以肝圆韧带为标志左肝管显露术的应用性研究

目的 围绕以肝圆韧带为标志的左肝管应用解剖,寻找左肝管显露的最佳入路. 方法 解剖30例肝脏标本,分别测量左肝管长度、管径、夹角和以肝圆韧带为中心的左肝管肝面定位,以及左肝管在Glisson鞘中与门静脉左支及肝左动脉之间的毗邻关系,并牵拉肝圆韧带作左肝管的显露术. 结果 左肝管在肝内的径路相对恒定,从其在Glisson鞘中与门静脉左支及肝左动脉的毗邻关系上看,膈面入路有利于左肝管的显露,且由于肝圆韧带与门静脉左支囊部相连,牵拉肝圆韧带更有利于暴露左肝管. 结论 在肝门部或肝脏面因各种原因难以解剖时,通过以肝圆韧带为标志在肝膈面解剖左肝管,是肝脏外科中显露左肝管的最佳入路.     

21例肝门胆管癌CT分析

目的: 分析肝门胆管癌的CT表现. 方法: 回顾分析21例经临床、病理证实的肝门胆管癌的CT资料. 结果: 浸润型9例,外生型11例,管内型1例,所有病灶均位于左右肝管汇合处,CT表现为肝内胆管不同程度的"软藤样"扩张,平扫仅33%病例显示肿块,增强扫描可见肿块呈缓慢持续强化. 结论: 肝门胆管癌的CT表现特征为:肝门区胆管内等密度或低密度肿块伴肝内胆管不同程度的"软藤样"扩张.增强扫描可见肿块呈缓慢持续强化.     

肝内胆管癌18例临床分析

目的: 提高肝内胆管癌的诊治水平.方法: 回顾分析1990年以来18例肝内胆管癌临床资料.结果: 肝内胆管癌缺乏特异性的症状;1990年1月~2000年3月的11例肝内胆管癌全部误诊,2000年4月~2004年3月的7例经CT检查和B超引导肝穿刺活检明确诊断,其中2例为迟发性肝内胆管癌;左肝内胆管癌12例,右肝内胆管癌6例;随访15例,3个月、6个月及1年生存率分别为80.0%(12/15),66.7%(10/15)和53.3%(8/15);9例肝叶切除术和6例非肝叶切除术患者的1年生存率分别为77.8%(7/9)和16.7%(1/6)(P=0.039).结论: CT检查结合B超引导肝穿刺活检能帮助明确诊断肝内胆管癌,肝叶切除可改善预后.     

切开肝内胆管治疗复杂肝内胆管结石的手术入路和方法

目的 探讨显露和剖开肝内各叶、段胆管的手术方法,提高复杂性肝内胆管结石病的治疗效果。方法 从肝内胆管手术显露的角度,研究了30个成人肝脏标本肝内各叶、段胆管与血管走行位置的解剖关系,设计了新的手术方法、用于治疗复杂性肝内胆管结石46例。结果 肝内胆管与血管走行的位置关系。从肝脏的脏面观：左右肝管均位于门静脉左右干的前上缘。左内叶胆管、右前叶胆管位于相应门静脉支的前内侧（近肝门侧）。右后叶胆管有73.3%(22/30)位于门静脉右前支（18／30）或门静脉右前下段支（4／30）脏面深侧;80％（24／30）走行于门静脉右后叶支脏面深侧（20／30）或后上缘（4／30）。左外叶胆管基本上都走行于门静脉矢状部脏面深侧,只有2个标本的左外叶下段支胆管在其浅侧。肝动脉在肝内各叶段的分支基本上走行与Glisson鞘内胆管与门静脉之间或侧旁。从肝脏膈面观：肝内各叶、段胆管与血管的解剖位置关系大致与脏面观相反或接近相反。据此,从肝脏脏面显露肝门、可以连续切开左右肝管和多数左内叶及右前叶胆管,但难以显露右后叶及右叶各段胆管和左外叶胆管;而从肝脏膈面进路切开肝方叶或肝中裂、再沿右后叶胆管投影方向切开肝实质,则可避开右肝内的门静脉主要分支,比较容易显露和切开右肝内各叶、段胆管汇合部及狭窄段。从肝左叶膈面切开左外叶胆管,可避免损伤左门静脉矢状况。设计经肝的脏面显露和剖开肝门及左右肝管与经肝的膈面显露和剖开肝内叶、段胆管相结合的手术方法,治疗复杂性肝内多叶、多段胆管多发结石并胆管狭窄的病人46例。无手术死亡。31例平均随访39个月,效果优良28例（90％）,好转2例（6.5%),无效1例（3.5%)。结论 经肝的脏面和膈面相结合的手术入路,显露和剖开肝内外胆管及其狭窄段,便于取出结石。将剖开的肝内外胆管与空肠Roux－en-y大口吻合,则可解除胆道狭窄,建立通畅的胆流通道,是治疗复杂性肝内胆管结石有效的手术方法。     

