肝后下腔静脉破裂修补术应用解剖

目的:为肝后下腔静脉破裂修补术提供解剖学资料.方法:50例成人尸体正常肝标本,从正后方剖开肝后下腔静脉,观测肝静脉入口的大小和位置,第二、三肝门之间的距离,第二肝门上方下腔静脉的长度及第二肝门、第三肝门的长度,第三肝门处静脉回流情况.结果:三条肝静脉主干入口分布于肝后下腔静脉上部,形成第二肝门;肝短静脉汇聚于肝后下腔静脉下部,形成第三肝门,静脉支数大多数在4～8支之间,开口下腔静脉右侧壁及前壁的大部分静脉均来自肝右叶,左侧壁静脉主要来自尾状叶;第二、三肝门之间存在一个稀疏间隙.下腔静脉的上口和最高1条肝静脉入口上缘的间距为(21.2±4.7)mm,第二肝门的高度为(21.4±6.3)mm,第三肝门的高度为(40.6±8.7)mm,第二、三肝门之间的距离为(21.9±5.8)mm.结论:第二、第三肝门组成及分布各有规律,二者之间存在间隙,对临床修补肝后下腔静脉破裂,提高病人抢救成功率具有重要意义.     

第二肝门和第三肝门的范围及其临床意义

目的:探讨第二肝门和第三肝门的范围和临床意义。方法:解剖经防腐固定血管灌注的成人尸肝标本56例,从正后方剖开肝后下腔静脉,测量肝静脉入口的大小和位置,追踪其行程和引流范围。结果:直径大于5mm的肝静脉行程长,引流范围广,入口汇聚于二个区域:肝静脉汇聚于肝后下腔静脉上部,副肝静脉汇聚于肝后下腔静脉下部,二者之间存在一个稀疏间隙;小于5mm的肝静脉,分布散行程短,引流范围小,就近入注腔静脉。结论:根据直径大于5mm的肝静脉的分布规律,结合其临床意义,把肝后腔静脉分为上、中、下三段,第二肝门位于上段长(21±4)mm,第三肝门位于下段长(36±10)mm,肝门间段长(17±9)mm。     

改良式绕肝提拉法前入路在右半肝切除术中的应用

目的 评价改良式绕肝提拉法前入路在右半肝切除术中的临床应用价值.方法 提出重视"手术高危区"的解剖分离,建立肝后隧道,置单或双悬吊带提拉肝脏,绕肝提拉法前入路进行右半肝切除术.结果 本组7例,包括肝癌2例、肝血管瘤2例、严重肝损伤2例及右肝内胆管结石1例,手术均获得成功,未发生与本术式相关的并发症.结论 改良式绕肝提拉法前入路进行右半肝切除术安全可靠.此法同时适用于肝良性病变及严重肝损伤的右半肝切除术,是值得推荐的一种手术方式.     

肝后下腔静脉的应用解剖

目的 通过对肝后下腔静脉、第二肝门、第三肝门的详细观测,为肝脏外科手术的临床实践提供解剖学参考.方法 随机选择40具成人尸体离体肝脏标本,从正后方剖开肝后下腔静脉,测量第二肝门处肝静脉的口径、长度、与下腔静脉的角度;观测第三肝门处肝短静脉的数量及分布.结果 肝左、中、右静脉的内径分别为(9.17±3.58)mm、(9....     

绕肝提拉法在高难度肝叶切除术中的应用解剖

目的:观察肝后段下腔静脉(inferior vena cava,IVC)前间隙内的副肝静脉(accessory hepatic veins,AHV)分布规律,为高难度肝叶切除术、肝移植术提供解剖学基础。方法:(1)随机选取经防腐固定的正常成人肝标本28例,观察下腔静脉壁上AHV开口情况;(2)在肝标本上模拟绕肝提拉法,以纸带代替术中绕肝带,观察纸带下AHV分布情况;(3)在解剖放大镜下解剖IVC前间隙内的AHV。结果:(1)28例标本共有AHV292支,可分为左、右侧组,两组间相对无血管区长(62.1±7.0)mm,宽(9.1±3.0)mm。(2)模拟手术组:纸带穿过相对无血管区,其下方AHV平均2.1支(0～3),内径细小(1.9±1.1)mm。(3)IVC前间隙的AHV走行迂曲,与下腔静脉壁开口分布规律相似。结论:绕肝提拉法术式是安全可行的。     

