左肝管全程剖开胆肠吻合术的应用解剖学研究

左肝管全程剖开手术,必须熟悉左肝管与邻近血管的局部解剖关系.为此我们用 ABS 丙酮溶液灌注塑型了6具新鲜成人尸肝脏,解剖40例(成人30,儿童10)肝脏标本,测量了左肝管长度和管径,左肝管与肝总管夹角。全程剖开左肝管与右肝管,并观察左肝管与右肝管、左肝动脉、门静脉左干和肝圆韧带的关系,提出了右肝管全程剖开手术方法和注意事项。     

Arterial supply and biliary drainage of the dorsal liver: A dissection study using controlled specimens

Liver surgeons favor using the entity called the 'dorsal liver' (i.e. the caudate lobe and other paracavally located liver parenchyme of segments 7 and 8). According to minute dissection of 48 livers, we describe the territories of the left/right portal veins, hepatic ducts and hepatic arteries in the dorsal liver. In the caudate lobe, the right hepatic artery, rather than the left hepatic artery (23/48 vs 19/48 for right vs left, respectively), tended to supply the 'left' portal vein territory. Similarly, paradoxical drainage patterns, such as the right hepatic duct draining the left portal vein territory, were found in seven of 48 livers. In the territory of the hilar bifurcation, right hepatic artery dominance was also evident and various bile drainage patterns were found. These included double drainage by the bilateral hepatic ducts (3/48) and drainage into the confluence of bilateral ducts (6/48). In contrast, the arterial supply and biliary drainage of the paracavally located parenchyme of segments 7 and 8 usually depended on the proper segmental arteries and ducts and their variations were within the range of those found in other parts of the right lobe. Therefore, the dorsal liver concept may not be anatomical but, rather, simply aimed at usefulness in surgery. Nevertheless, clear subdivision of the caudate lobe according to biliary drainage and/or arterial supply seemed difficult because of the paradoxical relatioships among the portal vein, hepatic artery and bile duct. Consequently, the present results support extended surgery based on the dorsal liver concept for carcinomas involving the caudate lobe.     

肝方叶舌状切除胆肠吻合术的应用解剖学

观测了40例成人肝脏标本,按临床肝方叶舌状切除术和胆肠吻合术的实际出发,分析了第一肝门部位的左右肝管、门静脉左右干、肝左右动脉的排列关系:肝方叶内的 Glisson's 系统的分支、分布及肝中静脉的属支范围和它们的规律等。为临床该术式的实施提出了解剖学依据,且讨论了应用要点及术中注意的问题。     

经瘘管胆道纤维镜取石或造影的应用解剖

为胆道纤维镜取石或造影插管提供有关解剖数据,在20个肝脏铸型标本和20个成人肝脏标本上,对各级胆道进行了观测。     

A study of the accessory hepatic vein to segments VI and VII with a morphological reconsideration of the human liver

Introduction The liver is supplied by the common hepatic artery from the celiac trunk and by the portal vein from the gastrointestine. This double blood supply to the liver by the hepatic artery and the portal vein produced a complicated structure in the liver. For the blood outflow, we can see right, intermediate and left hepatic veins, and irregular veins: the accessory hepatic veins. These veins drain the blood in the liver into the inferior vena cava. In this study, we studied the layout of the accessory hepatic vein draining segments 6 and 7 in the human livers and attempted to reconsider the structure of the liver by the layout of the accessory hepatic vein. Methods Sixty livers were subjected in this study. They were prepared by using forceps to trace the layout of the blood vessels inside the livers. We carefully examined the relation between the layouts of the accessory vein to the segments 6 and 7 and of the portal vein. The confluence patterns of the accessory hepatic vein into the inferior vena cava were also examined to find the character of the vein. The relation between the accessory hepatic vein and standard hepatic veins was also studied. Results We found 2.2 accessory hepatic veins in one liver on average in our study. The vein was always within the area of segments 6 and 7, and did not surpass the boundary. We found at most five accessory hepatic veins in a liver in two cases. The accessory hepatic vein to the segments 6 and 7 always had its stem on the dorsal side to the portal vein. Different from the stem, the periphery of the accessory hepatic vein freely distributed with the peripheral branches of the portal vein. The area distributed by the accessory vein was also always dorsal part within the segments 6 and 7. The vein was small usually, but was big in few cases. When the vein was big, the area became solely drained by the accessory vein, because the standard hepatic veins (right and intermediate hepatic veins) did not reach the area, and we did not find any communication between the accessory vein and the standard veins. As the remaining region in the segments 6 and 7 became smaller, the draining right standard hepatic vein became shorter and smaller. Discussion The region drained by the accessory hepatic vein excluded the standard hepatic veins. Therefore, there are two different draining venous networks in the area of segments 6 and 7 classified by Couinaud. Conclusion The accessory hepatic vein draining segments 6 and 7 distributed somewhere dorsal side in the segments 6 and 7. The area where the accessory vein distributed was the region where standard hepatic veins did not reach. This would suggest that the region drained by the accessory hepatic vein makes an isolated segment in the liver in the segments 6 and 7 by the Couinaud’s Classification. The area might have a unique blood circulation system.     

