探讨Glisson蒂横断法肝切除术在儿童肝母细胞瘤切除中的应用的安全性和有效性。

选择解放军火箭军特色医学中心肝胆外科2018年4月至2019年12月期间收治的16例病理诊断明确为肝母细胞瘤的患儿。所有患儿术前均完成术前新辅助化疗3个周期(C5VD方案)，完善相关检查及全肝体积与剩余肝脏体积测定，行吲哚氰绿试验完成肝脏储备功能评估。手术方式采用Glisson蒂横断法肝切除术，术中首先解剖肝门，鞘外法解剖悬吊左、中、右3支肝蒂。根据需要切除不同的肝段，有计划地阻断相应肝蒂，精准控制切除肝段的入肝血流。行左半肝切除时先阻断左肝蒂，再沿缺血线断肝；行右半肝切除时先阻断右肝蒂与中肝蒂，再沿缺血线断肝；行肝S_5，8段切除时先阻断左肝蒂与中肝蒂，沿缺血线行S_5，8段左侧缘断肝，再阻断中肝蒂与右肝蒂，沿缺血线行S_5，8段右侧缘断肝；左三肝切除时，完全阻断中肝蒂、左肝蒂，沿S_5，8段与S_6，7段之间的缺血线断肝；行右三肝切除时，在结扎横断右肝蒂和中肝蒂基础上，还要沿肝圆韧带把支配S₄段的Glisson蒂离断，此时肝脏表面可显示S₄段与S_2，3段间的缺血线，沿缺血线切除包括S_{4，5，6，7，8}段的右三肝组织。统计患儿手术时间，术中出血量、输血量，术后严重并发症发生情况，肿瘤病理分型，术后1周复查谷草转氨酶(GOT)和谷丙转氨酶(GPT)水平、测定血浆凝血酶原时间(PT)、国际标准化比值(INR)；记录患者住院时间；出院后第1、3、6个月，门诊复查腹部超声，血常规，GOT、GPT、INR，出院后第12、18个月复查腹部CT普通扫描和增强扫描。

16例患儿均采用Glisson蒂横断法肝切除术顺利完成手术，其中4例为横断左肝蒂完成标准左半肝切除，5例为横断右肝蒂与中肝蒂完成标准右半肝切除，3例横断左肝蒂、中肝蒂以及S_5，8段肝蒂完成标准左三肝切除，保留S_6，7肝段，4例横断右肝蒂、中肝蒂及支配S₄段的左肝蒂的部分3级分支完成标准右三肝切除，术后保留S_2，3肝段。手术平均时间为(208.1±45.2) min，术中平均出血量为(268.7±99.8) mL，术中平均输血量为(200.5±50.6) mL。术后1例发生胆漏，经充分引流保守治疗后治愈，无一例发生围手术期死亡。未发生术后出血、肝功能衰竭、肺静脉栓塞等严重并发症。术后标本病理结果显示：16例患儿中，单纯胎儿型9例(56.3%)、混合性胎儿型和胚胎型4例(25.0%)、混合性上皮和间叶型2例(12.5%)、小细胞未分化型1例(6.2%)。术后1周复查GOT(64.6±20.4) U/L，GPT(70.2±14.5) U/L，PT(12.2±1.6) s，INR(1.2±0.2)，平均住院时间(8.4±1.2) d。门诊随访3～18个月，出院后第1、3、6个月，门诊复查腹部超声无局部复发，血常规，GOT、GPT、INR均正常，出院后第12、18个月门诊复查腹部CT普通扫描和增强扫描，随访期间无一例肿瘤复发。

儿童肝母细胞瘤切除时采用Glisson蒂横断法肝切除术具有简单、安全、快捷有效的特点，对于完整切除肿瘤，保护剩余肝组织功能，减少术中出血作用尤为明显，有利于儿童术后快速康复。

To explore the safety and effectiveness of Glisson pedicle transection hepatectomy in the resection of childhood hepatoblastoma.

