The Clinical And Basic Study On The Effects Of Intraperitoneal And Extraperitoneal Pringle Hepatic Hilar Occlusion On Hepatic Ischemia-reperfusion Injury

Objective:The control of intraoperative bleeding has always been a problem that laparoscopic hepatobiliary surgeons face and need to solve.Hepatic parenchyma amputation and bleeding control technology is the core link of laparoscopic hepatectomy(LLR).Total hepatic blood flow occlusion(PM)is the most widely used hepatic vascular occlusion method,which can effectively reduce intraoperative bleeding.Intraoperative PM occlusion is divided into intraperitoneal occlusion(IPM) and extraperitoneal occlusion(EPM).In order to evaluate the safety and efficacy of IPM occlusion with Bulldog clamp,IPM was compared with EPM occlusion and a prospective randomized controlled study was conducted.Methods: From March 1,2020 to July 31,2021,80 patients with hepatobiliary diseases such as liver cancer and hepatolithiasis in the second affiliated Hospital of Anhui Medical University were enrolled in this study,including 40 cases of IPM blocking and 40 cases of EPM blocking.The perioperative data of the two groups were collected and short-term follow-up within 3 months after operation.Result: In terms of basic characteristics,there was no significant difference in age,sex,preoperative ALT,AST,ALB,TBIL,CRP between IPM group and EPM group.In LLR,Bulldog was used to block IPM.Compared with EPM block,there was no significant difference in the location and mode of hepatectomy,difficulty grade of operation,intraoperative blood loss,intraoperative blood transfusion and hepatectomy time(P > 0.05).However,the blocking time,blocking times and operation time in IPM group were lower than those in EPM group.There was no postoperative death in both groups.There was no significant difference in ALT and AST on the first day after operation in IPM group,and there was no significant difference in TBIL and ALB on the first,third and fifth day after operation between the two groups.However,CRP on the first day,ALT on the third day,AST on the third day,CRP on the third day,ALT on the fifth day,AST on the fifth day,CRP on the fifth day and hospital stay after operation in the IPM group were lower than those in the EPM group.Conclusion: The method of blocking IPM with Bulldog is simple,safe and effective.The IPM group can reduce the blocking time,blocking times and operation time,and there is no significant difference in postoperative complications between the two groups.In addition,the inflammatory reaction is lighter,the liver function injury is smaller and the recovery is faster after IPM occlusion.We speculate that this may be related to the less hepatic ischemia-reperfusion injury after hepatic hilar occlusion by IPM method.Obejective: PM occlusion of the first hepatic hilum is the most common method in hepatectomy,which can effectively reduce the amount of bleeding,but it can also lead to hepatic ischemia-reperfusion injury(HIRI).In liver surgery,the severity of HIRI has a strong impact on postoperative morbidity and mortality,which has become a key clinical problem that hepatobiliary surgery has to face.This clinical study found that IPM blocking with Bulldog can reduce inflammation and promote the recovery of liver function compared with EPM.The purpose of this study was to compare the effects of IPM blockade and EPM on HIRI by animal experiment.Method:The animal model of partial hepatic ischemia-reperfusion in rats was established.33 healthy male SD rats were randomly divided into: A.Sham operation group(Sham),B.IPM hepatic hilar occlusion group(n = 15)and C.EPM hepatic hilar occlusion group(n = 15).The blocking time was 30 min in both IPM group and EPM group.The changes of hepatic microcirculation before and after occlusion were detected by laser Doppler(LDR).24 h after occlusion,rat liver tissue samples were collected for HE staining and rat vena cava blood for liver function test.Result:After successfully establishing the animal model of partial hepatic ischemia-reperfusion in rats,LDR detection showed that PU in the middle lobe and left lobe of the liver decreased significantly in the IPM group,while the pu value decreased more significantly in the EPM group than in the IPM group.HE staining showed hepatic sinusoidal congestion and edema,hepatocyte swelling,vacuolation and inflammatory cell infiltration,while the histopathological changes of EPM were more obvious.The degree of injury was more serious,such as apoptosis and necrosis of flaky hepatocytes,more red blood cells in hepatic sinusoid and obvious infiltration of inflammatory cells.The histological score in EPM group was significantly higher than that in IPM group.The levels of ALT and AST in IPM group and EPM group increased 24 hours after ischemia-reperfusion,while those in EPM group increased more significantly.Conclusion: In the rat model of partial hepatic ischemia-reperfusion,we found that Bulldog was also used to block IPM.Compared with EPM occlusion,IPM group had less effect on hepatic microcirculation,less hepatocyte injury and less inflammatory reaction,and hepatic ischemia-reperfusion injury in IPM group was lower than that in EPM group.