sub redacia EUGEN TRCOVEANU

EDITURA Gr.T. Popa U.M.F. Iai 2007

Tehnoredactare: Dr. Radu Moldovanu, Dr. Alin Mihai Vasilescu Coperta: Arh. Dorin Nistor Corector: Dr. Oana Epure

ntreaga responsabilitate a opiniilor exprimate n capitolele acestei lucrri revine autorilor. Includerea materialelor din aceast carte n cadrul unor website-uri, cri, monografii, articole, publicaii electronice, se poate face doar prin consimmntul autorilor i editurii.

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AUTORIIrina-Draga CRUNTUProfesor universitar, doctor n medicin, medic primar anatomo-patologie, Disciplina Histologie, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Radu MOLDOVANUAsistent universitar, doctor n medicin, medic specialist chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Mihail Gabriel DIMOFTEConfereniar universitar, doctor n medicin, medic primar chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Dan NiculescuProfesor universitar, doctor n medicin, medic primar chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Liviu DUBEIMedic specialist chirurgie general, doctorand chirurgie general

Eugen TRCOVEANUProfesor universitar, doctor n medicin, medic primar chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai, Director Centrul de Cercetare n Chirurgie General Clasic i Laparoscopic

Dan ENEDoctorand chirurgie general

Oana Gabriela EPUREDoctor n medicin, medic primar medicin de familie

tefan Octavian GEORGESCUProfesor universitar, doctor n medicin, medic primar chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Alin Mihai VASILESCUAsistent universitar, doctorand , medic rezident chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

Simona Eliza GIUCDoctorand chirurgie general

Nuu VLADAsistent universitar, medic specialist chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai.

Cristian Dumitru LUPACUConfereniar universitar, doctor n medicin, medic primar chirurgie general, Clinica I Chirurgie I. Tnsescu - Vl. Buureanu, Spitalul Sf. Spiridon Iai, Universitatea de Medicin i Farmacie Gr.T. Popa Iai

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CUPRINSAUTORI .................................................................................................... 3 CUPRINS .................................................................................................. 5 CUVNT NAINTE ............................................................................... 11 PREFA ............................................................................................... 13 CAPITOLUL 1 ................................................................................... 15 ANATOMIA CHIRURGICAL A FICATULUI .............................. 15Eugen Trcoveanu

1.1 INTRODUCERE ........................................................................ 15 1.2 MORFOLOGIE I RAPORTURI .............................................. 15 1.3 MIJLOACE DE FIXARE I SUSINERE................................ 18 1.4 SEGMENTAREA FICATULUI................................................. 18 1.5 SISTEMUL BILIO-VASCULAR I INERVAIA ................... 21 CAPITOLUL 2 .................................................................................. 25 HISTOARHITECTONIC I HISTOFIZIOLOGIE HEPATIC . 25Irina-Draga Cruntu, Simona Eliza Giuc

2.1 CARACTERISTICI GENERALE.............................................. 25 2.2 ELEMENTE DE VASCULARIZAIE ..................................... 27 2.3 HISTOARHITECTONICA HEPATIC ................................... 28 2.4 CORELAII NTRE HISTOARHITECTONICA HEPATIC I PROFILUL MORFO-FUNCIONAL HEPATOCITAR ................ 31 2.5 HEPATOCITUL ......................................................................... 32 2.6 SINUSOIDUL HEPATIC........................................................... 36 2.7 CILE BILIARE INTRAHEPATICE ....................................... 39 2.8 PRODUCEREA I CIRCULAIA LIMFEI ............................. 40 2.9 REGENERAREA HEPATIC .................................................. 40 2.10 HISTOFIZIOLOGIE HEPATIC............................................ 41 2.10.1 Formarea bilei ..................................................................... 41 2.10.2 Funcii n relaie cu metabolismul proteic .......................... 43

