胆囊床内血管的应用解剖

目的：为腹腔镜胆囊切除手术提供形态学基础.方法：对128例肝脏标本进行解剖,观察胆囊床内血管的位置、行程,测量其在胆囊床内的长度和直径.结果：胆囊床内血管有：（1）胆囊动脉深支及分支,占71.1%（91例）;（2）肝中静脉及其属支,占12.5%（16例）,其突入形式分①肝中静脉主干,②右前叶支、或左内叶支、或两者一起突出,③右前叶支属支、左内叶支属支、或两者一起突出3种类型;（3）肝门静脉右支及其分支,分主干和分支两类,主干占39.8%（51例）,肝门静脉右支的分支占14.8%（19例）;（4）肝门静脉左支的分支,占2.34%（3例）;（5）胆囊静脉,在胆囊附着面有小静脉与肝中静脉、肝门静脉左、右支的分支相连.结论：切除胆囊时应注意胆囊床左、右缘,以及具有肝门右切迹的病例,保护突入胆囊床内的肝中静脉及其属支,以防止出血.     

胆囊动脉的分支与肝胆外科的关系

观察了100例胆囊动脉,其中有49.0％是多支型。有93.0％的胆囊动脉分支供应肝组织,有20.2％胆囊动脉深支与副肝管、胆囊下肝管或胆囊下门静脉分支伴行或交叉。这些应用解剖学要点,值得肝胆外科施术时加以重视。     

腹腔镜胆囊切除术的应用解剖

在３０例成人肝外胆道标本上解剖观察了胆囊管与邻近的结构，胆囊淋巴结，胆囊动脉的动源，行程以及与肝脏的关系，提出了腹腔镜胆囊切除术中胆囊淋巴结可作为了寻找胆囊管的标志，结扎胆囊管的位置宜选择在离胆囊颈左侧６ｍｍ以外处，而结扎担囊动脉的部位应在胆囊体浆膜下，距胆囊颈６．３ｍｍ范围内，在处理胆囊窝时应注意有胆囊动脉的肝支和胆囊下肝管的存在。     

胆囊床血管的超声和应用解剖学研究

目的：为腹腔镜胆囊切除术保护胆囊床内血管提供形态学基础；探讨术前彩色多普勒超声探查肝中静脉的意义。方法：（1）对30例正常成人肝标本在超声影像下观察胆囊床血管的位置、大小及与胆囊床的毗邻关系；（2）对30例超声观察后的肝标本进行解剖，观察胆囊床内超声显示的血管的位置、来源，测量其长度和直径，比较超声下血管与解剖观察血管的形态和走行；（3）对20例肝铸型标本胆囊床血管进行观察；（4）采用彩色多普勒超声对168例正常成人活体肝脏进行观测，记录胆囊床血管的直径、位置及毗邻关系，并与解剖观察结果比较。结果：30例成人肝标本胆囊床超声影像下观察到5例直径大于2mm，长度大于2cm的变异血管；解剖证实，这些血管均为肝中静脉起始部或其属支，距胆囊床表面0～3mm，其中位于胆囊床正中的2例，位于左、右缘的分别为1例和2例，均与胆囊床长轴平行。胆囊床血管彩色多普勒超声影像检查，距胆囊床0～3mm范围内内径超过2mm的肝中静脉或其属支有29例，肝门静脉分支1例。结论：直径超过2mm，距胆囊床表面0～3mm的胆囊床变异血管为肝中静脉起始段或其属支，出现率为17．3％。腹腔镜胆囊切除术术前进行彩色多普勒超声检查，能明确胆囊床内肝中静脉或其属支及肝门静脉分支的位置及与胆囊床的关系。     

肝总动脉分支变异一例

作者于１９９８年作腹部标本时发现一例肝总动脉分支的变异。该肝总动脉从腹腔于发出后隔网膜囊向右走行在胃后方,而后在近胃窦部上方从左至右依次发出１支肝左动脉,２支肝右动脉及１支胃十二指肠动脉。从肝左动脉发出１支胃右动脉。两支肝右动脉均行于门静脉前方并与之成锐角。左侧肝右动脉继而行经肝总管的前方进入胆囊三角,在此发出１支胆囊动脉浅支。右侧肝右动脉则经胆总管前方绕过胆囊的后方,在此发出１支胆囊动脉深支后径胆囊管的后方进入肝右叶。此种肝总动脉分支的变异给肝胆外科的手术操作及肝的动脉造影增加了难度。故对临床…     

