Laparoscopic surgery has the advantages of less trauma, fast recovery, cosmetic appearance, and short hospital stay. In recent years, with the continuous maturation of laparoscopic surgical technology and the improvement and innovation of laparoscopic instruments, the types of surgeries have expanded, the difficulty has continued to increase, and the safety of surgeries has continued to improve. Laparoscopic surgeries have penetrated into various fields of abdominal surgery. In 1991, Reich et al. [1] first reported 2 cases of laparoscopic hepatectomy (laparoscop-ic hepatectomy, LH). In 1994, Zhou Weiping [2] completed the first LH in China. Since then, reports of such surgeries have continued to increase. Due to the rich blood supply of the liver, laparoscopic hilar blood flow occlusion is difficult, resulting in excessive intraoperative bleeding and high risks. Existing laparoscopic liver resection instruments are expensive, have unsatisfactory hemostatic effects, and are complicated to use. At present, laparoscopic surgery The implementation of liver resection is still in the exploratory development stage clinically, and is only carried out in some tertiary hospitals. From January 2004 to December 2009, we performed complete laparoscopic left hemihepatectomy on 22 patients with primary lesions located in the left hemihepatectomy, and the results were satisfactory. The report follows.

1. Materials and methods

1. 1. General information: Among the 22 cases, 14 were male and 8 were female. Age 27~67 years old. The course of disease ranges from 1 month to 20 years. Through medical history, physical examination, B-ultrasound, ERCP, CT or MRCP, 3 cases of hepatic hemangioma, 15 cases of intrahepatic bile duct stones and 4 cases of primary liver cancer were confirmed. None of the patients had a history of upper abdominal surgery.

1. 2 Preoperative liver function status: Liver function was grade A in 20 cases and grade B in 2 cases. After liver protection treatment, it was converted to grade A. There were no abnormalities such as ascites, hypoalbuminemia, and prothrombin time.

2 Surgical method

2. 1. Laparoscopic left lateral hepatic lobectomy to establish 12 mmHg pneumoperitoneum, establish 5 Trocar channels, cut off the ligaments around the liver, and free the left lobe of the liver; The first porta hepatis was dissected, and the left branches of the hepatic artery and portal vein were dissected out. The left hepatic artery and the left branch of the portal vein were clamped and cut by ligation locks to control the blood flow into the liver. It can be seen that the left hemi-liver showed ischemic changes. Dissect the second porta hepatis, separate the main trunk of the left hepatic vein, and tie it with No. 7 silk sutures to control the blood flow out of the liver. If the anatomy of the left hepatic vein is not ideal, it can be temporarily left alone until the liver is cut to the left hepatic vein. Then ligate with No. 7 silk suture. According to the anatomical landmarks of the liver lobes, use electrosurgery, ultrasonic scalpel and other liver cutting instruments to separate the liver parenchyma on the pre-cut line. When the diameter of the intrahepatic pipe is greater than 2 mm, it needs to be clamped with titanium clips before cutting to prevent Bleeding, bile leakage. Rinse the wound and completely stop bleeding. Spray medical bioprotein glue on the liver section and/or cover it with hemostatic gauze. Place abdominal drainage and use a specimen bag to remove the specimen.

3 Results

Among the 22 cases, 19 underwent anatomical left hemihepatectomy, 3 were converted to open surgery, 2 were combined with cholecystectomy, and 3 were combined with common bile duct stone removal. The average operation time is 250 minutes. Intraoperative bleeding averaged 250 ml. There were 3 cases of minor bile leakage after operation. The lumen drainage tube drained light bile fluid, up to 60 ml/d, and the bile leakage stopped 5 to 8 days after operation. There were no complications such as postoperative bleeding, infection, or residual bile duct stones. The T-tube was removed on the 21st day after surgery. The patient recovered and was discharged 6 to 14 days after surgery. The surgical liver resection specimen is 4 to 13.5 cm x 5 to 6.5 cm in size. It is taken out through the expanded left subcostal incision and sutured with 2-4 stitches. There were no deaths.

4 Discussion

Due to the anatomy and physiology of the liver, laparoscopic liver resection is considered a "forbidden zone". The liver has a dual blood supply of the hepatic artery and portal vein, and the blood supply is abnormally rich. It is easy to bleed during resection, and it is difficult to control during the operation. During laparoscopic liver resection, some parts are difficult to expose and the operation is difficult; laparoscopically cannot Liver resection techniques using open surgery, such as portal block, manual pressure for hemostasis, and flexible suture hemostasis [3]. Recently, with the improvement of laparoscopic technology and the continuous improvement of equipment, laparoscopic liver resection has made great progress, but it is still under constant exploration [4-6].

It is generally believed that the indications for laparoscopic left hemihepatectomy are: (1) The lesion is located in segments II, III, and IV of the liver, does not invade the other side, and does not involve the first and second porta hepatis. and inferior vena cava; (2) The diameter of benign tumors is ≤15 cm, and the diameter of malignant tumors is ≤10 cm; (3) If it is a malignant tumor, it is not associated with portal vein tumor thrombus, and there is no intrahepatic metastasis or distant metastasis; (4) No heart or lung metastasis , liver, kidney and other important organ functions and coagulation dysfunction. The contraindications are: (1) The lesions involve the porta hepatis and the inferior vena cava; (2) The tumors are large, generally benign tumors have a diameter of >15cm, and malignant tumors have a diameter of >10cm. Due to the large size of the tumor, it is difficult to turn and expose it. Especially for malignant tumors, even if they are reluctantly removed, the tumor will inevitably be broken during the operation. A history of upper abdominal surgery and severe abdominal adhesions are relative contraindications.

