256排螺旋CT三维重建右半肝门静脉和肝静脉及其解剖关系的临床应用研究

目的 应用256排螺旋CT行上腹部血管造影,描述右半肝门静脉与肝静脉的CT表现、两者解剖关系和肝分段的再定义,探讨其临床意义。方法 随机收集100例受检者CT平扫及三期增强扫描图像,观察三维重建后右半肝门静脉分支、肝静脉属支的分布情况,并对相关数据进行统计学分析。结果 门静脉分布情况：S5段分为4型,A型66%,B型10%,C型8%,D型16%;S6段分为6型,A型56%,B型15%,C型4%,D型17%,E型4%,F型4%;S7段分为3型,A型73%,B型23%,C型4%;S8段分为5型,A型67%,B型3%,C型2%,D型8%,E型20%。肝静脉分布情况：肝左静脉、肝中静脉、肝右静脉分别汇入下腔静脉有45%,肝左静脉与肝中静脉形成共干汇入下腔静脉有55%;36%出现肝右下后静脉,11%肝右静脉细小,由发达的肝中静脉代偿性引流右半肝;15%肝中静脉主干位于门静脉主干分叉处上方,41%肝中静脉位于Rex-Cantlie线右侧。肝静脉与门静脉解剖关系分为4型,以A型最多,占64%,D型最少,占3%。结论 右半肝肝静脉和门静脉解剖形态复杂多样,门静脉主干变异时肝静脉与门静脉空间分布也随之发...     

肝内门一腔静脉内支架吻合分流术（TIPSS）的应用解剖学

在４３例肝脏标上从肝脏面解剖出肝静脉，门静脉，肝管和肝协脉，观察了肝静脉的汇合类型，肝静脉与门静脉相交部位口径，两静脉间距和至第二肝门的距离，结合ＴＩＰＳＳ术进行了讨论，作者认为由肝静脉穿刺门静脉行吻合分流的首选部位是在肝右静脉与门静脉右支及其分支之间，其次在肝中静脉与门静脉左支之间，而肝左静脉与门静脉左支之间吻合较难达到分流目的。     

肝动脉分支分布变异1例

作者在解剖一老年男性尸体时，发现其肝动脉的分支分布变异，现报道如下：腹腔干发出3大分支，即脾动脉、肝总动脉和副左肝动脉。肝总动脉正常，距腹腔干1.85cm处发出肝固有动脉和胃右动脉，肝固有动脉又发出肝左、右地动脉。①副肝右动脉：起自胃右动脉，在距肝总动脉分支处0.24cm处发出，总长为4.6cm，跨过门静脉的前方，走行于胆总管的后方，随后分为两支进入肝右叶。     

肝内肝门静脉解剖及变异的多层螺旋CT成像分析及意义

目的：用多层螺旋CT前瞻性地观测肝内肝门静脉的解剖和变异。方法 对200名正常人,使用16排多层螺旋CT行上腹部CT动态增强扫描,将肝内肝门静脉的解剖和变异进行分型。并对肝门静脉系统各血管参数进行定量研究,行统计学分析。结果：肝门静脉正常型占81.5% (163例),Ⅰ、Ⅱ、Ⅲ型变异分别占11.5％ (23例、6.5％(13例)、0.5％ (1例),未发现有门脉左支水平段或右支缺如。在不同性别间门静脉直径（Dpv）、脾静脉直径（Dsv）及肠系膜上静脉直径（Dsmv）有统计学意义（P<0.05）;除男性≥50岁组较＜50岁组门静脉长度（Lpv）有所延长外,其他男性、女性不同年龄组间,肝门静脉系统各管径均无统计学意义（P>0.05）。结论：多层螺旋CT门静脉血管成像（multi-slice CT portography,MSCTP）能方便而清楚地显示肝内门静脉解剖和变异。     

第一肝门的腹腔镜肝脏手术入路解剖学研究

目的:为腹腔镜肝脏外科提供第一肝门的应用解剖及手术入路设计。方法:成人尸体肝脏标本30例结合临床手术入路设计,研究肝门静脉主干及其属支的管径、汇合形式及分支直径、长度(从分叉至进入肝实质),横沟的长度、门静脉分叉点与肝方叶尖、尾状叶尖的距离。观察肝门静脉左、右支在横沟内与左、右肝动脉及肝左、右管的伴行关系。结果:①肝门静脉在胰颈或胰体之后由肠系膜上静脉、脾静脉[直径分别为(11.42±2.85)mm、(7.91±3.06)mm]汇合而成。其汇合类型分为3型;②横沟呈槽状,长度为(4.19±0.36)cm;③肝门静脉左支长为(1.45±0.17)cm,直径为(11.97±1.65)mm;④门静脉右支长为(1.57±0.05)cm,直径为(11.75±0.98)mm。结论:腹腔镜下解剖分离第一肝门是可行的;肝门阻断入路操作简单,效果切实;还可以进行手术区域的肝门管道预处理及肝门静脉保护。     

