巴马小型猪肝脏应用解剖学观察

目的　对小型猪肝脏进行应用解剖学研究 ,为肝移植实验研究奠定基础。方法　活体和离体 10例巴马小型猪肝脏进行解剖学观察。结果　小型猪肝脏重量、体积与体重成正相关 ,根据体重 (kg)可较准确估计肝脏重量 (g)和体积 (cm3 ) ,回归方程式分别为 :①Y =2 15 98 9 11X ,R2 =0 99;②Y =2 13 84 8 73X ,R2 =0 95。小型猪肝脏分为左外侧叶、左中叶、右中叶、右外侧叶和尾状叶 ,各叶比例分别为 (33 6 7± 0 4 8) %、(2 0 94± 1 0 8) %、(32 80± 1 81) %、(12 78± 1 4 3) %和 (3 98±0 4 4 ) %。结论　小型猪肝内管道系统解剖与人相近 ,变异较少见 ,是肝移植研究较理想的动物器官模型之一     

猪辅助性异位部分肝移植供肝的修整和断面处理

目的：探讨辅助性异位部分肝移植（AHPLT）供肝的修整和断面处理方法。方法：按照猪肝脏的解剖结构，切除左半肝，将供肝右半肝植入受体右肝下，观察受体存活率，肝功能，供肝胆汁分泌情况及病理改变；分组按不同方法处理供肝断面，A组单纯缝扎，B超用大网膜衬垫后缝扎加医用胶涂布，观察断面的处理效果，分析总结。结果：1．用供肝右半肝植入的方法，行AHPLT的肝衰受体存活率和肝功能显著优于肝衰模型组，植入肝脏胆汁分泌和肝细胞存活良好。2．B组供肝断面的撕裂机率和出血率，腹腔出血率，出血所致的病死率均显著低于A组，结论：ALPLT时，用供肝右半肝植入是合适的；供肝断面应在衬垫下缝扎，并涂布医用胶。     

腹腔镜解剖性肝中叶切除术

肝中叶是指肝左内叶和右前叶,包括Couinaud肝段划分法中的Ⅳ、Ⅴ、Ⅷ段,邻近第一、二、三肝门及肝后下腔静脉,是进出肝脏重要管道的枢纽区。肝中叶切除术用于治疗局限于Ⅳ、Ⅴ、Ⅷ段的肝胆疾病,如原发性肝癌、转移性肝癌、肝血管瘤及其他肝脏良性肿瘤、胆囊癌、肝门部胆管癌、肝中央区肝胆管结石病、寄生虫病等,与超左半肝及超右半肝切除术相比,肝中叶切除术治疗肝脏中央区肝胆疾病能保留更多的功能性肝实质,降低术后肝功能衰竭发生率,特别适合肝脏储备功能下降的患者。     

猪原位辅助性部分肝移植治疗急性肝功能衰竭的模型

目的建立猪原位辅助性肝移植(APOLT)治疗急性肝功能衰竭的动物模型,并评价其治疗效果。方法选取健康雌性良种幼猪18头,其中12头建立急性肝功能衰竭模型,另6头作为肝移植的供者。将急性肝功能衰竭的幼猪随机平均分为2组:对照组,不作任何处理;实验组,进行APOLT术,切除受者肝脏左叶,将修整后的供肝右叶移植于原肝左叶肝床处,供肝肝上下腔静脉与受者肝肝上下腔静脉行端侧吻合,供肝门静脉与受者肝门静脉行端侧吻合,受者脾动脉在结肠后与供肝动脉行端端吻合,胆总管置管外引流。结果对照组7d生存率仅为17%,而实验组为83%。实验组术后第7d肝功能基本恢复正常,组织学检查示原肝细胞再生明显。结论门静脉注射氨基半乳糖 脂多糖诱导的猪急性肝功能衰竭是一个理想的动物模型;APOLT对急性肝功能衰竭具有较好的疗效。     

