肝圆韧带在腹部手术修复与重建中的应用

肝圆韧带是由胚胎时期的左脐静脉闭锁而成,连通脐部与门静脉左支囊部,邻近胆道与胃,其潜在性腔隙可扩张再通,管壁具有张力高、韧性好等优点。据文献报道,肝圆韧带已广泛应用于消化道穿孔修补、十二指肠残端包埋、胆管损伤、坏疽修补以及门静脉肠系膜上静脉修复重建、下腔静脉修补等领域,此外,肝圆韧带还可用于肝脏断面、胰腺断面的覆盖材料及食管裂孔疝的修补等方面。但有关肝圆韧带用于腹部外科修复重建的相关基础研究还很少,临床研究也多为病例报告和回顾性分析,随机对照研究较少,今后应加强这方面的研究,使肝圆韧带能更好的应用于临床。     

门静脉、肠系膜上静脉的解剖与临床应用的初步研究

目的 为提高肝门胆管癌和壶腹周围癌的手术切除率,使该区域受肿瘤浸润的血管能同时切除,血管直接重建提供解剖学依据.方法 在实施肝门胆管癌切除术及胰十二指肠切除术中,对病人的肝蒂内门静脉干、胰腺钩突内的肠系膜上静脉干进行解剖学定位并分段测量长度及可以纵向折叠的长度,以此估计可切除的静脉长度及重新再建血管的长度.结果 测量肝蒂内门静脉干104例,男性(5.8±1.99)cm,女性(5.5±O.81)cm,优势长度大于4.5cm者,男性56例占76.7%,女性25例占80.6%.胰腺钩突内段肠系膜上静脉干测量54例,男性(3.7±0.77)cm,女性(3.5±0.64)cm,优势长度大于3.0cm者,男性28例占77.6%,女性14例占77.8%.门静脉纵向折叠移动的范围在1.8～4.2cm,平均折叠2.2(1.8～2.4)cm者占66.3%,平均折叠2.8(2.5～4.2)cm者占33.7%.切除胰十二指肠后胰腺钩突内肠系膜上静脉段纵向折叠范围平均4.0cm,最长达5.2cm.结论 肝门胆管癌和壶腹周围癌切除术合并受浸血管切除在一定范围是可行的.     

应用MRI测量髌骨及髌韧带的参数及其意义

目的 通过MRI测量髌骨和髌韧带的参数,为临床诊断和治疗提供数据.方法 无髌骨损伤,伴随有或无前交叉韧带损伤患者共141例,行膝关节MRI检查.在MRI矢状面图像上测量髌骨长度和厚度以及髌韧带的长度.结果 总样本髌骨的平均长度、厚度及髌韧带长度分别是（41.1±3.6）mm、（21.4±1.7）mm、（41.5±5.2）mm,无韧带损伤组（A组）髌骨平均长度和厚度及髌韧带长度分别是（43.2±3.2）mm、（20.4±1.5）mm、（42.2±5.2）mm;前交叉韧带重建术后功能良好组（B组）患者髌骨平均长度和厚度及髌韧带长度分别是（40.3±2.8）mm、（22.6±1.3）mm、（40.4±4.3）mm;前交叉韧带重建术后恢复不良组（C组）患者髌骨平均长度和厚度及髌韧带长度分别是（42.4±2.7）mm、（20.7±1.4）mm、（45.4±4.1）mm.B、C组患者髌韧带长度差异有统计学意义,重建术后不良患者髌韧带松弛.结论 通过MRI测量髌骨和髌韧带的相关数据,为膝关节疾患的诊断及手术提供参考数据.     

肝圆韧带及其作为自体修复材料在上腹部手术中的应用

肝圆韧带是胚胎左脐静脉的闭锁遗迹,自脐移行至肝圆韧带切迹,经镰状韧带游离缘达肝圆韧带裂,最后连于门静脉左干囊部,由远及近分为腱膜下段、游离段及裂隙段,分别长(6.5±1.9)cm、(7.2±2.6)cm、(3.5±0.9)cm,总长(17.6±5.5)cm;各段均有残腔,直径分别为(0.4±0.1)mm、(0.8±0.3)cm、(1.1±0.4)mm.愈向头端管径愈粗、管壁愈厚[1].     

