左外叶活体肝移植肝静脉的临床应用解剖

目的 :观察肝左叶静脉解剖结构 ,模拟左外叶活体肝移植肝静脉切取方法。方法 :解剖正常人肝脏标本 30具 ,观察肝脏铸型标本 30具 ,测量肝左静脉长度、管径及属支分布情况。结果 :肝左静脉主要由左外叶上段静脉支和下段静脉支汇合并延续而成 ,主要接收或不接收较有意义的属支有左后上缘静脉支和左叶间裂静脉支。结论 :肝左外叶静脉血管解剖变异较多 ,活体取肝前应仔细研究其结构特点 ,设计合理的切取模式 ;移植前肝静脉需行必要的整形 ,以便与受体静脉进行吻合。少数情况下肝左外叶活体移植为禁忌证。     

国人肝段的再认识

目的:对肝内门静脉和肝静脉重新认识,提出一种新的国人肝段划分方法,为影像学和肝外科提供断层解剖学资料。方法:使用50例上腹部连续断层标本和20例多层螺旋CT图像及三维重建图像,研究了肝内门静脉的走行和分布以及肝静脉及其属支的回流范围及其两者之间的相互关系。结果:国人肝段新的划分方法:门静脉右支主干存在时,依肝中静脉所在的正中裂将肝分为左、右半肝。右半肝被一弯曲的右叶间裂分成右前上叶和右后下叶。右前上叶依垂直段间裂分为腹侧和背侧段。右前上叶的腹侧段被水平亚段间裂分为上、下两个亚段。右后下叶依水平段间裂分为上、下两段。肝左静脉主干存在时,依肝左静脉主干所在的左叶间裂将左半肝分成左后上叶和左前下叶。左前下叶依左段间裂分为内侧和外侧段。水平亚段间裂将左前下叶的内侧段分为上、下两个亚段。依弧形背裂分尾状叶和右前上叶及左前下叶内侧段。结论:国人肝段新的划分法不仅有利于肝内微小病变的精确定位,而且便于肝外科探索新的和更加安全的术式来施行各种肝切除和肝移植。     

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。     

国人肝段在冠状断层上的划分

目的：为肝内微小病变精确定位诊断和外科治疗提供冠状断层解剖学依据。方法：采用30例上腹部连续冠状断层标本、20例肝内门静脉和肝静脉解剖正常的薄层MSCT断层图像及其三维重建图像,在冠状断层上对其门静脉肝段进行精确划分。结果：经胆囊、门静脉左支及肝左静脉的冠状断面上,肝中静脉主干是划分右前上叶和左前下叶的识别标志,门静脉左支角部是左前下叶的段间裂识别标志,亦是右前上叶和左前下叶的亚段间裂识别标志。经肝门静脉主干的冠状断面上,门静脉右前支主干是右前上叶的段间裂识别标志,该层面以前为右前上叶的腹侧段,该层面以后则为右前上叶的背侧段。经网膜孔的冠状断面上、下腔静脉的右缘是划分尾状叶和右半肝的识别标志,门静脉右后支主干是划分右前上叶背侧段和右后下叶下段的标志,经下腔静脉和肝右静脉的冠状面上,肝右静脉主干是划分右前上叶的背侧段和右后下叶上段的标志;门静脉右后支主干是右后下叶的段间裂识别标志。结论：国人门静脉肝段在冠状断面上的精确划分,不仅有利于肝内微小病变的精确定位,且有利于探索新的和更加安全的外科术式。     

猪活体肝脏移植的应用解剖

目的：探讨猪活性肝移植解剖学基础，方法：在10例新鲜成年猪肝大体和管道铸型标本上，观测猪肝分叶，分段，动脉，肝门静脉，胆管和肝静脉的分布和汇注规律。结果：猪肝外观由三大叶组成，即左外叶，叶叶和右后叶，尾状叶与邻叶界限不明显，中叶的中分线是左右半肝的真正分界线，此界面内无重要的管道结构，结论：猪活体肝移植是一个良好的实验动物模型，猪肝移植物应以左半肝为好。     

