肝尾状叶及其血管的断层解剖学研究

为给肝尾状叶疾病的影像诊断和外科手术提供形态学依据，本文利用成人腹部连续横断层标本22例、矢状断层标本14例和冠状断层标本5例研究了肝尾状叶及其血管的断层解剖。肝尾状叶有5面，在外形上可分为固有肝尾状叶(Spigelian叶)、腔静脉旁部和尾状突三部分。固有肝尾状叶，在横断面上，14例(63．6％)伸出腔静脉后突，11例(50％)出现孤立乳头突现象；在矢状断面上，4例(28．6％)下端出现分叉。在15例(68．2％)横断层和12例(85．7％)矢状断层标本上，可见肝尾状叶鞘系，主要出现于肝门静脉左支横部层面。在断层标本上，可见1～3支尾状叶静脉，大部分汇入下腔静脉肝后段的中、下份。粗大的肝右后下静脉分别见于10例(45.5％）横断层、4例(28.6％）矢状断层和l例冠状断层标本上。此外，文内还详细探讨了肝尾状叶在横、矢、冠状断面上的识别、毗邻及其在影像诊断和在肝切除术中的意义。     

尾状叶切除术的应用解剖

目的：通过肝尾状叶的应用解剖学研究,为肝脏尾状叶切除术的入路和发展提供解剖学基础。方法：通过40具尸肝尾状叶标本的解剖观察和8具肝脏铸型标本的观察研究,揭示尾状叶的形状、边界、毗邻和血管胆管分布规律。结果：①尾状叶左侧的形态、大小、边界变异不大,其血液供应胆管引流有一个相对固定的“蒂”,手术切除比较容易;②尾状叶的血管供应胆管引流繁杂,但均连接于Glisson's管的一二级分支的前上缘,沿肝门板后方向上解剖找出尾状叶“蒂”,从中再解剖动脉、门静脉、胆管易行,甚至一起结扎、切断也可;③肝短静脉数量、注入部位变异大,然而其走行多与腔静脉壁垂直,顺着方向解剖比较安全。结论：尾状叶切除的手术入路有四条：左入路、右入路、前入路和后入路。     

肝尾状叶的外科解剖及其临床应用

在42例成人肝脏标本上，研究了肝尾状叶的形态，动脉、静脉和肝管的分布特征；尾状叶常有3个突起，即尾状突、乳头突和下腔静脉后突，且变异较大；尾状叶有两个恒定的蒂，其结构排列由浅入深分别是门静脉支、肝动脉支和肝管。尾状叶静脉有2～5支，其中以3支居多，主要汇入下腔静脉肝后段的中、下1／3部的左前壁。中结合解剖学研究总结了施行肝尾状叶肿瘤切除术的方法和经验。     

尾状叶门静脉的应用解剖学

目的:为腹腔镜肝尾状叶切除等手术提供形态学基础.方法:32具尸体标本采用大体解剖方法观测尾状叶门静脉数量、直径、走行、来源、游离部长度(肝外长度)及毗邻解剖关系;对15例铸型标本的尾状叶门静脉进行观测;采用64排螺旋CT对5例新鲜肝标本进行扫描,并进行三维重建.记录螺旋CT影像下尾状叶门静脉内径、数量、走向及毗邻关系,与解剖研究结果比较.结果:1支以上的固有尾状叶门静脉的出现率为62.5%,其中主要以固有尾状叶门静脉后支和前支为主(27.5%),另外也有固有尾状叶门静脉左支和右支(12.5%);腔静脉旁部门静脉主要为1支,10例腔静脉旁部的实质也有固有尾状叶的分支(主要为右支或前支);尾状突门静脉主要为1支,来自于门静脉左、右支;重建的三维图像可以直观形象地体现尾状叶门静脉的空间位置关系,并可按各种方向任意旋转演示.结论:尾状叶门静脉呈左、右支双重供应,但以左侧供应为主;明胶-氧化铅血管造影可真实显示尾状叶门静脉.     