门静脉双管转流加肝十二指肠韧带大块切除治疗胆管癌

由于胆管癌常侵犯肝十二指肠韧带,因此将肝十二指肠韧带完整大块切除是最彻底的手术方法。作者设计了门静脉循环的双管转流,以维持术中足够的肝血供并防止门静脉系统淤血。双管转流的两条途径为:左股动脉经肝园韧带内的脐静脉至门静脉左干脐部,以及肠系膜上静脉至股静脉。重建门静脉及肝动脉时,需行自体血管移植。即使胆管癌早期,肿瘤在肝十二指肠韧带内不仅纵向而且还沿淋巴管及神经周围间隙横向浸润,致使手术效果不满意,生存率很低。如果将肝十二指肠韧     

再次打开脐静脉的循环应用于肝胰胆外科的静脉再建术

胆道和胰腺癌常侵犯门静脉和肝动脉 ,切除后需用移植物以重建 ,作者首次报道应用脐静脉以重建被切除的血管 ,于 1998年 3月至 1999年 5月共施行 7例 ,其中 3例为胰头癌、2例近端胆管癌、1例胆囊癌、1例肝细胞癌和胆管癌。患者年龄为 4 6～ 79岁 ,3例胰腺癌施行胰十二指肠切除 ,3例胆管癌和 1例肝细胞癌伴胆管癌施行肝叶和尾叶切除。重建 2 cm肠系膜上静脉 1例 ,门静脉 -肠系膜上静脉汇合处 3cm和 1.5cm各 1例 ,下腔静脉 8cm 1例 ,左门静脉 4 cm、1.3cm各 1例 ,右门静脉 4 cm 1例。手术方法　近脐点切断圆韧带 ,清除其周围脂肪组织 ,再打开脐…     

游离右侧结肠和肠系膜根部可以避免重建门静脉时使用静脉移植血管

在胰十二指肠切除术常需切除受侵的门静脉 ,如切除长度 4～ 5 cm时则不需静脉移植血管以完成重建 ,可直接行端端吻合。如切除长度较长 ,常需自体静脉或人造血管修复。作者介绍一简易手术方法以直接修复切除 6～ 10 cm的门静脉段。作一长正中切口 ,按常规游离胰头 ,在其颈部切断 ,备作胰十二指肠切除。先结扎脾静脉 ,不需再建脾静脉。如作全胰切除 ,不切断胰颈部 ,在肠系膜上和门静脉旁游离全胰。在连接肠系膜上和门静脉处切断脾静脉。如估计静脉两切端不能拉拢时 ,作下列手术。完全游离右侧结肠、结肠系膜和肠系膜根 ,从十二指肠和胰腺处游…     

门奇静脉断流术加大网膜经肝圆韧带腹壁固定治疗门静脉高压症

目的：门奇静脉断流术（断流术）加大网膜经肝圆韧带腹壁固定仿自然分流治疗门静脉高压症的效果。
方法：18例门静脉高压症患者,在行贲门周围血管离断的同时,将大网膜经过肝圆韧带固定于前腹壁,手术前后测量门静脉系统和脐静脉的血流动力学变化。
结果：18例患者全部手术成功,无手术死亡病例。术后2周,门静脉血流量减少,血流速度无明显变化,脐静脉内径增宽,血流速度无明显变化;术后3,6个月,门静脉血流量较术前明显降低,血流速度略升高,脐静脉内径增宽,腹壁后方脐静脉旁发现1条或多条伴行的扩张静脉,脐静脉血流速度增快。
结论：断流术加大网膜经肝圆韧带腹壁固定是一种良好的仿自然分流方式,方法简便,值得临床推广。     

