What causes hepatic hemangiomas? The factors that cause hepatic cavernous hemangioma are unclear, but most patients believe it is related to congenital development. It is speculated that it may be related to the following factors:1. Developmental abnormalities, which are caused by abnormal development of blood vessels during embryonic development, resulting in spongy expansion. About 50% of this disease develops in childhood and most have a family history. Therefore, congenital abnormal development is the most acceptable theory. 2. Regional blood circulation stagnation in the liver leads to the formation of spongy dilatation of blood vessels. Persistent intrahepatic venous blood stagnation leads to venous expansion.3. Local necrosis of liver tissue and vascular dilation into vacuolation. vascular congestion and dilation around the necrotic liver tissue and finally formation of vacuolation.4. Deformation of capillaries after capillary infection leads to capillary dilation. It is also believed that it may be related to endocrine, and women with multiple pregnancies or oral estrogen are easy to develop. The size of hepatic hemangioma varies greatly, from a few millimeters in small cases to more than 40 cm in large cases, and those with a diameter of more than 10 cm are generally referred to as giant hemangiomas. About 85% of hepatic hemangiomas are solitary, located in the right lobe of the liver and often close to the liver surface, with expansive growth, dark red or blue-purple to the naked eye, and may be irregularly lobulated; microscopically, the lesions contain many thin-walled venous cavities of varying sizes, lined with The common ones are: hepatic cavernous hemangioma: the tumor is honeycomb-shaped in cross-section and consists of blood sinuses of different sizes. Other rare hemangiomas such as sclerosing hemangioma, hemangioendothelioma and hepatic capillary hemangioma are rare in China. The clinical manifestations of hepatic hemangioma are not specific and often depend on the location and size of the tumor. If the tumor enlarges and presses the normal liver tissue, it may cause swelling or pain in the liver area; if it presses the adjacent organs such as gastrointestinal tract, it may cause abdominal distension, loss of appetite, nausea, vomiting and other gastrointestinal symptoms. Some patients may develop anemia, thrombocytopenia, and coagulation dysfunction due to the rapid growth of the tumor, but these symptoms are extremely rare. With the improvement of various diagnostic imaging techniques, hepatic hemangiomas can be easily detected, and the diagnosis can be basically confirmed by ultrasound, MRI scan or CT examination. In the past, including many clinicians also had insufficient knowledge about this disease, and they were worried about tumor cancer or rupture, which led to strong anxiety of patients and rashly took various treatment measures, which was really unnecessary. As mentioned earlier, hepatic hemangioma is not a real tumor and there are no reports of cancer; meanwhile, the chance of hemangioma rupture is extremely small, with less than 40 cases of hemangioma rupture reported in domestic and foreign literature since 1898, and most of the cases are traumatic or medical rupture, with few reports of spontaneous rupture and cancer. How is it treated? The treatment of such benign occupying lesions is mainly aimed at relieving symptoms. So, once the symptoms of abdominal pain appear, is it necessary to treat them? Our answer is no. The clinical symptoms of hepatic hemangioma are not typical. Ischemic heart disease, peptic ulcer, cholecystitis, skeletal muscle disorder and other diseases may cause similar symptoms, while some patients may also have abdominal pain symptoms due to excessive mental burden, so it is difficult to clarify the causal relationship between symptoms and hepatic hemangioma clinically. Moreover, a survey also found that about 50% of patients with hepatic hemangioma still have abdominal pain symptoms after surgery, even more significantly than before surgery. Therefore, for such patients, other diseases should be investigated first, and psychological guidance and appropriate analgesic treatment should be provided, rather than blindly choosing surgical treatment. Of course, if the patient presents with anemia, thrombocytopenia, and coagulation dysfunction, it is a clear indication for surgery. It is now the common opinion in academic circles that patients with tumor diameter less than 5 cm or even 10 cm and no obvious discomfort in the liver area may not require any special treatment, but the development of hemangioma should be monitored by regular follow-up ultrasound or MRI. A number of overseas studies have followed up patients with hepatic hemangioma and found that only 10% of the patients had significantly larger hemangiomas during the follow-up period, and some even had smaller hemangiomas. Even if the tumor is more than 10 cm in diameter, follow-up is safe if it does not cause clear symptoms in older patients. The key to choosing surgery is to weigh the risk of no treatment against the risk of treatment. The proportion of hepatic hemangiomas treated surgically in large international hepatobiliary centers is less than 5%, and the current consensus is that this type of disease should not be treated aggressively, but should be closely followed and observed, and the indications for surgery should be very strictly controlled. In 1898, Hermann first reported surgical resection for hepatic hemangioma, which is still the most thorough and effective treatment. There are two main types of surgical resection for hepatic hemangiomas: hepatic hemangioma dissection and anatomical hepatectomy. Hepatic hemangioma swells and grows, pushing and compressing the surrounding normal liver tissues, bile ducts, and blood vessels to form a lax gap, and this gap is searched for during surgery so that the hemangioma can be removed intact. This procedure can reduce the amount of bleeding and postoperative complications and maximize the preservation of normal liver tissue. Of course, hemangioma debulking has its limitations. If the tumor is multiple and confined to one liver segment, anatomic hepatectomy should be considered for complete removal of the lesion. Currently, various methods such as hepatic artery embolization, radiofrequency ablation by percutaneous