尾状叶切除术应用解剖学研究

目的：为肝尾状叶切除术提供形态学理论基础。方法：选取37具成人离体尸肝标本，采用雕琢法和断层解剖观测肝尾状叶形态、毗邻，血管系统的来源、走行，肝后腔静脉前间隙。结果：尾状叶三管系统的来源，Spiegel叶多以左肝三管系统为主，而腔静脉旁叶多以右肝或分权处为主，三管系统中，以门静脉分支分布最为稳定，尾状叶静脉变异较大；三管系统在进入尾状叶时形成簇；尾状叶有前平面及肝后腔静脉前间隙；尾状叶Spiegel叶与腔静脉旁部存在较为明显的界线，其外部标志大致与其外切迹相当，腔静脉旁部与尾状突无明显的界线。结论：肝尾状叶位置特殊，毗邻关系复杂，三管系统进入尾状叶的位置比较恒定。尾状叶的手术切除术应首先确定边界，根据相应的解剖标志来选择手术方式及入路。     

肝尾状叶的断层解剖与CT研究

目的:为临床影像诊断肝尾状叶病变提供形态学依据。方法:采用30例成人横断层标本和30例成人腹部CT图像,各选取肝尾状叶所在的4个连续横断面,观测尾状叶与脊柱的对应高度、位置、形态、毗邻关系及有关径值。结果:尾状叶在T10～L1脊柱高度均可100%显示;静脉韧带裂和下腔静脉分别居尾状叶的前、后方,可作为各层面识别尾状叶的标志结构;尾状叶的横断面形态,头侧层面以钩形多见,尾侧层面以舌形为主,断面标本和CT图像中分别有23.33%(7/30)和16.67%(5/30)乳头突与肝分离。结论:通过对肝尾状叶断面标本及其CT测量值的对比,显示两者间无显著差异;第一肝门层面肝尾状叶与肝右叶的最大横径之间有相关关系。     

尾状叶静脉的应用解剖与CT研究

目的：为腹腔镜肝尾状叶切除等手术提供形态学基础。方法：①32具尸体标本采用大体解剖方法观测尾状叶静脉数量、直径、走行、回流部位、游离部长度（肝外长度）及毗邻解剖关系。②对15例铸型标本的尾状叶静脉进行观测。③采用64排螺旋CT对10例肝脏标本进行扫描，并进行三维重建。记录螺旋CT影像下尾状叶静脉内径、数量、走向及毗邻关系。与解剖研究结果比较。结果：固有尾状叶静脉有1～3支，34．38%（11例）有固有尾状叶上静脉，90．63％（29例）有固有尾状叶中静脉，59.38％（19例）有固有尾状叶下静脉。腔静脉旁部静脉和尾状突静脉都为1支，尾状突静脉出现率34．38％（11例）。尾状叶静脉主要汇入到下腔静脉肝后段的左上区（2区）、左中区（6区）、左下区（10区）。其游离部的长度长短不一。结论：了解尾状叶静脉的形态特点及分布规律，对于提高腹腔镜尾状叶切除术中操作的安全性具有临床意义。     

肝尾状叶应用解剖学研究方法的设计与比较

目的为临床应用解剖学系统研究肝尾状叶位置、形态、毗邻,血管系来源、走形、分布及胆道系,设计简易、高效,具有针对性研究方法,以期为肝尾状叶切除术提供形态学理论基础。方法选用防腐与新鲜管道灌注的肝脏,采用大体解剖、断层、管道铸型、管道造影术等方法,对肝脏尾状叶进行系统的解剖学研究。结果上述各方法均能清晰地显示肝尾状叶位置、形态、毗邻、血管系来源,及胆道系统,但各具特色。大体解剖法清楚明确地显示肝尾状叶位置、形态、界邻结构;断层法通过不同方向的肝断面,清楚准确地展示和表述诸结构的断面形态、位置及毗邻;管道铸型法清晰直观地显示肝尾状叶内部管道结构;管道造影法使标本在CT机、MRI扫描后,获得数据集,利用Mimics10.01、3D-Doctor、Amkira4.1等电脑软件,能进行肝脏尾状叶外表和内部结构3D可视化。结论大体剖制法、断层法、管道铸型法、管道造影术等是系统研究肝脏尾状叶位置、形态、毗邻和内部管道结构有效的方法。     

下腔静脉肝后段的应用解剖学

目的:对下腔静脉肝后段进行应用解剖学研究,为腹腔镜肝尾状叶切除等手术提供形态学基础资料.方法:选32具尸体标本,行下腔静脉肝后段(HIVC)的应用解剖学研究.结果:HIVC长(61.2±10.9)mm,下口内径(19.3土1.8)mm,上口内径(22.1±3.5)mm,在HIVC上1/3与中1/3之间有一个无肝短静脉区,长度为(19.1±7.4)mm.肝左静脉与肝中静脉的开口都位于左上区,其间距为0～5 mm;肝右静脉开口位于前上区.肝右下静脉口径为(5.7±2.4)mm,大于5 mm有16例.尾状叶静脉开口大部分位于HIVC的中、下1/3段,且内径大于5 mm的尾状叶静脉位于HIVC中1/3段的左中区,其他肝短静脉汇入HIVC的位置集中在中、下1/3段,大部分位于左下区和前下区.结论:在HIVC上中1/3交界处的无肝短静脉区,可放置球囊;在肝尾状叶切除手术时,从右侧依次切断尾状叶静脉较为安全.     

