肝脏尾状叶肿瘤切除技术探讨

肝尾状叶解剖学上分Spiegel部、下腔静脉旁部及尾状突三部分, 位于肝脏背侧, 紧邻下腔静脉、三支肝静脉及门静脉左右支。尾状叶定位依赖于解剖标志定位及染色定位, 特别是反染技术。尾状叶手术左侧径路适合于Spiegel部切除, 右侧径路适合下腔静脉旁部及尾状突切除, 背侧径路、前侧径路结合其他径路可以达到完整切除尾状叶目的。本文介绍了多径路联合全尾状叶肿瘤切除、部分尾状叶切除及腹腔镜尾状叶切除。     

在人体肝脏中门静脉分段、固有肝静脉和尾状叶外切迹之间的关系

有关人体肝脏的尾叶详细解剖尚不完全清楚 ,为了保证尾叶切除术的安全操作 ,有必要阐明肝内门静脉分段、肝静脉系统和尾叶外切迹之间的关系。取日本Gunma大学医学院外科 88具成人尸体的肝脏 ,固定于福马林 (10 % )溶液。仔细解剖尾叶的门静脉和肝静脉与其外切迹之间的关系。肝尾叶列为 Couinaud 段 ,由 8小段组成。 Ku-mon将尾叶分成 3部分 :Spiegle叶 ,相当于 Couinaud 段和习称的尾状叶 ;腔静脉旁部分 ;尾状突。Couin-aud和 Healey等后来又将尾叶分成两个亚段 (左 段和右背段 Ir) ,Ir段相等于 Kumon的腔静脉旁部分 ,Couinaud称之为…     

中国人三维数字化肝脏模型系统的建立

目的 建立中国人的可视化三维虚拟肝脏系统,为临床诊断、治疗提供决策依据,为肝外科虚拟手术的发展提供可视化平台.方法 选取中国可视化人的腹部断层图像资料,开发三维可视化软件,对肝脏重要结构进行精确分割,联合运用表面重建与体积重建的方法,建立数字肝脏模型系统,并赋予该系统多种交互功能.结果 三维数字肝脏模型系统成功建立.该系统具有任意移动、旋转、缩放、切割和多种显示等功能;具备多种测量功能;具备一定的虚拟手术功能.重建效果准确、逼真.结论 三维肝脏系统能真实展示肝内、外重要结构的解剖特征,功能全面,操作简便.它的建立为临床诊疗提供了有效的参照系统,为肝外科虚拟手术的发展提供了平台.     

肝全尾状叶的解剖学研究及切除体会

目的从外科实用角度研究肝全尾状叶的解剖,估计在尾状叶切除中和背驮式肝移植中可能遇到的问题.方法对35个正常新鲜肝标本施行解剖.事前经门静脉灌注硫酸钡胶以便观察尾状叶的门脉系分支状况.结果全尾状叶由3个部分组成:(1)Spigel叶(固有尾状叶):位于下腔静脉左侧,约呈三角椎形,有三个面,顶部和底部.(2)腔静脉旁部:位于下腔静脉右侧和前侧,上达肝右静脉根部,外侧为右后叶门静脉上段支.(3)尾状突:位于下腔静脉与第一肝门之间的嵴状肝组织.结论尾状叶位于肝后,环绕肝后下腔静脉.全尾状叶切除时需充分游离肝脏.手术的关键步骤是结扎切断汇入下腔静脉的尾叶静脉,这在背驮式肝移植中也是一个重要步骤.     

单-肝尾叶切除(英)

肝尾叶位于肝门的后方．围绕肝后腔静脉。根据23具尸体的肝腐蚀标本，Kunmon于1985年将肝尾叶分为尾本叶、腔静脉旁和尾叶突3个部分，尾本叶位于下腔静脉的左侧，闭塞的静脉导管沟组成其内侧缘；尾状突位于主门静脉、右门静脉支和下腔静脉之间；腔静脉旁部分位于下腔静脉的前方，向头部伸层而抵达大肝静脉的根部。1～2支左门静脉分支供应尾本叶，1支右或后门静脉支灌注尾状突，1～3支右或左门静脉支供应腔静脉旁部分，动脉和胆管的走行大致相同。单-肝尾叶切除比较困难。     

肝脏尾状叶病变的手术治疗

肝尾状叶是肝脏特殊的一部分,其位置深在,其腹侧为第一肝门,头侧为第二肝门,背侧为第三肝门和下腔静脉(图1).而另一方面,尾状叶在肝脏疾病的解剖和病理生理方面也和其他部位的肝脏密切相关,比如Bismuth Ⅲb和Ⅳ型的肝门部胆管癌通常会侵犯尾状叶胆管.     