前入路绕肝悬吊解剖性肝右三叶切除术治疗巨大肝癌

前入路肝切除术是指先离断肝实质后游离肝脏的肝切除方法;绕肝悬吊是指在肝后下腔静脉前方放置悬吊带,供在切肝过程中提起肝脏.2011年10月中山大学孙逸仙纪念医院采用前入路、绕肝悬吊、解剖性肝右三叶切除术治疗1例54岁男性肝癌患者.肿瘤位于肝左内叶和右半肝,长径约16 cn.术前肿瘤分期为ⅢA期,T3N0M0;术前评估ICG R15为5.4％,肝左外叶肝脏体积占标准肝脏体积的44％;左肝管受压、轻度扩张.术中首先分离、切断入肝血流,包括肝右动脉、门静脉右支、肝中动脉、门静脉左内叶分支;然后在镰状韧带的右侧离断肝实质,期间在肝后下腔静脉前打隧道并悬吊肝脏;切断右肝管;接着分离、切断肝中静脉和肝右静脉;游离肝周韧带,移出肝右二叶;最后行左肝管、肝总管端端吻合.手术时间为4h,术中出血量为350 mL.患者术后康复顺利,术后4个月复查MRCP示胆管吻合口通畅,肝内未见肿瘤复发.     

建立经腹腔镜切取活体猪左半供肝的动物模型

目的 评价经腹腔镜切取活体猪左半供肝的可行性.方法 建立经腹腔镜切取活体猪左半供肝的动物模型,其技术包括CO2气腹的建立与戳孔布局,解剖肝十二指肠韧带,腹腔镜术中超声辅助确定断肝平面,肝脏的游离,离断肝实质,肝内管道的处理.将切取的左半供肝进行冷灌注及修整,并取少量肝组织块行病理学检查.结果 10头猪接受了手术,除1头因下腔静脉出血后发生气栓死亡外,其余均成功建立模型.手术时间为(208±25)min,热缺血时间为(8±2.3)min,手术出血量为(313±75)ml.供肝切取后,残肝重要结构保留完好;供肝管道结构及组织学形态正常.结论 经腹腔镜切取活体猪左半供肝的技术是安全可行的.     

小体积肝移植动物模型建立

目的模拟建立不同移植量原位部分肝移植大动物模型。方法通过肝周骨骼化去神经效果解剖,原位灌注和肝切除术建立小型猪不同移植量原位部分肝移植动物模型。结果全肝供肝肝移植和右半肝供肝原位部分肝移植7天存活率均为100%。右中叶联合尾状叶供肝肝移植量为动物体重0.61%,7天存活率仅20%。结论右中叶联合尾状叶供肝部分肝移植可视为小体积肝移植。     

150例活体肝移植供肝的后台修整

目的 总结150例活体供肝的后台修整经验.方法 回顾性分析2007年2月至2008年5月间完成的150例活体供肝的修整资料.结果 150例供肝中,包含肝中静脉及尾状叶的左半肝3例,肝左静脉与肝中静脉成形;左外侧叶2例;带肝中静脉右半肝67例,肝右静脉与肝中静脉成形;不带肝中静脉右半肝78例.78例不带肝中静脉右半肝中23例未进行S_5、S_8静脉的重建,供肝血流恢复后S_5、S_8肝组织均有不同程度的淤血.其余55例用不同材料重建S_5、S_8静脉:新鲜尸体髂静51例,受体大隐静脉1例,受体曲张脐静脉1例,受体肝内门静脉1例,受体肝静脉1例.145例右半肝供肝中门静脉为C型的7例,均成形为一个开口.结论 HTK是活体供肝的最佳灌注、保存液,供肝流出道恰当的成形、重建不但可简化供肝植入的操作步骤,还可最大限度的保护有功能的肝组织,是受体术后顺利恢复的关键.     

经裸区肝脏悬吊法行右肝巨大肿瘤切除术

Belghiti等于2001年首次提出肝脏悬吊法经前入路行右半肝切除术,但由于其在肝后下腔静脉前方盲目建立隧道过程中,易撕裂肝短静脉和肝实质引起出血,难以推广。此后陈孝平等建立一种新的肝脏悬吊技术,即沿腔静脉右侧肝后间隙经肝裸区做隧道置悬吊技术。该方法简单、安全,能充分显露深部肝断面,便于止血,尤其是可有效控制来自肝静脉分支的出血。本文介绍我们应用经裸区肝脏悬吊法行右肝巨大肿瘤右半肝切除的经验,并就其相关的解剖学要点,操作要领以及术中应注意的问题进行讨论。     

