔镜场景配准融合以引导手术；开腹组施行的是常规解剖性肝切除，无术中可视化技术辅助。比较两组病人的术中指标和术后并发症、结石清除率和复发率等。结果    两组病人术前基线资料差异无统计学意义，均完成解剖性肝切除术，腹腔镜组中有5例（22.7%）中转开放手术，腹腔镜组术中出血量要明显低于开腹组（中位数150 mL vs.270 mL，P=0.047），术后胆瘘发生率明显降低（9.1% vs.35.7%，P=0.029），术后住院时间缩短（中位数8 d vs.11 d，P=0.045）。两组的其他指标如手术时间、术中输血率、总并发症发生率和严重并发症发生率等差异均无统计学意义（P均＞0.05），两组均未发生围手术期死亡。在疗效方面，腹腔镜组的术中结石清除率高于开腹组（77.3% vs.50.0%，P=0.049），通过术后计划性和非计划性取石后，两组的最终结石清除率相似（90.9% vs.89.3%，P=1.000）。术后随访过程中发现，两组发生反复胆管炎或结石复发差异无统计学意义。结论    本研究表明，在治疗胆道术后的肝胆管结石病时，可视化技术引导下的腹腔镜肝切除术是安全可行的，不仅可以达到开放手术的结石清除率，还有望减少术中出血、降低术后胆瘘发生率和缩短术后住院时间，值得临床推广应用。

关键词: 肝胆管结石病, 胆道术后, 腹腔镜解剖性肝切除, 可视化技术, 手术导航

Abstract: Clinical efficacy of visualization techniques-assisted laparoscopic hepatectomy for treating hepatolithiasis in patients with previous biliary surgery    ZENG Xiao-jun, LI Xin-ci, TAO Hai-su, et al. First Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University,Guangdong Provincial Clinical and Engineering Center of Digital Medicine,Guangzhou 510280, China
Corresponding author:YANG Jian,E-mail:yangjian486@126.com
Abstract    Objective    To evaluate the safety and efficacy of visualization techniques-assisted laparoscopic hepatectomy in the treatment of hepatolithiasis in patients with a history of previous biliary surgery. Methods    Clinical data of 50 patients with a history of previous biliary surgery who underwent hepatectomy for hepatolithiasis at Zhujiang Hospital of Southern Medical University between January 2022 and June 2023 were retrospectively collected and divided into laparoscopic hepatectomy（LH）group（n=22）and open hepatectomy（OH）group（n=28）. The two groups received the surgical plan by three-dimensional visualization technology before surgery, and the LH group performed anatomical hepatectomy with the help of visualization techniques ［indocyanine green（ICG）fluorescence imaging combined with augmented reality navigation（ARN）］. The ARN guided the surgery by fusing the 3D model with the laparoscopic scene. The OH group performed routine conventional anatomical hepatectomy without the assistance of visualization techniques. Intraoperative indexes and post-operative complications, stone clearance, and recurrence rates were compared between the two groups. Results    There was no significant difference in preoperative baseline characteristics between the two groups. Both groups completed anatomical hepatectomy, with 5 cases（22.7%）in the LH group converted to open surgery. Intraoperative blood loss was significantly lower in the LH group than in the OH group（median 150 mL vs. 270 mL, P=0.047）. The incidence of postoperative bile leakage was significantly lower（9.1% vs. 35.7%, P=0.029）, and the length of postoperative hospital stay was shorter（median 8 days vs.11 days, P=0.045）in the LH group. There was no significant difference between the two groups in other indicators such as operation time, intraoperative blood transfusion rate, overall complication rate, and major complication rate（all P＞0.05）, and no perioperative death occurred in either group. In terms of efficacy, the intraoperative stone clearance rate was higher in the LH group than in the OH group（77.3% vs. 50.0%, P=0.049）, and the final stone clearance rate after planned and unplanned postoperative stone removal was similar in the two groups（90.9% vs. 89.3%, P=1.000）. There were no statistically significant differences in the incidence of recurrent cholangitis or stone recurrence between the two groups during follow-up. Conclusion    This study demonstrates that visualization techniques-guided LH is safe and feasible in treating hepatolithiasis with a history of biliary surgery, not only achieving the same stone clearance rate of OH, but also promising to reduce intraoperative blood loss, decrease the incidence of postoperative bile leakage, and shorten postoperative hospital stays, which is worth promoting for clinical application.

Key words: hepatolithiasis, post-biliary surgery, laparoscopic anatomical hepatectomy, visualization techniques, surgical navigation