保留十二指肠的胰头切除术实用外科血管解剖学研究

目的研究胰头和十二指肠之间的血管解剖 ,为临床上开展关于十二指肠、胰头以及胆总管末端手术提供解剖学基础。方法对 30例甲醛固定的成人尸体和 10例新鲜尸体的十二指肠、胆总管下段及Vater壶腹的血液供应进行解剖研究。结果十二指肠降部和水平部血运由胰十二指肠前、后动脉弓及分支供应 ;胆总管下段血运主要是由胰十二指肠上后动脉供应 ;Vater壶腹血运主要是由胰十二指肠上后动脉发出的乳头动脉供应。结论胰十二指肠前、后动脉弓是供应十二指肠降部和水平部、胆总管下段和Vater壶腹的主要动脉。在行保留十二指肠的胰头切除术时应注意保护前、后动脉弓。     

Surgical anatomy of the cervical carotid artery for carotid endarterectomy

Carotid endarterectomy (CEA) is the main treatment for atherosclerotic plaque of the cervical internal carotid artery. The surgical anatomy of the carotid arteries was studied in the carotid triangle of 49 cadavers. The carotid bifurcation was located at the level of the lower third of C-3. The superior thyroid artery arose from the anterior wall of the external carotid artery in 70% of specimens and from the distal portion of the common carotid artery in 30%. The lingual artery arose as a separate trunk between the origins of the superior thyroid and facial arteries in 81% of specimens, with the facial artery from a common trunk in 18%, and with the superior thyroid artery in 1%. The occipital artery arose from the posterior aspect of the external carotid artery above the level of origin of the facial artery in 57% of specimens, between the origins of the facial and lingual arteries in 32%, and below the origin of the lingual artery in 11%. The origin of the occipital artery was positioned low and the distal portion of the occipital artery was crossed by the hypoglossal nerve in 20%. The ascending pharyngeal artery arose from the posterior wall of the external carotid artery above the level of origin of the lingual artery in 66% of specimens, below the origin of the lingual artery in 9%, from the proximal portion of the occipital artery in 19%, from the carotid bifurcation in 2%, and from the internal carotid artery in 2%. The branches of the external carotid artery are the key landmarks for adequate exposure and appropriate placement of cross-clamps on the carotid arteries. It is necessary to understand the surgical anatomy of the carotid arteries to carry out successful removal of plaque and minimize postoperative complications in a bloodless surgical field.     

Arterial arcades of the head and neck of the pancreas

The arterial vascularization of the right half of pancreas is structured as arcades: anterior, intermediate and posterior pancreatico-duodenal, and prepancreatic arcade. These blood vessels present as a complex of anastomoses between the large viceral arteries: the coeliac trunk and the superior mesenteric artery. The paper describes variations of origin, course and branching of the arcades' constituents, relevant for the contemporary surgery of pancreas and adjacent organs. A particular attention was drawn to the two anatomical entities: retropancreatic fibrous band and arterial vascularization of the major duodenal papilla.     

面神经颅外段血供的应用解剖学研究

目的探讨面神经颅外段的动脉来源及分布. 方法 15例新鲜尸体头颈部标本经双侧颈总动脉插管,加压注入红色乳胶或过氯乙烯填充剂,观察面神经颅外段的血供来源及分布. 结果面神经营养动脉来源于耳后动脉的茎乳动脉、颞浅动脉面神经支、面横动脉、颈外动脉上面神经支、颈外动脉下面神经支、面动脉后面神经支和面动脉前面神经支,其外径分别为(0.8±0.2) mm、(0.9±0.4) mm、(1.9±0.3) mm、(1.0±0.2) mm、(1.1±0.4) mm、(1.0±0.2) mm和(1.1±0.6) mm.各营养动脉除营养面神经外还发出分支相互吻合,构成了丰富的面神经血管网. 结论了解面神经颅外段动脉血供来源及分布,为避免腮腺咬肌区手术损伤面神经营养血管提供了解剖学基础.     

