应用放射造影术进行肝脏数字化及其管道三维重建的研究及意义

目的探索应用放射造影术进行数字化虚拟肝脏及其管道三维可视化重建研究。方法采用4例新鲜肝脏标本进行聚乙烯醇-氧化铋造影填充剂管道灌注,经64层螺旋CT无间断连续扫描后,获得肝脏断层图像数据集加以数字化处理,利用Mimics10.01、3D-Doctor、Amkira4.1等电脑软件,构建数字化虚拟肝脏模型及其管道三维可视化重建,并对其各管道进行图像质量评估。结果①4例标本灌注全部满意,管道连续、饱满圆滑、无伪影,构建的数字化肝脏可视模型,其形态逼真,能随意旋转、放大和缩小;肝内管道系统的空间结构与外形的三维关系显示清晰,将肝脏外形与内部管道透明成像显示,可进行虚拟肝切实验;②肝内管道显影清晰,肝静脉显示级数为11.7±0.81,门静脉显示级数为11.8±0.76,胆管显示级数为10.1±0.98,肝动脉显示级数为10.2±0.98;管道三维重建图像质量平均优秀率依次为:96.21%、97.05%、97.63%、97.82%;肝内管道图像平均优秀率为97.18%。结论应用放射造影术,结合螺旋CT扫描可获得精确完整的肝脏数据资料,构建出理想的数字化虚拟肝脏及管道模型,图像质量高、空间立体感强烈,可进行临床术前虚拟肝切实验及数字化网络教学应用。     

显示肝段铸型标本的设计与制作

近年来随着内窥镜技术的发展 ,微创外科也得到了很大的发展 ,如肝胆外科采取腹腔镜下进行胆囊甚至肝段的切除。这就要求手术操作者具有较娴熟的解剖学知识。针对这种情况 ,作者为了清晰地显露肝段内管道的走行及毗邻关系 ,采取了一种先行管道灌注 ,再锯取各肝段分别腐蚀后重新复位粘接的方法 ,较好地达到上述目的 ,报道如下 :1　标本制作　　完整取下肝脏冲洗备用 ,注意不要伤及肝脏表面。将肝动脉、肝静脉、门静脉及胆总管分别插管 ,其中将肝动脉和胆道系先行灌注 2 0 %的过氯乙烯。然后从门静脉或肝静脉注入 10 %福尔马林 ,将肝脏外形撑起…     

肝内血管系联合铸型标本的设计与制作方法

肝内血管分布有3个组成系统：即穿过肝门的血管系(包括肝门静脉和肝动脉)与肝静脉系。血管系的3种血管管径大小相差很大，采用常规的灌注方法，肝静脉、肝门静脉管道铸型过密，而肝固有动脉铸型过细，制作出的铸型标本往往是只能观察肝脏外形及轮廓，而内部血管分布不清楚。在借鉴过去的铸型的经验基础上，我们对肝内血管铸型的制作进行了一些摸索与改进。现简介如下。     

肝门静脉CT三维重建在腹腔镜肝脏外科的应用研究

目的：报道肝门静脉CT三维重建应用于腹腔镜肝脏外科并评价其价值。方法：铸型标本4例及拟进行腹腔镜肝脏肿瘤切除的患者8例，用CT图像进行三维重建，评价其在腹腔镜肝脏外科的应用价值。结果：①铸型标本螺旋CT三维重建图像清晰显示肝门静脉的最远分支，血管边缘清晰光滑，肝实质与肝门静脉的空间关系明确。②病例CT三维重建图像清晰显示门静脉5级分支，肝静脉隐约显影，肿瘤内无门静脉分支血管，腹腔镜手术证实三维重建诊断，三维重建图像显示肿瘤空间位置及与周围血管关系，镜下所见与重建图像一致。结论：螺旋CT三维重建效果好，在很大程度上弥补了腹腔镜手术的局限性，是腹腔镜肝脏外科术前的重要检查方法，在腹腔镜肝脏外科的应用具有良好的前景。     