右叶部分肝移植肝静脉的临床应用解剖

目的：为右叶部分肝移植提供肝静脉的解剖学基础。方法：观测52个铸型标本中肝静脉的走行、分布、分型，肝中静脉肝左静脉合干比率，肝短静脉的数量，大小，及其在肝静脉的各类型中的出现率。结果：肝静脉的分型中A型、B型、C型分别为65．4％、26．9％、7．7％。肝中静脉肝左静脉合干机率67．3％。肝短静脉出现率为32．6％，肝右静脉汇入下腔静脉处与肝中静脉汇入肝左静脉或下腔静脉处的距离2．Ocm以内者占80．7％。结论：本文结果为右叶部分肝移植提供了肝静脉的解剖学基础，提示中国人肝静脉的结构似乎较适合右叶部分肝移植。     

基于肝内肝门静脉解剖的肝脏右前叶分段新概念

目的根据肝内肝门静脉的走形分布,提出肝脏分段的新概念,为影像学和肝脏外科提供资料。方法采用60例正常的活体肝移植供肝影像资料,研究右前叶肝内肝门静脉的走形和分布以及肝静脉及其属支的回流范围,10例Mevis三维软件重建图像,探讨两者之间的关系。结果 Couinaud分段中的Ⅷ段门脉支可大致分为腹侧支和背侧支,最多可达4支;约90%的背侧支越过肝右静脉分布到Couinaud分段中的VII段。V段的门脉分支大多来自右前叶或Ⅷ段门脉的腹侧支。因此,可将右前叶分为腹侧段:Couinaud分段中的Ⅷ段的腹侧段(S8v)和V段(S5)背侧段:Couinaud分段中的Ⅷ段的背侧段(S8d)两个部分。结论新的划分方法不仅有利于肝内病变的精确定位,而且便于肝脏外科实施新的、更安全的术式。     

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。     

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     

兔肝脏及附属管道的应用解剖学研究

目的　对兔肝脏及其附属管道进行应用解剖学研究。 方法　对20只日本大耳兔分别进行活体和离体形态学观察,制作门静脉和肝静脉管道铸型标本观察其分支与走行,测定各肝叶质量及其所占肝脏百分比。 结果　兔肝肝裂明显,依据肝叶形态、肝裂走行和门静脉主干分支形式将兔肝脏分为五叶,分别为尾状叶、左外叶、左中叶、右中叶、右外叶,各肝叶质量分别为(g)：3.93±1.13、15.93±3.50、14.83±3.31、15.08±4.34、12.08±3.55。左中叶和右中叶根部肝组织融合,其余各肝叶相对独立,尾状叶包括相对独立的乳头突和尾状突两部分。各肝叶有相对独立的Glisson系统和肝静脉走行于肝蒂内。 结论　兔肝解剖学特点与多数哺乳类实验动物肝脏解剖相似,同时又具有其自身特点,适合于肝脏外科疾病动物模型的制作。     

肝尾状叶切除术中寻找肝静脉的探讨

目的　为肝尾状叶切除术提供解剖学依据。方法　选择 6 0例肝脏标本 ,对紧贴尾状叶的肝中、肝左、肝右静脉段进行解剖和形态观测。结果　紧贴尾状叶的肝中、肝左、肝右静脉从下至上距尾状叶脏面的距离越来越小 ,从下至上彼此的间距亦越来越小 ;肝中、肝左、肝右静脉不在同一平面 5 2例 (8 6 7% )。结论　在尾状叶切除术中 ,先找到肝中静脉末端之后 ,才能更容易寻找肝中、肝左、肝右静脉     

肝门静脉的应用解剖

目的观测肝门静脉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形态学资料。方法 50例肉眼观察无病变的成人肝标本,对肝门静脉分支分型等形态特征进行解剖观察,测量肝门静脉主干及其主要分支的相关数据并进行统计学分析。结果肝门静脉主干54.0%在肝实质外分叉,其分叉点距肝实质的垂直距离为(8.94±3.17)mm;34.0%紧贴肝实质分叉。左支主干长(47.44±7.23)mm;左支横部长(23.90±5.29)mm,外径为(7.43±1.09)mm,矢部长(24.02±4.97)mm,外径为(7.07±1.36)mm,角部角度为(114.18±22.59)°;右支主干长(20.63±6.59)mm,外径为(9.26±1.77)mm。依据肝门静脉的分支情况可将其分为8型。结论肝门静脉变异情况并不少见,其分叉点距肝实质的垂直距离及左、右支主干径值与分支等均存在一定的变化,在肝外科手术实施时,对肝门静脉主干分支各型应给予高度的重视。。     