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。     

变异肝动脉的解剖学特点及其临床意义

目的　观察变异肝动脉的解剖学特点,为临床相关血管影像学检查、手术及介入治疗等提供形态学资料。 方法　按常规方法解剖25例成人尸体标本,沿肝总动脉追踪、寻找肝固有动脉的分支并观察分布情况。 结果　本组肝固有动脉及其分支变异率为28%。其中有2例属Hitta分型外的变异肝动脉,肝固有动脉右侧壁未见胃右动脉,而是在左侧壁发出1支动脉主干,远端分支分布于肝和胃,本文称为“肝胃动脉（HGA）”;其中标本2从HGA主干后壁发出1分支,远端也分布于肝和胃,本文称为“肝胃副动脉”。 结论　本组2例起于肝固有动脉左侧壁的HGA,是胃小弯右侧的主要动脉来源,并有分支营养肝和胃的其他部位。此种变异补充了变异肝动脉的形态学资料,对临床有一定的指导价值。     

变异肝动脉的解剖学特点及其临床意义

目的　观察变异肝动脉的解剖学特点，为临床相关血管影像学检查、手术及介入治疗等提供形态学资料。 方法　按常规方法解剖25例成人尸体标本，沿肝总动脉追踪、寻找肝固有动脉的分支并观察分布情况。 结果　本组肝固有动脉及其分支变异率为28%。其中有2例属Hitta分型外的变异肝动脉，肝固有动脉右侧壁未见胃右动脉，而是在左侧壁发出1支动脉主干，远端分支分布于肝和胃，本文称为“肝胃动脉（HGA）”；其中标本2从HGA主干后壁发出1分支，远端也分布于肝和胃，本文称为“肝胃副动脉”。 结论　本组2例起于肝固有动脉左侧壁的HGA，是胃小弯右侧的主要动脉来源，并有分支营养肝和胃的其他部位。此种变异补充了变异肝动脉的形态学资料，对临床有一定的指导价值。     

Embryology of Extra‐ and Intrahepatic Bile Ducts,the Ductal plate

In the human embryo, the first anlage of the bile ducts and the liver is the hepatic diverticulum or liver bud. For up to 8 weeks of gestation, the extrahepatic biliary tree develops through lengthening of the caudal part of the hepatic diverticulum. This structure is patent from the beginning and remains patent and in continuity with the developing liver at all stages. The hepatic duct (ductus hepaticus) develops from the cranial part (pars hepatica) of the hepatic diverticulum. The distal portions of the right and left hepatic ducts develop from the extrahepatic ducts and are clearly defined tubular structures by 12 weeks of gestation. The proximal portions of the main hilar ducts derive from the first intrahepatic ductal plates. The extrahepatic bile ducts and the developing intrahepatic biliary tree maintain luminal continuity from the very start of organogenesis throughout further development, contradicting a previous study in the mouse suggesting that the extrahepatic bile duct system develops independently from the intrahepatic biliary tree and that the systems are initially discontinuous but join up later. The normal development of intrahepatic bile ducts requires finely timed and precisely tuned epithelial–mesenchymal interactions, which proceed from the hilum of the liver toward its periphery along the branches of the developing portal vein. Lack of remodeling of the ductal plate results in the persistence of an excess of embryonic bile duct structures remaining in their primitive ductal plate configuration. This abnormality has been termed the ductal plate malformation. Anat Rec, 291:628–635, 2008. © 2008 Wiley‐Liss, Inc.     

