腹腔镜肝部分切除减少出血的麻醉管理
Anesthetic Management of Laparoscopic Hepatectomy to Reduce Bleeding
DOI: 10.12677/acm.2025.153591, PDF,   
作者: 曹益会:昆明医科大学第二附属医院麻醉科,云南 昆明
关键词: 腹腔镜肝切除术出血控制性低中心静脉压Laparoscopic Liver Surgery Blood Loss Controlled Low Central Venous Pressure
摘要: 在肝脏手术中实现适当的止血仍然是麻醉医生的主要关注点。因此,已经并且仍在开发许多技术来进一步降低失血和输血率。根据最新数据,文章综述的目的是总结在腹腔镜肝脏手术中减少失血量的麻醉管理的最佳可用方法。
Abstract: Proper hemostasis during liver surgery remains a major concern for anesthesiologists. Therefore, many technologies have been and are still being developed to further reduce blood loss and transfusion rates. Based on the latest data, the purpose of this literature review is to summarize the best available methods for anesthesia management to reduce blood loss in laparoscopic liver surgery.
文章引用:曹益会. 腹腔镜肝部分切除减少出血的麻醉管理[J]. 临床医学进展, 2025, 15(3): 90-98. https://doi.org/10.12677/acm.2025.153591

参考文献

[1] Bray, F., Ferlay, J., Soerjomataram, I., et al. (2018) Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68, 394-424. [Google Scholar] [CrossRef] [PubMed]
[2] Zhou, J., Sun, H., Wang, Z., et al. (2020) Guidelines for the Diagnosis and Treatment of Hepatocellular Carcinoma (2019 Edition). Liver Cancer, 9, 682-720. [Google Scholar] [CrossRef] [PubMed]
[3] Shang, H.T., Bao, J.H., Zhang, X.B., et al. (2019) Comparison of Clinical Efficacy and Complications between Laparoscopic Partial and Open Partial Hepatectomy for Liver Carcinoma: A Meta-Analysis. Journal of Laparoendoscopic & Advanced Surgical Techniques A, 29, 225-232. [Google Scholar] [CrossRef] [PubMed]
[4] Morise, Z. and Wakabayashi, G. (2017) First Quarter Century of Laparoscopic Liver Resection. World Journal of Gastroenterology, 23, 3581-3588. [Google Scholar] [CrossRef] [PubMed]
[5] Cunningham, J.D., Fong, Y., Shriver, C., et al. (1994) One Hundred Consecutive Hepatic Resections: Blood Loss, Transfusion, and Operative Technique. Archives of Surgery, 129, 1050-1056. [Google Scholar] [CrossRef] [PubMed]
[6] Arnoletti, J.P. and Brodsky, J. (1999) Reduction of Transfusion Requirements during Major Hepatic Resection for Metastatic Disease. Surgery, 125, 166-171. [Google Scholar] [CrossRef
[7] Katz, S.C., Shia, J., Liau, K.H., et al. (2009) Operative Blood Loss Independently Predicts Recurrence and Survival after Resection of Hepatocellular Carcinoma. Annals of Surgery, 249, 617-623. [Google Scholar] [CrossRef
[8] Heiss, M.M., Mempel, W., Delanoff, C., et al. (1994) Blood Transfusion-Modulated Tumor Recurrence: First Results of a Randomized Study of Autologous versus Allogeneic Blood Transfusion in Colorectal Cancer Surgery. Journal of Clinical Oncology, 12, 1859-1867. [Google Scholar] [CrossRef
[9] Kusano, T., Sasaki, A., Kai, S., et al. (2009) Predictors and Prognostic Significance of Operative Complications in Patients with Hepatocellular Carcinoma Who Underwent Hepatic Resection. European Journal of Surgical Oncology, 35, 1179-1185. [Google Scholar] [CrossRef] [PubMed]
[10] Budjan, J., Schoenberg, S.O. and Attenberger, U.I. (2017) CT und MRT der Leber: Wann, was, warum? Radiologe, 57, 366-372. [Google Scholar] [CrossRef] [PubMed]
[11] Yeo, C.T., Macdonald, A., Ungi, T., et al. (2018) Utility of 3D Reconstruction of 2D Liver Computed Tomography/Magnetic Resonance Images as a Surgical Planning Tool for Residents in Liver Resection Surgery. Journal of Surgical Education, 75, 792-797. [Google Scholar] [CrossRef] [PubMed]
[12] Xiao, G., Tang, H. and Lu, B. (2025) Application of Intraoperative Ultrasound in Laparoscopic Liver Resection with Pringle Maneuver: A Comparative Study with the Pringle Maneuver. Journal of Laparoendoscopic & Advanced Surgical Techniques A, 35, 15-21. [Google Scholar] [CrossRef] [PubMed]
[13] Yoshioka, M., Taniai, N., Kawano, Y., et al. (2019) Laparoscopic Repeat Hepatectomy with Indocyanine Green Fluorescence Navigation: A Case Report. Journal of Nippon Medical School, 86, 291-295. [Google Scholar] [CrossRef