肝尾叶切除

<正>1肝尾叶切除的分类1单独尾叶切除;2合并大面积肝切除+尾叶切除。2主要入路2.1左右两侧入路:1肝脏完全游离;2控制肝上、肝下下腔静脉;3控制右肝静脉;4控制中/左肝静脉干;5把尾叶丛下腔静脉分离(离断第三肝门);6把尾叶portal triad离断;7把paracaval部分从肝静脉分离;8把尾突离断。2.2左侧入路:1用于小肝癌3 cm;2手术与左右两侧入路相同,但主要入路从左侧。2.3右侧入路:1用于体型偏瘦患者和小肝癌;     

虚拟可视化肝脏在肝脏手术中的应用现状

基于现代影像学和计算机技术发展起来的虚拟可视化肝脏技术，通过动态显示肝脏三维虚拟结构模型，能从各个角度仿真显示肝内管道复杂的解剖结构，提供全方位的肝脏立体信息，在计算机中构建虚拟的手术环境，为外科医生制订手术方案、手术模拟、手术导航提供了客观、准确、直观的手段，推动肝脏外科的发展。现主要介绍虚拟可视化肝脏在肝脏手术中的应用现状。[第一段]     

肝脏尾状叶肿瘤手术途径探讨

肝脏尾状叶肿瘤中最常见的是原发性肝癌和转移癌。其次,肝门胆管癌可通过尾状叶的胆管引流或直接浸润而侵犯肝尾状叶。迄今,手术切除仍是有效治疗肝尾状叶恶性肿瘤的唯一手段。由于尾状叶位置深、手术显露困难,且毗邻下腔静脉、肝静脉、门静脉等重要血管一直是肝脏外科手术的禁     

机器人辅助腹腔镜单一体位右侧肾癌根治并下腔静脉Ⅲ级癌栓取栓术

目的 探讨单一体位机器人辅助腹腔镜根治性肾切除并下腔静脉Ⅲ级癌栓切除术的关键步骤及围术期结果。方法 患者女性,57岁。10 d前至当地医院体检,B超检查示右肾占位。MRI进一步检查示右肾实性占位,考虑透明细胞癌,伴右肾静脉及肝段下腔静脉内癌栓形成。超声造影示下腔静脉肝后段可见一低回声占位,范围约74 mm×40 mm,边界尚清,上缘距膈肌约19 mm。关键手术步骤:（1）切开侧腹膜向内推开结肠和十二指肠,游离、显露下腔静脉和左肾静脉。（2）在下腔静脉与腹主动脉之间左肾静脉后上方找到右肾动脉,用Hem-o-lok夹闭后切断。（3）在右侧肾静脉下方游离下腔静脉,结扎性腺血管及部分腰静脉,下腔静脉远心端游离后放置血管阻断带备阻断用。（4）将左肾静脉、第一肝门适当游离后,分别放置血管阻断带备阻断用。（5）沿下腔静脉向上分离,切断肝脏三角韧带、右侧冠状韧带后挑起肝脏,游离出右侧肾上腺中央静脉后用Hem-o-lok夹闭后切断。（6）解剖出肝后间隙并建立部分肝后隧道,游离右肝,分离并结扎下腔静脉外侧缘的肝短静脉;挑起肝尾状叶再解剖肝后间隙并结扎部分下腔静脉内侧缘的肝短静脉。（7）将右肝向左侧旋转显露...     

