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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2020, Vol. 13 ›› Issue (03): 166 -172. doi: 10.3877/cma.j.issn.1674-6899.2020.03.009

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腹腔镜肝切除评分模型可行性分析
夏阿东 1, 王巍 2 , †( ), 白光 2, 张一范 1, 杨涛 2, 黄寅鹏 2   
  1. 1. 121000 锦州医科大学研究生学院
    2. 121001 锦州医科大学附属第一医院普外科（微创）肝胆
  • 收稿日期:2020-04-01 出版日期:2020-06-30
  • 通信作者: 王巍

Practicability of surgical difficulty scoring model for laparoscopic liver resection

Adong Xia 1, Wei Wang 2 , †( ), Guang Bai 2, Yifan Zhang 1, Tao Yang 2, Yinpeng Huang 2   

  1. 1. Jinzhou Medical University, Jinzhou 121000, China
    2. Department of (Minimally Invasive) Hepatobiliary of General Surgery, Jinzhou Medical University Affiliated First Hospital, Jinzhou 121001, China
  • Received:2020-04-01 Published:2020-06-30
  • Corresponding author: Wei Wang
  • About author:
    Corresponding author: Wang Wei, Email:
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目的

应用腹腔镜肝脏切除术难度评分模型来评估手术难度，通过对比不同难度分组间的差异来评价该评分模型的临床可行性。

方法

回顾锦州医科大学附属第一医院普外科(微创)肝胆病区2016年10月至2019年10月行腹腔镜肝切除术的68例患者，收集围手术期资料，分别用Hasegawa和Ban提出的评分模型(scoring model of Hasegawa和scoring system of Ban，即SM-H与SS-B)进行分组。通过比较不同难度组间的差异来评价评分模型的实用价值。

结果

按SM-H进行分组的低度困难组与中度难度组之间的术中出血量、手术时间、住院时间比较，差异有统计学意义(P<0.05)；按SS-B进行分组的低、中度困难组之间比较，差异无统计学意义(P>0.05)。

结论

SM-H腹腔镜肝脏切除术难度评分模型将为肝胆外科医师在对低、中度困难病例实施腹腔镜肝脏切除术前进行难度评估起到直观的量化作用。SS-B在预估低、中难度腹腔镜肝脏切除病例的术中出血量、手术时间、住院时间方面有一定参考意义。

关键词: 腹腔镜, 肝脏切除术, 评分模型, 可行性
Objective

To use the surgical difficulty scoring model for laparoscopic liver resection to evaluate the difficulty of surgery, and to analyze the practicability of scoring model by comparing the differences between each difficulty groups.

Methods

The clinical data of 68 patients were reviewed in this study, who underwent a pure laparoscopic liver resection in the department of (minimally invasive) Hepatobiliary of General Surgery, Jinzhou Medical University Affiliated First Hospital, from Oct. 2016 to Oct.2019. First, the characteristics and surgical outcomes during perioperative period were collected. Next, these cases were scored by using the scoring models, respectively presented by Hasegawa (scoring model of Hasegawa, SM-H) and Ban (scoring system of Ban, SS-B), then divided into groups of different difficulty. Finally, the practicability of the scoring model in practical application was evaluated by comparing differences among each groups on the factors of the blood loss in surgery, the length of surgical time and the length of hospital stay.

Results

There were significant differences(P<0.05) in the blood loss, length of surgical time and length of hospital stay between the low difficulty group and medium difficulty group by adopting SM-H. And by applied the SM-B, there were no significant differences(P>0.05) could be found between the low difficulty group and medium difficulty group, in the factors of blood loss, surgical time or length of hospital stay.

Conclusions

SM-H, this laparoscopic liver resection surgical difficulty scoring model could provide a very intuitive quantitative way for hepatobiliary surgeons to evaluate the difficulty of surgery before performing laparoscopic liver resection in low or medium difficulty cases. SM-B has some reference significance in estimating blood loss, surgical time or length of hospital stay in the case of low and mid-difficult laparoscopic liver removal.