[14] Wada, T., Kawada, K., Takahashi, R., et al. (2017) ICG Fluorescence Imaging for Quantitative Evaluation of Colonic Perfusion in Laparoscopic Colorectal Surgery. Surgical Endoscopy, 31, 4184-4193. [Google Scholar] [CrossRef] [PubMed]
[15] Kaibori, M., Ishizaki, M., Matsui, K., et al. (2011) Intraoperative Indocyanine Green Fluorescent Imaging for Prevention of Bile Leakage after Hepatic Resection. Surgery, 150, 91-98. [Google Scholar] [CrossRef] [PubMed]
[16] Li, Z., Sun, Y.M., Wu, F.X., et al. (2014) Controlled Low Central Venous Pressure Reduces Blood Loss and Transfusion Requirements in Hepatectomy. World Journal of Gastroenterology, 20, 303-309. [Google Scholar] [CrossRef] [PubMed]
[17] Vassiliou, I., Arkadopoulos, N., Stafyla, V., et al. (2009) The Introduction of a Simple Maneuver to Reduce the Risk of Postoperative Bleeding after Major Hepatectomies. Journal of Hepato-Biliary-Pancreatic Surgery, 16, 552-556. [Google Scholar] [CrossRef] [PubMed]
[18] Wu, G., Chen, T. and Chen, Z. (2021) Effect of Controlled Low Central Venous Pressure Technique on Postoperative Hepatic Insufficiency in Patients Undergoing a Major Hepatic Resection. American Journal of Translational Research, 13, 8286-8293.
[19] Liu, Z., Yang, X., Yang, H., et al. (2024) Controlled Low Central Venous Pressure Maintenance Level during Laparoscopic Hepatectomy Negatively Associated with PHLF Incidence: A Retrospective Propensity Score Matching Study. Surgical Endoscopy, 39, 1101-1113. [Google Scholar] [CrossRef] [PubMed]
[20] Lin, C.X., Guo, Y., Lau, W.Y., et al. (2013) Optimal Central Venous Pressure during Partial Hepatectomy for Hepatocellular Carcinoma. Hepatobiliary & Pancreatic Diseases International, 12, 520-524. [Google Scholar] [CrossRef
[21] Wang, W.D., Liang, L.J., Huang, X.Q., et al. (2006) Low Central Venous Pressure Reduces Blood Loss in Hepatectomy. World Journal of Gastroenterology, 12, 935-939. [Google Scholar] [CrossRef] [PubMed]
[22] Yoneda, G., Katagiri, S. and Yamamoto, M. (2015) Reverse Trendelenburg Position Is a Safer Technique for Lowering Central Venous Pressure without Decreasing Blood Pressure than Clamping of the Inferior Vena Cava Below the Liver. Journal of Hepato-Biliary-Pancreatic Sciences, 22, 463-466. [Google Scholar] [CrossRef] [PubMed]
[23] Catheline, J.M., Capelluto, E., Gaillard, J.L., et al. (2000) Thromboembolism Prophylaxis and Incidence of Thromboembolic Complications after Laparoscopic Surgery. International Journal of Surgical Investigation, 2, 41-47.
[24] Sand, L., Lundin, S., Rizell, M., et al. (2014) Nitroglycerine and Patient Position Effect on Central, Hepatic and Portal Venous Pressures during Liver Surgery. Acta Anaesthesiologica Scandinavica, 58, 961-967. [Google Scholar] [CrossRef] [PubMed]
[25] Hu, W., Li, Z. and Hu, Z. (2021) A Commentary on ‘Milrinone Is Better Choice for Controlled Low Central Venous Pressure during Hepatectomy: A Randomized, Controlled Trial Comparing with Nitroglycerin’ [Int. J. Surg. (2021) 94: 106080]. International Journal of Surgery, 94, Article 106130. [Google Scholar] [CrossRef] [PubMed]
[26] Wisén, E., Svennerholm, K., Sand Bown, L., et al. (2018) Vasopressin and Nitroglycerin Decrease Portal and Hepatic Venous Pressure and Hepato-Splanchnic Blood Flow. Acta Anaesthesiologica Scandinavica, 62, 1161. [Google Scholar] [CrossRef] [PubMed]
[27] Jian, Y., Xiaochen, J., Zongjian, S., et al. (2022) The Impacts of Corrected Left Ventricular Ejection Time Combined with Dobutamine on Hepatocellular Carcinoma Patients. Scientific Reports, 12, Article No. 21151. [Google Scholar] [CrossRef] [PubMed]
[28] Dunki-Jacobs, E.M., Philips, P., Scoggins, C.R., et al. (2014) Stroke Volume Variation in Hepatic Resection: A Replacement for Standard Central Venous Pressure Monitoring. Annals of Surgical Oncology, 21, 473-478. [Google Scholar] [CrossRef] [PubMed]
[29] Mei, X., Liu, J., Wang, Y., et al. (2019) [Application of Stroke Volume Variation-Guided Liquid Therapy in Laparoscopic Precision Hepatectomy]. Journal of Central South University (Medical Sciences), 44, 1163-1168.