多层螺旋CT显示肝圆韧带的初步研究

目的：探讨肝圆韧带的多层螺旋CT表现及其临床意义。方法：对130例无肝脏疾病的患者行16层CT腹部平扫及增强扫描,采用多平面重组（MPR）、层块最大密度投影（slab-MIP）和层块容积再现（slab-VR）等后处理技术重点观测肝圆韧带。结果：在斜矢状位MPR,slab-MIP,slab-VR图像上肝圆韧带表现为符合其解剖走行特点的密度稍高的光滑条索灶,显示率为90.8%（118/130）。裂隙段中点处直径为(5.44±0.96)mm（3.2～7.2 mm）,游离段中点处直径为(3.43±0.91)mm（1.6～6.0 mm）。结论：多层螺旋CT能清晰显示肝圆韧带,可为以肝圆韧带为自体修复材料的上腹部手术提供较为可靠的术前影像学判断。     

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.     

股静脉作为血管移植材料可行性与安全性的应用解剖研究

目的探讨股静脉作为血管移植材料的可行性与安全性。方法取60具成人尸体共114侧下肢标本,解剖观察股静脉、股深静脉、腘静脉及静脉交通支,测量股深静脉汇入股静脉处至收肌腱裂孔下缘的股静脉段长度,即股静脉可切取的解剖长度,以及静脉压扁外径。分析2010年3月-2011年5月收治的120例下肢股静脉段血栓形成患者CT静脉造影(computed tomography venography,CTV)检查资料,观察其下肢静脉回流通路。结果男性尸体身高平均158.3 cm,股静脉可切取长度为(18.8±2.3)cm,相对长度为0.118±0.013,静脉压扁外径为(15.8±0.8)mm;女性尸体分别为149.2 cm、(15.1±1.5)cm、0.101±0.010、(14.0±1.1)mm。男女股静脉可切取长度比较,差异有统计学意义(t=6.354,P=0.000);静脉压扁外径比较差异有统计学意义(t=5.555,P=0.000)。股静脉可切取长度与身高成正相关(r=0.964,P=0.000),股静脉压扁外径与身高成正相关(r=0.382,P=0.003)。解剖观察见16侧(14.0%)肢体存在双股静脉变异支,48侧(42.1%)肢体存在1支股-腘静脉交通支,38侧(33.3%)肢体存在1支股深-腘静脉交通支。CTV检查示,下肢股静脉血栓形成以后,大隐静脉及股-腘或股深-腘静脉交通支可代偿股静脉。结论大隐静脉和股-腘静脉交通支或股深-腘静脉交通支的存在,保证了切取股静脉作为血管移植材料的可靠性及安全性。     

扩大胰十二指肠切除术中联合肝动脉、肝固有动脉与髂内静脉切除重建应用的可行性研究

目的探讨在行扩大胰十二指肠切除联合血管切除术中应用肝动脉(HA)或肝固有动脉(PHA)与肠系膜上动脉(SMA)吻合、髂内静脉(IIV)与肠系膜上静脉(SMV)或门静脉(PV)吻合应用的可行性。方法解剖20具成人尸体的HA、PHA、SMA、SMV、PV、左IIV及右IIV,测量各血管长度、血管壁厚度和血管直径;用多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影检测20例胰头癌患者和本组5例患者的上述血管,并进行比对。根据比对结果,对5例已经发生血管浸润的胰头癌行扩大胰十二指肠切除术,行HA或PHA与SMA、IIV与SMV或PV吻合重建。结果尸体的HA-PHA长度为(5.50±1.50)cm,血管壁厚度为(0.20±0.01)mm,血管直径为(5.02±1.32)mm;SMA长度为(4.00±1.00)cm,血管壁厚度为(0.21±0.01)mm,血管直径为(6.05±1.06)mm。左IIV、右IIV及PV主干或SMV血管直径分别为(11.06±0.16)mm、(11.10±0.13)mm及(11.56±0.20)mm;左IIV、右IIV及PV主干或SMV的管壁厚度分别为(0.10±0.01)mm、(0.10±0.02)mm和(0.10±0.02)mm。活体多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影显示HA或PHA和SMA管壁厚度及血管直径分别稍比尸体解剖大0.1 mm和0.3 mm,差异均无统计学意义(P>0.05),而HA-PHA的长度比SMA长1～2 cm(P<0.05)。5例行扩大胰十二指肠切除术同时联合HA或PHA和SMA、IIV和PV或SMV切除重建患者的生存期均长于同期姑息性或放弃手术者,无一例发生远期并发症。结论有血管侵犯的胰头癌不是根治术的绝对禁忌证;就本组5例扩大胰十二指肠切除联合血管切除重建的患者比同期发生血管浸润的胰头癌仅施行探查或姑息性手术的33例患者生存时间而言,前者生存时间明显延长;HA或PHA和IIV是最好的自体血管代用材料,没有明显增加术后并发症;熟识尸体局部解剖结构对手术医生有一定的指导性意义。     