Surgical anatomy of the pancreas for limited resection

The fusion fascia of the head of the pancreas is called the "fusion fascia of Treitz" and that of the body and tail of the pancreas is termed the "fusion fascia of Toldt". The fusion fascia is histologically composed of a loose connective tissue membrane. All of the important pancreaticoduodenal arcades of arteries and veins are situated on this membrane, i.e., between this membrane and the pancreatic parenchyma. The topography of the head of the pancreas shows that, after departing from the gastroducodenal artery, the anterior superior pancreaticoduodenal artery runs toward a point 1.5 cm below the papilla of Vater, then turns to the posterior aspect of the pancreas to join the anterior inferior pancreaticoduodenal artery. For preserving the duodenum, the artery toward the papilla is very important. The artery toward the papilla of Vater runs along the right side of the common bile duct after departing from the posterior superior pancreaticoduodenal artery. The gastrocolic trunk of Henle has been reported to be found in about 60% of individuals. It is possible that the gastroepiploic vein and anterior superior pancreaticoduodenal vein (ASPDV) can be divided at pancreaticoduodenectomy, with preservation of the superior right colic vein, if this area is free of carcinoma. The ASPDV and anterior inferior pancreaticoduodenal vein form an arcade on the anterior surface of the pancreas. However, arcade formation was not found between the posterior superior pancreaticoduodenal vein and posterior inferior pancreaticoduodenal vein in many of the individuals examined. The vein joined by the inferior mesenteric vein was also investigated. Received: July 3, 2000 / Accepted: August 8, 2000     

颈内动脉海绵窦段分支及其临床意义

目的　研究颈内动脉海绵窦段的分支的出现、起始、外径和分布等的显微外科解剖， 为海绵窦的显微手术的开展提供形态学依据。方法　采用经颈内动脉灌注苯乙烯的４６ 例成人头颅， 在手术显微镜（１０ 倍） 进行观察和测量。结果　颈内动脉海绵窦段由后向前分为后升部、后曲、水平部、前曲和前升部；颈内动脉此段分支有脑膜垂体干、小脑幕动脉、垂体下动脉、脑膜背侧动脉、海绵窦下动脉和垂体被囊动脉以及异常的眼动脉等， 其出现率分别为８７ ％ 、８７ ％ 、９４ ％ 、８１ ％ 、８８ ％ 、３２ ％ 和６ ％ 。结论　本文较系统、全面地阐明了海绵窦段的显微外科解剖，对临床进行显微外科手术、血管介入和影像学检查有指导意义     

Microvascular anatomy of the uncus and the parahippocampal gyrus.

The microanatomical examination of the uncal and the parahippocampal arteries was performed in 17 brain hemispheres injected with India ink and gelatin. The mentioned arteries may originate from the anterior choroidal artery, the internal carotid artery, the middle cerebral artery, and the posterior cerebral artery. The uncal or the unco-parahippocampal branches of the anterior choroidal artery were divided into rostral and caudal; the former were present in 70.6%, and the latter were present in 94.1%. The uncal or the unco-parahippocampal branches of the internal carotid artery, which originated 1.4 to 4.2 mm from its bifurcation site, existed in 58.8%. The same branches of the middle cerebral artery, which most often arose from the temporopolar artery, were present in 64.7%. Finally, these branches of the posterior cerebral artery, which usually arose from the anterior hippocampal artery, were observed in 47.1%. Large parahippocampal branches of the anterior choroidal artery were noted in 52.9%. The internal carotid artery and middle cerebral artery gave rise to these branches in 23.5 and 64.7%, respectively. The posterior cerebral artery always gave off 2 to 10 parahippocampal vessels. The largest of them originated within the rostral hippocampo-parahippocampal arterial complex. The authors discuss the microanatomical characteristics and possible clinical significance of the uncal and the parahippocampal arteries.     