Preoperative cholangiography of the caudate lobe: Surgical anatomy and staging for biliary carcinoma

The biliary branches of the caudate lobe (B1) join the right hepatic duct, the left hepatic duct, the confluence of these ducts, and/or the right posterior segmental bile duct. Therefore, in the preoperative staging of biliary tract carcinoma it is important to delineate the anatomy of B1 and the extent of cancer spread into B1. Tube cholangiography through percutaneous transhepatic biliary drainage or selective cholangiography by percutaneous transhepatic cholangioscopy enables us to obtain fine images of B1. We have developed cholangiography in the cephalad anterior oblique position to visualize B1 more clearly and distinctly. Four separate types of biliary branches are identified in the caudate lobe: (1) A duct running from the cranial portion of the right caudate lobe along the inferior vena cava to the hepatic hilus (B1r); (2) a duct from the cranial portion of the left caudate lobe to the hepatic hilus (B1ls); (3) a duct from the left lateral part of the left caudate lobe to the hepatic hilus (B1li); and (4) a duct from the caudate process to the hepatic hilus (B1c). The findings of the root of B1 in resected patients with biliary tract carcinoma were classified into four groups: not stenotic, short segmental stenosis, long segmental stenosis, and poorly imaged. A study of 64 branches of B1 in 42 resected patients with biliary tract cancer revealed carcinoma invasion in or near the root of B1 in all patients with poorly imaged or long segmental stenosis of B1, and in 33% of those with short segmental stenosis of B1.     

The caudate processus hepatic vein: a boundary hepatic vein between the caudate lobe and the right liver

OBJECTIVE: This study was conducted to find the boundary vein indicating the intersegmental plane between the caudate lobe and the adjacent liver segments. SUMMARY BACKGROUND DATA: Major hepatic veins of the human liver commonly run through the intersegmental plane and are widely used for the landmarks to define the boundary of both sides of liver segments. As the caudate lobe is a small independent unit of the liver separate from the right and left livers, the existence of the boundary hepatic vein to the adjacent liver segments has been expected. METHODS: Fifty-four adult cadaveric livers were minutely dissected to elucidate the correlation between the portal vein branches and the hepatic veins on both the caudate lobe and the adjacent liver segments. RESULTS: Among the hepatic veins of the caudate lobe, the caudate processus hepatic vein entering the inferior vena cava at hepatic hilum runs in the segmental plane between the caudate processus and the right liver. Three types of the caudate processus hepatic vein directly entering the inferior vena cava and 1 type of the exceptional hepatic vein that was the tributary of the right hepatic vein were observed. They drained the blood of the caudate processus and a part of the right liver, respectively. CONCLUSIONS: The caudate processus hepatic vein is one of the candidates of the hepatic vein indicating the boundary between the caudate lobe and the adjacent liver segments. New procedures will be developed on the liver surgeries by acquiring the anatomic features of this vein.     

Right hepatic lobectomy and subsegmental resection of the left caudate lobe for gallbladder carcinoma involving the hepatic hilus: Preservation of the ventral portion of the left caudate lobe

A case of gallbladder carcinoma in a 75-year-old woman with familial hyperbilirubinemia and preoperative hepatic dysfunction is presented. Tube cholangiography through a percutaneous transhepatic biliary drainage (PTBD) catheter demonstrated a stricture and the hepatic confluence without filling of the gallbladder and showed two bile duct branches arising from the left caudate lobe. Cholangiography also disclosed that the left dorsal branch, which joined the right hepatic bile duct, was involved with tumor, while the left ventral branch, which joined the left hepatic duct, was not. Extended right hepatic lobectomy with resection of the dorsal portion of the left caudate lobe, preserving the ventral portion of the left caudate lobe, was performed. Postoperative cholangiography showed that the ventral branch of the left caudate lobe bile duct was preserved. Precise preoperative anatomic diagnosis of the biliary system in patients with hepatobiliary cancer allows successful subsegmental resection of the caudate lobe. Received for publication on July 23, 1997; accepted on Oct. 6, 1997     