肝中动脉发出2支胆囊动脉1例

在做一离体肝脏标本时,见肝中动脉发出双支胆囊动脉(图1),较少见,报道如下: 该标本肝固有动脉在距其起点2.50 cm处分为肝左、右动脉,起点处外径为3.84 mm.肝左、右动脉的夹角成60.1.,其起点外径分别为2.76 mm、1.90 mm.肝右动脉经胆总管、胆囊颈后方行4.34 cm进入肝右叶.肝中动脉在距肝左动脉起点0.68 cm处成63.20夹角发出,起点外径为2.30 mm.肝中动脉自肝总管前方穿胆囊三角前行4.05 cm入肝右叶.肝中动脉在行1.44 cm,1.97cm后分别发出胆囊动脉浅支和深支,其起点外径分别为1.18mm和1.00 mm.2支胆囊动脉沿胆囊体上行,分支分布于胆囊.     

肝右动脉和胆囊动脉的起源行程及分布的应用解剖学

在62具成人体尸体上,对肝右动脉和胆囊动脉的起源,行程及分支分布进行了观察,有58例胯右动脉起源于肝固有动脉（93．5％）,多经胆囊三角（Calot三角）分出胆囊动脉入胆囊,终支入肝右叶,胆囊动脉起于肝右动脉占76．2％,起于肝固有动脉占9．5％,胆囊动脉以单支型为主,多经Calot三角入胆囊。     

肝脏第IX段临床应用解剖及恶性肿瘤的介入栓塞化疗

目的探讨肝脏第IX段临床应用解剖及其占位性病变的介入治疗。方法对50例肝脏进行解剖观察;对6例肝脏第IX段占位性病变进行介入栓塞化疗。结果肝脏第IX段动脉主要来源于肝右动脉,部分来自肝中动脉或肝左动脉;门静脉主要来自门静脉右前叶上段支,小部分来自门静脉左支横部;胆管汇入右肝管;静脉血由数支细小静脉经第3肝门直接汇入肝后下腔静脉,部分汇入肝右静脉。第IX段肝脏肿瘤通过血管介入治疗后,肿瘤显著缩小;其中4例合并黄疸患者肝功能明显缓解。结论肝脏第IX段是一个结构上较为独立的区域,有其特殊的管道系统和引流系统,位置深隐,单独或联合手术切除较困难;通过介入技术可以对该区段进行相应的治疗。利用微导管采用超选技术,可以对肝脏第IX段的病变进行精确的治疗,微创、副作用小、可重复操作,能够弥补外科手术的局限性,达到甚至超过外科手术的治疗效果。     

肝门静脉、肝右动脉及胆囊动脉变异1例

在肝门部结构中,肝动脉及胆囊动脉的变异较为常见,而肝门静脉的变异较少见,我们在解剖一成年男性标本时见其肝门静脉、肝右动脉及胆囊动脉存在变     

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。     

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.     

Couinaud肝段在横断面上的划分

为给ＭＲ图像精定位肝内占位性病变提供断面解剖学依据，利用２０例腹部连续横断面标本，研究了肝段在横断面上的划分。正中裂为下腔静脉中点至肝中静脉或胆囊窝中份的连线；在叶间裂的上份为下腔静脉中点至镰状韧带的连线，门静脉左支脐部和肝圆韧带裂是其中、下份的天然标志；肝左静脉位一左段间裂中；右叶间裂为下腔静脉中点至肝右静脉的连结；肝门或门静脉右支可作为右段间裂的标志；背裂为下腔静脉缘至门静脉或静脉韧带裂右端的     

Accessory liver lobe attached to the wall of the gallbladder: a cadaveric case report

Accessory liver lobe is found incidentally during laparoscopy, laparotomy or autopsy performed for unrelated reasons. The occurrence of accessory liver lobe attached to the gallbladder is reported rarely in the literature. During regular dissection classes, we came across an accessory liver lobe in the wall of the gallbladder in an adult male cadaver. On its left, it was connected to the quadrate lobe by a short fold of peritoneum. On the right, it was attached to the wall of the gallbladder. The fragment was triangular in shape, and was 20 mm in length, 11 mm in width and 6 mm thick. The histology of the fragment revealed the unusual architecture of hepatic tissue with the absence of the classical hexagonal lobule pattern. Cords of hepatocytes surrounding the central vein, with an absence of portal canals, were observed. There were branches of hepatic artery, portal vein and hepatic duct in its peritoneal fold. Smooth muscle fibers were also observed along its attachment on the wall of the gallbladder. Awareness of the incidence of accessory liver lobe in the wall of the gallbladder is of clinical importance during the diagnosis and treatment of gallstones.     