肝外型门静脉瘤的CT诊断

目的 探讨CT对肝外型门静脉瘤的诊断价值.方法 回顾性分析经CT检查确诊的5例肝外型门静脉瘤的病例资料.结果 肝外型门静脉瘤的CT表现为肝外门静脉主干的局限性瘤样扩张,而肝内段门静脉则无明显扩张,肝内、肝外段门静脉交界区管腔呈截然改变.3例合并有肝硬化、脾肿大,其中1例伴有门静脉高压、食道下段静脉曲张;2例无肝硬化征象者中1例伴有脾肿大,1例未发现其他伴发病变.结论 肝外型门静脉瘤具有典型的CT表现,根据CT表现可对本病做出定位及定性诊断.     

肝左外叶切除大口盆式胆肠内引流治疗复杂性肝内胆管结石

目的 研究复杂的肝内胆管结石的手术方法.方法 :对46例肝内胆管广泛结石病人,实施肝左外叶切除、左肝管全程剖开、肝门胆管整形、大口盆式肝胆管空肠Roux-Y吻合术,并进行疗效观察.结果 :本组无手术死亡,无严重手术并发症.34例随访3年以上,27例症状完全消失,5例偶有胆管炎症状,优良率达94.1%.结论 :肝左外叶切除大口盆式肝胆肠管空肠Roux-Y吻合术治疗肝内胆管广泛多发结石,远期疗效满意.     

肝内胆管结石外科治疗67例分析

目的: 探讨对不同类型的肝内胆管结石采取不同手术方式治疗的效果. 方法: 回顾分析经手术治疗的肝内胆管结石67例,其中合并肝胆管狭窄44例(占65.7%).分型:中央型结石24例,周围型结石5例,全程局限型结石34例,全程弥漫型结石4例.手术方式:肝叶段切除术28例,肝门胆管切开取石、高位胆管空肠吻合术21例,肝叶段切除、胆管空肠吻合术18例. 结果: 64例获得5个月~6年的随访,全组优良58例(占90.6%),差6例(占9.4%).残余结石17例(占26.6%),再手术4例(占6.3%). 结论: 肝内胆管结石病情复杂,应根据不同类型结石采取不同的手术方式,盲目扩大肝叶段切除适应讧并不能提高手术治疗效果,反而会增加并发症的发生.     

肝癌切除联合门静脉、肝动脉置泵化疗的临床观察

目的 探讨肝癌切除联合门静脉、肝动脉置泵化疗治疗肝癌的临床疗效及其应用价值. 方法 1998年3月至2002年3月采用肝癌切除63例,随机分为2组,Ⅰ组24例仅行肝癌切除,Ⅱ组39例肝癌切除时联合门静脉、肝动脉置泵化疗,58例获随访. 结果 5例手术后3个月内死于肝肾功能衰竭,53例术后恢复良好.术后1,2,3年复发率和生存率据统计学检验,Ⅱ组的手术后复发率明显低于Ⅰ组(P<0.05),Ⅱ组的手术后生存率明显高于Ⅰ组(P<0.01). 结论 肝癌切除联合门静脉、肝动脉置泵化疗,可以降低术后复发率,提高生存率.     

肝癌根治术中门静脉插管皮下置泵栓塞化疗的疗效

目的:探讨原发性肝癌根治术中门静脉插管皮下置泵,术后定期泵内灌注化疗的疗效.方法:术后每3个月经皮下泵灌注超液化碘油5ml,并行CT扫描检查.结果:3个月内复发11例,复发率达17.5%;半年复发18例,复发率达28.6%; 1年复发25例,复发率达39.7%; 2年复发33例,复发率达52.4%.33例复发病例中28例为肝内亚临床复发,手术再切除13例,再切除率为39.4%.结论:肝癌根治术中门静脉摘管皮下置泵栓塞化疗能有效预防肝癌早期复发,显著降低复发率,并可早期发现术后肝内亚临床复发,提高复发肿瘤再切除率.     