门静脉的解剖与变异

目的：利用经动脉性门静脉造影CT重建门静脉、肝静脉三维结构，观察生理状态下的门静脉的解剖与变异。方法：150例病人，导管置入于肠系膜上动脉内，注入造影剂后门静脉期和肝静脉期连续扫描肝脏。三维重建门静脉及肝静脉，分析门静脉的解剖与变异。结果：150次成像中门静脉变异25例，12例（8．0％）显示门静脉呈三分叉状，10例（6，7％）门静脉先分出右后支，然后上行分为左支和右前支，1例（0．7％）门静脉左支水平段缺如，门静脉右支缺如2例（1．3％），余下125例（83．3％）显示正常左右门静脉分支。结论：门静脉的三维图像重建及类型分析对术前手术方式的确定有一定的临床意义。     

国人肝段在冠状断层上的划分

目的：为肝内微小病变精确定位诊断和外科治疗提供冠状断层解剖学依据。方法：采用30例上腹部连续冠状断层标本、20例肝内门静脉和肝静脉解剖正常的薄层MSCT断层图像及其三维重建图像,在冠状断层上对其门静脉肝段进行精确划分。结果：经胆囊、门静脉左支及肝左静脉的冠状断面上,肝中静脉主干是划分右前上叶和左前下叶的识别标志,门静脉左支角部是左前下叶的段间裂识别标志,亦是右前上叶和左前下叶的亚段间裂识别标志。经肝门静脉主干的冠状断面上,门静脉右前支主干是右前上叶的段间裂识别标志,该层面以前为右前上叶的腹侧段,该层面以后则为右前上叶的背侧段。经网膜孔的冠状断面上、下腔静脉的右缘是划分尾状叶和右半肝的识别标志,门静脉右后支主干是划分右前上叶背侧段和右后下叶下段的标志,经下腔静脉和肝右静脉的冠状面上,肝右静脉主干是划分右前上叶的背侧段和右后下叶上段的标志;门静脉右后支主干是右后下叶的段间裂识别标志。结论：国人门静脉肝段在冠状断面上的精确划分,不仅有利于肝内微小病变的精确定位,且有利于探索新的和更加安全的外科术式。     

右半肝内门静脉的断层影像解剖学研究

目的 探讨右半肝内门静脉的走行、分布规律及门静脉肝裂和肝静脉的关系,进而为肝段的划分提供断层解剖学依据. 方法使用30例上腹部连续断层标本(10例横断面、20例冠状面)以及20例多层螺旋CT图像和三维图像,探讨右半肝内门静脉的分支类型和常见变异以及肝内门静脉和肝静脉之间的关系. 结果 50例标本和图像中,右半肝内门静脉均可分为前上和后下两组分支.76%(38150)的门静脉右前支的分支向后分布至肝右静脉后方的部分区域.40%(20/50)的门静脉右后支的起始部向尾侧发出的第一分支分布至肝右静脉前的部分区域.门静脉右前支的分布区域,越过肝中静脉偏向左侧,在15例无门静脉右支主干的标本和图像中尤其明显.肝右前叶无明显横裂存在.门静脉的亚段分型有显著的个体差异,且无优势分支类型. 结论右半肝可分为右前上叶和右后下叶,两叶之间为一弯曲的"裂隙".肝右前上叶有一恒定的纵裂存在.肝右静脉不是右叶间裂的准确定位标志,尤其在其上份和下份.肝中静脉不是正中裂的准确识别标志,尤其在门静脉右支主干缺如的人群中.     

肝铸型标本肝静脉吻合的观测及临床意义

目的：观察肝静脉之间的吻合情况；方法：观察88个铸型标本中肝静脉侧支吻合的出现率，并对一例有丰富吻合支的肝脏用游标卡尺测量吻合中点处的直径；结果：88个肝铸型标本中有侧支吻合22例，显示率25％；1例丰富吻合标本，其中有17处吻合，最大直径为2．28mm，最小直径为0．62mm。副肝静脉与肝静脉吻合3处；结论：在肝静脉结扎或病理变化后，侧支循环开放、增多，受累肝段与未受累肝段间发生浅表和深部肝静脉侧支吻合，使得肝内血管解剖变得异常复杂而完全不同于正常解剖结构，为肝外科手术中处理肝静脉提供了解剖学依据。     

肝固有动脉分支及吻合变异1例

作者在解剖1具成年男性尸体标本时,发现其肝固有动脉分支及吻合变异,现报道如下: 在该例标本中,肝总动脉由腹腔干发出,向右上走行2.5 cm后,在肝门静脉前方分成2支,行向肝门(图1). (1)存在两条肝固有动脉 左支(外径0.25 cm)由肝总动脉发出,沿肝门静脉左前方上行约1.3 cm,分为左、右2支入肝左叶(未从肝门进入).此支距起点0.6 cm处发出胃右动脉;在末端向右发出一吻合支与肝固有动脉右支吻合.     

