右半结肠毗邻层面的应用解剖学观察及其临床意义

目的应用尸体解剖方法研究右半结肠毗邻的层面关系，为精准右半结肠膜解剖手术提供可靠的应用解剖学依据。 方法对经福尔马林固定的5具尸体（男性4具，女性1具）右半结肠毗邻层面进行解剖学观察。 结果右半结肠与其周围的毗邻层面，形成了右Toldt′s融合筋膜区、胰头十二指肠融合筋膜区、大网膜-横结肠融合筋膜区等三个区域。（1）右Toldt′s融合筋膜区：因回盲部、升结肠及其系膜筋膜背侧叶与原始后腹膜形成右Toldt′s融合筋膜而来。右Toldt′s融合筋膜区的头侧界为十二指肠环下缘，内侧界为肠系膜上动脉右缘，右侧与尾侧边界为回盲部、升结肠与后腹膜的愈着缘。在右Toldt′s融合筋膜区背侧依次存在后腹膜延续层面（原始后腹膜）和泌尿生殖层2个层面，依次形成了右Toldt′s融合筋膜间隙、肾前间隙和肾后间隙等三个间隙；（2）胰头十二指肠融合筋膜区：因结肠肝曲及其系膜筋膜背侧叶与胰头十二指肠固有筋膜形成融合筋膜而来。头侧界为胃大网膜在十二脂肠球部附着处，尾侧界为十二指肠环下缘，外侧界为十二指肠环外侧缘，内侧界为大网膜的右缘（其内标志为胃网膜右静脉）。胰头十二指肠融合筋膜区背侧依次为胰头十二指肠、后腹膜延续层面（原始后腹膜）和泌尿生殖层3个层面。依次形成了胰头十二指肠前间隙、胰头十二指肠后间隙、肾前间隙和肾后间隙等4个融合筋膜间隙。右Toldt′s融合筋膜间隙向头侧延续，被胰头十二指肠层面分隔为胰头十二指肠前间隙与胰头十二指肠后间隙；胰十二指肠前上静脉起自胰头，跨越胰头十二指肠前间隙，汇入肠系膜平面的Henle干（Henle trunk）；（3）大网膜-横结肠融合筋膜区：起自大网膜右缘，向左侧由大网膜与横结肠系膜筋膜前叶融合而形成的区域。由腹侧向背侧形成网膜囊、胰周间隙和胰后间隙3个间隙。大网膜第3层覆盖于胰体尾浅面，大网膜第4层包绕胰体尾和脾脏，该两层间为胰周间隙。大网膜第4层与横结肠系膜无血管区紧密融合，在胰腺下缘分离，其间与胰后间隙相通。 结论在胚胎发育理论基础上，应用解剖学方法重新认识右半结肠周围毗邻层面关系。了解这些层面及其相互之间的融合筋膜间隙，有助于安全、精准和有效地施行右半结肠根治性膜解剖手术。

The adjacent layers of the right-side colon and its clinical significance

Objective The autopsy method was used to study the adjacent layers related to right-side colon,which provided a reliable applied anatomical basis for accurate membrane anatomic right hemin-colectomy.Methods Five corpses fixed in formalin(four males and one female)were anatomically observed on the adjacent layers of right-side colon.Results The right-side colon can be divided into three fusion fascia regions according to surrounding adjacent layers:the Toldt′s fusion fascia region,the pancreaticoduodenal fusion fascia region,and the omental-transverse colon fusion fascia region.(1)The right Toldt′s fusion fascia region:It is derived from the ileocecal,ascending colon and the its dorsal mesentery fused to primary posterior peritoneum.The cranial border of the right Toldt′s fusion fascia region is the lower edge of the duodenal ring.The medial border is the right margin of the superior mesenteric vein.The right and caudal border is the rim between the ileocecal,ascending colon and posterior peritoneum.On the dorsal side of the right Toldt′s fusion fascia region,there are two layers:posterior peritoneal continuation(primary posterior peritoneum)and urogenital stratum.They form three spaces include the right Toldt′s fusion fascial space,anterior renal space and posterior renal space.(2)The pancreaticoduodenal fusion fascia region:It is derived from the fusion fascia formed by the hepatic flexure of the colon and its dorsal mesentery and propria fascia of the pancreaticoduodenal.The cranial border is the duodenal bulb which gastric omentum adhere to.The caudal border is the lower edge of the duodenal ring.The lateral border is the lateral edge of the duodenal ring.The medial border is the right edge of the greater omentum(The anatomy mark is the Right Gastroepiploic Vein).On the dorsal side of the pre-pancreaticoduodenal fusion fascia region,there are three layers:pancreaticoduodenal,posterior peritoneal continuation(primary posterior peritoneum)and urogenital stratum.They form four fusion fascial spaces include the pre-pancreaticoduodenal space,retro-pancreaticoduodenal space and anterior renal space and posterior renal space.The right Toldt′s fusion fascial space continues to the cranial and separated by the pancreaticoduodenal layer into the pre-pancreaticoduodenal space and retro-pancreaticoduodenal space.The anterior superior pancreaticoduodendal vein generates from the head of pancreas,stretch across the pre-pancreaticoduodenal space,and joins to the Henle trunk in the mesentery.(3)The omental-transverse fusion fascia region:This region from the right edge of the omentum,to the left,consisting of the right margin of the omentum and anterior layer of transverse mesenteric fascia.This region forms three spaces from the ventral side to the dorsal side,which is omental bursa,the peri-pancreatic space and the retro-pancreatic space.The third layer of omentum covers the ventral surface of the pancreas.The fourth layer of omentum surrounds the body and tail of the pancreas and the spleen from the dorsal side,There is a peripancreatic space between the third layer and the fourth layer of the omentum.The fourth layer of omentum fuse to the avascular zone of the transverse mesocolon tightly,and separates with it at the lower edge of the pancreas,the space between them is the retro-pancreatic space.Conclusion Based on the theory of embryo development,the relationship between adjacent layers of the right semicolon was studied by anatomical method.Well understanding of these layers and their interfused fascia spaces will facilitate safe,accurate,and effective right hemicolectomy.