肝脏右后下静脉的临床解剖学研究

目的 观测肝脏右后下静脉(inferior right hepatic veins,IRHV)的解剖学结构.方法 60具成人尸体肝脏标本,根据肝右后静脉汇入下腔静脉肝后段上、中、下1/3的部位分为上、中、下三组.观察测量IRHV的出现率、数目、口径、肝外行程及其与肝右静脉的关系.结果 IRHV出现率为83.33%,口径为2.62～18.46(14.32±1.21)mm,肝外长度为3.26～47.65(10.78±7.81)mm.IRHV直径与其数量呈负相关.IRHV直径与肝右静脉直径呈负相关,IRHV数量与肝右静脉直径呈正相关.结论 IRHV口径粗大,出现率高,有肝外行程,和肝右静脉呈彼消此长关系.在肝切除术中应注意避免损伤,活体肝移植时应施行IRHV的修复重建.

Abstract：

Objective To observe the anatomy of the inferior right hepatic veins (IRHV).Methods The IRHVs were divided into 3 groups according to the location where they entered into the retrohepatic inferior vena cava at: the upper 1/3, middle or lower 1/3. The incidence, number, caliber, extrahepatic length and the relationship between the major hepatic veins (the right, middle and the left hepatic veins) and the IRHV were observed and measured in 60 adult cadavers. Results The incidence of IRHV was 83.33% with an average diameter of 2.62-18.46(14.32±1.21)mm. Its extrahepatic length was 3.26-47.65 (10.78±7.81)mm. There was a marked negative correlation between the diameter of the IRHV and its number, a marked negative correlation between the diameter of the IRHV and the diameter of the right hepatic vein and a marked positive correlation between the number of the IRHV and the diameter of the right hepatic vein. Conclusions There were high variations in the incidence and anatomy of the IRHV which were related to the diameter of the right hepatic vein. The IRHV was not to be torn during liver resection and should be reconstructed in right liver grafts.     

旋髂浅动脉穿支皮瓣在口腔鳞癌术后修复重建中的解剖基础和临床应用

目的探讨应用旋髂浅动脉穿支皮瓣修复口腔鳞癌根治术后缺损的解剖基础及临床效果。方法在10具新鲜尸体上进行双侧旋髂浅动、静脉的解剖测量。选择2017年6月至2019年6月,湖南省肿瘤医院肿瘤整形外科收治的口腔鳞癌术后缺损患者,术前使用超声多普勒血流仪探查标记穿支位置,根据口腔内缺损组织的面积设计旋髂浅动脉穿支皮瓣,制备皮瓣并转移至口腔,显微镜下吻合动、静脉。术后随访6~30个月,观察皮瓣的存活情况及口腔功能的恢复情况。结果10具新鲜尸体完成双侧解剖,共获得20侧旋髂浅动、静脉的解剖数据。旋髂浅动脉直径为(1.94±0.30)mm,浅支直径为(0.94±0.25)mm,深支直径为(1.25±0.27)mm。至少有2条来自深支的肌皮穿支穿过缝匠肌[(2.15±0.37)条],肌皮穿支直径为(0.75±0.15)mm。旋髂浅静脉直径为(1.72±0.14)mm。浅支动脉蒂长度为(6.5±1.2)cm,深支动脉蒂长度为(8.5±1.9)cm,静脉蒂长度为(9.2±2.1)cm。共选择16例口腔鳞癌术后缺损患者,男14例,女2例,年龄31~70岁,平均48.8岁。切取旋髂浅动脉穿支皮瓣面积6 cm×4 cm~12 cm×6 cm,血管蒂动脉平均长度约6.8 cm,静脉平均长度约7.6 cm。1例术后出现皮瓣静脉危象,皮瓣坏死,其余患者皮瓣均存活良好。2例出现供区淋巴瘘,拔管延迟。16例术后随访6~30个月,1例9个月时出现颈部淋巴结转移,其余患者未发现复发或转移;供区未见并发症,患者对口腔功能恢复满意。结论旋髂浅动脉穿支皮瓣厚薄适中,质地柔软,血管蒂直径及长度恒定,血供稳定,供区瘢痕隐蔽,是修复口腔鳞癌根治性切除术后缺损的良好选择。     

Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer

BACKGROUND: Tumour clearance during pancreatectomy may be facilitated by resection of the portal-superior mesenteric vein, but this is associated with increased perioperative risk. There is no consensus about which patients benefit from portal-superior mesenteric vein resection. METHODS: A systematic appraisal was carried out of the literature on portal-superior mesenteric vein resection during pancreatectomy to identify recurrent themes to guide management. A computerized search of the Medline and Embase databases found 52 non-duplicated studies providing relevant data in 1646 patients. Pooled data were examined for information on outcome categories relating to operation, complications, histopathology and overall outcome. RESULTS: The median (range) number of patients with portal-superior mesenteric vein resection per cohort was 23 (4-172). Median operating time was 513 (168-1740) min and blood loss 1750 (300-26000) ml. Postoperative morbidity ranged from 9 to 78 per cent with a median per cohort of 42 per cent. There were 73 perioperative deaths (5.9 per cent of 1235 for whom mortality data were provided). Median survival was 13 months, and 1-, 3- and 5-year survival rates were 50, 16 and 7 per cent respectively. Specimen histopathology confirmed positive nodes in 67.4 per cent. CONCLUSIONS: This is the largest collective report to date on portal-superior mesenteric vein resection in pancreatectomy. The high rate of nodal metastases and low 5-year survival rates suggest that by the time of tumour involvement of the portal vein cure is unlikely, even with radical resection.     

Common facial vein: an alternative patch material in carotid angioplasty

Patch angioplasty is a popular adjunct to carotid endarterectomy to facilitate arteriotomy closure. The long saphenous vein is the common autogenous patch in use. We tested the feasibility of using the ipsilateral common facial vein (CFV), which is usually sacrificed during exposure of the carotid bifurcation. A consecutive series of 17 patients undergoing carotid endarterectomy was examined to show the use of CFV patch in arteriotomy closure in 18 procedures. During exposure of the carotid bifurcation, the facial vein was harvested and distended with heparinized saline to assess the size of the vein. If the vein had an adequate diameter, it was everted and used as a double-layered patch. Patients were followed up postoperatively with serial duplex scanning at 3, 6 and 12 months, and yearly thereafter. The median (range) age of the patients in the series was 66 years (52-72 years). Of the 18 CFV harvested, 2 were rejected because of small calibre. The median (range) length of the vein harvested was 5 cm (4-6 cm). The average diameter of harvested vein was 5 mm. The median (range) time taken for harvesting, distending and everting the vein was 10 min (8-12 min). There were no perioperative deaths or strokes. There was no significant re-stenosis during the follow up of 24 months (18-36 months), with a mean peak velocity of 0.86 m/s (0.58-1.29 ). The use of everted CFV patch in carotid angioplasty is safe, quick, convenient and durable, whereas saphenous veins are spared and lower limb incisions avoided.     