继发性肝脏淋巴瘤5例MDCT诊断分析

目的 探讨多排螺旋CT(MDCT)对继发性肝脏淋巴瘤的诊断价值.方法 回顾性分析经病理及临床治疗证实的5例继发性肝脏淋巴瘤的MDCT及临床资料,并复习有关文献.结果 全组MDCT平扫均表现为肝内多发较低密度病灶,其中4例表现为类圆形肿块或结节,边界较清晰(3例位于门静脉左右分支邻近或汇管区,1例位于肝脏周边),剩余1例表现为左叶弥漫多发斑片状结节.增强扫描5例肿瘤动脉期均呈轻-中度强化,周边较明显,门脉期强化均略加强,但较正常肝组织强化弱.其中4例肿瘤中见血管走行,类似“血管漂浮征”.所有肿瘤未见钙化及坏死.5例均见腹腔或腹膜后肿大淋巴结,呈轻-中度较均匀强化;2例伴胆管轻度局限扩张.结论 继发性肝脏淋巴瘤以多发病灶常见,多位于门静脉左右支邻近或汇管区,并伴有腹腔或腹膜后淋巴结肿大.MDCT对肝脏淋巴瘤的诊断有较大价值,平扫病灶呈较均匀的稍低密度,增强呈轻至中度延迟强化,部分病灶内可见类似“血管漂浮征”.     

肝内胆管手术入路的解剖及临床应用

目的 探讨显露肝内叶、段胆管的手术入路。方法 研究30例成人肝脏标本的肝内叶、段胆管与血管的毗邻关系。结果 左右肝管均位于肝脏脏面门静脉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面支或右前叶下段支脏面深侧者占73％（22／30）;位于门静脉右后支脏面深侧或后上缘者占80％（24／30）。左外叶胆管位于门静脉矢状部脏面深侧者占93％（28／30）。选择经肝的脏面显露肝门、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并狭窄患者38例,均获成功。结论 经肝的脏面与膈面相结合的手术入路,比较容易显露和切开肝内胆管及其狭窄段、便于取出结石。     

The main hepatic anatomic variations for the purpose of split-liver transplantation

BACKGROUND/AIMS: Variant hepatic anatomy must be recognized and appropriately managed during split-liver transplantation to ensure complete vascular and biliary supply to both grafts. The aim of this study was to demonstrate the importance of an assessment of the hepatic anatomical structures for the purpose of split-liver transplantation. MATERIAL AND METHODS: Human cadaveric livers (n = 60) were obtained during routine autopsies. The cadavers and the livers had to comply with the following requirements: (1) minimum age 18 years, (2) no liver pathology expected from medical history, and (3) no liver pathology noted at autopsy. Resections were carried out en bloc with liver, celiac trunk, left gastric artery, lesser omentum, superior mesenteric artery, and head of the pancreas. The main anatomical structures of the liver as hepatic artery, portal vein, biliary tree, and hepatic veins were dissected and correlated hepatic segments for the application of liver splitting. RESULTS: The right the median, and the left hepatic veins were unique, with in 59 (98.3%), 53 (88.3%) and 46 (76.3%) cases, respectively. The portal vein trunk divided into right and left branches in 59 (98.3%) cases. A median branch appeared in 9 (15.2%) cases and no bifurcation of the portal vein occurred in 1 (1.6%) case. The right and left hepatic ducts were multiple in 47 (78.3%) and 57 (95%) cases, respectively, however, the median, hepatic duct was unique in 16 (26.6%) cases. Examining the intrahepatic distribution of the right hepatic duct, we found 4 branches in 28 (59%) cases (segments V, VI, VII, and VIII) 2 branches in 11 (23%) cases, (segments V and VI) and 2 branches in 8 (17%) cases (segments VII and VIII). Fifty-seven cadavers had multiple left hepatic ducts. The intrahepatic dissection showed that the distribution of the major branches were toward hepatic segments II and III. Three separate branches of the left hepatic duct were found in 11 (19%) cases (segments II, III, and IV). Two intrahepatic ducts coming from hepatic segments V and VI drained separately into the left intrahepatic biliary tree in 1 (2%) case. The arterial supply of the liver was by right and left hepatic artery with only 9 (15%) cases there being median hepatic artery. The right hepatic artery, coming from the superior mesenteric artery, was present in 15 (25%) cases and a left hepatic artery originating from the left gastric artery in only 2 (3.3%) cases. The left hepatic artery had 2 exceptional origins, in 1 (1.6%) case coming directly from the abdominal aorta and in the other from the superior mesenteric artery. The right and left hepatic artery was accessory, in 11 (18.3%) and 2 (3.3%) cases, respectively. The right hepatic artery was dominant in 4 (6.6%) cases. The median hepatic artery was directed to segment IV in 6 (10%) cases and to segment II and III in 3 (4.9%) cases. CONCLUSION: The study showed that the technique of controlled liver splitting for transplantation in 2 recipients is an acceptable method to increase the number of liver allografts. The anatomical and technical details of the splitting procedure are critical for the success of this technique. Good graft function and avoidance of complications depend on each graft having an intact arterial and portal blood supply as well as biliary and venous drainage from all retained liver segments. The absence of a bifurcation of the portal vein is a rare anomaly and would certainly contraindicate a partition.     

