腹内控制肝上及肝下下腔静脉的局部解剖学研究及其应用

作者对１６例新鲜成人尸体膈下肝上下腔静脉进行了局部解剖学研究，测量其直径为３５．９４±５．６８ｍｍ，长度１６．８７±５．１４ｍｍ，可安全置放阻断带加以控制。临床上对２１例累及二、三肝门的肝叶或肝段切除术，经腹在断肝前用阻断带控制肝上及肝下下腔静脉及第一肝门，防治术中可能发生的肝静脉或／和下腔静脉损伤出血。本组３例术中损伤肝中静脉，经阻断带迅速控制下腔静脉，修补裂口，抢救成功。作者认为该法可推广应用。     

���ڸ�������ҪѪ�ܵĸ�Ѫ����������ƣ���27�����棩

目的 探讨紧邻肝内外重要血管的肝血管瘤的安全切除。方法 回顾性分析1996～2003年手术切除的27例紧邻肝内外重要血管的肝血管瘤的临床资料。肝上下腔静脉、肝下下腔静脉、肝右静脉或肝中肝左静脉共干预置阻断带。使用多功能手术解剖器行刮吸法切除肿瘤。结果 27例肝血管瘤均安全切除。肝上下腔静脉、肝下下腔静脉、肝右静脉或肝中肝左静脉共干预置阻断带，成功完成下腔静脉裂口修补2例，肝中静脉修补3例，肝右静脉修补1例。结论 肝上、肝下下腔静脉和主肝静脉预置阻断带有利于复杂情况下的肝血管瘤的安全切除．     

使用转流泵的肝周脉管阻断肝切除法(日)

作者使用肝移植时使用的转流泵(Bio-pump)进行了7例肝周脉管阻断(HVE)肝切除。见表1。方法:以扩大右半肝切除为例。直肠内置体温监测仪。为防止低体温,双下肢缠绑铝箔。切口为上腹横弧型。分离切断胆囊管的胆总管侧应留长些,备肝切术后灌流查有无胆漏。分离出管状右肝管、右肝动脉、门脉右支。先断右肝动脉和门脉右支,门脉右支近端需连续缝合。最后结扎切断右肝管。打开小网膜囊后,用探子再通肝圆韧带内血管,用细管插入并入门脉左支,备肝冷灌流用。分离肝上的下腔静脉,膈静脉入下腔静脉支需用丝线贯穿缝扎。肝下的下腔静脉剥离至右肾静脉,从尾状叶入下腔静脉的肝短静脉亦应小心结扎。门脉脱血是从Treitz韧带左侧肠系膜下静脉,分离出足够长度后置入17Fr套管。体循环     

保持下腔静脉通畅的全肝血流阻断切肝术

目的探讨保持下腔静脉通畅的全肝血流阻断切肝术（THVEPC）的应用价值。方法对25例位于第二肝门区肿瘤施行第一肝门＋左、中、右肝静脉阻断切肝术，保持下腔静脉血流畅通，11例病人同时行肝短静脉结扎。结果25例病人中原发性肝癌17例、转移性肝癌1例、肝母细胞瘤2例、肝巨大血管瘤5例。肿瘤直径14．7cm（5～43cm）。肿瘤侵犯2根主肝静脉16例，侵犯3根主肝静脉9例。行右三叶切除7例，右半肝切除3例，中肝叶切除6例，Ⅷ段切除3例，左三叶切除4例，尾状叶切除2例。共结扎肝静脉16根，血管带阻断20根，血管夹或心耳钳阻断18根。切断1根主肝静脉14例，切断2根主肝静脉11例。平均第一肝门阻断时间25．5min（15～42min），平均肝静脉阻断时间16．4min（5～28min）。平均术中出血量820ml（100～6000ml）。行肝静脉修补4例。结论保持下腔静脉通畅的全肝血流阻断切肝术既能达到无血切肝的目的，又避免了下腔静脉阻断所引起全身血流动力学紊乱，是一种更符合生理的新技术。     