Ventral margin of the paracaval portion of human caudate lobe

The topographic anatomy of the ventral margin of the caudate lobe of the human liver is still obscure. We hypothesized the existence of a "precaudate plane", as a flat or slightly curved plane defined by the ventral margins of both the ligamentum venosum and hilar plate. Using 61 cadaveric liver specimens, without great differences in external shape or significant variations in the hilar bifurcation, we examined whether the paracaval caudate branches (PCs) ran through the plane to the ventral side. In 22 of the 61 specimens (36.1%), the PC extended over the plane for less than 10 mm (10 specimens), for 10–20 mm (7 specimens), or for more than 20 mm (5 specimens). The ventral extension consistently included the dome-like area under the terminals of the middle and right hepatic veins. Therefore, the ventrally extended PCs often interdigitated with these veins and their tributaries. The ventral extension often reached the upper, diaphragmatic surface. However, several branches were too difficult to discriminate from the PC, especially those with morphologies intermediate between the PC and segmental portal branches to S4 or S2. We discuss how to identify and manage the ventrally extended PCs before and during surgery. Received: October 12, 2000 / Accepted: December 23, 2000     

Studies on the radiographic anatomy of the biliary tree of the caudate lobe

The cholangiograms obtained through percutaneous transhepatic cholangioscopy (PTCS) were studied for the purpose of clarifying radiographic anatomy of confluence of the bile ducts of the caudate lobe and the main trunks at the hepatic hilum. PTCS was performed on a total of 112 patients at our department, January, 1979 through December, 1984. Among them 60 cases without lesions in the hepatic hilum were used for this study. Four types of the bile duct of the caudate lobe were distinguished by cholangiography in the 60 cases: 1) A duct ran from the cranial portion of the right caudate lobe along the inferior vena cava to the hepatic hilum in 53 (Blr); 2) A duct ran from the cranial portion of the left caudate lobe to the hepatic hilum in 50 (Blls); 3) A duct ran from the left lateral part of the left caudate lobe to the hepatic hilum in 59 (Blli) and 4) A duct from the caudate process to the hepatic hilum in 42 (Blc). We found that cholangiogram following percutaneous transhepatic biliary drainage or selective cholangiogram using the PTCS make an accurate identification of the bile duct of the caudate lobe possible.     

Relation among portal segmentation, proper hepatic vein, and external notch of the caudate lobe in the human liver

OBJECTIVE: To identify portal segmentation and a portal fissure in the caudate lobe of the human liver in relation to the hepatic venous system and the external notch at the caudal edge of the caudate lobe. SUMMARY BACKGROUND DATA: Although the anatomy of the caudate lobe has been studied, the detailed anatomy has not yet been clarified; this is necessary to develop safe procedures for caudate lobe resection. METHODS: A total of 88 formalin-fixed human livers were dissected to visualize the portal vein and hepatic vein systems of the caudate lobe in relation to the external notch. RESULTS: The patterns of portal branching were classified into two types. In 58 livers (67.4%), the territories of the first-order portal branches were clearly divided into two areas (the Spiegel lobe and the paracaval portion). In the remaining 28 livers (32.6%), the territories of the second-order portal branches were clearly divided into two areas. These two areas were distinctly separated by an internal plane, which was coincident with the external notch. The caudate lobe had a systematized hepatic venous system that consisted of one (87.5%) or two (11.4%) proper hepatic veins and plural accessory hepatic veins. The proper hepatic veins laid along the internal plane between these two portal areas. CONCLUSION: The caudate lobe exhibited distinct portal segmentation with a portal fissure that was indicated internally by the proper hepatic vein and externally by the notch at the caudal edge of the caudate lobe.     