肝尾状叶的形态学研究

本文选取了成人肝标本 30例 ,对肝尾状叶的位置、毗邻和形态进行了观测。发现肝尾状叶上的裂隙或切迹出现率为 93.3% ,平均裂宽 2 .4±0 .8mm,平均裂深 5± 3mm。 30例标本中发现有 69个蒂 ,其中 2蒂者 2 2例 ,占 73.3% ;3蒂者 7例 ,占2 3.3% ;4蒂者 1例 ,占 3.3%。静脉韧带上方或下方有右膈下静脉注入下腔静脉。探讨了肝尾状叶手术切除中应注意的问题     

国人肝段的再认识

目的:对肝内门静脉和肝静脉重新认识,提出一种新的国人肝段划分方法,为影像学和肝外科提供断层解剖学资料。方法:使用50例上腹部连续断层标本和20例多层螺旋CT图像及三维重建图像,研究了肝内门静脉的走行和分布以及肝静脉及其属支的回流范围及其两者之间的相互关系。结果:国人肝段新的划分方法:门静脉右支主干存在时,依肝中静脉所在的正中裂将肝分为左、右半肝。右半肝被一弯曲的右叶间裂分成右前上叶和右后下叶。右前上叶依垂直段间裂分为腹侧和背侧段。右前上叶的腹侧段被水平亚段间裂分为上、下两个亚段。右后下叶依水平段间裂分为上、下两段。肝左静脉主干存在时,依肝左静脉主干所在的左叶间裂将左半肝分成左后上叶和左前下叶。左前下叶依左段间裂分为内侧和外侧段。水平亚段间裂将左前下叶的内侧段分为上、下两个亚段。依弧形背裂分尾状叶和右前上叶及左前下叶内侧段。结论:国人肝段新的划分法不仅有利于肝内微小病变的精确定位,而且便于肝外科探索新的和更加安全的术式来施行各种肝切除和肝移植。     

Arterial supply and biliary drainage of the dorsal liver: A dissection study using controlled specimens

Liver surgeons favor using the entity called the 'dorsal liver' (i.e. the caudate lobe and other paracavally located liver parenchyme of segments 7 and 8). According to minute dissection of 48 livers, we describe the territories of the left/right portal veins, hepatic ducts and hepatic arteries in the dorsal liver. In the caudate lobe, the right hepatic artery, rather than the left hepatic artery (23/48 vs 19/48 for right vs left, respectively), tended to supply the 'left' portal vein territory. Similarly, paradoxical drainage patterns, such as the right hepatic duct draining the left portal vein territory, were found in seven of 48 livers. In the territory of the hilar bifurcation, right hepatic artery dominance was also evident and various bile drainage patterns were found. These included double drainage by the bilateral hepatic ducts (3/48) and drainage into the confluence of bilateral ducts (6/48). In contrast, the arterial supply and biliary drainage of the paracavally located parenchyme of segments 7 and 8 usually depended on the proper segmental arteries and ducts and their variations were within the range of those found in other parts of the right lobe. Therefore, the dorsal liver concept may not be anatomical but, rather, simply aimed at usefulness in surgery. Nevertheless, clear subdivision of the caudate lobe according to biliary drainage and/or arterial supply seemed difficult because of the paradoxical relatioships among the portal vein, hepatic artery and bile duct. Consequently, the present results support extended surgery based on the dorsal liver concept for carcinomas involving the caudate lobe.     

How should we treat short hepatic veins and paracaval branches in anterior hepatectomy using the hanging maneuver without mobilization of the liver?

This study investigates the relevant anatomy for applying the hanging maneuver to hepatectomy by an anterior approach, where liver mobilization is not possible. Using 176 cadaveric livers, we morphometrically investigated the distribution of venous openings within the retrohepatic portion of the inferior vena cava (IVC); next, we conducted a series of experiments to identify which course for insertion of a pair of forceps preserved the thickest of these veins. After anterior dissection of the liver, we carried out an anterior incision along a plane within an area free of venous openings in the IVC. The area free of venous openings was between the thickest caudate vein and the inferior right hepatic vein (IRHV), and averaged 16.2 mm in width. When forceps were inserted along the rightward course connecting the right inferior angle of the right lobe and the same pocket-like space between the terminals of the middle and right hepatic veins, the caudate vein was very likely to be preserved, whereas the IRHV was not. In contrast, the leftward course connecting the gallbladder fossa and the pocket-like space provided an almost opposite incidence of damage. The portal territory of the hilar bifurcation was most likely to be damaged during a virtual incision along an avascular plane; however, the caudate branch of left portal origin was rarely damaged. The rightward course may be the best method for forceps insertion in cases where there is no IRHV. To preserve the caudate vein and the IRHV, taping on the right side of the IRHV and retracting to the right, or changing the direction of the forceps from leftward to rightward when the tip of the forceps is anterior to the IVC is recommended. The hanging maneuver by an anterior approach without mobilization is convenient for right or left hepatectomy for large tumors or hardened liver.     