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。     

Spatial anatomy of the round ligament,gallbladder, and intrahepatic vessels in patients with right-sided round ligament of the liver

Purpose

To analyze the vascular structure of the liver in patients with a right-sided round ligament.

Methods

We reviewed 16 patients with a right-sided round ligament and 3 polysplenia and situs inversus patients with a left-sided round ligament who underwent multidetector row CT with contrast media. The patient population consisted of 13 men and 6 women (mean 62 years). We analyzed the axial and volume-rendered images for the location of the round ligament, gallbladder, portal veins, hepatic veins, and hepatic artery. The following imaging findings for the patients with polysplenia and situs inversus were horizontally reversed.

Results

The prevalence of a right-sided round ligament with and without polysplenia was 75 and 0.11 %, respectively. The gallbladder was located to the right, below, and left of the round ligament in 27.7, 38.8 and 33.3 %, respectively. Independent branching of the right posterior portal vein was noted in 57.8 %. PV4 was difficult to identify in 36.8 %. The middle hepatic vein was located to the left of the round ligament. Two branching patterns for the lateral and medial branches of the right anterior hepatic artery were noted: the common (44.4 %) and separated types (55.5 %). Both of the right anterior hepatic artery and portal vein ramified into two segments; the lateral segment with many branches and the medial segment with a few branches.

Conclusions

The right-sided round ligament divided the right anterior section into the lateral and medial segments based on the portal vein and hepatic artery anatomy.

     

Reconfirmation of the right medial division of the portal venous system of liver

With the development of hepatic surgery and radiology, an increasing amount of researchers have reported discrepancies between the real distribution of the hepatic portal vein branches and Couinaud's segmentation, especially for further division of the right medial division. The present study investigated 25 cadaveric liver dissections and 30 three-dimensional reconstruction images of intrahepatic vessels. The ramifications, course, distribution and quantity of the portal branches were analyzed. An oblique fissure that had few vessels was found among third-order branches of the hepatic portal vein of the right medial division. The right medial division could be redivided into the ventral subsegment and dorsal subsegment by this oblique fissure. A hepatic vein coursed in the oblique fissure between the ventral subsegment and dorsal subsegment. The hepatic vein could serve as an anatomical landmark of the inter-subsegmental plane. This new method of identifying further division of the right medial division is a novel concept providing further information on conventional segmental anatomy.     

Fetal intrahepatic gallbladder and topographical anatomy of the liver hilar region and hepatocystic triangle

The fetal gallbladder (GB) is embedded in a deep fossa surrounded by the liver parenchyma. Using 15 specimens with intrahepatic GB (crown-rump length 45-92 mm; approximately 9-13 weeks of gestation), we assessed the fetal topographical anatomy of the hepatocystic triangle and the porta hepatis. The cystic duct displayed a long upward course (0.9-4.5 mm along the supero-inferior axis) from the GB, along the duodenum, to the common bile duct in the hepatoduodenal ligament, via an independent mesentery separated from liver parenchyma by a recess of the peritoneal cavity. Notably, the course varied in length among specimens, not among stages. At the porta hepatis, we were able to distinguish the supraportal course of the posterior right hepatic duct overriding a portal vein branch to segment 8 (6/15) from the other, infraportal course (9/15). In the latter type, the portal vein bifurcation was superior to the cystic duct course. Two margins of the hepatocyctic triangle were very long in fetuses because of the inferiorly located intrahepatic GB. Thus, the triangle seems to be difficult to identify in prenatal ultrasound. During changes in location after 9 weeks, the GB fundus remains attached to the liver because the cystic artery was often embedded in the liver parenchyma. A failure in the embedding and re-exposure process of the GB may result in anomalous peritoneal folds around the GB.     

右半肝肝段解剖研究进展

对肝内血管解剖结构及肝段的准确认识是肝切除术前评估和活体肝移植肝段选择的基础。特别是活体肝移植供体肝段的选择,需要考虑到肝段的体积、门脉及动脉血供和静脉回流,更需要对肝内各管道的解剖结构有精确的把握。右半肝管道立体交叉关系复杂,门静脉及肝静脉变异均多见。国际上通用的Couinaud肝段划分法,将右半肝分为4段,段Ⅷ、段Ⅴ为上下关系,段Ⅶ,段Ⅵ为上下关系。但随着肝脏手术的进展,影像学技术的提高,人们对右半肝肝段解剖划分提出质疑并有了新的观点。大部分学者倾向于以肝内门静脉3级分支分布形式作为划分右半肝肝段的主要依据,同时肝静脉引流情况也是重要的辅助依据,但分段方式并未形成统一。