有关右叶部分肝移植的胆管临床应用解剖

目的：研究胆管的临床应用解剖，为右叶部分肝移植提供解剖基础。方法：在88个铸型标本中对胆管的分布、走行、汇合方式、分型中所占的比例、涉及右叶肝移植的胆管大小等内容作观察。结果：有47个标本清楚显示胆管，A型占76．6％；B型占8．5％；C型占2．1％；D型占10．6％；无E型；F型占2．1％。胆管的分型中A型远较国外高，E型、C型远比国外低。结论：本组结果有利于右叶部分肝移植，提示中国人胆管的结构较适合右叶肝移植。     

Anatomical assessment of bile ducts of Luschka in human fetuses

Bile ducts of Luschka (also called subvesical or supravesicular ducts) can cause bile leakage during laparoscopic cholecystectomy, especially if surgery is carried out in ignorance of such variations. The aim of this study was to clarify the clinical anatomy of these ducts in human fetuses and frequency of the ducts locating near gallbladder fossa. Thirty-two fetal cadaver livers were dissected and the gallbladders were separated from the livers and ducts were investigated under a surgical microscope. All observed ducts were examined microscopically and connective tissue cords were excluded. Bile ducts of Luschka locating near cystic fossa were found in 7 of 32 fetuses (21.9%). Three of the seven ducts ran towards to liver segment 5 (S5); three ducts were found in the gallbladder fossa; and one duct ran towards to liver segment 4 (S4). Also it was found that three of the seven ducts drained into the subsegmental duct of S5, two ducts drained into the right hepatic duct, one duct drained into the right anterior branch bile duct, and one duct drained into the subsegmental duct of S4. Subvesical ducts running along the gallbladder fossa between the gallbladder and the liver parenchyma were found in a relatively high incidence in fetuses than adults. Awareness and knowledge about incidence of such ducts alerts the surgeon during laparoscopic cholecystectomy. Therefore morbidity due to bile leaks can be reduced.     

肝尾状叶应用解剖的研究与手术原则

目的为肝脏尾状叶合理化切除提供应用解剖学理论依据.方法通过24具尸体的肝尾状叶标本的解剖观察,揭示尾状叶的形状、边界、毗邻和血管、胆管分布规律.结果①尾状叶左侧的形态、大小、边界变异不大,其血液及胆管引流有一个相对固定的“蒂”,手术切除比较容易;②尾状叶的血管供应、胆管引流繁杂,但均连接于Glisson＇s管的一、二级分支的前上缘;③肝短静脉数量、注入部位变异大,其走行多与腔静脉壁垂直.结论尾状叶切除的手术入路有四条可供选择：左入路、右入路、前入路和后入路.     

A Study on the Anomalies of Gallbladder and Associated Structures

The gallbladder is a piriform structure on the undersurface of liver. It collects bile from the liver to concentrate it and to store it. The gallbladder has a cystic duct which joins the common bile duct and through these ducts bile passes into the duodenum. There is usually a single gallbladder (arising from the cystic bud of hepatic diverticulum) with one cystic duct supplied by a cystic artery taking origin from the right hepatic artery. But in few persons there are double gallbladder or double cystic ducts or different variations in the origin and course of cystic arteries. A study was undertaken in 2006 to detect the anomalies of these structures among the people Kolkata (a metropolis of eastern part of India), by dissection of cadavers. This study was conducted from the year 2006 to 2009 in the Department of Anatomy of Calcutta National Medical College and in other medical colleges of Kolkata. Three cases of double gallbladder and few other variations like double cystic duct were found in this study. These findings will help the clinicians (specially the surgeons, radiologists of the eastern part of India) to undertake any investigative or surgical procedure in the region of extra hepatic biliary apparatus. This study will enhance our knowledge not only surgical Anatomy, but also in embryology and in gross anatomy.     

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.     

Clinical anatomy related to the hepatic veins for right lobe living donor liver transplantation

The complexity of liver reconstruction has limited partial right lobe living donor liver transplantation. It is largely due to the difficulty of dealing with the middle hepatic vein. We sought to define the anatomic features of hepatic veins. Forty‐one fresh adult livers, 43 formalin‐fixed adult cadaver livers, and 91 adult liver corrosion casts were used for the study. We determined the number of branches, the maximum diameter, the whole length, the extrahepatic length of the hepatic veins, and the deviation of the middle hepatic vein from the main portal fissure. Nakamura and Tsuzuki's classification of hepatic vein types was used. Type A, B, and C accounted for 59.4, 27.8, and 12.8% of all specimens in this study, respectively. The middle and left hepatic veins formed a common trunk in 60.3% of the specimens, and the length of the common trunk was 1.12 ± 0.62 cm. The degree of deviation to the right of the middle hepatic vein from the main portal fissure was 14.11° ± 12.65°. The frequency of hepatic vein types and the degree of deviation to the right of the middle hepatic vein in this study is markedly different from that reported in other literature. The anatomic features of the hepatic veins in this study suggest that right lobe living donor liver transplantation is more suitable for Chinese. Clin. Anat. 2013. © 2012 Wiley Periodicals, Inc.     