肝细胞癌累及肝后下腔静脉前间隙的CT表现及其解剖学基础

目的：探讨肝细胞癌累及肝后下腔静脉前间隙的CT表现及其解剖学基础，为临床提供全面的影像学信息。方法：回顾性分析27例CT扫描资料和临床资料完整的肝细胞癌累及肝后下腔静脉前间隙的病例，均经手术病理或经临床综合指标诊断。另选择临床诊断为肝细胞癌，但肝后下腔静脉前间隙无异常者5例作为对照组。着重观察病灶部位、大小、密度，肝后腔静脉前间隙是否受侵犯，肝后腔静脉前间隙内肿块强化特征。结果：（1）27例肝内病灶直接和／或经肝裸区累及肝后下腔静脉前间隙；其中3例肝内病灶经肝裸区累及肝后下腔静脉前间隙；20例为肝内病灶直接累及肝后下腔静脉前间隙；4例为肝内病灶直接累及和经肝裸区累及肝后下腔静脉前间隙两种途径；（2）肝内病灶直接累及肝后下腔静脉前间隙表现为肝内肿块侵出肝脏，肝后下腔静脉前间隙消失，下腔静脉与肝脏交界处边缘不齐。肝内病灶经肝裸区累及肝后下腔静脉前间隙表现为肝内肿块经肝裸区长入肝后下腔静脉前间隙内形成软组织肿块，且其强化特点与肝内病灶一致。结论：肝细胞癌可直接和／或经肝裸区累及肝后下腔静脉前间隙。根据CT表现，可判断肝细胞癌是否累及肝后下腔静脉前间隙。     

下腔静脉肝后段的应用解剖学

目的:对下腔静脉肝后段进行应用解剖学研究,为腹腔镜肝尾状叶切除等手术提供形态学基础资料.方法:选32具尸体标本,行下腔静脉肝后段(HIVC)的应用解剖学研究.结果:HIVC长(61.2±10.9)mm,下口内径(19.3土1.8)mm,上口内径(22.1±3.5)mm,在HIVC上1/3与中1/3之间有一个无肝短静脉区,长度为(19.1±7.4)mm.肝左静脉与肝中静脉的开口都位于左上区,其间距为0～5 mm;肝右静脉开口位于前上区.肝右下静脉口径为(5.7±2.4)mm,大于5 mm有16例.尾状叶静脉开口大部分位于HIVC的中、下1/3段,且内径大于5 mm的尾状叶静脉位于HIVC中1/3段的左中区,其他肝短静脉汇入HIVC的位置集中在中、下1/3段,大部分位于左下区和前下区.结论:在HIVC上中1/3交界处的无肝短静脉区,可放置球囊;在肝尾状叶切除手术时,从右侧依次切断尾状叶静脉较为安全.     

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。     

经下腔静脉肝后段肝内穿刺介入的相关解剖学研究

目的:研究经下腔静脉肝后段(PIVC)肝内穿刺进行介入操作的安全性,为第2肝门重建术和 直接肝内门腔分流术的临床应用提供解剖学基础.方法:对31例正常下腔静脉肝后段及肝脏的离体标本进行解剖学观察,了解下腔静脉肝后段和肝静脉的相关解剖结构特点.结果:(1)下腔静脉肝后段:长度(7.01±1.30)cm;经下腔静脉肝后段肝内穿刺安全范围是(5.43±1.23)cm,95%可信区间是3.02～7.84 cm.(2)肝静脉:上组:肝右静脉、肝中静脉及肝左静脉的直径分别是(15.3±3.6)、(8.7±1.9)和(9.3±1.8)mm.肝左静脉与肝中静脉共同开口于下腔静脉90.3%(28例);3支静脉分别开口于下腔静脉9.7%(3例);下组肝小静脉:不同直径的肝小静脉(≥10mm、10～5mm、≤5mm)的肝小静脉构成比分别是5.0%(11条)、24.0%(52条)和71.0%;标本出现率分别是35.5%(11例)、87.1%(27例)和96.8%(30例);RIVC分布位置分别是右侧壁下份、右侧壁及前壁下份、前壁及左壁下份.(3)模拟测量比较常规TIPS穿刺距离和DIPS穿刺距离:经RHV和经MHV的TIPS穿刺距离分别是(38.6±8.1)mm和(46.6±8.2)mm.DIPS穿刺距离是(31.2±7.9)mm.TIPS与DIPS三组模拟测量穿刺距离之间差异有统计学意义(P<0.001),以DIPS穿刺距离最短,以经MHV的TIPS穿刺距离最长.结论:(1)在下腔静脉肝后段有(54.3±12.3)mm的安全穿刺范围;(2)下腔静脉肝后段下份不同直径的下组肝小静脉,其直径越小,出现率越高,数量越多;(3)DIPS的穿刺距离最短,经MHV常规TIPS穿刺距离最长.     