Human liver caudate lobe and liver segment

Recently, the caudate lobe has seemed to be the final target for aggresive cancer surgery of the liver. This lobe has five surfaces: the dorsal, left and hilar-free surfaces and the right and ventral-border planes. Surgeons have divided the caudate lobe into three parts: Spiegel’s lobe, which is called the ‘caudate lobe and papillary process’ by anatomists, the caudate process, viewed as almost the same entity by anatomists, and the paracaval portion corresponding to the dorsally located parenchyma in front of the inferior vena cava. All three parts are supplied by primary branches originating from the left and right portal veins, including the hilar bifurcation area. The hilar bifurcation branch often (50%) supplies the paracaval portion and it sometimes (29%) extends its territory to Spiegel’s lobe. It was postulated by Couinaud that the paracaval portion or the S9 is not defined by its supplying portal vein branch but by its ‘dorsal location’ in the liver. Couinaud’s caudate lobe or dorsal-liver concept caused, and still now causes, great logical confusion for surgeons. We attempt here to describe the margins of the lobe, border branches of the portal vein, the left/ right territorial border of the portal vein or Cantlie’s line and other topics closely relating to the surgery within these contexts. Finally, the caudate lobe as a liver segment will be discussed.     

肝门静脉肝内分支的形态观测及临床意义

目的 测量肝门静脉入肝后的左干、右干的有关数据，为临床肝脏疾病导管介入治疗等应用提供形态学资料。方法 取无肝病死亡后的人体肝脏标本，用游标卡尺和三角尺等进行有关数据的测量。结果 肝门静脉左干横部的长度为23～33mm；横部的根部外径为6．2～10．8mm；左干矢状部外径为6．5～9．9mm；左干外上叶支外径为3．3．6．5mm。肝门静脉右支主干长度为15～25．8mm；根部的外径为8．4～12．0mm；右后叶支外径为5．0～9．4mm；右前叶支外径为4．6～9．2mm。结论 有关形态学测量数据在肝脏疾病的导管介入性治疗和诊断应用中具有一定的参考价值。     

Right ligamentum teres joining to the right branch of the portal vein

Ligamentum teres joining to the right branch of the portal vein in a 79-year-old Japanese male cadaver was noted during student dissection at Kumamoto University in 2004. The ligamentum teres entered the liver along the left side of the gallbladder fossa. The quadrate lobe was not distinguished from the left lobe in the visceral surface. When the liver parenchyma was removed by tearing off to expose the branches of the portal and hepatic veins, it was clarified that the ligamentum teres unusually joined to the bifurcation of the upper anterior and lower anterior branches of the right branch of the portal vein. The ligamentum teres is the remnant of the umbilical vein working throughout fetal life. Initially a pair of the umbilical veins entered the sinus venosus. During the fourth and fifth weeks they connect to the hepatic sinusoids, which become the portal and hepatic veins, and the parts entering the sinus venosus of both umbilical veins disappear. By the eighth week, as all remainder of the right umbilical vein disappears, the left umbilical vein is the only one to carry blood from the placenta to the liver. It results in the ligamentum teres joining to the left branch of the portal vein. However, in the present case it is thought that the right umbilical vein remained instead of the left one for some reason, and it then became the right ligamentum teres joining to the right branch of the portal vein.     

Retrograde portography of the right caudate lobe via the middle hepatic vein

Hepatobiliary resection with caudate lobectomy has been conducted in the surgical treatment of bile duct carcinoma of the hepatic hilus. However, insufficient attention has been paid to the anatomy of the right portion of the caudate lobe, and techniques to visualize the portal branches of the right caudate lobe (P1r) have not been reported. Contrast medium was injected into the dorso-caudal branches of the middle hepatic vein (MHV) and images were obtained by digital subtraction venography. Retrograde portography of the P1r was achieved in 64 (84%) out of 76 cases. The mean number of visualized branches was 2.1 (137 out of 64) and the P1r coursed beyond the trunk of the MHV in 36 (56%) out of the 64 cases. Contrast medium flowed into the right portal vein from 59 P1r branches in 32 cases and into the left portal vein in 20 cases. No complications were encountered. Retrograde portograms of the P1r may provide valuable information not previously available to surgeons operating on the caudate lobe.