肝动脉外科解剖在肝动脉置管术中的应用及意义

目的 目前术中肝动脉置管术(IHAC)已广泛应用于肝脏恶性肿瘤的综合治疗，但多采用盲目插管的方法，影响了IHAC的疗效。通过术中肝动脉的外科解剖结合肝动脉造影，了解肝总动脉及其主要分支的行径及相互关系，证明肝动脉外科解剖在IHAC中的意义。方法 采用电凝锐性解剖技术对116例肝脏或胆道疾病患者行肝动脉外科解剖，详细记录肝总动脉(CHA)、肝固有动脉(PHA)、肝左、右动脉(LHA、RHA)及胃十二指肠动脉(GDA)的位置和相互间的成角(锐角或钝角)，并在术中观察自然状态下导管经胃网膜右动脉插入后的走向。部分病例结合肝动脉造影资料进行分析。结果 (1)GDA与CHA呈水平或钝角72例(62％)。其中20例行IHAC，导管经胃网膜右动脉插入时全部进入CHA；(2)GDA与CHA呈锐角，而与PHA呈水平或钝角36例(31％)，13例行IHAC，导管或进入PHA或RHA；(3)PHA缺如8例(7％)。此外，116例中RHA起源于肠系膜上动脉9例(7．7％)，肝左动脉源于胃左动脉7例(6．0％)，肝左、右动脉之间在肝门部存在明显异常交通支2例(1．7％)。结论 影响IHAC准确性的关键是GDA与CHA的成角，以及肝动脉解剖异常。由于绝大多数GDA与CHA成角为钝角，加上一定比例的肝动脉解剖异常，因此，非肝动脉外科解剖的盲目插管其成功率不足25％，应引起临床的高度重视。

Application of surgical dissection of hepatic artery in the arterial catheterization and its significance

Objective To investigate the clinical significance of surgical dissection of hepatica artery in the arterial catheterization by intraoperative hepatic arterial dissection combined with an angio- graphic study. Methods By using the technique of sharp dissection with electronic coagulator, surgical dissection of hepatic artery were undertaken in 116 patients with hepatic or biliary diseases. During the operation, the common hepatic artery (CHA) and its branches: proper hepatic artery (PHA), right and left hepatic arteries (RHA and LHA), and gastro-duodenum artery (GDA), were exposed and the loca- tion and the angles between CHA and the branches, particularly CHA and GDA, were also recorded. Data of angiography of hepatic artery were obtained from some patients and compared with the results surgical- ly. Results Among the 72 cases (62%) having an obtuse angle between GDA and CHA, 20 underwent IHAC and all the catheters of the 20 patients were inserted into CHA. Among the 36 cases (31%) hav- ing an acute angle between GDA and CHA, 13 cases underwent IHAC and the catheter was inserted into RHA and PHA in 5 and 8 patients respectively. PHA was found to be absent in 8 cases (7%). In addi- tion, RHA was originated from superior mesenteric artery and LHA from left gastric artery in 9 cases (7.7%) and 7 cases (6.0%) respectively. Moreover, an abnormal communication between RHA and LHA at porta hepatis was found in 2 cases (1.7%). Conclusion The most important factor impacting on IHAC was the angle between GDA and CHA as well as the abnormal anatomy of hepatic artery. Due to an obtuse angle between GDA and CHA in most cases and certain abnormal anatomy of hepatic artery in some cases, it was believed that a successful rate of IHAC might be less than 25% without surgical dis- section of hepatic artery, which should be emphasized clinically.