全血管阻断下的肝切除

在肝脏肿瘤,特别是位于中央或靠近肝静脉和腔静脉者的手术中,主要危险仍然是大出血和空气栓塞。作者探讨全血管阻断(TVI)时行肝切除的价值,即彻底游离肝脏,阻断肝上、下方下腔静脉(IVC)和肝门血管。对16例位于肝中叶或接近肝静脉和下腔静脉的肿瘤,均行TVI法,4例还阻断腹腔动脉上方的主动脉,另2例行扩大肝切除和尾叶切除时,还分别阻断有关的肝静脉。3例的肿瘤侵犯到左、右肝管分叉处,故行胆道切除和重建术,1例由于肿瘤侵犯到门静脉分支处加作了门静脉切除,另一例还行腔静脉切除,腔静脉取自体大腿浅表静脉重建。血管阻断时间为     

采用不含肝中静脉的右半肝行成人间活体肝移植

目的探讨采用不含肝中静脉的右半肝行成人间活体肝移植的可行性及安全性。方法2002年1月至2005年8月,我院施行了16例成人间右半肝活体肝移植,术中采用了不含肝中静脉的右半肝移植物,同时进行了一系列改良的手术技术包括肝右静脉的重建,右肝下静脉的重建,肝中静脉分支的搭桥等改进。结果全组供者无严重并发症及死亡。前2例受者中,1例发生肝静脉吻合口狭窄,1例因发生小肝综合征,死于肝功进行性恶化。后14例受者中发生并发症5例:急性排斥反应,肝动脉栓塞,胆漏,左膈下脓肿及肺部感染各1例;1例再移植术后肺部感染死于MODS。14例中除肝右静脉与下腔静脉(IVC)直接吻合外,其中5例加行右肝下静脉重建,另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅。移植物与受者重量比(GRWR)为0.72%~1.15%,11例<1.0%,其中2例<0.8%,无小肝综合征发生。结论采用了改进的手术技术,特别是肝静脉流出道的充分重建可有效的避免小肝综合征,从而使采用不含肝中静脉的活体右半肝移植成为安全可靠的手术方式。     

活体右半供肝Ⅴ和Ⅷ段静脉回流的重建方法

目的 总结活体右半供肝移植中,不含肝中静脉的右半供肝Ⅴ、Ⅷ段静脉回流的重建方法.方法 回顾性分析55例活体右半供肝移植中,不含肝中静脉的右半供肝Ⅴ、Ⅷ段静脉回流重建的临床资料.所有供者均通过了受者标准肝体积、供肝与受者体重比(GRWR)、供肝与受者标准肝体积比及供肝内血管解剖等指标的综合评估.供肝在切取、灌注及修整后,51例采用尸体髂静脉作为重建材料,其他4例分别采用受者的大隐静脉、曲张的脐静脉、肝内门静脉和肝静脉作为重建材料,以串联的方式重建供肝断面Ⅴ、Ⅷ段静脉回流.肝移植时,供肝肝右静脉与受者肝右静脉开口吻合,重建的Ⅴ、Ⅷ段静脉与受者肝中、肝左静脉汇合部吻合,供肝门静脉与受者门静脉右支或主干吻合.门静脉开放血流后依次重建肝动脉及胆道.术后对供、受者进行常规监测.结果 1例受者术后发生流出道梗阻,术后第43天死亡;1例受者术后第7天出现不明原因的急性重型肝组织坏死,行尸体供肝肝移植后痊愈.其余53例受者恢复顺利,术后4周时腹部CT检查显示重建的移植肝Ⅴ、Ⅷ段静脉回流通畅.55例供者术后均恢复顺利,术后2周出院.结论 不含肝中静脉的活体右半供肝Ⅴ、Ⅷ段静脉回流的重建在活体肝移植中是可行的,应选择合适的重建材料及手术方式.受者肝移植后临床效果良好.     

右叶活体肝移植的肝静脉应用解剖研究

目的 研究右叶活体肝移植的肝静脉应用解剖.方法 解剖观测133例成人肝静脉的分支数、最大径、长度、肝外长度、汇合;肝中静脉相对于肝中裂的偏移程度等指标.结果 A型:粗大的肝右静脉和小的右副肝静脉,占59.4%,B型:中等大小的肝右静脉和中等大小的右副肝静脉,占27.8%,C型:小的肝右静脉和粗大的右副肝静脉,占12.8%.肝左静脉与肝右肝静脉共干,占60.3%,共干长度(1.12±0.61)cm,大小(1.29±0.40)cm.96.15%肝中静脉相对于肝中裂的向右偏移,偏移程度(14.11±12.65)°.结论 该组肝静脉的结果 提示中国人的肝静脉分型中各型所占的比例与国外文献报道明显不同;中国人可能更适合右叶活体肝移植.     

Porcine living liver transplantation using a vascular prosthesis to replace the intrahepatic vena cava.