第Ⅷ肝段巨大型海绵状血管瘤的手术方法（附4例报告）

第Ⅷ肝段巨大型海绵状血管瘤不必常规进行全肝血流阻断法切除，下腔静脉可预置阻断带，但膈下肝上下腔静脉分离有时较困难，致预置阻断带不成功．本组4例手术顺利完成的关键就在于在常温下间歇阻断第一肝门入肝血流的同时，用剥离法将肿瘤剥除．此种手术方法与行第Ⅶ肝段切除术相比，既简便又安全，值得推广。     

经腹路布一加氏综合征根治术─—附1例报告

本文报告经腹路行布一加氏综合征根治性手术１例。手术在常温全麻下进行，取双肋缘下“人”字形切口进腹，经充分游离肝上、下段下腔静脉后，显露肝右、中、左静脉，将复盖于肝静脉前方的肝组织适当游离，以充分显露肝静脉入口平面之下腔静脉狭窄部。常温下阻断全肝血流后，直视下切开下腔静脉狭窄部，切除一约４ｍｍ厚之环形膈膜及疤痕组织，取自体大隐静脉补片成形。术终时下腔静脉压由５．８８ｋＰａ降至２．７５ｋＰａ。全肝血流阻断时间为３８分钟。术后恢复顺利。术后１８天下腔静脉造影示原梗阻部消失；彩色多普勒检查示下腔静脉血流通畅，肝静脉及门静脉口径均较术前缩小。     

肝静脉阻断技术在肝切除术中的应用

目的 探讨肝静脉阻断技术在复杂肝脏肿瘤切除术中防止肝静脉破裂大出血及空气栓塞的作用。方法 对71例肝脏肿瘤手术切除病例施行了1根以上主肝静脉阻断。所有肿瘤均位于第二肝门并侵犯或压迫1根以上主肝静脉。肝静脉阻断方法采用绕线结扎、血管带阻断或血管夹及心耳钳夹闭法。结果 71例中无1例肝静脉分离破裂，行肝静脉结扎28例，血管带阻断26例，血管夹阻断17例；阻断右肝静脉34例，右肝静脉＋中肝静脉2例，左、中肝静脉共干24例，左、中肝静脉分干2例，左、中、右三干9例。施行半肝全血流阻断35例（右侧24例，左侧11例）。交替半肝全肝血流阻断4例，第一肝门阻断加部分肝静脉阻断23例。第一肝门阻断加全部肝静脉阻断（不阻断下腔静脉的全肝血流阻断）9例。71例肝肿瘤均顺利切除。结论 肝静脉阻断技术是一种安全、有效的血流阻断技术。不阻断下腔静脉的全肝血流阻断术既能控制术中出血，又能保证全身血流动力学稳定。     

前入路法肝静脉阻断切肝术

目的探讨前入路法肝静脉阻断技术在复杂肝切除术中的应用价值。方法2003年1月至2006年6月对第二军医大学东方肝胆外科的85例第二肝门区肿瘤,采用前入路法肝静脉阻断技术切除,其中右肝静脉阻断24例,左、中共干阻断31例,左、中、右三干阻断30例。分离第二肝门显露右肝静脉及左中共干前壁,从第二肝门处自上而下分离出肝腔静脉间隙,分离右裸区至腔静脉右侧壁,显露右肝静脉右侧壁,分离左裸区至左肝静脉左侧壁,用辛氏钳分别由上而下沿腔静脉纵轴夹住肝静脉根部,完成肝静脉阻断。结果分离过程中无一例肝静脉破裂,肝静脉平均分离时间(6.2±2.4)min,明显短于后入路法肝静脉分离所需时间[(18.3±6.2)min]。结论前入路法阻断肝静脉操作安全、简便,尤其适用于肿瘤压迫肝静脉根部或肿瘤巨大无法行后入路法分离肝静脉者。     