以胰腺为轴心的相关筋膜及安全外科平面解剖研究

目的研究胰十二指肠区域血管的应用解剖、相关系膜及系膜间隙的解剖学特点,观察胰十二指肠区域解剖标志及安全外科平面,为临床上开展胰头及十二指肠、胆总管末端手术提供解剖学基础。方法对7具甲醛固定的成人尸体的十二指肠、胰腺周围供血血管及胆总管下段作了解剖学观察,对横结肠系膜构成的网膜囊及胰腺周围胚胎时期形成的潜在的筋膜间隙和解剖层次标志进行观察描述。结果准确定位胃左动脉和肝总动脉,由胰腺前筋膜形成的肝胰襞及胃胰襞是一个很好的标志。当进行胰腺游离及后方淋巴结清扫时,在胰腺后筋膜及肾前筋膜间有一无血管平面可以应用。肾前筋膜是避免损伤腹膜后血管、肾上腺的安全界面,为避免腹膜后血管及肾上腺的损伤,肾前筋膜应作为安全分离平面的后界。胰十二指肠前后动脉弓及分支主要供应十二指肠降部和水平部的血运,行保留十二指肠的胰头切除术时应注意保护胰十二指肠前后动脉弓。结论充分理解胚胎发育过程胰腺周围筋膜及筋膜间隙的形成,对于手术中正确理解、辨识解剖平面非常重要,沿着筋膜间隙的操作可避免出血及副损伤,也是肿瘤外科根治性切除的基本要求。     

Topographic microsurgical anatomy of the paraclinoid carotid artery

In this publication, the authors describe the microanatomic topography of the entire paraclinoid area with respect to the paraclinoid segment of the internal carotid artery and its surrounding anatomical structures. Special attention was given to the borders of the paraclinoid area, cavernous sinus, arterial vessels, and cranial nerves passing through the region. The paraclinoid region was defined as a pyramid-formed space formed by the dural covering of the anterior clinoid process. The superior border is formed by the continuity of the anterior petroclinoid fold, anteriorly on the superior surface of the anterior clinoid process and medially in the direction of the diaphragma sellae. This dural sheet encircles the internal carotid artery and forms the so-called distal dural ring of the internal carotid artery. The medial border of the paraclinoid region is formed by the body of the sphenoid bone and the adjacent periosteal sheet. The inferior border is formed by a fibrous plate between the middle and anterior clinoid processes. This so-called proximal dural ring separates the venous compartments of the cavernous area from the paraclinoid area. The lateral border is formed by the lateral surface of the anterior clinoid process with its dural covering. The arterial supply of this region is provided by branches of the intracavernous carotid segment and the ophthalmic artery. The important nerves in close vicinity to the paraclinoidal area are the optic and the oculomotor nerves. Understanding and knowledge of the topographic anatomy of the paraclinoid area is essential for microsurgical exposure of this region. Electronic Publication     

Persistent hypoglossal artery: Diagnostic and therapeutic considerations concerning carotid thromboendarterectomy

Fetal anastomotic connections between the developing internal carotid and basilar arterial systems are via the three presegmental arteries: the otic artery, the hypoglossal artery, and the trigeminal artery. After formation of the posterior communicating artery from the caudal branch of the internal carotid artery, the presegmental arteries are generally obliterated. Rarely, however, these primitive carotid-basilar anastomoses will persist into adult life, and may be detected as incidental findings at the time of cerebral angiography during evaluation of the patient with suspected cerebrovascular disease. In addition, persistence of such anastomoses may result in the coexistence of anterior and posterior circulation symptoms, precipitating diagnostic confusion. Two patients with symptoms and persistent hypoglossal artery undergoing carotid thromboendarterectomy are discussed, with emphasis on clinical presentation, diagnostic criteria and intraoperative management. (J VASC SURG 1994;20:995-9.)     

