超声刀在不同类型肝切除术中的应用选择

目的比较开放手术中超声刀法和钳夹法离断肝实质以及开放手术对比腹腔镜手术中应用超声刀离断肝实质对于控制出血的效果。方法收集2019年1月至2019年6月在复旦大学附属华山医院普外科同一手术小组因肝脏肿瘤接受肝脏切除手术的263例病人的临床病理资料。观察开放手术中超声刀法和钳夹法离断肝实质的两组病人,以及开放手术和腹腔镜手术中应用超声刀离断肝实质的两组病人,比较其手术时间、术中出血量、肝门阻断时间、术后肝功能恢复和并发症的发生情况。结果组间比较,病人基本的临床病理资料差异均无统计学意义;其手术时间、肝门阻断时间、术后肝功能恢复以及术后并发症发生率方面差异也无统计学意义。开放超声刀组术中出血量明显多于腹腔镜超声刀组(285±76)ml比(207±53)ml,P=0.02]。虽然总体比较开放超声刀组和开放钳夹法组两组之间的术中出血量没有明显差别(285±76)ml比(251±58)ml,P=0.27],但是分层分析显示在肝硬化较重的S2~S4级病人中,开放超声刀组的术中出血量明显多于开放钳夹法组(323±82)ml比(263±63)ml,P=0.03];在脂肪肝病人中,开放超声刀组的术中出血量也明显多于开放钳夹法组(309±81)ml比(259±71)ml,P=0.04]。结论超声刀在腹腔镜下使用较开放手术更能体现其优势,开放手术中肝硬化和脂肪肝较重的病人不推荐使用超声刀。

Clinical application of harmonic scalpel in patients who underwent various liver resections

Objective To compare the effects of transection of liver parenchyma by harmonic scalpel and clamping in open surgery and transection of liver parenchyma by harmonic scalpel in open surgery versus laparoscopic surgery for controlling bleeding.Methods The clinical and pathological data of 263 patients who underwent liver resection in the same surgical team of Department of General Surgery,Huashan Hospital,Fudan University from January 2019 to June 2019 were collected.The patients who underwent open surgery were divided into harmonic scalpel and traditional clamp crushing groups,and the two groups of patients who underwent open surgery and laparoscopic surgery with harmonic scalpel were also compared.The operation duration,intraoperative blood loss,hilar occlusion duration,postoperative liver function and complications were evaluated.Results There was no significant difference in the basic clinicopathological data,operation time,hilar occlusion duration,postoperative liver function and postoperative complications between these groups.However,the intraoperative blood loss in the open harmonic scalpel group was(285±76)ml,which was significantly more than that in the laparoscopic harmonic scalpel group(207±53)ml,P=0.02];but the difference in intraoperative blood loss between the open harmonic scalpel group and the open clamp crushing group didn′t reach significant(285±76)ml vs.(251±58)ml,P=0.27].In addition,in patients with severe cirrhosis(S2-S4),the open harmonic scalpel group had significantly more intraoperative blood loss than the open clamp crushing group(323±82)ml vs.(263±63)ml,P=0.03];and in patients with fatty liver,the intraoperative blood loss in the open harmonic scalpel group was also significantly more than that in the open clamp crushing group(309±81)ml vs.(259±71)ml,P=0.04].Conclusion The use of harmonic scalpel in laparoscopy is superior to that in open surgery.The use of harmonic scalpel is not recommended in patients with severe liver cirrhosis and fatty liver in open surgery.