带血管蒂肾上腺转位治疗柯兴氏病

为研究膈下和肾上腺上动静脉的长度及外径、肾上腺静脉回流方式以用于治疗柯兴氏病,作者在手术中解剖出上述血管用游标卡尺进行长度及外径测量。用带血管蒂肾上腺背部肌间转位治疗柯兴氏病６例。结果显示,右膈下动脉从下腔静脉右缘至末支肾上腺上动脉长７５～１１０ｍｍ,左膈下动脉从腹主动脉左缘至末支肾上腺上动脉长７０～９０ｍｍ,均有伴行静脉。肾上腺上动脉源于膈下动脉,末支外径１．５～２．５ｍｍ,分离后长４０～８０ｍｍ。肾上腺转位时的血管蒂由肾上腺上动静脉或膈下肾上腺上血管组成。治疗病例随访４～３５个月,无皮质功能不足或复发。作者认为膈下、肾上腺上血管分离后长度能够使保留的肾上腺达到转位床。带血管蒂肾上腺肌间转位是治疗柯兴氏病较理想的术式。     

机器人辅助腹腔镜单一体位右侧肾癌根治并下腔静脉Ⅲ级癌栓取栓术

目的 探讨单一体位机器人辅助腹腔镜根治性肾切除并下腔静脉Ⅲ级癌栓切除术的关键步骤及围术期结果。方法 患者女性,57岁。10 d前至当地医院体检,B超检查示右肾占位。MRI进一步检查示右肾实性占位,考虑透明细胞癌,伴右肾静脉及肝段下腔静脉内癌栓形成。超声造影示下腔静脉肝后段可见一低回声占位,范围约74 mm×40 mm,边界尚清,上缘距膈肌约19 mm。关键手术步骤:（1）切开侧腹膜向内推开结肠和十二指肠,游离、显露下腔静脉和左肾静脉。（2）在下腔静脉与腹主动脉之间左肾静脉后上方找到右肾动脉,用Hem-o-lok夹闭后切断。（3）在右侧肾静脉下方游离下腔静脉,结扎性腺血管及部分腰静脉,下腔静脉远心端游离后放置血管阻断带备阻断用。（4）将左肾静脉、第一肝门适当游离后,分别放置血管阻断带备阻断用。（5）沿下腔静脉向上分离,切断肝脏三角韧带、右侧冠状韧带后挑起肝脏,游离出右侧肾上腺中央静脉后用Hem-o-lok夹闭后切断。（6）解剖出肝后间隙并建立部分肝后隧道,游离右肝,分离并结扎下腔静脉外侧缘的肝短静脉;挑起肝尾状叶再解剖肝后间隙并结扎部分下腔静脉内侧缘的肝短静脉。（7）将右肝向左侧旋转显露...     

Hepatectomy with total vascular exclusion. Anatomical principles based on 64 dissections

Intra-operative hemorrhage is the main surgical risk during liver resections. Nowadays hepatectomies for large or posterior liver tumors close to the hepatocaval junction can benefit from total hepatic vascular exclusion (HVE) involving portal triad exclusion and clamping of the inferior vena cava (IVC) below and above the liver. Anatomical aspects of HVE have been studied in 64 subjects by segmental occlusive phlebographies of the IVC, injection of corrosive substances into the hepatocaval network, biometry of the retrohepatic IVC and serial sections of injected livers. A total HVE should exclude the right suprarenal and phrenic veins. Clamping of the suprahepatic IVC depends on the termination of the left inferior phrenic vein. Clamping of the subhepatic IVC must be retrohepatic: the right lobe of the liver has to be mobilized to free the right border of the retrohepatic IVC into which flows the right suprarenal vein 40 +/- 20 mm above the right renal vein and under the superior right hepatic vein. Both suprahepatic and retrohepatic clamps excluding the retrohepatic portion of the IVC (46.6 +/- 13 mm) and the hepatocaval junction should come in contact behind the IVC without overlapping.     