腹腔镜下肝门血流阻断肝切除术的解剖学基础

目的　探讨腹腔镜下肝门血流阻断在肝切除术（LH）的解剖基础及手术路径。 方法　解剖尸体肝脏,分离血流阻断所涉及各肝门结构,观察在二维平面中毗邻,测量在肝外长度及夹角;观察LH视频中肝门结构,总结镜下的位置及特征。 结果　肝动脉平面低于肝管（90%）,肝门静脉分叉位置固定于后方;肝左和肝中静脉在肝外大多共干（90%）,肝右静脉与共干间存在间隙,与肝后下腔静脉(IVC)前方相通;肝短静脉位于IVC两侧,有（7±3）支;IVC韧带在尸体中易忽略,活体中较明显,为包绕IVC的膜性结构,厚度个体差异大;各结构在肝外长度及夹角为肝门血流阻断提供足够空间;镜下各结构位置及特征与实体比较有特殊性。 结论　LH中应用肝门血流阻断有解剖依据及路径遵循。     

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.     

Histological basis of the liver hanging maneuver

Background  Liver hanging maneuver (LHM) consists in passing a tape between the retrohepatic inferior vena cava (RHIVC) and the liver to perform various kinds of hepatectomies. LHM is a well-known procedure but its histological basis remains poorly documented. Methods  Ten anatomical specimens comprising RHIVC, and surrounding hepatic parenchyma were studied after conventional staining and immunohistochemistry with specific antibody for alpha smooth muscle actin. Results  RHIVC wall structure consists of a thick muscular layer of longitudinal smooth muscle fibers and a peripheral loose connective tissue without smooth muscle fibers adherent to the liver parenchyma. This loose connective tissue between the liver and the RHIVC is the avascular plane for the passage of the clamp during LHM. Conclusion  The histological structure of the RHIVC does not seem to have any special hemostatic property. The low bleeding rate during LHM can be only explained by the very low density of RHIVC afferent veins.     

Anatomical basis for clamping of the right hepatic vein outside the liver during right hepatectomy

The possibility and value of clamping the right hepatic vein (HV) outside the liver during right hepatectomy remain a matter of debate. We carried out an anatomical study on ten fresh cadaveric subjects with no abdominal scarring or hepatic lesions, to determine the biometry of the extraparenchymatous segment of the right HV. One or several accessory right HVs were found in 90% of cases on release of the right edge of the inferior vena cava (IVC). These accessory right HVs had a diameter greater than that of the superior right HV in 10% of cases. In 70% of cases, the extraparenchymatous segment of the vein was free of collateral branches, and in 30% of cases, it was joined by a branch close to its point of exit from the hepatic parenchyma. The length of the vein that can be clamped (length between the point of exit from the hepatic parenchyma and the point of entry of the right HV into the IVC) was 8.6 ± 1.8 mm (6–12). The right HV entered the vena cava, at an acute angle, in 100% of cases. Clamping of the right HV was possible in all cases. Knowledge of these anatomical points makes it possible to isolate an extraparenchymatous segment of the right HV more safely. The right HV can be isolated and clamped outside the liver in more than 80% of cases, making it possible to carry out right hepatectomy on an exsanguinous liver.     

尾状叶切除术应用解剖学研究

目的：为肝尾状叶切除术提供形态学理论基础。方法：选取37具成人离体尸肝标本，采用雕琢法和断层解剖观测肝尾状叶形态、毗邻，血管系统的来源、走行，肝后腔静脉前间隙。结果：尾状叶三管系统的来源，Spiegel叶多以左肝三管系统为主，而腔静脉旁叶多以右肝或分权处为主，三管系统中，以门静脉分支分布最为稳定，尾状叶静脉变异较大；三管系统在进入尾状叶时形成簇；尾状叶有前平面及肝后腔静脉前间隙；尾状叶Spiegel叶与腔静脉旁部存在较为明显的界线，其外部标志大致与其外切迹相当，腔静脉旁部与尾状突无明显的界线。结论：肝尾状叶位置特殊，毗邻关系复杂，三管系统进入尾状叶的位置比较恒定。尾状叶的手术切除术应首先确定边界，根据相应的解剖标志来选择手术方式及入路。     

术前三维重建在肝癌大范围肝切除中的应用

目的:探讨术前三维重建技术在大范围肝切除中的应用价值。方法:回顾性分析2016年1月~2018年6月泰州市人 民医院总院收治的45例行大范围肝切除（≥4个肝段）肝癌患者的临床资料,所有患者术前均行薄层CT检查,应用三维重建 系统（IQQA-Liver）进行术前评估,充分显示肿瘤与肝脏血管的关系,并行手术模拟规划,分别计算肝脏体积、模拟手术肝切 除体积、剩余肝脏体积、手术切缘等。并与手术中实际切除肝脏体积及切缘对比。结果:45例患者三维重建后均能清晰显 示肝脏、肝内外血管、肿瘤、肿瘤与肝脏血管关系。患者术前模拟切除肝脏体积（845.2+285.5）mL,实际切除肝脏体积 （826.3±268.1）mL,两者比较差异无统计学意义（t=0.425, P>0.05）。模拟手术切缘（11.2±3.4）mm,实际切缘（10.6±2.8）mm, 两者比较差异无统计学意义（t=0.471, P>0.05）。此两项指标术前模拟与手术实际均呈正相关性（r=0.95, P<0.01;r=0.83, P<0.01）。结论:三维重建技术能够清晰显示肝脏肿瘤与肝脏脉管的关系,准确评估肝切除的体积及手术切缘,在大范围肝 切除术中具有一定的临床应用价值。     