下颈椎侧块螺钉固定与椎动脉、神经根的解剖关系及评价

目的　通过解剖学研究和影像学手段 ,了解下颈椎侧块螺钉固定与椎动脉之间的关系以及斜位片在置钉过程中对神经根的监测价值。方法　 (1)取 2 8具尸体的C3 ～C7标本 ,年龄 2 8～ 79岁。摄取标本各椎体的横断面片 ,测量X线片上C3 ～C7横突孔外缘与侧块背面中心内侧 1mm处的连线在横断面上与矢状轴之间的成角。 (2 )取 10具标本 ,以侧块背面中心点内侧 1mm处为入针点、横突与侧块相交处为出针点在C3 ～C6侧块内置入克氏针。当针尖未超出或超出侧块远侧皮质 2、4、6mm时 ,摄取标本左右 4 5°斜位片。把斜位片上椎间孔分为上、下两部分 ,上部实际是真正的椎间孔 ,下部则相当于横突间孔位置。观察针尖在斜位片上椎间孔内的位置并计数 ,同时与实际解剖比较两者的一致性。　结果　 (1)C3 ～C6横突孔外缘与侧块背面中心内侧 1mm处的连线在横断面上与矢状轴成外偏 5°～ 12°的角度 ,椎体间差别无统计学意义 (P >0 0 5 )。 (2 )以横突与关节突相交处为出针点 ,实际观察当针尖超出侧块远侧皮质 2mm时 ,未突入横突间孔 ;当超出距离为 4、6mm时 ,针尖则突入横突间孔。X片上显示当针尖未超出远侧皮质时 ,斜位片上有 15 %针尖出现于椎间孔下部 ;当针尖超出 2mm时 ,斜位片 4 1 3%针尖出现于椎间孔下部 ;当针尖超出 4mm     

A comparative study of the anatomy of rat and human livers

To compare the fundamental structure of the human liver, in relation to that of the rat a comparative study was performed, in which 20 rat livers and 78 human cadaver livers were examined. The rat livers had four lobes (left, middle, right, and caudate). The left and middle lobes formed a single lobe but the middle lobe had a deep notch to which the round ligament attached. The right lobe was split into two sub-lobes and the caudate lobe was divided into the paracaval portion and the Spiegel lobe, which was split into two sub-lobes. The left, right, and caudate lobes had one primary portal branch, whereas the middle lobe had two portal branches. The left and the right sub- and caudate lobes had one large hepatic vein each, whereas three large hepatic veins were observed in the middle lobe. Based on the ramifying patterns of the portal and hepatic veins, the rat middle lobe possessed left and right hepatic components and a main portal fissure. The following rat hepatic lobes were equivalent to the following human liver segments: the left lobe to segment II; the middle lobe to segments III, IV, V, and VIII; and the right lobe to segments VI and VII. The fundamental structures of rat and human livers were similar, and the findings demonstrated a new interpretation of the anatomy of the human liver. Received for publication on June 30, 1998; accepted on Dec. 4, 1998     

Rare Portal Venous Anomaly in a Living Liver Donor: A Case Report

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.     

Infraportal bile duct of the caudate lobe: a troublesome anatomic variation in right-sided hepatectomy for perihilar cholangiocarcinoma

OBJECTIVE: We present our experiences with infraportal bile duct of the caudate lobe (B1) and discuss surgical implications of this rare variation. SUMMARY BACKGROUND DATA: Although various authors have investigated biliary anatomy at the hepatic hilum, an infraportal B1 (joining the hepatic duct caudally to the transverse portion of the left portal vein) has not been reported. METHODS: Between January 1981 and December 2005, 334 patients underwent hepatectomy combined with caudate lobectomy for perihilar cholangiocarcinoma. Four of them (1.2%) had infraportal B1 and were investigated clinicoanatomically. RESULTS: All infraportal B1 were B1l, draining Spiegel's lobe; no infraportal B1r (draining the paracaval portion) or B1c ducts (draining the caudate process) were found. The infraportal B1l joined the common hepatic duct or the left hepatic duct. Three patients underwent right trisectionectomy with caudate lobectomy; for one, in whom preoperative diagnosis was possible, combined portal vein resection and reconstruction were performed before caudate lobectomy to resect the caudate lobe en bloc without division of infraportal B1. For the other 2 patients, the infraportal B1 was divided to preserve the portal vein, and then the caudate lobe was resected en bloc. The fourth patient underwent right hepatectomy with right caudate lobectomy; the cut end of the infraportal B1 showed no cancer by frozen section, so the bile duct was ligated and divided to preserve the left caudate lobe. CONCLUSION: Infraportal B1 can cause difficulties in performing right-sided hepatectomy with caudate lobectomy or harvesting the left side of the liver with the left caudate lobe for transplantation. Hepatobiliary and transplant surgeons should carefully evaluate biliary anatomy at the hepatic hilum, keeping this variation in mind.