隨著兒童肝移植的興起和操作技術(shù)的日臻完善,在行兒童肝移植手術(shù)時(shí),越來(lái)越多的肝移植中心采用切取活體的部分肝臟(一般為左外葉)作為供肝。在行活體部分供肝切取前,有必要對(duì)供體行動(dòng)脈造影以明確供體的血管解剖,在具體手術(shù)操作上,與規(guī)則性左外葉切除一致。但有幾個(gè)需注意的問(wèn)題。
(1)肝門阻斷:行肝左外葉切除時(shí),不宜行肝門阻斷,因?yàn)檫@樣可以保證不存在熱缺血時(shí)間,但可預(yù)置一阻斷管備意外時(shí)使用。切肝時(shí),用蚊式鉗鉗夾兩側(cè)小量肝組織,兩側(cè)創(chuàng)面的管道組織同時(shí)給予結(jié)扎或縫扎。
。2)可以在鐮狀韌帶右側(cè)擠壓剩余之肝臟,但切不可擠壓用于移植之左側(cè)肝臟。
(3)一般應(yīng)先游離肝臟,即先剪開左三角韌帶、左冠狀韌帶、鐮狀韌帶,使整個(gè)肝左外葉游離后再解剖肝門。
(4)肝動(dòng)脈處理:解剖出肝門后,往上游離肝動(dòng)脈,在左肝動(dòng)脈發(fā)出營(yíng)養(yǎng)左內(nèi)葉的動(dòng)脈支的近心端游離左外葉動(dòng)脈。由于左內(nèi)葉通常有足夠的側(cè)支血管為其提供動(dòng)脈血,所以,如果肝動(dòng)脈左內(nèi)支不太粗時(shí),可以將其結(jié)扎,這樣一般不會(huì)出現(xiàn)肝左內(nèi)葉缺血,同時(shí)可以獲得較長(zhǎng)的左外葉動(dòng)脈。另外,對(duì)起源于胃左動(dòng)脈的左外葉動(dòng)脈,必須加以保留。
。5)門靜脈的處理:在肝動(dòng)脈的后方,將門靜脈從周圍纖維組織中分離出來(lái)。因?yàn)殚T靜脈無(wú)彈性,分離時(shí)必須小心。門靜脈應(yīng)該保留盡可能長(zhǎng)的長(zhǎng)度。
。6)肝動(dòng)脈和門靜脈游離完成后,再分離肝左靜脈。在肝左靜脈和肝中靜脈之間仔細(xì)解剖,可將肝左靜脈游離出來(lái)。同時(shí)可將一臍帶線繞過(guò)肝左靜脈,這樣既可以控制但又不阻斷肝左外葉的出汗血流(圖5-9)。
圖5-9 活體部分供肝獲取法
1.膽總管2.肝動(dòng)脈3.門靜脈4.肝左靜脈
。7)肝實(shí)質(zhì)切開一半后,直視下在肝圓韌帶的基底部可見(jiàn)到膽管。要仔細(xì)解剖膽管,明確是單獨(dú)一支膽管還是兩支小膽管。
。8)肝創(chuàng)面處理。兩側(cè)肝創(chuàng)面直接縫扎止血后,采用褥式縫合法加強(qiáng)。但近肝靜脈處不可采用褥式縫合,以防肝靜脈回流受阻。肝創(chuàng)面也可以采用纖維膠粘貼。
。9)整個(gè)手術(shù)過(guò)程應(yīng)維持肝左外葉的正常血流,直至快速將肝動(dòng)脈、門靜脈和肝靜脈切斷。肝左外葉切取后,立即置于預(yù)備的冰鹽水中,用4℃UW溶液灌注肝動(dòng)脈和門靜脈。灌注的同時(shí),應(yīng)對(duì)創(chuàng)面的滲液作進(jìn)一步縫扎處理。
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