Apoptosis of bile duct epithelial cells in hepatic allograft rejection

Liver biopsy remains the 'gold standard' for monitoring rejection in liver transplant patients. Portal inflammation, bile duct damage and endothelialitis are recognized features of hepatic allograft rejection. The pathogenesis of the bile duct injury during rejection, however, remains unclear. To define the mechanism of bile duct damage, we studied the light- and electronmicroscopic appearance of hepatic tissue from selected patients in whom allograft failure was solely due to rejection. Of the 25 orthotopic liver transplant rejection cases examined, 17 were mild, seven were moderate and one was severe rejection. Light microscopy examination of the damaged bile duct epithelium revealed evidence of apoptosis which was confirmed by electronmicroscopy. Furthermore, there appeared to be a positive correlation between the grade of rejection and the number of apoptotic cells. Also included in the study were 13 cases of chronic active hepatitis and 10 normal livers which showed the least apoptotic cells. We conclude that the identification of apoptotic cells in damaged bile ducts in allograft biopsies might be helpful in the diagnosis of rejection and in assessment of the severity of rejection.     

Anomalous hepatic arterial anatomy discovered during pancreaticoduodenectomy

Introduction A number of variations in hepatic arterial anatomy have been described. Anomalous arterial supply is of particular relevance to the hepatobiliary, pancreatic or liver transplant surgeon. Case report We describe the case of a 57-year-old gentleman who presented with painless obstructive jaundice and was found to have a mass in the head of the pancreas. At pylorus-preserving pancreaticoduodenectomy a distal quadrifurcation of the hepatic artery was discovered. It gave rise to the right hepatic artery, left hepatic artery, intermediate branch and a right accessory hepatic artery. The right accessory hepatic artery gave rise to the gastroduodenal artery. Conclusion The surgeon and interventional radiologist need to be aware of the potential for such aberrant anatomy in order to avoid potentially disastrous complications.     

Surgical anatomy of sub-hepatic biliary system

IntroductionThe anatomy of liver and extra-hepatic biliary apparatus has always been the focus of attention among anatomists and surgeons. It has gained greater significance in the recent years in view of technical refinements in the field of cholecystectomy, hepatic surgery and transplantation. Present study emphasizes the normal as well as variations of extra-hepatic biliary apparatus, as most of the published work on the surgical anatomy of the extra-hepatic biliary apparatus refers various ethnic groups variations. Literature on this topic in western U.P. subjects is scanty.MethodA study was conducted on 59 individuals undergoing hepatobiliary surgery after informed consent in the Department of Surgery and on 30 cadavers in the Department of Anatomy, LLRM Medical College Meerut, and Saraswathi Institute of Medical Sciences, Hapur during September 2004 to May 2011.ResultThe study revealed that in all cases, the union of hepatic ducts was extra-hepatic, of which 10% were angular low union and 5% parallel low union. In 95% cases cystic duct had angular union and 4% had parallel type of union with common hepatic duct and in one case cystic duct united with accessory hepatic duct. 16% cases had short cystic duct i.e. 1–2 cm in length. 94% cases show usual relation in hepatoduodenal ligament and in 6% common bile duct was to the left of hepatic artery.DiscussionThe obtained results presented variations regarding certain parameters when compared to previous studies and they represent the ethnic parameters of western UP.     

活体造影法肝内胆管的解剖学研究及临床意义

目的　通过经皮胆道直接造影,研究肝内胆管的解剖与变异的类型与分布。 方法　经皮胆道造影50例, 用20 ml注射器接体外引流管进行造影,胆管充分显影的状态下,旋转拍摄胆管,观察胆管解剖与变异。 结果　50例成像中胆管变异42.0％（21例）。12.0% (6例)显示右前叶肝管、右后叶肝管及肝左管呈三分叉状汇合形成肝总管。8.0% (4例) 肝左管先和右前叶肝管汇合,在肝门处与右后叶肝管汇合。20.0% (10例) 肝左管先和右后叶肝管汇合,在肝门处与右前叶肝管汇合。2.0% (1例)多个肝管在肝门处汇合。 结论　胆管解剖与变异的分析对术前手术方式的确定有一定的临床意义。     

肝右叶各段槽形切除胆肠吻合术的应用解剖学

用30例(离体肝25,肝管道(?)型5)肝脏,观察、测量了肝右叶内各段区的Ⅱ、Ⅲ级胆管.依其规律性设计各段区的槽形切除术式,充分暴露Ⅱ、Ⅲ级胆管,使其利于引流和清除结石,进而施行胆肠吻合术。本文介绍了寻找各段区Ⅱ、Ⅲ级胆管的方法,切除范围及其临床应用要点。