BACKGROUND: This study aimed to determine whether the porcine model could be adapted to accommodate living donor liver transplantation (LLT). Because the pig hepatic anatomy precludes a standard approach, a study was designed to evaluate the results using a segment of vascular prosthesis to replace the intrahepatic portion of the inferior vena cava (IVC) with establishment of hepatic venous drainage into the graft. METHODS: A total of 10 LLT were performed using 20 pigs. After left hepatectomy, the intrahepatic IVC was replaced with a modified aorto-iliac prosthesis, anastomosing the proximal (aortic limb) to the infradiaphragmatic IVC, one distal iliac limb to infrahepatic IVC and the other (after shortening) to establish hepatic venous drainage after transplant. Conventional venous bypass was used, and no immunosuppressives were administered. RESULTS: All donors survived the 10-day posthepatectomy observation period. Eight of the 10 transplanted pigs survived at least 2 days (mean 7.6 days; range 3-13 days). No evidence of caval graft thrombosis was observed. CONCLUSIONS: Replacement of the recipient intrahepatic IVC by a vascular prosthesis allows to overcome the major technical obstacle which has limited the use of pigs in LLT.     

Sling suspension of the liver in donor operation: a gradual tape-repositioning technique

BACKGROUND: To control bleeding in the deeper parenchymal plane in right hepatectomy, Belghiti et al. (J Am Coll Surg 2001;193:109) proposed a liver-hanging maneuver using a sling passed between the anterior surface of the inferior vena cava (IVC) and the liver parenchyma. We applied this technique in donor operations in which a hepatic parenchymal transection should be performed before dividing the feeding or draining vessels for the graft. METHODS: After passing a tape between the liver and the IVC, the lower tip of the tape is pulled up behind the hepatic hilum to enable effective traction of the dorsal part of the liver. To preserve significant middle hepatic vein (MHV) tributaries in right-liver graft, the tape is gradually repositioned behind the veins, and parenchymal transection is completed before dividing the venous tributaries. Congestion of the graft is minimal until harvest. In right hepatectomy with the MHV, the tape is switched behind the MHV to preserve the MHV. RESULTS: Since March 2000, this technique has been used in 71 consecutive donor operations, including 37 right hepatectomies without the MHV, 8 right hepatectomies with the MHV, 20 left hepatectomies with the caudate lobe, and 6 right lateral sectorectomies. Taping behind the liver was successful in all but one donor (98.6%). There were no major complications related to this procedure. CONCLUSIONS: This new approach to the sling suspension of the liver with a gradual tape manipulation facilitated the suspending action and was useful in four types of donor operation. These techniques are feasible in most living donors and are recommended as basic procedures to enhance the safety of the donor and the quality of the graft.     

Auxiliary heterotopic partial liver transplantation in pigs with acute liver failure

Fulminant hepatic failure is usually fatal without liver transplantation; however, orthotopic liver transplantation is often difficult to perform due to the high risk of coagulopathy and the development of multiple organ failure. Auxiliary heterotopic partial liver transplantation (APLT), however, has the potential to provide an effective hepatic support system considering that the host liver is left in situ and the surgical procedure is less invasive. In this report, we describe the beneficial effects of performing 60% APLT on the hepatic function and survival of pigs with acute hepatic failure induced by hepatic artery ligation. The pigs were divided into a control group of nine animals (group 1) that had portal vein and hepatic artery ligation with a side-to-side portacaval shunt, and an APLT group of seven animals (group 2) that had portal vein and hepatic artery ligation with APLT. The two left lateral lobes of the donor liver were resected, reducing the liver weight to about 60%, and the graft was placed in the right subhepatic space. No deaths occurred intraoperatively. In group 1, eight pigs died of massive liver necrosis within 48 h and one died between 48 and 72 h (median surivival 23 h). In group 2, two pigs died within 72 h due to preservation or anesthetic problems, but five survived for more than 3 days (median survival 13.4 days), with a significant difference between the two groups (P<0.05). One animal was killed 30 days after APLT and excellent graft function was demonstrated by the synthesis of clotting factors, ammonia detoxification, and glucohomeostasis. Moreover, evidence of hepatic regeneration was found in the transplanted livers. These results indicate that APLT provides metabolic support and improves survival in animals with induced acute liver failure.     