The paracaval segments of the liver

Two segments constitute thedorsal sector: I to the left and in front of the inferior vena cava, and IX in front and to the right of the cava; they are united inferiorly by the caudate process. Segment I includes the caudate lobe, and segment IX is incorporated in the posterior surface of the right liver. Small dorsal pedicles, which are quite numerous, arise from the posterior margin of the main portal elements, and ascend upward. Segment I receives twigs from the left or right livers, many from the right lateral pedicle (67 biliary branches enter the right lateral duct, the unique duct in three cases). Segment IX consists of three subsegments. IXb lies under the interval between the middle and right superior hepatic veins, in 40% of the cases examined the veins come from the left portal vein or the bifurcation, in 6 cases the ducts enter the left hepatic duct, in 40 cases the branches extend higher than the plane of the main hepatic veins, in 18 cases reaching the upper surface of the liver. IXc is under the right hepatic vein, and IXd is to the right of a vertical plane passing by the right superior vein. Hepatic veins, enter the cava directly, sometimes the middle or the left hepatic veins.     

Course and anastomoses of the large hepatic veins to main structures on the liver surface

The upper liver veins of fifty adult people were dissected from their orifices up to their second ramifications. The courses of the hepatic veins to the main portal fissure and umbilical fissure were determined. Three large upper hepatic veins can be expected in 74%, an accessory one occurs in 26%. The three or four upper hepatic veins join V. cava inferior by two (66%) or three (34%) common terminal branches (length 0.9 cm). Mean diameters of right hepatic vein 1.5 cm, middle hepatic and left hepatic veins 1 cm, accessory upper hepatic vein 0.6 cm. The course of the middle hepatic vein to "cava-gallbladder-line" was determined. The most common vein of the umbilical fissure joins the left, occasionally the middle hepatic vein. The intrahepatic distribution of the liver veins was projected to the surface of the liver considering the typical resection lines. We recommend the following anatomical way of proceeding: right extended and left lateral lobectomy remain right to lig. falciforme hepatis; right lobectomy 1 cm right, left lobectomy 1 cm left to "cava-gallbladder-line".     

Anomalous intrahepatic portal system in a patient with hilar bile duct cancer

We report a case of anomaly of the intrahepatic portal system in a 65-year-old man with hilar bile duct cancer. Preoperatively, percutaneous transhepatic portography demonstrated that there was a right posterior portal vein arising from the main portal vein. In addition, a large portal branch originated from the left portal vein and coursed toward the right hepatic lobe. Following portal embolization of the right posterior branch, the patient underwent an extended right hepatectomy with a caudate lobectomy. Intraoperatively, to the left at the porta hepatis and then it first gave off the right anterior portal vein originated from the left portal vein and coursed toward the right hepatic lobe horizontally behind the gallbladder and then separated into superior and inferior segmental branches to supply the right anterior segment of the liver. The ramification of some major branches without malposition of the gallbladder or round ligament was the important clinical feature of this anomaly.     

Proposal for a reclassification of liver based anatomy on portal ramifications

BACKGROUND: Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery. METHODS: A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed. RESULTS: In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally. CONCLUSIONS: We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.     

浅析经颈静脉肝内门体静脉分流术治疗门静脉高压并发症

目的评估经颈静脉肝内门体静脉分流术(TIPS)治疗肝硬化门静脉高压并发症的安全性和有效性。方法自2013年12月至2014年6月,收集31例接受TIPS治疗的肝硬化门静脉高压症的临床资料。术前均接受肝脏CT增强扫描和血管三维重建,了解肝静脉与门静脉的解剖结构关系,以便确定穿刺门静脉分支的靶点,术中,28例栓塞曲张的食管胃底静脉,28例置入巴德公司的一个裸支架加一个Fluency覆膜支架,2例置入单个Fluency覆膜支架。结果 31例患者中30例TIPS操作成功,其中穿刺门静脉右支26例,穿刺门静脉左支4例,成功率为96.8%(30/31);1例因门静脉海绵样变性未成功;无严重并发症发生,近期止血率为100%。结论 TIPS治疗肝硬化门静脉高压并发症是安全和有效的。     

