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。     

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。     

肝尾状叶门管系统的应用解剖研究进展

目的：探讨肝尾状叶门管系统的应用解剖研究现状,为将来肝尾状叶在临床应用中运用三维可视化技术提供解剖学依据。方法：总结前人对肝尾状叶的门管系统的组成、分布以及相关毗邻位置的研究。结果：尾状叶门管系统结构复杂,通过CT三维重建技术可得到定位。结论：门管系统在尾状叶的研究中具有多向发展。     

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。     

肝尾状叶切除术中寻找肝静脉的探讨

目的　为肝尾状叶切除术提供解剖学依据。方法　选择 6 0例肝脏标本 ,对紧贴尾状叶的肝中、肝左、肝右静脉段进行解剖和形态观测。结果　紧贴尾状叶的肝中、肝左、肝右静脉从下至上距尾状叶脏面的距离越来越小 ,从下至上彼此的间距亦越来越小 ;肝中、肝左、肝右静脉不在同一平面 5 2例 (8 6 7% )。结论　在尾状叶切除术中 ,先找到肝中静脉末端之后 ,才能更容易寻找肝中、肝左、肝右静脉     

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     

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。     

左,右肝管全程部开的应用解剖

用６个取自新鲜成人尸体的肝脏，注入ＡＢＳ丙酮溶液制成铸型。另外还解剖了经固定的４２例（成人３２，儿童１０）肝脏标本，测量左，右肝管长度，管径，并观察左，右脖管与肝动脉，门静脉及其分支的关系。提出了左，右肝管全程剖开的手术方法和注意事项。     

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.     

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。     

左外叶活体肝移植的解剖学研究

目的：模拟左外叶活体肝移植门静脉、肝动脉和胆管的切取方法。方法：解剖正常人肝脏标本30具，观察肝脏铸型标本30具，测量门静脉、肝动脉及胆管长度、管径及属支或分支分布情况。结果：左外叶门静脉的血供来自门静脉左支，主要为左外叶上段门静脉支、左外叶下段门静脉支；动脉主要来源于肝固有动脉、肝左动脉、肝中动脉，偶有迷走动脉支；胆道引流属支有左外叶上段胆管支、左外叶下段胆管支。结论：左外叶解剖变异较多，活体取肝前应仔细研究其结构特点，设计合理的切取模式；对门静脉、肝动脉和胆管支需行必要的整形，以便与受体相应的管道进行吻合。     

全肝血流阻断切肝术的应用解剖学

目的：为给临床提供肝血流阻断切肝术的解剖学基础。方法：在３７具成人尸体上解剖并观测了与肝血流阻断部位有关的结构。结果：①肝裸区深度４６．６±６．１ｍｍ，下腔静脉的膈上段长１１．７±２．４ｍｍ，外径２６．３±３．０ｍｍ，肝上段长１１．４±２．１ｍｍ，外径２７．４±５．２ｍｍ，肝下段长２７．７±６．７ｍｍ，外径为２８．１±３．８ｍｍ；②肝十二指肠韧带长４０．６±４．７ｍｍ，门静脉外径１４．０±３．４ｍｍ，肝固有动脉长２１．３±５．１ｍｍ，外径４．６±１．０ｍｍ；③膈与腹腔动脉起点间腹主动脉长２４．７±５．２ｍｍ，外径２４．５±３．１ｍｍ。结论：下腔静脉的膈上段、肝上段、肝下段、肝十二指肠韧带内结构、膈与腹腔动脉起点间腹主动脉段作为肝血流阻断的部位是可行的。     

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.     

肝左内叶及右前叶肝段超声解剖

目的:为发生于肝左内叶和右前叶的肝占位性疾病治疗提供超声解剖资料。方法:随机选取健康成人61例(男42,女19),利用彩色多普勒超声诊断仪经腹途径获取各断面超声声像图,并观察测量。结果:Ⅳa亚段内门静脉分支仅见1种类型;Ⅳb亚段内门静脉分支见2种类型,分别占62.30%、37.70%;右前叶门静脉分支见3种类型:a型占75.41%,b型占16.39%,c型占8.20%;左内叶两亚段间有48例可见肝静脉属支走行,占78.69%,其中肝中静脉属支占95.83%,肝左静脉属支占4.17%;右前叶两亚段间有54例可见肝静脉属支走行,占88.52%,其中肝中静脉属支占92.59%,肝右静脉属支占7.41%。结论:在超声水平,进一步证明右前叶两亚段间及左内叶两亚段间存在肝静脉属支,并可作为相邻两亚段间分界的解剖学标志。     

肝尾状叶应用解剖的研究与手术原则

目的为肝脏尾状叶合理化切除提供应用解剖学理论依据.方法通过24具尸体的肝尾状叶标本的解剖观察,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,其血液及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;③肝短静脉数量、注入部位变异大,其走行多与腔静脉壁垂直.结论尾状叶切除的手术入路有四条可供选择：左入路、右入路、前入路和后入路.     

Location of the ventral margin of the paracaval portion of the caudate lobe of the human liver with special reference to the configuration of hepatic portal vein branches

The topographic anatomy of the ventral margin of the paracaval portion of the caudate lobe of the human liver has not been clearly described to date. To this end we hypothesize the existence of a precaudate plane, a flat or slightly curved plane defined by the ventral margins of the ligamentum venosum and the hilar plate. Using 76 cadaveric livers, we investigated whether the paracaval portion of the caudate lobe extended ventral to this plane and whether the paracaval caudate branch of the portal vein (PC) ran through this plane to its ventral side. In 28 of the specimens (36.8%), the PC extended over the plane to a variable depth: less than 10 mm in 10 specimens, 10-20 mm in 10, and more than 20 mm in eight specimens. This ventral extension of the PC consistently included its penetration into the dome-like area under the terminals of the three major hepatic veins; therefore, the ventrally extended PC often interdigitated with these veins and their tributaries (in practice, the ventral margin of the paracaval portion of the caudate lobe could generally be considered to run alongside the middle hepatic vein). Moreover, the ventral extension of the PC often reached the upper, diaphragmatic surface or the dorsal surface of the liver immediately to the right of the inferior vena cava. Several branches (termed border branches) in the ventral extension were difficult to identify as belonging to the PC. We discuss both the marginal configuration of the paracaval portion of the caudate lobe and how to identify and operate on the ventrally extended PC and related border branches during liver surgery.     

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.     

Architecture of the caudal vena cava wall of the dog at the level of the liver caudate lobe

The vascular segment of the caudal vena cava of the dog at the level of the caudate lobe was shown to be intimately related to hepatic tissue through the hepatic capsule and parenchyma. The tunica adventitia of the caudal vena cava was formed mainly by smooth muscle cells with collagen and elastic fibers arranged in bundles. The thin tunica media of the vein was also formed by smooth muscle cells, collagen and elastic fibers arranged in bundles. The tunica intima presented an elastic subendothelial network. The hepatic segment of the caudal vena cava showed a myoconnective architecture and propulsive characteristics in terms of its hemodynamic pattern.