Patients undergoing laparoscopic liver resection recover quickly after surgery. They get out of bed within 24 hours and start eating in 1 to 3 days. However, you need to pay attention to complications such as blood, bile leakage, liver insufficiency, and lung infection after surgery. Complications such as small intestinal perforation, phlebitis, and gas embolism may also occur later. Gigot et al [7] retrospectively analyzed 186 cases of laparoscopic liver resection (102 malignant and 84 benign). The incidence of complications was 16·1, and 2 cases (1.1) had suspected gas embolism. The complications of laparoscopic liver resection are currently on a downward trend. For postoperative complications, prevention should be given priority and the surgical operation should be precise. If you encounter unexplained bleeding during the operation, you must not blindly electrocoagulate or clamp to stop the bleeding. The cause and location should be discovered first before treatment. If bleeding cannot be controlled, immediate conversion to laparotomy should be performed. Before the end of the operation, the abdominal cavity should be carefully explored, and the wound should be washed to confirm that there is no bile leakage, bleeding, or intestinal injury. Pay attention to the patient's vital signs and the nature of the drainage fluid after surgery to detect complications early and provide appropriate treatment.

Preoperative CT or MRCP examinations can help to fully understand the condition of the liver, the location of the lesion, and its relationship with the porta hepatis and liver blood vessels. Controlling bleeding is the key to a successful operation, especially blocking the blood flow into the liver. The left hepatic artery, left hepatic duct and left branch of the portal vein are separated and dissected and ligated with a ligation lock. The distal end is clamped with a titanium clip. After cutting, the left half of the hepatic artery can be seen. The liver turned black and showed obvious ischemic changes. Regarding whether to block the blood flow out of the liver, our approach is generally not to block it, but wait until the liver is cut to reach the left hepatic vein before ligating it with No. 7 silk suture. If the left hepatic vein does not coexist with the middle hepatic vein and is relatively free when dissecting the second porta hepatis, the left hepatic vein and liver tissue can be sutured together first. Do not forcefully separate the left hepatic vein, because it is easy to tear the blood vessel and is time-consuming. A simpler method is to do it on the left side of the falciform ligament and the upper edge of the left liver [8]. Cutting off the liver tissue: Cutting off the liver is the second difficulty in laparoscopic liver lobectomy. The ultrasonic scalpel is routinely used to cut liver tissue, with less smoke and clear anatomy. Our experience is that less tissue should be clamped each time, the liver cutting speed should be slow, and the slow gear is basically used. The advantages of this are less bleeding, less smoke, and easy identification. The tissue structure makes it difficult to accidentally damage the liver, bile ducts and blood vessels, but the cutting time is long and requires sufficient patience. Ultrasonic scalpel is not ideal for liver cutting in patients with cirrhosis. We found that using high-frequency electrocoagulation scalpel is more effective. Adjust the intensity of the electrocoagulation blade to about 80W (product of German ERBE company, adjust to 4th gear), and cut while cutting. It has edge coagulation, fast cutting speed, and satisfactory hemostatic effect. It can reduce the cost of using the ultrasonic knife. However, the disadvantage is that there is a lot of smoke. You can properly exhaust the gas during cutting to reduce the impact of the smoke.

As long as you are proficient in laparoscopic technology and liver surgery technology, and have rich clinical experience and necessary equipment conditions, laparoscopic liver resection is safe and feasible, and Wang Gang et al [9] and Hironori Kaneko et al. The report of [10] is consistent. Carrying out this kind of surgery requires relatively high professional knowledge and skills of the surgeon, including: (1) A united and collaborative team is an important guarantee for the successful completion of the surgery. (2) Hard-working dedication, especially in the early stages of laparoscopic liver lobectomy, the operation time is as long as 5-7 hours. (3) Rich experience in hepatobiliary surgery, the surgeon must have a thorough understanding of the fine anatomy of the liver.

(4) Proficient laparoscopic skills must include flexible laparoscopic suturing, knotting, and cutting techniques. In addition, the accumulation of technology and experience must be emphasized. (5) Strictly control the indications, and try to select patients whose tumors are close to the left outer lobe of the liver and whose mass is small in the early stage, and who have no history of cirrhosis, liver lobe atrophy, fibrosis, or abdominal surgery.

In short, laparoscopic liver resection has the advantages of minimally invasive surgery, such as light surgical trauma, less bleeding, quick postoperative recovery, less pain, low complication rate, and cosmetic appearance. Many studies have shown that laparoscopic surgery has a smaller impact on the body's immune system than open surgery, and the short-term efficacy of laparoscopic liver resection is better than that of conventional open liver resection [9]. However, there is currently a lack of data on its long-term efficacy in a large number of cases. Controlled study. With the continuous accumulation of experience in laparoscopic resection surgery and the advancement and innovation of laparoscopic surgical instruments, its surgical indications will continue to expand, and laparoscopic liver resection will gradually be carried out and popularized.