肝蒂内结构肝内分支的形态观测及临床意义

目的研究肝蒂内结构在肝内的分布状况,对肝叶及肝段进行量化分析;探讨肝脏手术时血管和胆管的保护及定位标志,为相关临床科室手术提供解剖学依据。方法取20例无肝病死亡后的人体肝脏标本及肝脏铸形标本,用游标卡尺和三角尺等进行有关数据的测量,所的数据用SPSS10.0软件进行统计学分析。结果肝蒂内结构入肝实质后三者以肝门静脉分支为主轴,攀附伴行。门静脉大多分为左、右干,部分右干缺如,且右干变异较大,肝管汇合方式常见为3型。结论肝脏血管丰富,解剖结构复杂,出血难以控制。肝脏的分叶与分段对于肝脏手术具体方式有指导作用。每一肝段都有它的单独管道系统,可以作为一个外科切除单位。     

兔肝脏及附属管道的应用解剖学研究

目的　对兔肝脏及其附属管道进行应用解剖学研究。 方法　对20只日本大耳兔分别进行活体和离体形态学观察,制作门静脉和肝静脉管道铸型标本观察其分支与走行,测定各肝叶质量及其所占肝脏百分比。 结果　兔肝肝裂明显,依据肝叶形态、肝裂走行和门静脉主干分支形式将兔肝脏分为五叶,分别为尾状叶、左外叶、左中叶、右中叶、右外叶,各肝叶质量分别为(g)：3.93±1.13、15.93±3.50、14.83±3.31、15.08±4.34、12.08±3.55。左中叶和右中叶根部肝组织融合,其余各肝叶相对独立,尾状叶包括相对独立的乳头突和尾状突两部分。各肝叶有相对独立的Glisson系统和肝静脉走行于肝蒂内。 结论　兔肝解剖学特点与多数哺乳类实验动物肝脏解剖相似,同时又具有其自身特点,适合于肝脏外科疾病动物模型的制作。     

腹腔镜肝规则切除铸型标本的制作及意义

腹腔镜肝切除是新兴的微创肝脏外科 ,具有创伤小 ,恢复快 ,可立即接受后续治疗等优点。由于肝脏血供丰富及腹腔镜无法用手直接止血等特点 ,手术难度较大 ,因此 ,了解肝裂层面与肝内管道的关系及手术入路中血管直径大小非常重要。以往的肝脏铸型标本未能显示肝裂层面 ,作者旨在制作一种新型标本 ,能清晰显示肝内血管与肝裂层面的关系 ,为腹腔镜肝规则切除提供解剖学基础。1　制作方法1.1　定形铸型灌注参照李忠华法[1] 进行灌注 ,新鲜尸体中取出肝脏 ,尽量保留肝门处管道及下腔静脉上下端 ,细心分离肝门部的结构 ,选用小口径的插管插肝管及肝…     

肝脏的三维可视化及切除术模拟研究

从CT断层数据提取出肝体、动脉、静脉、门静脉和肿瘤,采用轮廓拼接技术重建出肝脏和内部管道,然后利用交互式切割工具对其进行模拟手术切割,开发出一个基于PC的肝脏可视化与模拟切割系统。系统以V isual C++为开发工具,结合可视化类库VTK,用户可通过图形界面调节不透明值并观察肝脏及其内部管道的空间结构,同时实现交互式调节切割平面以模拟肝脏肿瘤切除术。切割面的动态调节与模拟肝切除术的效果图表明针对具体病人的CT数据进行重建可以直观地展示其三维结构,通过切割的模拟有利于术前规划和选择恰当的手术方位以减少对肝实质和血管的伤害。     

正常肝脏微血管的分布和走行——哺乳动物肝脏微血管形态学研究Ⅰ

以传统的墨汁灌注和自行建立的双色素灌注制作透明标本的方法研究小鼠、大白鼠及家兔肝脏微血管的分布和走行。发现肝动脉微血管有７种分布和走行方式。每种微血管的功能不尽相同。其中动脉性毛细血管和肝动—门静脉直接吻合枝文献中有争议，而横贯小叶性动脉及肝动—动脉吻合枝未见文献报导     

管道骨骼线三维重建在肝脏可视化的应用

目的 研究三维重建数字化虚拟肝脏的方法.方法 将肝脏管道灌注后的肝脏标本进行螺旋CT扫描,获取CT扫描连续图像数据集.然后使用面绘制移动立方体(MC)算法重建肝脏及其内部管道结构表面模型,并对模型进行平滑和简化.确定出管道树上的关键节点,并使用改进的种子生长法生成管道树.将生成管道的表面模型和管道树相结合实现交互式分析.结果 肝脏管道灌注和铸型良好,螺旋CT扫描获取连续肝脏断面图像数据集242张.基于骨骼线提取的肝脏管道结构三维重建肝脏模型形态逼真,交互性强,通过设定各结构的透明度和颜色能单独或组合显示肝脏、肝静脉和下腔静脉、门静脉、胆囊,并可通过旋转、放大、缩小模型观察各结构.结论 基于肝脏管道骨骼线的方法进行肝脏及其管道系统三维重建可视化肝脏,生成肝脏和内部管道系统,立体空间感强,交互性好.     