大鼠部分肝切除术后Hedgehog信号分子的表达

目的: 探讨部分肝切除术后Hedgehog(Hh)信号分子的表达及其意义。方法: 切除肝脏左叶和中叶以建立SD大鼠部分肝切除术模型。18只雄性SD大鼠随机均分为3组:假手术组(A)、部分肝切除术组1(B)、部分肝切除术组2(C)。A、B组于术后24 h、C组于术后48 h取肝组织,用免疫组化染色法和Western blotting检测肝组织Ki-67、Sonic Hedgehog(Shh)、Indian Hedgehog(Ihh)和Glioblastoma-2(Gli-2)的表达。结果: HE染色显示B、C组可见肝细胞水肿,点状坏死。C组可见处于不同分裂期的细胞。B、C组Ki-67、Shh、Ihh和Gli-2的表达明显高于A组(P<0.01),C组Ki-67、Shh、Ihh及Gli-2的表达高于B组(P<0.01)。结论: 部分肝切除术后Hh信号通路被激活,可能参与促进肝脏修复再生。     

30%小体积肝移植大鼠模型的手术技巧及改良

背景：活体肝移植显著缓解了供肝短缺矛盾,如何使供者献出的肝量最小,同时受者得到最大的临床受益成为了目前的研究热点。 目的：探索一种简便、稳定的小体积肝移植大鼠模型的建立方法。 方法：以Kamada“二袖套法”非动脉化原位肝移植SD大鼠模型为基础并参考国内外文献,制作30%小体积肝移植模型。实验分为Ⅰ组为体内肝叶减除;Ⅱ组为体外肝叶减除组;Ⅲ组为改良后小体积肝移植模型。主要观察供体手术各阶段时间;移植后并发症和生存情况。 结果与结论：改良后模型较改良前的供肝获取时间和肝叶减除时间均显著缩短(P< 0.05)。Ⅱ组的供肝冷缺血时间显著长于Ⅰ组和Ⅲ组(P < 0.05)。改良后的小体积肝移植模型手术成功率较改良前显著提高(P< 0.05),改良后7及14 d存活率均高于改良前模型(P < 0.05)。改良模型较改良前生存时间延长了9 d。改良模型的手术总并发症例次较改良前组显著较少(P < 0.01)。提示采用此改良方法能建立稳定的30%小体积肝移植大鼠模型,而且在操作简便、减少并发症、提高手术成功率和术后存活率等方面有显著优势。     

The study on sectional anatomy and imaging of accessory hepatic veins

To evaluate the distribution and clinical value of accessory hepatic veins (AHVs), we investigated the number and caliber of the AHVs and the angles between the shafts of AHVs and inferior caval vein. We analyzed the anatomical dissections, serial transverse and coronal sections (0.1–0.2 mm) of a frozen liver, and the ultrasonographical and enhanced CT images of healthy patients. We found that: (1) Most of the angles between the AHVs and inferior caval veins on the thin sections (78%) and liver dissections (72%) were acute (P < 0.01), while the AHVs with right angles had significantly larger average calibers (P < 0.05). However, on the contrary, most of the angles between the AHVs and inferior caval veins were right angles as observed in ultrasonography (89%) and spiral CT images (83%) (P < 0.01). The angle parameters appear to be more selective when displaying the AHVs on ultrasonography and spiral CT images. (2) The presentation rates of the AHVs in ultrasonic and spiral CT images were much lower than those of the anatomical dissections (P < 0.01). (3) There were no apparent differences in displaying right inferior hepatic veins between ultrasonography and spiral CT (P > 0.05). However, the presentation rate of small AHVs was much lower in spiral CT images (P < 0.05). (4) The ultrasonographical and spiral CT scans provide effective reference for the diagnosis of Budd-child syndrome, hepatectomy, especially liver hanging maneuver.     

Glisson蒂横断法肝切除术在儿童肝母细胞瘤切除中的应用

目的 探讨Glisson蒂横断法肝切除术在儿童肝母细胞瘤切除中的应用的安全性和有效性.方法 选择解放军火箭军特色医学中心肝胆外科2018年4月至2019年12月期间收治的16例病理诊断明确为肝母细胞瘤的患儿.所有患儿术前均完成术前新辅助化疗3个周期(C5VD方案),完善相关检查及全肝体积与剩余肝脏体积测定,行吲哚氰绿试...