活体右半肝移植的流出道重建21例

目的 探讨活体右半肝移植中的流出道重建技术,预防肝静脉淤血的发生.方法 回顾分析21例成人活体右半肝移植的临床资料.供者标准肝体积为1150.1～1629.8 cm3,供肝重量为585～920 g,与受者标准肝体积比为43%～67%,与受者重量比为0.82%～1.59%,供者残肝体积百分比为32%～55%,供肝大泡脂肪变性均＜10%.对于含肝中静脉的供肝,将肝中静脉和肝右静脉开口修整成尽可能大的三角形开口,供肝植入时,与受者肝右静脉扩大的三角形开口行端侧吻合.不含肝中静脉的供肝,如存在粗大的肝中静脉属支(直径超过5 mm),则用自体或异体血管搭桥(无粗大的肝中静脉属支者采用肝右静脉)与受者腔静脉直接吻合.供肝门静脉右支直接与受者门静脉主干吻合,供肝动脉与受者肝动脉行端端吻合,供肝右肝管与受者肝管行端端吻合.结果 21例供肝中,4例含肝中静脉,17例不含肝中静脉,其中有2例采用自体大隐静脉搭桥,5例采用冷冻的异体髂动脉搭桥,10例采用肝右静脉直接与受者腔静脉吻合.术后1个月,重建肝中静脉属支的7例受者流出道均通畅.含肝中静脉者、不含肝中静脉的血管搭桥者及不含肝中静脉且未使用血管搭桥者术后1年存活率分别为75%、85.7%和70%,三者间比较,差异均无统计学意义(P＞0.05).术后受者发生胆道并发症7例;发生小肝综合征1例,经脾动脉栓塞治疗后痊愈.术后供者未发生严重并发症,随访6～31个月,均恢复正常工作生活,无一例死亡.结论 含肝中静脉与不含肝中静脉的右半供肝植入后均可取得良好的临床效果.如果右半供肝不含肝中静脉,采用自体或异体血管重建肝中静脉属支是预防肝淤血和保证移植肝功能的有效方法.     

Close relation between the inferior vena cava ligament and the caudate lobe in the human liver

Background/Purpose This study was conducted to clarify the real relation between the inferior vena cava (IVC) ligament and the caudate lobe in the human liver and also to elucidate their surgical importance in liver surgery. Methods Specimens obtained from 20 adult cadaveric livers were submitted for the study. Histological structures of the IVC ligament and its relationship to the caudate lobe and the IVC were microscopically investigated. Results The IVC ligament was a broad membranous connective tissue bridging the left and right side edges of the caval groove in which the IVC was embedded. At both edges of the caval groove, the IVC ligament was continuously transformed from the Glisson's capsules of the caudate and right lobes. The component of the portal triad, which originated from that of caudate lobe, and lymphatics were distributed in the IVC ligament without exception and ectopic hepatocytes existed in it in 4 of the 20 cases. Conclusions A close relation between the IVC ligament and the caudate lobe was confirmed. The findings suggested that the IVC ligament is a kind of degenerated hepatic tissue. When dissecting it, surgeons should manipulate it carefully to prevent unexpected bleeding and bile leakage.     

Beneficial effects of 3-dimensional visualization on hepatic vein reconstruction in living donor liver transplantation using right lobe graft.

BACKGROUND: Recently, virtual operation planning and navigation systems have been introduced in the field of neurosurgery and orthopedic surgery. We report here the beneficial effects of 3-dimensional (3D) visualization on hepatic venous reconstruction in living donor liver transplantation (LDLT) using right lobe graft. METHODS: 3D-image reconstruction of the liver was rendered with 3-mm slices of helical computed tomography (CT) data using zioM900 (Zio Software Inc., Tokyo, Japan). To understand the anatomy of the donor's vessels and design an operation plan, a picture of the vessels in and around the liver was reconstructed. RESULTS: The 3D image demonstrated two short hepatic veins next to the inferior right hepatic vein (IRHV) as well as a large IRHV. The 3D image showed a more precise diameter of the right hepatic vein (RHV) and the IRHV and a more accurate distance between the two hepatic veins than did images measured by 2-dimensional CT. This preoperative information allowed the donor surgeon to dissect the inferior vena cava (IVC) and hepatic veins with reduced blood loss because of reduced risk of injury to the blood vessels. The 3D image revealed that both the RHV and the IRHV branched off at the same angle from the cylindrical IVC. Preoperative planning based on this information secured smooth anastomosis. CONCLUSIONS: 3D visualization is useful for hepatic venous reconstruction of the recipient as well as for donor surgery in LDLT using right lobe graft.