[30] Hemingway, D.M., Chang, D., Cooke, T.G., et al. (1991) The Effects of Vasopressin Infusion on Hepatic Haemodynamics in an Experimental Model of Liver Metastases. British Journal of Cancer, 64, 212-214. [Google Scholar] [CrossRef] [PubMed]
[31] Raedler, C., Voelckel, W.G., Wenzel, V., et al. (2004) Treatment of Uncontrolled Hemorrhagic Shock after Liver Trauma: Fatal Effects of Fluid Resuscitation versus Improved Outcome after Vasopressin. Anesthesia & Analgesia, 98, 1759-1766. [Google Scholar] [CrossRef
[32] Fayed, N., Refaat, E.K., Yassein, T.E., et al. (2013) Effect of Perioperative Terlipressin Infusion on Systemic, Hepatic, and Renal Hemodynamics during Living Donor Liver Transplantation. Journal of Critical Care, 28, 775-782. [Google Scholar] [CrossRef] [PubMed]
[33] Verstraete, M. (1985) Clinical Application of Inhibitors of Fibrinolysis. Drugs, 29, 236-261. [Google Scholar] [CrossRef] [PubMed]
[34] Esfandiari, B.R., Bistgani, M.M. and Kabiri, M. (2013) Low Dose Tranexamic Acid Effect on Post-Coronary Artery Bypass Grafting Bleeding. Asian Cardiovascular and Thoracic Annals, 21, 669-674. [Google Scholar] [CrossRef] [PubMed]
[35] Pan, D.Q., Chen, L.L., Sun, B., et al. (2019) [Effect of Tranexamic Acid Combined Flexion Position of Hip and Knee on Perioperative Bleeding Following Unilateral Total Knee Arthroplasty]. China Journal of Orthopaedics and Traumatology, 32, 759-764.
[36] Cheriyan, T., Maier, S.P., Bianco, K., et al. (2015) Efficacy of Tranexamic Acid on Surgical Bleeding in Spine Surgery: A Meta-Analysis. The Spine Journal, 15, 752-761. [Google Scholar] [CrossRef] [PubMed]
[37] Gai, M.Y., Wu, L.F., Su, Q.F., et al. (2004) Clinical Observation of Blood Loss Reduced by Tranexamic Acid during and after Caesarian Section: A Multi-Center, Randomized Trial. European Journal of Obstetrics and Gynecology and Reproductive Biology, 112, 154-157. [Google Scholar] [CrossRef
[38] Ker, K., Edwards, P., Perel, P., et al. (2012) Effect of Tranexamic Acid on Surgical Bleeding: Systematic Review and Cumulative Meta-Analysis. The BMJ, 344, e3054. [Google Scholar] [CrossRef] [PubMed]
[39] Boonstra, E.A., Molenaar, I.Q., Porte, R.J., et al. (2009) Topical Haemostatic Agents in Liver Surgery: Do We Need Them? HPB (Oxford), 11, 306-310. [Google Scholar] [CrossRef] [PubMed]
[40] Olmez, A., Karabulut, K., Aydin, C., et al. (2012) Comparison of Harmonic Scalpel versus Conventional Knot Tying for Transection of Short Hepatic Veins at Liver Transplantation: Prospective Randomized Study. Transplantation Proceedings, 44, 1717-1719. [Google Scholar] [CrossRef] [PubMed]
[41] Wells, C.I., Ratnayake, C.B.B., Mentor, K., et al. (2020) Haemostatic Efficacy of Topical Agents during Liver Resection: A Network Meta-Analysis of Randomised Trials. World Journal of Surgery, 44, 3461-3469. [Google Scholar] [CrossRef] [PubMed]
[42] Briceño, J., Naranjo, A., Ciria, R., et al. (2010) A Prospective Study of the Efficacy of Clinical Application of a New Carrier-Bound Fibrin Sealant after Liver Resection. Archives of Surgery, 145, 482-488. [Google Scholar] [CrossRef] [PubMed]
[43] Chapman, W.C., Clavien, P.A., Fung, J., et al. (2000) Effective Control of Hepatic Bleeding with a Novel Collagen-Based Composite Combined with Autologous Plasma: Results of a Randomized Controlled Trial. Archives of Surgery, 135, 1200-1204. [Google Scholar] [CrossRef] [PubMed]
[44] Petroianu, A. (2011) Hemostasis of the Liver, Spleen, and Bone Achieved by Electrocautery Greased with Lidocaine Gel. Surgery Today, 41, 300-302. [Google Scholar] [CrossRef] [PubMed]