The hepaticocaval intersection: current anatomosurgical aspects. Apropos of 32 dissections

Segmental occlusive phlebography of IVC coupled with a slit in its posterior wall, injection of corrosive substances into portal and hepaticocaval network, biometry of the retrohepatic IVC and serial sections of injected livers from 32 fresh subjects has allowed definition of the hepaticocaval intersection which constitutes one of the rare current stumbling-blocks to hepatic surgery. Emergency surgery for hepaticocaval injuries exposes patients to the risk of gas embolus and massive haemorrhage. Using a median sternolaparotomy approach they require previous temporary hemostasis by quadruple clamping or intracaval shunt: in more than half of cases the length of the subhepatic, suprarenal IVC of less than 1 cm does not permit application of a clamp and necessitates introduction of an intracaval shunt by the atrial route. Cold surgery for certain hepatic tumors close to the intersection can benefit from vascular exclusion of liver but the right middle capsular and inferior phrenic veins must be clamped: clamping of the suprahepatic IVC is dependent on the site of the intersection in relation to diaphragm. The principal right hepatic vein, lacking collateral over 1 cm external to liver in 1 of 2 cases, can be controlled extraparenchymatously after mobilization of right liver, but caution is needed because of the predominance of "accessory" hepatic veins in 25% of cases. Control of hepatic veins external to liver on left side is dangerous since a common trunk is frequent (87.5%), collateral branches numerous and often vulnerable. Relations between intersection, diaphragm and right atrium also define modalities of treatment of hepatic lesions in membranes of terminal IVC and in Budd Chiari's syndrome.     

Liver resection with repair of major hepatic veins

BACKGROUND: Liver resections for tumors adjacent to major hepatic veins often require reconstruction of venous wall defects. We describe a new operative approach that facilitates repair of major hepatic veins during hepatectomies. METHODS: In 3 cases of liver tumors, the resection line had to include partially the wall of the right hepatic vein, middle hepatic vein and left hepatic vein of the preserved liver. The procedure was carried out by employing portal triad clamping combined with extrahepatic occlusion of the hepatic veins. Venous grafts for vascular repair were harvested from the inferior mesenteric vein. RESULTS: In all 3 patients, histology showed tumor-free resection margins. Follow-up of 32 to 42 months revealed no recurrence and excellent liver function. CONCLUSIONS: Combination of selective hepatic vascular exclusion with venous repair techniques, facilitates extensive liver resections in patients with tumors adjacent to the major hepatic veins and maximizes preservation of healthy liver tissue.     

Superior approach for the exclusion of hepatic veins in major liver resection: A safe and easy technique

We describe a technique for isolating and excluding the hepatic veins during liver resection. First, the bare area near the right and left wall of the suprahepatic inferior vena cava (IVC) is dissected, exposing the right, left, and superior walls of the right hepatic vein (RHV) and the left-middle hepatic vein (LMHV). Two Satinsky clamps are used to clamp the roots of the right and common trunk of the LMHV, parallel to the IVC. It is not necessary to dissect the posterior wall of the hepatic veins. We used this method during major liver resection in 65 patients. The mean dissecting time of each hepatic vein was 7.31 ± 3.6 min. No hepatic vein was lacerated during dissection and exclusion. The postoperative complication rate was 31.2%. Thus, the superior approach is a safe and easy maneuver when the posterior wall of the hepatic vein is difficult to dissect due to tumor invasion. Li Aijun and Pan Zeya contributed equally to this work.     

Extended Left Hepatectomy by Severing All Major Hepatic Veins with Reconstruction of the Right Hepatic Vein

Curative liver resection is technically challenging when multiple liver metastases from colon cancer involve the confluence of the three major hepatic veins. We report two cases of successful extended left hemihepatectomy achieved by severing all of the major hepatic veins together with the wall of the inferior vena cava, to resect liver metastases from colon cancer. Reconstruction of the right hepatic vein was done after unroofing the right anterior area of the liver with a direct anastomosis of the right hepatic vein. We did not need to perform total vascular exclusion or portovenous shunting during the liver transection. This simple and safe method can increase the surgical indications for previously unresectable tumors.     