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??Applied anatomy of the blood supply of the uncinate process in laparoscopic pancreatoduodenectomy WANG Wei*??JIANG Chong-yi??CHEN Yin-tao??et al. *Department of General Surgery??Pancreato-Biliary Clinical Center??Minimally Invasive Surgery Center??Huadong Hospital??Fudan University??Shanghai 200040??China
Corresponding author??WANG Wei??E-mail??hdwangwei@fudan.edu.cn
Abstract Objective To investigate the origin and distribution of arteries in the uncinate process, and provide precious anatomy structure of the blood supply of the uncinate process for laparoscopic pancreatoduodenectomy (LPD). Methods Twelve cases of cadaver specimen fixed with formaldehyde and 1 cases of fresh casting mold specimen of pancreatic vessels allied with pancreatic duct were studied for the blood supply of the uncinate process of pancreas in Department of Anatomy, Shanghai Medical College of Fudan University. The distribution of dorsal pancreatic artery (DPA) of 12 cases of LPD performed between January 2014 and December 2014 in Pancreato-Biliary Clinical Center??Huadong Hospital??Fudan University were also observed in operations. Results ??1??The right branch of DPA distributes to the uncinate process. (2) From ventral aspect, the right branch of the DPA was divided into two smaller branches at four o’clock. And those two branches anastomosed with each other at eight o’clock??which formed a closed arterial loop in the uncinate process. The arterial loop communicated with the common hepatic artery and the pancreaticoduodenal arterial arcade by hub-and-spoke arterial anastomosis. (3) In 12 cases of LPD??4 cases (66.7%) of DPA originated from the splenic artery and 2 cases (33.3%) from superior mesenteric artery. Conclusion The uncinate process is supplied by the pancreaticoduodenal arterial arcade and the right branch of DPA, and they communicate with each other by hub-and-spoke arterial anastomosis in the uncinate process. In order to decrease the risk of bleeding in LPD procedure??the surgeons should pay attention to the right branch of DPA and the anastomosed branches from the uncinate process arterial circle.     

Blood supply to the anterior cruciate ligament and supporting structures

The blood supply to the knee arises from a vascular plexus that surrounds the joint. The descending genicular artery, the medial and lateral inferior genicular arteries, the medial and lateral superior genicular arteries, the middle genicular artery, and the anterior and posterior tibial recurrent arteries contribute vessels that supply the various structures of the knee. The intra-articular soft tissues of the knee (the infrapatellar fat pad and synovium) mediate the blood supply to the cruciate ligaments, and preservation and utilization of these tissues should be considered when repair or reconstruction of the anterior cruciate ligament is being performed.     

A geometrical model of vertical translation and alar ligament tension in atlanto-axial rotation

Introduction

While allowing the greatest range of axial rotation of the entire spine with 40° to each side, gradual restraint at the extremes of motion by the alar ligaments is of vital importance. In order for the ligaments to facilitate a gradual transition from the neutral to the elastic zone, a complex interaction of axial rotation and vertical translation via the biconvex articular surfaces is essential. The aim of this investigation is to establish a geometrical model of the intricate interaction of the alar ligaments and vertical translatory motion of C1/C2 in axial rotation.

Methods

Bilateral alar ligaments including the odontoid process and condylar bony entheses were removed from six adult cadavers aged 65–89 years within 48 h of death. All specimens were judged to be free of abnormalities with the exception of non-specific degenerative changes. Dimensions of the odontoid process and alar ligaments were measured. Graphical multiplanar reconstruction of atlanto-axial rotation was done in the transverse and frontal planes for the neutral position and for rotation to 40° with vertical translation of 3 mm. The necessary fibre elongation of the alar ligaments in the setting with and without vertical translation of the atlas was calculated.

