尾状叶静脉、门静脉的应用解剖学与CT研究

发布时间：2018-03-31 10:25

  本文选题：下腔静脉肝后段　切入点：应用解剖　出处：《南方医科大学》2008年硕士论文

【摘要】： 研究背景和目的: 原发性肝癌是我国最常见恶性肿瘤之一,严重威胁人民健康。其治疗方法首选外科手术治疗。同肝脏其他部分一样,尾状叶可以发生良性肿瘤和原发性或转移性的恶性肿瘤。以往,多是因为技术上的原因,尾状叶切除一般是连同肝左叶或肝右叶切除。然而,我国的肝细胞癌85%是发生在肝硬化的基础上,若单纯由于技术上的原因,尾状叶癌切除时切除过多的肝组织,显然是不利的。全尾状叶切除是20世纪90年代肝脏外科技术发展的结果。同时随着腹腔镜手术的开展,腹腔镜尾状叶切除术也成为许多学者研究的热点,其技术要求高、风险大,对肝脏外科医师来说是一种挑战。但在熟悉尾状叶解剖学结构的前提下,手术仍是安全、可行的。事实上,外科医生只是进行解剖学的临床演绎。国外关于尾状叶方面的研究有报道。日本学者做得比较多,他们主要采用大体解剖与灌注结合,有时也采用组织学切片,但很少与影像方面结合。国内也有报道,但尚不够系统和全面,特别是与腹腔镜肝尾状叶切除术中涉及到的尾状叶静脉、门静脉分布规律的解剖学和影像学研究较少。因而对其作详尽的显微解剖与影像学研究非常必要。 随着微创诊疗技术的不断提高以及计算机辅助三维重建技术的迅猛发展,三维重建技术在医学领域的应用日益广泛。肝脏及其内部管道系统是三维立体的结构,而以往肝脏影像检查手段所提供的多为二维平面信息,不能完全、真实地反应肝脏及其内部管道系统和病变的三维立体、全方位的信息,存在一定的局限性,因此不利于术前的精确定位和手术方案的制定。 本课题采用了大体解剖、铸型标本和影像学手段的三者结合,进一步阐述尾状叶静脉、门静脉的位置、走行和相互毗邻关系,并对尾状叶静脉回流到下腔静脉肝后段的具体位置做了详细描述,进行了分区,以期为腹腔镜尾状叶切除术提供形态学理论基础。 材料和方法: 1.大体解剖观察:①用32具成人肝脏标本。肉眼观察无病理改变,观察尾状叶的位置形态及边界。②以雕琢法向第一肝门方向解剖,解剖观测尾状叶静脉、门静脉的来源、行程及肝外长度。③将下腔静脉肝后段(the retrohepaticsegment of the inferior vena cava,HIVC)从右后侧纵形剖开,将其平均横行分成3段,每一段又纵行分成4区,形成12个区。从腔内观察静脉开口的位置及口径。 2.铸型标本观察:观察15例铸型标本(南方医科大学陈列馆)尾状叶静脉、门静脉的属性、位置及相互毗邻关系。 3.放射造影观测:采用氧化铅与明胶混悬液为造影剂,对10例新鲜肝标本进行灌注,而后行CT扫描,并应用CT自带软件进行三维重建。 结果: 1.下腔静脉肝后段的解剖:①HIVC长为(61.2±10.9)mm,下口口径为(19.3±1.8)mm,上口口径为(22.1±3.5)mm,在下腔静脉肝后段上1/3与中1/3之间有一个无肝短静脉区,其长度(16.4±7.4)mm。②肝左静脉与肝中静脉的开口都位于左上区(2区),其间距为0～5.0mm;肝右静脉开口位于前上区(3区)。③肝右下静脉口径为(5.7±2.4)mm,大于5.0 mm有16例。④尾状叶静脉开口大部分位于HIVC的中、下1/3段,且口径大于5.0mm的尾状叶静脉位于HIVC中1/3段的左中区(6区),其它肝短静脉汇入HIVC的位置集中在中、下1/3段,大部分位于10区和11区。⑤肝左静脉或共干(肝左静脉与肝中静脉)开口上缘与肝右静脉开口下缘之间的间距即第二肝门的高度为(21.2±5.9)mm。第三肝门的高度为(38.6±9.2)mm。 2.尾状叶静脉的解剖:①固有尾状叶静脉主要有1-3支,有34.4%(11例)出现固有尾状叶上静脉,90.6%(29例)出现固有尾状叶中静脉,59.4%例(19)出现固有尾状叶下静脉。②腔静脉旁部静脉为1支,主要回流至HIVC中、下1/3。③引流尾状突的静脉主要为1支,出现率34.4%(11例),主要回流至HIVC下1/3中的10区。④尾状叶静脉主要汇入到HIVC的左上区(2区)、左中区(6区)、左下区(10区)。其游离部的长度长短不一。 3.尾状叶门静脉的解剖:①1支固有尾状叶门静脉的出现率为(31.1%),1支以上的固有尾状叶门静脉的出现率为68.9%,其中主要以固有尾状叶门静脉后支和前支为主(27.5%),另外也有固有尾状叶门静脉左支和右支(12.5%)。②腔静脉旁部门静脉主要为1支,10例腔静脉旁部的实质也有固有尾状叶的分支(主要为右支或前支)。③尾状突门静脉主要为1支,来自于门静脉左、右支。 4.尾状叶静脉、门静脉的三维重建:重建的三维图象可以直观形象生动的体现尾状叶静脉、门静脉的空间位置关系,并可按各种方向任意旋转演示。 结论: 本研究积累了尾状叶的解剖学资料,对腹腔镜尾状叶切除术中提高操作的安全性具有一定的临床意义。
[Abstract]:Research background and purpose:
Primary liver cancer is the most common malignant tumor in China, a serious threat to people's health. Surgical treatment is preferred. Like other parts of the liver, the caudate lobe can malignant tumor and primary or metastatic benign tumor. In the past, mostly because of technical reasons, the caudate lobe resection is generally along with resection of left hepatic lobe or right lobe of the liver. However, 85% of hepatocellular carcinoma in China is on the basis of cirrhosis, if only because of technical reasons, the caudate lobe resection for liver tissue too much, is clearly unfavorable. In addition to cut caudate in 1990s the development of liver surgery results at the same time. With laparoscopic surgery, laparoscopic resection of the caudate lobe has also become a hot topic for many