Secondary joining of the bile ducts during the hepatogenesis of the mouse embryo

Summary Development of the bile duct system of the mouse embryo was studied histologically and by an immunofluorescent technique. The hepatic primordium consisted of cranial and caudal portions. In the liver of young embryos, the hepatic cords were present in the presumptive cysticduct epithelium, and the histology of the presumptive cystic duct epithelium near the hilus was similar to that of the hilus epithelium. The results suggest that at least a part of the cystic duct epithelium develops from the cranial diverticulum of the hepatic primordium. Lumen structures were precursors of intrahepatic bile ducts and originated from type I (immature) hepatocytes. The lumina of the lumen structures appeared near the hilus area first, but most were discontinuous with those of the hepatic ducts. With the progress of development, the discontinuous lumen structures became distributed around the portal vein branches in the central part of the liver parenchyma, and gradually connected with each other and also with hepatic ducts. the discontinuous laminin immunofluorescence also appeared in the endodermal cells around the portal vein branches at the younger stages. Therefore, it is conceivable that the intrahepatic bile ducts originate from discrete cell populations of type I hepatocytes around the portal vein branches and subsequently become confluent, but not from the cells of hepatic ducts.     

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。     

Phylogenetic analyses of the hepatic architecture in vertebrates

The mammalian liver has a structural and functional unit called the liver lobule, in the periphery of which the portal triad consisting of the portal vein, bile duct and hepatic artery is developed. This type of hepatic architecture is detectable in many other vertebrates, including amphibians and birds, whereas intrahepatic bile ducts run independently of portal vein distribution in actinopterygians such as the salmon and tilapia. It remains to be clarified how the hepatic architectures are phylogenetically developed among vertebrates. The present study morphologically and immunohistochemically analyzed the hepatic structures of various vertebrates, including as many classes and subclasses as possible, with reference to intrahepatic bile duct distribution. The livers of vertebrates belonging to the Agnatha, Chondrichthyes, Amphibia, Aves, Mammalia, and Actinopterygii before Elopomorpha, had the portal triad‐type architecture. The Anguilliformes livers developed both periportal bile ducts and non‐periportal bile ducts. The Otocephala and Euteleostei livers had independent configuration of bile ducts and portal veins. Pancreatic tissues penetrated the liver parenchyma along portal veins in the Euteleostei. The liver of the lungfish, which shares the same origin with amphibians, did not have the portal triad‐type architecture. Teleostei and lungfish livers had ductular development in the liver parenchyma similar to oval cell proliferation in injured mammalian livers. Euteleostei livers had penetration of significant numbers of independent portal veins from their intestines, suggesting that each liver lobe might receive a different blood supply. The hepatic architectures of the portal triad‐type changed to non‐portal triad‐type architecture along the evolution of the Actinopterygii. The hepatic architecture of the lungfish resembles that of the Actinopterygii after Elopomorpha in intrahepatic biliary configuration, which may be an example of convergent evolution.     

管道铸型技术与血管造影3D可视化相结合

目的:以肝为例,探索将管道铸型与血管造影及3D可视化技术进行整合,充分揭示同一器官内部各管道系统之间的相互关系。方法:分别从肝静脉灌注自凝牙托灌注填充剂,从肝门静脉灌注乳胶、羧甲基纤维素-氧化铅填充剂。运用多层螺旋CT进行层距0.5mm薄层扫描,获取二维数据,应用Mimics软件对肝内的管道系统进行3D可视化。结果:重建后的肝门静脉充盈饱满,层次清晰,边缘光滑,层次分明。排除干扰后,自凝牙托材料灌注的肝静脉同样可以在运用CT扫描后,获取理想的管道三维重建模型。图像融合后能清晰显示肝门静脉和肝静脉在肝内的相互位置关系。结论:采用管道铸型技术与血管造影3D可视化相结合技术,不仅能在同一器官同时显示各管道系统的相互关系,更能在同一器官分别显示各管道系统。     

