腹腔镜肝左叶解剖性肝段切除的手术方式与围手术期结局：文献病例汇总分析

Surgical approaches and perioperative outcomes of laparoscopic anatomical segmentectomy of the left hepatic lobe: a literature-based case summary analysis

摘要:

背景与目的 腹腔镜解剖性肝切除已逐渐应用于肝脏局限性病变，但针对肝左叶肝段及亚段解剖性切除的相关报道较少，其手术入路选择、肝段边界识别及重要血管保护具有一定技术难度。本研究通过汇总现有文献中腹腔镜肝左叶解剖性肝段及（或）联合亚段切除的病例资料，分析其手术方式、入路选择、术中定位技术及围手术期结局，为相关术式的规范化开展提供参考。方法 检索中国知网、万方、维普、中国生物医学数据库以及PubMed、OVID、Embase和Cochrane Library等中英文数据库，纳入腹腔镜肝左叶解剖性肝段及（或）联合亚段切除的相关研究。由2名研究者独立完成文献筛选和资料提取，提取研究的基本特征、手术方式、手术入路、解剖定位及围手术期指标，并采用描述性方法进行汇总分析。结果 最终纳入10项研究，共60例患者，病例主要来自东亚地区，其中韩国4例、日本51例、中国5例；明确性别者56例，其中男性41例、女性15例。患者年龄为22~82岁，病理类型以肝细胞癌为主（50例），病变主要位于Couinaud S2、S3段，部分累及S4a、S4b及S1/4段，报道的肿瘤最大径为0.9~6.0 cm。手术方式以单一肝段或联合肝段切除为主，Glissonean入路应用较多，亦根据病变位置及解剖特点采用头侧入路、肝圆韧带入路、左外叶翻转法及足侧肝实质优先入路等。肝段边界定位主要采用缺血线、吲哚菁绿（ICG）荧光染色等方法，部分病例联合术中超声及三维重建技术。手术时间为115~464 min，多数集中于210~290 min；术中出血量为0~3 150 mL，多数病例低于300 mL。报道的术后并发症总体较少，主要为Clavien-Dindo并发症分级Ⅰ~Ⅱ级并发症、深静脉血栓合并肺栓塞及肝断面积液等，经相应治疗后均好转；术后住院时间为4~30 d。结论 现有文献显示，腹腔镜肝左叶解剖性肝段及（或）联合亚段切除在选择性病例中具有可行性，Glissonean入路联合ICG荧光、术中超声及三维重建等技术有助于肝段边界识别和精准切除。但目前相关证据主要来源于小样本病例系列，且存在明显的研究异质性，肝蒂解剖变异、肝静脉显露及段间平面控制仍是主要技术难点，尚需多中心、大样本研究进一步评价其长期疗效及安全性。

Abstract:

Background and Aims Laparoscopic anatomical hepatectomy has been increasingly applied to localized hepatic lesions; however, reports on anatomical segmentectomy or combined subsegmentectomy of the left hepatic lobe remain limited. Surgical access, identification of intersegmental planes, and preservation of major vascular structures remain technically challenging. This study aimed to summarize published cases of laparoscopic anatomical segmentectomy and/or combined subsegmentectomy of the left hepatic lobe and to analyze surgical procedures, operative approaches, intraoperative localization techniques, and perioperative outcomes, thereby providing a reference for standardized application of these procedures.Methods The China National Knowledge Infrastructure, Wanfang Data, VIP, and Chinese Biomedical Literature databases, as well as PubMed, OVID, Embase, and Cochrane Library, were searched for relevant studies of laparoscopic anatomical segmentectomy and/or combined subsegmentectomy of the left hepatic lobe. Two investigators independently screened the literature and extracted data on study characteristics, surgical procedures, operative approaches, anatomical localization techniques, and perioperative outcomes. Descriptive analysis was performed to summarize the available evidence.Results Ten studies involving 60 patients were included, with cases mainly reported from East Asia, including 4 from the Republic of Korea, 51 from Japan, and 5 from China. Among the 56 patients with available sex information, 41 were male and 15 were female. Patient age ranged from 22 to 82 years. Hepatocellular carcinoma was the predominant pathological diagnosis (50 cases). Lesions were mainly located in Couinaud segments S2 and S3, with some involving S4a, S4b, and S1/4; the reported maximum tumor diameter ranged from 0.9 to 6.0 cm. Surgical procedures mainly consisted of isolated segmentectomy or combined segmentectomy. The Glissonean approach was most frequently used, while cranial access, the round ligament approach, left lateral section flip-up technique, and parenchyma-first approach were also adopted according to lesion location and anatomical characteristics. Intersegmental boundaries were mainly identified using ischemic demarcation and ICG fluorescence, with intraoperative ultrasonography and three-dimensional reconstruction used in some cases. Operative time ranged from 115 to 464 min, mostly between 210 and 290 min, while blood loss ranged from 0 to 3 150 mL and was below 300 mL in most cases. Postoperative complications were generally uncommon and included Clavien-Dindo Classification grade I -Ⅱ complications, deep venous thrombosis with pulmonary embolism, and postoperative liver cut-surface fluid collection. All reported complications improved after appropriate management. Postoperative hospital stay ranged from 4 to 30 d.Conclusion Available evidence suggests that laparoscopic anatomical segmentectomy and/or combined subsegmentectomy of the left hepatic lobe is feasible in selected patients. The Glissonean approach combined with ICG fluorescence, intraoperative ultrasonography, and three-dimensional reconstruction may facilitate accurate identification of segmental boundaries and precise resection. However, the current evidence is mainly derived from small case series with substantial heterogeneity. Variations in hepatic pedicles, exposure of the hepatic veins, and control of intersegmental planes remain major technical challenges. Further multicenter studies with larger sample sizes and long-term follow-up are warranted to evaluate the efficacy and safety of these procedures.