肝门静脉解剖和影像三维重建的临床应用

目的 观测门静脉肝内段二级分支的形态特征和分支分布规律,为诊断和治疗肝脏疾病提供更为详尽的解剖学及影像学资料。 方法 100例无肝病的成人多排螺旋CT（64-MSCT）增强扫描肝门静脉获得数据,利用CT自带的GE ADW 4.5工作站对其进行三维重建,并结合50例成人肉眼无病变尸肝对肝门静脉进行解剖剥离,观测及比较肝门静脉分支规律并采集相关数据进行统计学分析。结果 影像重建和大体解剖的近第1肝门处肝门静脉内径分别为（11.20±1.48）mm和（10.86±2.01）mm;左、右支主干夹角分别为（93.58±24.03）°和（105.59±13.82）°;左支横部长分别为（29.50±6.51）mm和（23.90±5.29）mm,中点内径分别为（7.70±1.55）mm和（7.43±1.09）mm;右支主干长分别为（21.77±10.35）mm和（20.63±6.59）mm;中点内径分别为（9.10±1.66）mm和（9.26±1.77）mm。依据肝门静脉的分支情况可将其分为4型。结论 肝门静脉变异情况并不少见,其分支的直径与夹角等均存在一定的变化,在肝外科手术实施时,对门静脉主干分支各型应给予高度的重视。     

Persistent left hepatic venous connection with the right atrium and the ductus venosus

An anomalous left hepatic vein opening independently of the coronary sinus into the right atrium was found in the cadaver of an 88-year-old Japanese man. This vein originated from the left lobe of the liver, perforated the diaphragm at the left side of the vena caval foramen and opened into the right atrium. The left hepatic vein anastomosed mutually with the middle hepatic vein at the level of venule. The ligamentum venosum originated from the left branch of the portal vein and was connected directly to the left hepatic vein. The development of the central systemic venous system and a possible explanation for the morphogenesis of this anomaly were reviewed. As a result, the occurrence of this anomalous vein was explained as being due to the persistence of the left vitelline connection with the left sinus horn and the ductus venosus.     

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.     

三维动态对比增强磁共振肝门静脉造影成像效果及解剖学分析

目的：探讨三维动态对比增强磁共振肝门静脉造影(3DDCEMRP)的成像质量并观测肝内肝门静脉的解剖和变异。方法：共进行61例门静脉3DDCEMRP检查，通过对MPV、LPV、RPV，SV及SMV显示情况和对门脉右支显示能力的分析，评价3DDCEMRP的成像质量。测量门脉系统各主要干支的径线并对门静脉的解剖和变异做分型，计算各型的构成比。结果：所有病例均完整显示门静脉主干及肝内4级以上分支。61次成像中，4例(6．6％)显示门脉主干呈三叉状，3例(4．9％)门脉主干先发出右后支，继续上行分为左支和右前支，2例(3．3％)门脉右前支起自左支，l例(1．6％)门脉右支缺如，其余5l例(83．6％)显示正常门脉分支。结论：肝内门脉变异并不少见，3D DCE MRP是一种有效、微创技术。能方便而清楚地显示肝内门脉的解剖和蛮异。     

Absence of the portal bifurcation at the hilum of the liver due to intrahepatic origin of the left branch of the portal vein

Abstract The authors report a rare anomaly of portal vascularization which was detected by CT-scan and MRI and then confirmed surgically. There was no portal bifurcation at the hilum of the liver. After giving off its right dorsal branch, the portal vein entered the right liver and divided in the parenchyma into the right ventral and left branches. The arterio-biliary distribution was normal. Only a few similar cases have been reported. The left branch of the portal vein is reported to have few variations in contrast with the right one, which has many. The venous structure of the liver varies increasingly with the distance from the left umbilical vein. During a right hepatectomy, the possibility of such a vascularization makes it necessary to ensure that the left branch of the portal vein starts upstream before dividing a portal branch entering the right liver.     

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。