Main accessory sulcus of the liver

It has been proposed that the superficial part of the portal fissures weakens the surface hepatic parenchyma, allowing the development of accessory sulci caused by diaphragmatic pressure. To evaluate the relationship of the sulci in the antero-superior surface of the right liver with the right portal fissure, macroscopic post mortem examination of 85 livers was carried out and radio-opaque resins were injected into the portal and hepatic venous systems to obtain vascular casts. After formalin fixation, the 85 livers also underwent CT and MR scans and 3D image elaboration. Diaphragmatic sulci were found in 32 cases. We studied the sulci located in the right liver, i.e., those that lay to the right of the line of Cantlie. They were found in 28 instances and in 16 cases they were multiple. In the livers with a single sulcus, it extended between the anterior and right surfaces of the right liver and showed a curved course downward and forward, toward the inferior margin. In the cases with multiple sulci, one sulcus always showed a course similar to that of the single sulci. The 28 sulci, with similar position and course, showed variable characteristics (mean length=7.6 +/- 2.7 cm, mean width=0.8 +/- 0.7 cm, mean depth=1.4 +/- 0.8 cm). Both radiological images and corrosion casts showed a correspondence between these sulci and the right hepatic vein and the right portal fissure in 71% of cases. These sulci may represent the variable expression (cranial, intermediate, or caudal portions) of a potential sulcus, the main accessory sulcus (MAS), that develops along a theoretically predictable course corresponding to the superficial part of the right portal fissure. The high prevalence of location of the MAS at the level of the upper part of the right portal fissure can be ascribed to the presence at this level of the watershed between the roots of the tributaries of the hepatic veins coming from segments VIII and VII, draining respectively into the middle and right hepatic veins. Thus, the coexistence of the two portal and hepatic venous boundaries may represent a further predisposition to the effects of diaphragmatic pressure. The MAS may represent a marking for the right portal fissure, and hence a superficial reference for the deep course of the right hepatic vein.     

Ramification pattern and topographical relationship between the portal and hepatic veins in the left anatomical lobe of the human liver.

Sixty-one human livers obtained from donated Japanese adult cadavers were dissected to reveal the ramification pattern of the portal and hepatic veins, and their topographical relationship in the left anatomical lobe. The segmental portal vein supplying S2 (P2) tended to form a single stem, whereas that of S3 (P3) was usually double. An intermediate branch between P2 and P3 was observed in 23.0% of livers. In spite of variation between livers, definite P2 and P3 were identified in 47 specimens. One tributary of the left hepatic vein (LHV) was usually present for drainage of S2, and two tributaries were present for S3 (sometimes also for S2 and/or S4). The latter two tributaries of the LHV and the two subsegmental branches of S3 showed three patterns of three-dimensional interdigitations. From these results, the portal vein system did not seem to have a two segmental composition (i.e., S2 and S3) in 23.0% of specimens, whereas the hepatic vein system did not have an intersegmental course in 23.4%. Thus, there were obvious limitations in using each system to determine the liver segment. Taking the overlapping cases into consideration, the left anatomical lobe of 41.0% of specimens did not seem to fit the definition of Couinaud's liver segment. In addition, four patterns of fissure vein (or scissural vein), > 5 mm in diameter at its terminal, were identified: (1) middle hepatic vein type (left median vein, 9.8%); (2) LHV type (left medial vein, 41.0%); (3) true fissure vein (3.3%); and (4) absent cases (45.9%). The former two types also suggested limitations of the hepatic vein system as an indicator of the segmental border.     