Branching patterns of the intrahepatic portal vein and hepatic segments identified by percutaneous transhepatic portography

We studied branching of the intrahepatic portal vein and hepatic segment by percutaneous transhepatic portograms in 237 patients with liver, biliary tract, or pancreatic disease. At the hilum, the pattern was normal in 74% of the patients. In the others, branching of the right posterior branch was trifurcated or independent. Caudate branches usually ramified from first-order branches, but sometimes ramified from the right posterior branch. The left portal branch divided into a laterodorsal branch (second-order) and umbilical portion, from which the lateroventral branch (third-order) and several medial branches (fourth-order) arose. It seems to be better to divide the left lobe into anterior segment (supplied by medial and a lateroventral branch) and posterior segments (supplied by a laterodorsal branch) than into the lateral and medial segments. The right anterior branch of 27% of the patients was bifurcated. In the others, there were six other patterns, with four or five fourth-order branches arising from this branch. The anterior segment should be considered having not two subsegments, but four or five small subsegments. Small branches divided off from the main trunk of the right posterior branch. In resection for hepatoma, each such branch can be thought of as one small subsegmental branch.     

肝海绵状血管瘤血供来源研究方法的讨论

目的 探讨肝海绵状血管瘤供血来源及研究方法的科学性。方法 对５例病人,经肝右动脉支结扎后,分别行门静脉连续造影和注入亚甲兰肝染色,观察门静脉与瘤体关系;对２２例肝动脉支插管造影;２例切除肝叶经静脉行血管铸型标本观察。结果 门静脉造影在门静脉期,门静脉支被瘤体稚移,造影剂不进入瘤内;肝实质期,瘤体区形成低密度区,亚甲兰染色,仅见肝实质染色,瘤区不被染色,界限分明,血管铸型标本见瘤体完全腐蚀脱落、无静     

医学图像三维可视化系统在精准肝切除中的应用价值

目的 探讨医学图像三维可视化系统(MI-3DVS)在精准肝切除中的指导作用.方法 2008年6月至2010年9月南方医科大学珠江医院利用自行研发的MI-3DVS在术前对45例肝癌患者肝脏的CT薄层图像数据进行三维重建.根据肝内门静脉和肝静脉走行划分肝段,确定肿瘤所在位置,测算切除的功能性肝脏体积并计算剩余肝脏体积百分比.术前评估可切除性,制订个体化的手术方案,然后进行仿真手术演练,指导临床手术.结果 45例肝癌患者根据肝内肝静脉和门静脉的走行分布分为7种类型:常见型21例,与Couinaud分段相同;未分型6例;肝右叶未分型11例;肝左叶未分型4例;肝右静脉型1例;肝中静脉双支型1例;右后下静脉型1例.39例患者行开腹肝癌切除术,平均剩余肝脏体积百分比为74%±17%,术后病理检查均为肝细胞癌;6例患者行TACE治疗.所有患者术后未发生急性肝功能衰竭、出血、胆汁漏等严重并发症.出院后随访6个月,患者无瘤或带瘤生存.结论 用MI-3DVS进行术前评估和指导临床手术,符合肝脏解剖与生理特点,对精准肝切除有重要的指导作用.

Abstract：

Objective To investigate the guiding significance of medical image three-dimensional visualization system (MI-3DVS) in precise hepatectomy. Methods The clinical data of 45 patients with hepatic neoplasms who were admitted to the Zhujiang Hospital from June 2008 to September 2010 were prospectively analyzed. The preoperative image data of the liver were three-dimensionally reconstructed by MI-3DVS. According to the distribution of the intrahepatic portal veins and hepatic veins, the liver was divided into different sections,and then tumors can be located within these hepatic segments. The volume percentage of residual liver and volume of liver resected were detected. Evaluation of surgical resectability and surgery simulation were done before operation. Results According to the distribution of the intrahepatic portal veins and hepatic veins, all patients were divided into seven types: 21 patients were with normal type which was the same as Couinaud type, six with nondivided type, 11 with non-divided right liver type, four with non-divided left liver type, one with right hepatic vein type, one with double middle hepatic vein type and one with right posterior vein type. Thirty-nine patients received open hepatectomy, and the volume percentage of the residual liver was 74% ± 17%. Postoperative pathological examination confirmed that all the 39 patients were with hepatocellular carcinoma. Six patients received transcatheter arterial chemoembolization. No severe complications such as acute hepatic failure, bleeding, bile leakage were detected. All patients were followed up for six months, and they survived with or without tumor. Conclusion MI-3DVS has guiding significance in preoperative assessment and perioperative guidance for precise hepatectomy.