Key words: Laparoscopic, Liver resection, Scoring model, Practicability
表1 腹腔镜肝脏切除评分模型回顾
参考文献 时间 手术难度衡量指标 提出模型
Ban等[ 6 ] 2014年 基于专家主观判断 10级难度评分系统
Hasegawa等[ 7 ] 2017年 手术时间 难度评分模型
Kawaguchi等[ 8 ] 2018年 手术时间、出血量及转换A 基于切除范围的难度分级模型
Tong等[ 9 ] 2018年 转换及术后并发症A 转换及术后并发症风险预估模型A
Halls等[ 10 ] 2018年 术中并发症 术中并发症风险等级模型
图1 腹腔镜肝切除术纳入与排除患者
图2 腹腔镜肝切除术患者术前借助3D可视化技术协助判断肿瘤的定位和与血管关系
图3 Hasegawa提出的评分模型
图4 Ban等提出的评分系统(SS-B)
图5 Ban等提出的腹腔镜肝切除10级难度分级
图6 腹腔镜肝切除术患者分别按两种评分模型的分组情况
表2 腹腔镜肝切除术纳入患者的信息和手术资料
纳入患者 56例
年龄(岁) 55(41～66)
性别(男/女)[例(%)] 30(53.6%)/26(46.4%)
切除方式A[例(%)] 34(60.7%)/19(5.4%)/0(0.0%)/3(33.9%)
肿瘤的定位(S2～8)[例(%)] 18(32.1%)/10(17.9%)/8(14.3%)/5(8.9%)/0(0.0%)/6(10.7%)/9(16.1%)
BMI(kg/m2) 22.9(20.9～23.4)
PLT≤100×109/L[例(%)] 12(21.4%)
SM-H得分(0/1/2/3/4/5分)[例(%)] 30(53.6%)/8(14.3%)/6(10.7%)/12(21.4%)/0(0.0%)/0(0.0%)
SM-H难度分级B[例(%)] 38(67.9%)/18(32.1%)/0(0.0%)
肿瘤大小(cm) 4.0(2.6～5.5)
邻近或侵犯大血管[例(%)] 0(0.0%)
恶性肿瘤[例(%)] 10(17.2%)
Child-Pugh A[例(%)] 53(94.6%)
SM-B得分(1/2/3/4/5/6/7/8/9/10分)[例(%)] 2(3.6%)/7(12.5%)/2(3.6%)/8(14.3%)/25(44.6%)/6(10.7%)/0(0.0%)/3(5.4%)/1(1.8%)/2(3.5%)
SM-B难度分级C[例(%)] 11(19.6%)/39(69.6%)/6(10.7%)
手术时间(min) 145(96～165)
术中出血量(ml) 100(50～100)
术后并发症[例(%)] 6(10.7%)
并发症≥3级[例(%)] 0(0.0%)
住院时间(d) 10(8～12)
表3 腹腔镜肝切除术患者按SM-H分组时不同难度组间术前比较
组别 例数 年龄(岁) BMI(kg/m2) PLT<100×109/L[例(%)]
低度困难 38 55(42～63) 23.1(20.2～23.9) 3(7.9%)
中度困难 18 57(51～66) 22.48(21.1～23.0) 9(50.0%)
统计值 ? t＝252 t＝270 χ2＝10.48
P值 ? 0.113 0.206 0.001
表4 腹腔镜肝切除术患者按SM-H分组时不同难度组间术后比较
组别 例数 手术时间(min) 术中出血量(ml) 并发症[例(%)] 住院时间(d)
低度困难 38 133(89～146) 100(50～100) 0(0.0%) 10(8～11)
中度困难 18 148(100～250) 100(50～300) 6(33.3%) 15(8～18)
统计值 ? t＝227 t＝233 χ2＝10.92 t＝211
P值 ? 0.043 0.038 0.001 0.021
图7 腹腔镜肝切除术患者按SS-B分组时三组之间术后比较
表5 腹腔镜肝切除术患者按SS-B分组时不同难度组间术前比较
组别 例数 年龄(岁) BMI(kg/m2) PLT<100×109/L[例(%)]
低度困难 11 49(41～57) 23.9(23.1～29.0) 0(0.0%)
中度困难 39 59(49～64) 21.2(20.2～23.2) 9(23.1%)
高度困难 6 59(52～66) 22.9(20.9～23.4) 3(50.0%)
H值 ? 7.09 17.72 -
P值 ? 0.029 <0.000 0.053a
表6 腹腔镜肝切除术患者按SS-B分组时不同难度组间术后比较
组别 例数 手术时间(min) 术中出血量(ml) 并发症[例(%)] 住院时间(d)
低度困难组 11 95(70～145) 100(50～100) 0(0.0%) 8(8～12)
中度困难组 39 140(100～165) 100(50～100) 0(0.0%) 10(8～11)
高度困难组 6 255(249～266) 550(300～1 000) 6(100%) 20(17～24)
H值 ? 17.36 19.31 - 14.97
P值 ? <0.000 <0.000 0.001a 0.001
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