scholars, the technical requirements for high risk, it is a challenge to liver surgeons. But in the familiar caudate Ye Jiepou Study of structure under the premise of safety, operation is feasible. In fact, the clinical interpretation of surgeons only anatomy. Research on caudate lobe aspects of foreign reports. Japanese scholars have done more, they mainly use the gross anatomy and perfusion combined, sometimes using histological sections, but rarely with image combination. China has also been reported, but are still not systematic and comprehensive, especially with the liver caudate vein involved in operation, less study of portal vein distribution of anatomy and imaging. Thus the anatomy and imaging is very necessary to study the microsurgical.
With the rapid development of 3D reconstruction technology to improve the minimally invasive treatment technology and computer aided the application of 3D reconstruction technology is increasingly widespread in the medical field. The liver and its internal piping system is a three-dimensional structure, and the liver imaging two-dimensional of information, can not fully reflect the real, three-dimensional liver and the internal pipeline system and the lesions, the full range of information, there are some limitations, it is not conducive to the development of accurate positioning and preoperative surgical plan.
This paper use the gross anatomy of the three means of cast specimens and imaging combination, further elaborated the caudate portal position, Ye Jingmai, walking and adjacent to each other, and the caudate lobe veins in the specific location of retrohepatic inferior vena cava is described in detail. In the District, in order to provide morphology the theoretical basis for laparoscopic resection of the caudate lobe.
Materials and methods:
1. gross anatomy observation: 32 adult liver specimens. No pathological changes observed, position shape and boundary observation. The anatomy of the caudate lobe to the first hepatic portal to carve method, anatomical observation of veins of caudate lobe, source portal vein, stroke and extrahepatic length. The retrohepatic inferior vena cava (the retrohepaticsegment of the inferior vena cava, HIVC) from the right posterior longitudinal split, the average infestation is divided into 3 sections, each section is divided into 4 longitudinal area, formed 12 areas. Observe the position and aperture opening from the venous lumen.
2. specimen observation: Observation of the caudate vein of 15 cast specimens (Southern Medical University exhibition hall), the properties, position and adjacent relationship of the portal vein.
3. radiographic observation: 10 cases of fresh liver specimens were perfused with lead oxide and gelatin suspension as contrast agents, followed by CT scanning and three-dimensional reconstruction with CT software.
Result:
1.涓嬭厰闈欒剦鑲濆悗娈电殑瑙ｅ墫:鈶燞IVC闀夸负(61.2卤10.9)mm,涓嬪彛鍙ｅ緞涓，

本文编号：1690327