供肝动脉变异的术中处理

目的 探讨供肝动脉的变异类型及植入前重建的方法.方法 采取快速切取法获取供肝528例,对肝动脉解剖进行Hiatt分型,存在肝动脉变异者,肝移植前先行肝动脉重建,方法是将变异动脉与脾动脉端端吻合或与胃十二指肠动脉端端吻合,或将肠系膜上动脉远端(或近端)与肝总动脉(或腹腔干吻合),肠系膜上动脉的另一端与受者的备选动脉吻合.供肝的动脉重建以及供肝血管与受者的吻合均在3.2～3.5倍手术放大镜下进行.结果 528例供肝中,肝动脉解剖正常者(Hiatt Ⅰ型)436例(82.6 %,436/528),肝动脉变异者92例(17.4 %,92/528).变异肝动脉中,Hiatt Ⅱ型38例(7.2%,38/528),Hiatt Ⅲ型47例(8.9 %,47/528),Hiatt Ⅳ型3例(0.5 %,3/528),Hiatt Ⅴ型2例(0.4 %,2/528),Hiatt Ⅵ型2例(0.4 %,2/528).92例肝动脉变异者中,53例的异常动脉拥有共同起始之大干,能与受者的动脉直接进行吻合,故无需在植入前进行动脉重建;其余39例需在移植前对变异的动脉进行重建,其中18例将变异动脉与脾动脉端端吻合,13例将变异动脉与胃十二指肠动脉端端吻合,8例将肠系膜上动脉远端(或近端)与肝总动脉(或腹腔干)吻合,另一端与受者的备选动脉吻合.结论 肝动脉的变异率较高,切取和修整供肝时应准确辨认,避免误伤;对于变异的肝动脉,必须确保其入肝血流的连续性完整,否则需进行植入前血管重建,重建方式应根据动脉变异的类型和解剖学特点来决定.

Tactics in the management of the variation of the donor hepatic arteries

Objective To investigate the variation types and reconstruction menthod of the donor hepatic arteries prior to liver transDlantation.Methods Five hundred and twenty-six cases of liver grafts were harvested with the method of rapid procurement,and the donor hepatic arteries were classified according to Hiatt system.Hepatic artery reconstruction was performed on those with variation of hepatic artery. Spleen artery,gastroduodenal artery or superior mesenteric artery was used for re construction with variant hepatic artery.The reconstruction of hepatic artery before transplantation and anastomosis between donor and recipient artery were both completed under 3.2-3.5 fold magnification.Results Among these donors' hepatic arteries,436 cases were normal(82.6 %,Hiatt Ⅰ),and 92 cases abnormal(17.4 %)accoding to Hiatt system.Thirty-eight cases were classified into Hiatt Ⅱ(7.2 %,38/528),47 cases into Hiatt Ⅲ(8.9 %,47/528),3 cases into Hiatt Ⅳ(0.5 %,3/528),2 cases into Hiatt Ⅴ(0.4 %,2/528)and 2 cases into Hiatt Ⅵ(0.4 %,2/528)respectively.Among 92 cases of hepatic artery variation,53 cases with common originate trunk which can anastomosed to recipient artery directly had no artery reconstruction before transplantation,and the rest 39 cases were subjected to hepatic artery reconstruction prior to liver transplantation:18 cases were subjected to the anastomoses of varian hepatic artery to spleen artery,13 to anastomoses of variant hepatic artery to gastroduodenal artery,and in 8 cases,one end of superior mesenteric artery was anastomosed with donor common hepatic artery(or celiac trunk)for reconstruction,and another end of superior mesenteric artery anastomosed with the choosen recipient artery.Conclusion Hepatic artery variation is frequently encountered.Thus,accurate recognization was essential in liver graft harvesting and back-table procedure to avoid injury.All variant hepatic arteries must be retained for its integrity of liver blood flow,otherwise,it should be reconstructed before liver transplantation.The methods of appropriate reconstruction is dependent on variant type and anatomy of hepatic artery.