主肝静脉和肝短静脉的解剖学研究及其临床意义

目的:探讨主肝静脉和肝短静脉（SHVs）的数量、位置、分型、口径等参数。方法:取60具成人尸体标本, 测量肝左、中、右静脉的肝外长度、注入下腔静脉（IVC）管径;按其SHVs汇入下腔静脉左侧壁、前壁和右侧壁分为左、中、右3排，测量SHVs的数量、位置、口径及其与主肝静脉的关系。结果:肝左、中、右静脉开口于IVC肝后段上l/4段，其中肝左、中静脉共干者73.3%（44例），肝左、中、右静脉共开口者1.7%（1例），3支分别汇入者25.0%（15例），SHVs直径为1.5～17.8（5.4±1.4）mm,3～35支SHV从不同方向和节段注入下腔静脉。肝右静脉直径与SHVs直径呈负相关（r=-0.34，P＜0.05);肝左静脉直径与SHVs数目呈负相关（r=0.24， P＜0.05)。肝右后下静脉（IRHV）出现率为83.3%，平均直径为2.6～8.0（4.3±1.2）mm。结论:SHVs变异较大，管径粗者数量少。SHVs的口径、数目与主肝静脉口径、数目呈相互消长。肝右静脉直径愈大，SHVs直径愈小;反之SHVs直径愈大。肝左静脉直径愈大，SHVs数量愈少;反之SHVs数量愈多。     

下腔静脉及肝静脉短段病变型布-加氏综合征的外科治疗

目的 探讨布-加氏综合征的下腔静脉短段闭塞及肝静脉主干病变根治性切除的优缺点、术中的注意事项。方法 下腔静脉闭塞或狭窄段切除、人工血管原位移植术42例,肝静脉主干闭塞段切除、肝静脉流出道成形、人工血管原位移植术10例,肝静脉主干闭塞段切除、肝静脉-右心房吻合3例,经皮肝穿肝或副肝静脉破膜、扩张10例。结果 1例死于并发症,随访58例,平均30个月,介入复发3例,手术复发1例。结论 下腔静脉或肝静脉病变段切除、人工血管原位移植治疗布-加氏综合征,能根治病变、符合正常解剖生理、远期疗效好。     

A suitable animal model for laparoscopic hepatic resection training

Background There is a growing interest in using laparoscopy for hepatic resection. However, structured training is lacking in part because of the lack of an ideal animal training model. We sought to identify an animal model whose liver anatomy significantly resembled that of the human liver and to assess the feasibility of learning laparoscopic hepatic inflow and outflow dissection and parenchyma transection on this model. Methods The inflow and outflow structures of the sheep liver were demonstrated via surgical dissection and contrast studies. Laparoscopic left major hepatic resections were performed. Results The portal hepatis of all 12 sheep (8 for anatomic study and 4 for laparoscopic hepatic resection) resembled that of human livers. The portal vein (PV) was located posteriorly; the common hepatic artery (CHA) and the common bile duct (CBD) were located anterior medially and anterior laterally with respect to the portal hepatis. The main PV bifurcated into a short right and a long left PV. The extrahepatic right PV then bifurcated into right posterior and anterior sectoral PV. The CBD and CHA bifurcated into left and right systems. The cystic duct originated from the right hepatic duct. The cystic artery originated from the right HA in 11/12 animals. The left hepatic vein drained directly into the inferior vena cava (IVC). The middle and the right hepatic veins formed a short common channel before entering the IVC. Multiple venous tributaries drained directly into IVC. Familiarity with sheep liver anatomy allowed laparoscopic left hepatic lobe (left medial and lateral segments) resection to be performed with accuracy and preservation of the middle hepatic vein. Conclusions The surgical anatomy of sheep liver resembled that of human liver. Laparoscopic major hepatic resection can be performed with accuracy using this information. Sheep is therefore an ideal animal model for advanced surgical training in laparoscopic hepatic resection.     