[45] Koea, J.B., Batiller, J., Patel, B., et al. (2013) A Phase III, Randomized, Controlled, Superiority Trial Evaluating the Fibrin Pad versus Standard of Care in Controlling Parenchymal Bleeding during Elective Hepatic Surgery. HPB (Oxford), 15, 61-70. [Google Scholar] [CrossRef] [PubMed]
[46] Neuschwander, A., Futier, E., Jaber, S., et al. (2016) The Effects of Intraoperative Lung Protective Ventilation with Positive End-Expiratory Pressure on Blood Loss during Hepatic Resection Surgery: A Secondary Analysis of Data from a Published Randomised Control Trial (IMPROVE). European Journal of Anaesthesiology, 33, 292-298. [Google Scholar] [CrossRef
[47] Jaskille, A., Schechner, A., Park, K., et al. (2005) Abdominal Insufflation Decreases Blood Loss and Mortality after Porcine Liver Injury. The Journal of Trauma: Injury, Infection, and Critical Care, 59, 1305-1308. [Google Scholar] [CrossRef] [PubMed]
[48] Cannon, R.M., Brock, G.N., Marvin, M.R., et al. (2011) Laparoscopic Liver Resection: An Examination of Our First 300 Patients. Journal of the American College of Surgeons, 213, 501-507. [Google Scholar] [CrossRef] [PubMed]
[49] Komori, Y., Iwashita, Y., Ohta, M., et al. (2014) Effects of Different Pressure Levels of CO2 Pneumoperitoneum on Liver Regeneration after Liver Resection in a Rat Model. Surgical Endoscopy, 28, 2466-2473. [Google Scholar] [CrossRef] [PubMed]
[50] Tranchart, H., O’Rourke, N., Van Dam, R., et al. (2015) Bleeding Control during Laparoscopic Liver Resection: A Review of Literature. Journal of Hepato-Biliary-Pancreatic Sciences, 22, 371-378. [Google Scholar] [CrossRef] [PubMed]
[51] Kobayashi, S., Honda, G., Kurata, M., et al. (2016) An Experimental Study on the Relationship among Airway Pressure, Pneumoperitoneum Pressure, and Central Venous Pressure in Pure Laparoscopic Hepatectomy. Annals of Surgery, 263, 1159-1163. [Google Scholar] [CrossRef
[52] Jayaraman, S., Khakhar, A., Yang, H., et al. (2009) The Association between Central Venous Pressure, Pneumoperitoneum, and Venous Carbon Dioxide Embolism in Laparoscopic Hepatectomy. Surgical Endoscopy, 23, 2369-2373. [Google Scholar] [CrossRef] [PubMed]
[53] Jin, D., Liu, M., Huang, J., et al. (2021) Gas Embolism under Standard versus Low Pneumoperitoneum Pressure during Laparoscopic Liver Resection (GASES): Study Protocol for a Randomized Controlled Trial. Trials, 22, Article No. 807. [Google Scholar] [CrossRef] [PubMed]
[54] Honda, G., Kurata, M., Okuda, Y., et al. (2013) Totally Laparoscopic Hepatectomy Exposing the Major Vessels. Journal of Hepato-Biliary-Pancreatic Sciences, 20, 435-440. [Google Scholar] [CrossRef] [PubMed]
[55] Feltracco, P., Brezzi, M.L., Barbieri, S., et al. (2008) Epidural Anesthesia and Analgesia in Liver Resection and Living Donor Hepatectomy. Transplantation Proceedings, 40, 1165-1168. [Google Scholar] [CrossRef] [PubMed]
[56] Su, Y., Pu, Y., Zhao, Z., et al. (2020) Influence of Combined Epidural Anesthesia on Cognitive Function, Inflammation and Stress Response in Elderly Liver Cancer Patients Undergoing Surgery. Oncology Letters, 19, 2733-2738. [Google Scholar] [CrossRef] [PubMed]
[57] Guo, J.R., Shen, H.C., Liu, Y., et al. (2015) Effect of Acute Normovolemic Hemodilution Combined with Controlled Low Central Venous Pressure on Blood Coagulation Function and Blood Loss in Patients Undergoing Resection of Liver Cancer Operation. Hepatogastroenterology, 62, 992-996.
[58] Morariu, A.M., Maathuis, M.H., Asgeirsdottir, S.A., et al. (2006) Acute Isovolemic Hemodilution Triggers Proinflammatory and Procoagulatory Endothelial Activation in Vital Organs: Role of Erythrocyte Aggregation. Microcirculation, 13, 397-409. [Google Scholar] [CrossRef] [PubMed]