hepatic puncture or microwave curing are also available for clinical treatment. Although these methods have the advantage of being less invasive, they are mainly applied to small hemangiomas, precisely where the risk of small hemangiomas is much less than that posed by these treatments, and sometimes even fatal, such as multiple liver abscesses and extensive ischemic necrosis of intrahepatic bile ducts complicated by treatment via hepatic artery embolization, which are serious complications that are difficult to cure and even life-threatening to the patient. These serious complications are difficult to cure and even life-threatening for the patient. It is not recommended at present, and the rare reports of similar treatment abroad indicate that its scientific validity is yet to be demonstrated. Indications for surgical resection The key to choosing surgery is to weigh the risks of not treating the disease against the risks associated with treatment. The internationally accepted surgical indications are summarized as follows 1. Hepatic hemangioma with clinical symptoms, such as abdominal pain, abdominal distension, vascular compression of adjacent organs, kasabach-Merritt (abnormal platelet consumption) syndrome. (Uncontroversial) 2.Hemangioma with obvious growth rate, more than 2cm within 1 year, or tumor that has occupied more than half of the liver. (Uncontroversial) 3. Tumor size: <5cm generally does not require surgery and regular follow-up; 5-10cm should be decided according to the above indications; >10cm generally requires surgical resection (advocated by some surgeons). However, the authors believe that resection should be considered for hemangiomas that occupy most of the liver and have a tendency to continue to grow, in order to eliminate any future problems. The following are relative indications and should be considered with caution! In case of laparoscopic surgery for other diseases combined with hepatic hemangioma, simultaneous laparoscopic resection of the hemangioma may be considered without increasing the risk of surgery Newly discovered “hepatic hemangioma” that is difficult to distinguish from other hepatic occupying lesions, especially if combined with positive hepatitis virus markers or a history of chronic liver disease Hemangioma in a complex and dangerous location, adjacent to Hepatic hilar or inferior vena cava, which may increase the difficulty and risk of surgery if they continue to grow, especially if they are growing rapidly. Hepatic hemangioma has the characteristic of accelerated growth during pregnancy and the risk of rupture and hemorrhage during delivery. Surgical resection may be considered for large hepatic hemangiomas that may result in trauma to the liver when the person is involved in a strenuous sporting occupation or hobby, such as boxing. Advantages of laparoscopic surgery In recent years, with the dramatic improvement in the philosophy, techniques and equipment of liver surgery, resection of hepatic hemangiomas has become a very routine and safe treatment modality. Compared with open surgery, laparoscopic hepatic hemangioma resection has the advantages of less trauma, faster recovery and better cosmetic effect. In recent years, some experts at home and abroad have reported the application of laparoscopic technology in the treatment of hepatic hemangioma one after another. The core concept of laparoscopic surgery lies not only in the small trauma on the body surface, but also in the adoption of a reasonable surgical access and the separation of anatomical tissues and organs in a manner similar to microsurgery under the magnification of the lumpectomy, with minimal intraoperative bleeding, few postoperative abdominal adhesions and fast recovery of functions. After more than 30 years of development, especially in recent years, with the continuous improvement of laparoscopic instruments and the continuous improvement of operating techniques, laparoscopy has developed by leaps and bounds in the treatment of surgical diseases and is widely used in various fields of surgery, and surgeons can perform some malignant tumor surgeries to perfection with the help of laparoscopic microscopic magnification and advanced laparoscopic surgical instruments such as ultrasonic knife and cluster ligators, etc. Many of these surgeries require blood transfusion in conventional With the help of laparoscopy, many surgeries that require blood transfusion under conventional open surgery can be completed with intraoperative bleeding control of only tens of milliliters or even a few milliliters; the scope of surgery can be expanded, and many fields that are difficult to reveal under conventional open surgery, such as narrow pelvic cavity and subseptal space, can be revealed very clearly with the help of laparoscopy, making the surgery easier to perform, and the lymph nodes can be cleared as thoroughly or even better. Compared with open surgery, laparoscopic hepatic hemangioma resection has the advantages of less trauma, faster recovery and better cosmetic effect. In recent years, some experts at home and abroad have reported the application of laparoscopic techniques in the treatment of hepatic hemangioma. The majority of hepatic hemangiomas grow slowly and are not cancerous, so don’t choose risky and traumatic treatment with too much psychological burden, and select the indications for surgery strictly. If it is proved that hepatic hemangioma needs to be removed, most of them can be removed laparoscopically, which can not only cure the tumor, but also avoid the pain of “opening the intestines”, leaving scars and numb areas of skin, with fast recovery and beauty. At present, laparoscopic technology is basically omnipotent, and even if the tumor is more than 20 cm or located in the 7th or 8th segment of the liver, it can be removed laparoscopically. The size of the tumor and its complex relationship with blood vessels should not be a contraindication to surgical operation. Today, in the era of liver transplantation, the resection of hemangioma, no matter how large or badly located it is, can be easily resected compared with malignant tumors of the liver as long as the general condition permits. The author met a 70-year-old patient who was bedridden because of the large tumor and abdominal distension, and the second operation successfully removed 7 kg of hemangioma.