Results

The mean diameter of the odontoid process in the sagittal plane was 10.6 mm (SD 1.1). The longest fibre length was measured from the posterior border of the odontoid enthesis to the posterior border of the condylar enthesis with an average of 13.2 mm (SD 2.5) and the shortest between the lateral (anterior) border odontoid enthesis and the anterior condylar enthesis with an average of 8.2 mm (SD 2.2). In graphical multiplanar reconstruction of atlanto-axial rotation to 40° without vertical translation of C1/C2, theoretical alar fibre elongation reaches 27.1% for the longest fibres, which is incompatible with the collagenous structure of the alar ligaments. Allowing 3 mm caudal translation of C1 on C2 at 40° rotation, as facilitated by the biconvex atlanto-axial joints, reduces alar fibre elongation to 23.3%.

Conclusion

The biconvex configuration of the atlanto-axial joints is an integral feature of the functionality of upper cervical spine as it allows gradual vertical translation of the atlas against the axis during axial rotation, with gradual tensing of the alar ligaments. Vertical translation on its own, however, does not explain the tolerance of the alar ligaments towards the maximum of 40° of rotation and is most likely synergistic with the effects of the coupled motion of occipitocervical extension during rotation.     

Superior mesenteric artery stenting to augment splenorenal arterial bypass for intractable complex renovascular hypertension

An alternative source of visceral arterial inflow is sometimes necessary for renal revascularization when aortorenal endarterectomy or bypass is inappropriate due to severely diseased aorta. We report the case of a 46-year-old male with recurrent intractable renovascular hypertension in renal failure secondary to occlusion of the celiac axis due to progression of aortoarteritis following splenorenal arterial bypass performed 5 years before. Aortogram visualized intestinal arterial arcade supporting patent bypass with critically stenosed superior mesenteric artery. Successful angioplasty with stenting of superior mesenteric artery restored adequate renal flow through the bypass leading to recovery and easy control of hypertension.     

Persistent primitive hypoglossal artery with retrograde flow from the vertebrobasilar system: a case report

The persistent primitive hypoglossal artery (PPHA) is one of the pairs of arterial connections that exist in the human embryo between the developing anterior and posterior circulation. Normally the PPHA arises from the cervical internal carotid artery (ICA) and passes through the hypoglossal canal to join the caudal basilar artery (BA). In most cases the vertebral arteries (VA) are either hypoplastic or aplastic and the posterior communicating arteries (PComA) are absent; thus, the main supply to the posterior circulation comes from the internal carotid via the PPHA in an antegrade fashion. Atherosclerotic plaques in the ICA and PPHA present with ischemic symptoms of both the carotid and vertebrobasilar systems. We report a case of a 53-year-old female who presented with a transient episode of left lower extremity numbness and weakness. Work-up with computed tomography (CT) and magnetic resonance imaging (MRI) showed a small watershed infarct in the right middle cerebral artery (MCA)/posterior cerebral artery (PCA) territory. Diagnostic angiography revealed severe proximal stenosis of the cervical ICA and presence of a PPHA just above the stenosis with retrograde filling from the vertebrobasilar junction to the distal cervical ICA. The patient underwent a carotid endarterectomy with intraoperative EEG monitoring. Intraoperative blood flow measurements were made before and after endarterectomy showing evidence of reversal of blood flow to a normal antegrade fashion. The postoperative angiogram showed resolution of the right ICA stenosis and persistence of the PHA. To our knowledge this is the first case report of a PPHA exhibiting reversal of blood flow from the posterior into the anterior circulation. Awareness of this embryological anomaly and its interaction with acquired atherosclerotic disease will minimize misinterpretation of vascular diagnostic studies.     

Persistierende primitive Hypoglossusarterie (PPHA)

The persistent primitive hypoglossal artery (PPHA) is an embryonal communication between the posterior and anterior circulation of arteries supplying the brain; it is normally obliterated in the early embryonal stages. In a symptom-free patient with arterial occlusive disease, internal carotid artery occlusion was incidentally diagnosed using color duplex ultrasound, whereby the resupply of blood to the distal extracranial internal carotid artery occurred due to retrograde blood flow via the PPHA, resulting in nearly normal blood flow to the distal extra- and intracranial carotid circulation. We describe how color duplex ultrasonography can be used to differentiate therapy-relevant findings, when blood flow is lacking in the proximal internal carotid artery.     

Aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization

We report a case of aneurysmal rupture of the pancreaticoduodenal artery successfully treated by transcatheter arterial embolization. A 61-year-old man with a history of hypertension underwent surgery at our hospital in November 1995 for local peritonitis caused by perforation of the sigmoid colon secondary to cancer. On the 9th postoperative day, he developed shock, with complaints of epigastric and back pain. Abdominal computed tomography showed an enhanced mass, thought to be a peripancreatic aneurysm. Emergency angiography demonstrated an aneurysm arising from the arcade of the anterior pancreaticoduodenal artery. After diagnostic angiography, transcatheter arterial embolization was performed. With steel coils, the anterior superior pancreaticoduodenal artery and anterior inferior pancreaticoduodenal artery were embolized near the origin of the aneurysm. Angiography 7 weeks later revealed no recanalization of the aneurysm and the absence of anomalous collateral vessels. The patient has been well for 19 months without re-bleeding or recurrence of sigmoid colon cancer. Transcatheter arterial embolization is an effective therapeutic approach for aneurysm of the pancreaticoduodenal artery and is the preferred initial treatment. Received for publication on July 14, 1997; accepted on Sept. 30, 1997     

距骨的血液供应及其临床意义

本文观察了２４侧尸体足标本，均无已知临床血管疾病。在死后３６～４８小时之间行动脉灌注ＡＢＳ填充剂，以化学腐蚀和手工剔除的方法清除软组织。距骨的血供来自小腿下部三根主要动脉的分支，即跗骨管动脉和三角支、近端和远端跗骨窦动脉、颈上支及后结节血管丛。跗骨管动脉常发自足底内侧动脉，而三角支多单独自胫后动脉发出；跗骨管动脉通常比三角支和跗骨窦动脉都来得细小。以上的这些动脉相互吻合，形成了一个骨膜血管网，覆盖于全部的距骨非关节面上。而且，环绕着跗骨管、跗骨窦、距骨颈的上面和距骨体部的内侧面，由三角支、跗骨管动脉、跗骨窦动脉、颈上支及其相互之间的吻合血管网形成了一个不定形的距骨动脉环。本文还讨论了距骨缺血性坏死与动脉环的可能关系，距骨骨折脱位或手术后的缺血性坏死是由于距骨动脉环的毁损或功能受影响所致。三角支在距骨骨折脱位时具有重要意义，手术或手法复位时应注意保护。     

Hypoplasia of the internal carotid artery--report of an unusual case.

We present a rare case of unilateral internal carotid artery (ICA) hypoplasia associated with arterial anomalies in the circle of Willis. The ipsilateral middle cerebral artery was supplied via anomalous arteries from the posterior cerebral artery and the ICA. The ipsilateral common carotid artery also originated from the anomalous brachiocephalic trunk. The etiology of the hypoplastic ICA is uncertain, but the associated multiple vascular anomalies support the congenital origin.     

Persistent trigeminal artery associated with brainstem infarct--case report.

A 47-year-old male presented with a sudden onset of right hemiparesis and numbness of the left face. Magnetic resonance imaging demonstrated a lacunar infarct in the ventral pons. Cerebral angiography demonstrated a persistent trigeminal artery (PTA) anastomosing the left internal carotid artery to the distal basilar artery. Bilateral vertebral arteries and the basilar artery below the PTA junction were extremely hypoplastic. The bilateral posterior communicating arteries were embryonic. The posterior fossa circulation was almost independent from the circle of Willis. The poor vascular supply to the posterior fossa probably caused the brainstem infarct.