Right hepatic lobectomy and removal of inferior vena caval tumor embolus in a patient with hepatocellular carcinoma, using veno-venous bypass while preserving perfusion in the remnant liver: A case report

We describe a successful hepatectomy and the removal of a tumor embolus in a 43-year-old woman with hepatocellular carcinoma occupying the right lobe extending to the right branch of the portal vein and the inferior vena cava (IVC). Intraoperative echography revealed the tumor embolus in the IVC to originate from the main tumor via the right inferior hepatic vein, which extended cephalad from the confluence of the right hepatic vein to the IVC. Right hepatc lobectomy was performed via the anterior approach. Using femoro-axillary veno-venous bypass, we opened the IVC at the root of the inferior right hepatic vein to remove the tumor embolus after oblique clamping of the IVC between the right and middle hepatic veins was carried out to preserve perfusion in the remnant liver. Preserving perfusion in the remmant liver in radical hepatectomy for hepatocellular carcinoma with tumor embolism in the IVC appears to be a safe and advantageous technique in patients with poor liver reserve.     

肝脏CT影像解读分析系统在规范肝移植技术中的临床应用

目的分析肝移植术前应用肝脏CT影像解读分析系统研究肝静脉合干及其在下腔静脉注入的解剖与分布情况,按肝静脉解剖特征拟定肝移植的技术类型。方法统计武汉大学中南医院和中南大学湘雅三医院2000年5月至2007年8月期间共施行的248例背驮式肝移植患者的手术数据,并根据该248例患者的肝静脉解剖及其注入下腔静脉的数据对肝静脉类型进行分型并命名。另外收集武汉大学中南医院2010年3月至2013年4月期间实施的40例背驮式肝移植患者的术前肝脏CT影像解读分析系统的数据,分析每例患者的肝静脉在第二肝门合干及其注入下腔静脉的解剖情况,并分析肝短静脉在第三肝门注入下腔静脉的解剖情况,最后按笔者肝静脉分型标准在术前对肝脏CT影像解读分析系统的数据进行分型并拟定肝移植技术类型。结果 248例背驮式肝移植患者术中按肝静脉合干及其注入下腔静脉的解剖情况将肝静脉分为5型：Ⅰ型（左中肝静脉合干型）142例（57.25%）、Ⅱ型（右中肝静脉合干型）54例（21.77%）、Ⅲ型（左、中、右肝静脉共干型）14例（5.64%）、Ⅳ型（分别汇入型）34例（13.71%）〔其中ⅣA型16例（6.45%）,为同轴水平汇入;ⅣB型18例（7.25%）,为非同轴水平汇入〕、Ⅴ型（肝段型）4例（1.61%）。40例背驮式肝移植患者的术前肝脏CT影像解读分析系统的数据显示：Ⅰ型24例（60.00%）,Ⅱ型9例（22.50%）,Ⅲ型2例（5.00%）,Ⅳ型4例（10.00%）,Ⅴ型1例（2.50%）,肝脏CT影像解读分析系统的数据得出的肝静脉各型所占比例与笔者肝静脉分型标准中各型所占比例基本吻合。结论根据术前肝脏CT影像解读分析系统的数据确定肝静脉合干与非合干汇入肝后下腔静脉的解剖状况,从而按肝静脉分型标准归类后术前确定背驮式肝移植手术方式（Ⅰ、Ⅱ、Ⅲ型和ⅣA型可常规行经典式背驮式肝移植,ⅣB型和Ⅴ型仅能进行改良式背驮式肝移植或行经典式原位肝移植,亦可结扎或缝扎各肝静脉分支,在供、受体下腔静脉后、前正中行梭形切口或三角形开孔吻合）,为临床术前决策提供重要依据。