Preferential differentiation of the bile ducts along the portal vein in the development of mouse liver

Summary The development of bile ducts in the mouse liver was studied histochemically, with special reference to their preferential differentiation around the portal vein. Both portal vein and hepatic vein shared a common origin, the omphalomesenteric vein. In the early development of the liver, haematopoietic cells were predominant around both veins. With the progressive development of intrahepatic bile ducts, the following three steps were observed: cluster formation of type I hepatocytes around the portal vein, formation of primitive bile duct structures and basal lamina, then formation of ducts surrounded by connective tissue structures composed of type I and type III collagens and lectin-binding sites, which were predominant around the portal vein compared to the hepatic vein. These results suggest that the deposition of abundant connective tissue structures around the portal vein is a prerequisite for the cell differentiation and basal lamina formation in the bile duct precursors. A possible mechanism of the aggregation of type I hepatocytes around the portein vein is also discussed.     

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.     

左肝管全程剖开胆肠吻合术的应用解剖学研究

左肝管全程剖开手术,必须熟悉左肝管与邻近血管的局部解剖关系.为此我们用 ABS 丙酮溶液灌注塑型了6具新鲜成人尸肝脏,解剖40例(成人30,儿童10)肝脏标本,测量了左肝管长度和管径,左肝管与肝总管夹角。全程剖开左肝管与右肝管,并观察左肝管与右肝管、左肝动脉、门静脉左干和肝圆韧带的关系,提出了右肝管全程剖开手术方法和注意事项。     

肝内胆管的应用解剖与肝内胆管结石手术入路的研究

目的 探讨肝内叶、段胆管的解剖结构及肝内胆管结石的手术入路。方法 通过研究12例成人肝脏标本的肝内胆管与血管的位置、毗邻关系,设计出经肝的脏面显露左右肝管,经肝的膈面显露肝内叶、段胆管相对合的手术入路,并结合治疗56例复杂性肝内胆管结石患者。结果 左右肝管均位于肝脏脏面门静脉左右干的前上缘;左内叶、右前叶胆管位于相应门静脉的前内侧。右后叶胆管位于门静脉右前支或右前叶下段支脏面测侧者占66.7％(8/12);位于门静脉右后支脏面深侧或后上缘者占83.3％(10/12)。左外叶胆管位于门静脉矢状部脏面深侧者占91.7％(11/12)。选择经肝的脏面显露左右肝管,经肝的膈面显露肝内叶、段胆管相结合的手术入路,治疗复杂性肝内胆管结石患者56例,临床疗效满意。结论 选择经肝的脏面与膈面相结合的手术方式,较易取出结石。     

Aberrant bile ducts, 'remnant surface bile ducts,' and peribiliary glands: descriptive anatomy, historical nomenclature, and surgical implications

The term "aberrant bile ducts" has been used to designate three heterogeneous groups of biliary structures: (1) bile ducts degenerating or disappearing (unknown etiology, diverse locations); (2) curious biliary structures in the transverse fissure; and (3) aberrant right bile ducts draining directly into the common hepatic duct. We report our observations on these three groups. Twenty-nine fresh human livers of stillborns and adults were injected differentially with colored latex and dissected. Adult livers showed portal venous and hepatic arterial branches, and bile ducts not associated with parenchyma, subjacent to and firmly adherent with the liver capsule: elements of ramifications of normal sheaths were present on the liver's surface. These ramifications, having lost parenchyma associated with them, then sequentially lost their portal branches, bile ducts and arterial branches. This process affected the ramifications of the sheaths in the left triangular ligament, adjacent to the inferior vena cava, in the gallbladder bed and anywhere else on the liver's surface and resulted in the presence of bile ducts accompanied by portal venous and/or hepatic arterial branches and not associated with parenchyma for a period of time. This first group represented normal bile ducts that do not meet the criteria of aberration and could be appropriately designated "remnant surface bile ducts." Such changes were not found in the transverse fissures and review of the literature revealed that the curious biliary structures are the microscopic peribiliary glands. The third group met the criteria of aberration and the anatomy of a representative duct is described.