Portal and mesenteric vein thrombosis after portal vein embolization in a patient with protein S deficiency

Portal vein embolization can be performed safely, and so far no major complications have been reported. We report an extremely rare complication of portal vein embolization, a case of portal and mesenteric thrombosis in a 65-year-old patient with protein S deficiency. Right portal vein embolization was carried out prior to extended right hepatectomy for advanced gallbladder carcinoma involving the hepatic hilus. Computed tomography 14 days after embolization revealed massive thrombosis of the portal and the superior mesenteric veins. A protein S deficiency was found by means of an extensive workup for hypercoagulable state. Portal vein embolization may have triggered a cascade of events that was expressed as portal and mesenteric vein thrombosis resulting from deficiency of protein S. It may be better to determine the concentrations of such coagulation regulators prior to portal vein embolization.     

Internal spermatic vein diameter and age at operation reflect the response to varicocelectomy

It was evaluated whether the diameter of internal spermatic veins (measured directly during operation) correlates with the clinical grade and treatment outcome following varicocelectomy. Fifty-seven consecutive men undergoing left varicocelectomy were included in the study, and spermatic vein diameter was compared with the response to the operation. The diameter appeared larger with increasing clinical grade (subclinical: 3.40 +/- 1.64 mm; grade 1 : 2.74 +/- 0.84 mm; grade 2 : 3.70 +/- 1.09 mm; grade 3 : 4.38 +/- 1.30 mm). In patients 30 years or older, spermatic vein diameter in men whose post-operative semen parameters were unchanged or worsened was statistically larger than that of patients whose post-operative semen parameters were improved, in terms of both sperm concentration (3.90 +/- 1.24 mm versus 2.84 +/- 0.94 mm; P < 0.05) and sperm motility (3.98 +/- 1.24 mm versus 2.67 +/- 0.67 mm, P < 0.01). Although the diameter of internal spermatic veins measured directly during operation correlated well with clinical grade, it is the diameter and patient's age at operation, but not clinical grade, that determine the reversibility of testicular injury following varicocelectomy.     

Reconstruction of hepatic or portal veins by use of newly customized great saphenous vein grafts

Background and aims Segmental resection of major hepatic veins or the portal vein is sometimes required if one is to secure adequate surgical margins from hepatic or pancreatic malignancies. An external iliac vein is widely sacrificed as a vein graft to replace the defect, but this is associated with postoperative edema of the lower leg. We developed a new method for constructing the great saphenous vein to interpose the hepatic or portal veins.Patients and methods The great saphenous vein was divided transversely into three sections, which were aligned side-to-side. The three pieces were anastomosed to make a sheet 3 × 2 cm, which was rolled up into a cylindrical form of approximately 1 cm in diameter and 2 cm in length. We applied the finished vein grafts to interpose the major hepatic veins in three patients with metastatic liver tumors and the portal vein in two patients with pancreatic malignancies in cylindrical form and to reconstruct the portal vein in one patient with a pancreas cancer, using a three-row sheet as a patch graft.Results No patient developed venous thrombosis of the graft or edema of the lower leg.Conclusions The newly customized vein graft was safe and useful for the reconstruction of the major hepatic or portal veins.     

A selective approach to preexisting portal vein thrombosis in patients undergoing liver transplantation.

Splanchnic venous inflow is considered mandatory to ensure graft survival after liver transplantation. Over a 68-month period, we performed 570 liver transplants in 495 patients. Portal vein thrombosis was present in 16 patients. At transplant, the extent of the occlusion included portal vein alone (n = 4), portal including confluence of the splenic and superior mesenteric veins (n = 8), portal, splenic, and distal superior mesenteric veins (n = 2), and the entire portal vein, splenic vein, and superior mesenteric vein (n = 2). The operative approach included thrombectomy alone (n = 5), anastomosis at the confluence of the splenic and superior mesenteric splenic veins (n = 8), and extra-anatomic venous reconstruction (n = 3). The mean operative blood loss was 22 +/- 22 units, and the mean operative time was 9.7 +/- 4.8 hours. The 1-year actuarial survival rate was 81%, with a mean follow-up of 12.5 months. In summary, with a selective approach and the use of innovative forms of splanchnic venous inflow, portal vein thrombosis is no longer a contraindication to liver transplantation.