Sixteen children whose pathological diagnosis was confirmed to be hepatoblastoma admitted to the Department of Hepatobiliary Surgery, PLA Rocket Force Characteristic Medical Center from April 2018 to December 2019 were selected. All child patients completed 3 cycles of neoadjuvant chemotherapy (C5VD regimen) before operation. The related examinations, the whole liver volume and residual liver volume were accurately measured, and indocyanine green test was performed to evaluate the liver reserve function. The operation was performed by Glisson pedicle transection. During the operation, the hilum was first dissected, and the left, middle, and right hepatic pedicles were dissected and suspended outside the sheath. According to the needs of different liver segments, the corresponding liver pedicle was blocked in a planned way to accurately control the blood flow into the liver. When performed left hepatectomy, first blocked the left hepatic pedicle and then cut the liver along the ischemic line. When performed right hepatectomy, first blocked the right hepatic pedicle and the middle hepatic pedicle and then cut the liver along the ischemic line. When performed hepatic S_{5, 8} resection, first blocked the left hepatic pedicle and the middle hepatic pedicle along the ischemic line to cut the left side of the S_{5, 8} segment, and then blocked the middle and right hepatic pedicles to cut the liver along the ischemic line to the right of the S_{5, 8} segment marginal liver. When the left third hepatectomy was performed, the middle and left hepatic pedicles were completely blocked, and the liver was cut along the ischemic line between S_{5, 8} and S_{6, 7}. In the right third liver resection, on the basis of ligating and transected the right hepatic pedicle and the middle hepatic pedicle, the Glisson pedicle which dominates the S₄ segment was also cut along the round ligament of the liver. At this time, the liver surface could show the ischemic line between the S₄ segment and the S_{2, 3} segment, and the right three liver tissues including the S_{4, 5, 6, 7, 8} segments were removed along the ischemic line. Counted the child patients′ operation time, intraoperative blood loss, intraoperative blood transfusion, occurrence of serious postoperative complications, tumor pathological classification; re-check the levels of glutamic-oxaloacetic transaminase (GOT), glutamic-pyruvic transaminase (GPT), determined the plasma prothrombin time (PT), and international normalized ratio (INR) one week after surgery. The child patients′ hospital stay was recorded; at 1, 3, and 6 months after discharge, abdominal ultrasound, blood routine, GOT, GPT, INR were reviewed in the outpatient clinic, and normal abdominal CT scans and enhanced scans were reviewed at 12 and 18 months after discharge.

All 16 children underwent Glisson pedicle transection to complete the operation successfully. Among them, 4 cases completed standard left hepatectomy by transecting the left hepatic pedicle, 5 cases completed standard right hepatectomy by transecting the right and middle hepatic pedicle, 3 cases completed standard left three hepatectomy by transecting the left hepatic pedicle, middle hepatic pedicle and S_{5, 8} liver pedicle, and 4 cases of standard right third hepatectomy by cutting right hepatic pedicle, middle hepatic pedicle and some third-order branches of left hepatic pedicle. The average operation time was (208.1 ± 45.2) min, the average intraoperative blood loss was (268.7 ± 99.8) mL, and the average intraoperative blood transfusion was (200.5±50.6) mL. Bile leakage occurred in 1 case after operation, which was cured after adequate drainage and conservative treatment. No perioperative death occurred, no serious complications such as postoperative bleeding, hepatic failure, and pulmonary vein embolism occurred. The pathological results of postoperative specimens showed that among the 16 child patients, 9 cases (56.3%) of simple fetal type, 4 cases (25.0%) of mixed fetal type and embryo type, 2 cases (12.5%) of mixed epithelial and mesenchymal type 1 case (6.2%) of small cell undifferentiated type. One week after surgery, the levels of GOT (64.6±20.4) U/L, GPT (70.2±14.5) U/L, PT (12.2±1.6) s, INR (1.2±0.2), and the average hospital stay was (8.4±1.2) d. Outpatient follow-up for 3 to 18 months, at 1st, 3rd, 6th months after discharge, the outpatient re-examination of abdominal ultrasound showed no local recurrence, blood routine and GOT, GPT, INR were normal. In the 12th and 18th month after discharge, the general CT scan and enhanced scan of the abdomen were normal. No tumor recurred during the follow-up period.

The use of Glisson pedicle hepatectomy for hepatoblastoma in child is simple, safe, fast and effective. For complete resection of the tumor, protecting the function of the remaining liver tissue, reducing intraoperative bleeding is particularly obvious, which is conducive to the rapid recovery of children after operation.