肝裂的定位与肝段的划分

目的：精确定位肝裂与肝段,为肝脏病变的诊断和治疗提供解剖学依据。方法：用过氯乙烯分色灌注肝静脉和门静脉。固定灌注后的肝脏,再用雕刻法移去肝组织,保留肝静脉和门静脉,并对其进行详细地解剖学观察。结果：3条肝静脉的位置可精确定位3条肝裂。门静脉左、右支可精确定位1条段间裂。肝裂和段问裂将肝脏分成5叶8段。结论：肝裂和段间裂确定了肝叶和肝段的精确定位与划分,对肝脏病变的诊断和治疗非常重要。     

左、右肝管全程剖开的应用解剖

用6个取自新鲜成人尸体的肝脏,注入ABS丙酮溶液制成铸型。另外还解剖了经固定的42例(成人32,儿童10)肝脏标本,测量左、右肝管长度、管径,并观察左、右肝管与肝动脉、门静脉及其分支的关系。提出了左、右肝管全程剖开的手术方法和注意事项。     

Three liver grafts from a deceased whole liver

Although the lateral segment (LS) from the split-liver of a deceased donor or a live donor can increase the organ pool of pediatric patients awaiting liver transplantation, the shortage of organ donation in Asia countries is still serious and results in high death rates of pediatric patients. The medial segment (MS) of the liver is sacrificed during the standard technique of splitting a whole liver into an LS and an extended right liver because the cutting sites of portal vein, hepatic artery and bile duct are all in the bifurcation of the liver hilum to have adequate length of vascular and biliary pedicles for easier grafting. However, the surgical techniques of vascular and biliary reconstructions for liver transplantation, particularly from the experiences of living donor liver transplantation, have been much improved in the last decade. Therefore it may be possible for an additional MS of the liver to be an isolated graft for a small recipient on the premise that grafts of right lobe (RL) and LS are minimally injured. In light of detailed reviews of anatomies of hepatic arteries, hepatic veins, portal veins and bile ducts, the dissection and reconstruction of vessels and bile ducts for the MS can possibly be performed if the extra-hepatic length of the artery to the MS is long enough. As the artery for the MS, middle hepatic artery (MHA), usually derives from a branch of the left hepatic artery and often in the liver parenchyma, the length is usually too short to be reconstructed. If the MHA for the MS is isolated and its extra-hepatic length is more than 1cm, triple liver grafts from a deceased whole liver, consisting of the RL, MS and LS may be possible. The anatomies of the hepatic artery in abdominal computed tomography (CT) or magnetic resonance imaging (MRI) for live liver donors in our institution were retrospectively analyzed. The results showed that three types of hepatic arterial anatomies could be considered for possible recovery of triple segments: type I is an accessory left gastric artery to feed the lateral segment; type II is an isolated MHA; type III is an early bifurcation of the left hepatic artery and MHA.     

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.     

Applied anatomy of small branches of the portal vein in transverse groove of hepatic hilum

Purpose

The objective of this study was to provide the morphological details on small branches of the portal vein in transverse groove of hepatic hilum.

Methods

According to the surgery significance, the small branches of portal vein in transverse groove of hepatic hilum were named as “Short hepatic portal veins (SHPVs)”. SHPVs were minutely dissected in 30 adult cadaveric livers. The number, diameter, length, origin points, and entering liver sites of SHPVs were explored and measured.

Results

There were 181 SHPVs in 30 liver specimens, including 46 % (83/181) from the left portal vein, 31 % (56/181) from the bifurcation, and 23 % (42/181) from the right portal vein. At the entering liver sites of SHPVs, 22 % (40/181) supplied for segment IV, 9 % (17/181) for segment V, 4 % (7/181) for segment VI, 23 % (41/181) for segment VII, and 42 % (76/181) for segment I (caudate lobe). There were 6.0 ± 2.4 branches per liver specimen with range 3–12. The mean diameter of SHPVs was 2.25 ± 0.89 mm. The average length of SHPVs was 4.86 ± 2.12 mm.

Conclusions

SHPVs widely existed in each liver specimen. The detailed anatomical study of SHPVs could be useful to avoid damaging the short portal branches during hepatic operations, such as isolated or combined caudate lobectomy.     

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。