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2.10.3 Funcii n relaie cu metabolismul glucidic ........................ 43 2.10.4 Funcii n relaie cu metabolismul lipidic ........................... 44 2.10.5 Funcii n relaie cu metabolismul vitaminic ...................... 44 2.10.6 Funcii n relaie cu metabolismul fierului ......................... 44 2.10.7 Funcia de detoxifiere a organismului ................................ 45 2.10.8 Funcia imun ..................................................................... 45 2.10.8 Alte funcii .......................................................................... 46 CAPITOLUL 3 .................................................................................. 47 REZECII HEPATICE......................................................................... 47Cristian Lupacu, Radu Moldovanu

3.1 DEFINIIE, OBIECTIVE, PRINCIPII ...................................... 47 3.2 CLASIFICARE I TERMINOLOGIE ....................................... 48 3.3 ISTORIC ..................................................................................... 51 3.4 INDICAII I CONTRAINDICAII ........................................ 52 3.4.1 Indicaii ................................................................................. 52 3.4.2 Contraindicaii ...................................................................... 54 3.5 PREGTIREA PREOPERATORIE .......................................... 55 3.6 ANESTEZIA............................................................................... 57 3.7 INSTRUMENTAR ..................................................................... 57 3.8 DISPOZITIV OPERATOR ........................................................ 58 3.9 TEHNICA OPERATORIE ......................................................... 59 3.9.1 Incizia ................................................................................... 59 3.9.2 Explorarea............................................................................. 59 3.9.3 Mobilizarea ficatului ............................................................ 60 3.9.4 Ecografia intraoperatorie ...................................................... 60 3.9.5 Intercepia pediculilor vasculo-biliari .................................. 62 3.9.6 Particularitile exerezei hepatice n funcie de teritoriul rezecat643.9.6.1 Hepatectomia dreapt ..................................................................... 64 3.9.6.2 Hepatectomia stng ....................................................................... 65 3.9.6.3 Sectorectomii i segmentectomii .................................................... 66

3.9.7 Trana de seciune hepatic .................................................. 66 3.10 VARIANTE TEHNICE ............................................................ 66 3.10.1 Variante ale cii de abord ................................................... 66 3.10.2 Tipul rezeciei hepatice ...................................................... 67 3.10.3 Abordul pediculilor vasculo-biliari .................................... 67 3.10.4 Secionarea parenchimului hepatic..................................... 67 3.10.5 Atitudinea asupra tranei de rezecie .................................. 68 3.10.6 Clampajul vascular ............................................................. 68 3.10.7 Alte tehnici pentru controlul hemoragiei ........................... 70

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3.11 INCIDENTE I ACCIDENTE INTRAOPERATORII ............ 71 3.12 NGRIJIRI POSTOPERATORII .............................................. 71 3.13 COMPLICAII POSTOPERATORII ...................................... 72 CAPITOLUL 4 ................................................................................... 77 TRAUMATISME HEPATICE ............................................................. 77Cristian Lupacu

4.1 DATE GENERALE .................................................................... 77 4.2 SIMPTOMATOLOGIE .............................................................. 80 4.3 STRATEGIE DE DIAGNOSTIC ............................................... 82 4.4 TRATAMENT ............................................................................ 85 4.5 HEMOBILIA .............................................................................. 93 CAPITOLUL 5 .................................................................................. 95 TUMORILE HEPATICE BENIGNE .................................................. 95Eugen Trcoveanu

5.1 CHISTUL SEROS HEPATIC .................................................... 95 5.2 CHISTADENOMUL MUCINOS .............................................. 99 5.3 HEMANGIOMUL ...................................................................... 99 5.4 HIPERPLAZIA NODULAR FOCAL ................................ 102 5.5 ADENOMUL HEPATIC .......................................................... 103 CAPITOLUL 6 ................................................................................. 107 TUMORI HEPATICE MALIGNE..................................................... 107 6.1 TUMORILE MALIGNE PR