【摘要】：背景 伴隨著科學(xué)技術(shù)的發(fā)展,特別是影像學(xué)技術(shù)的成熟,外科學(xué)特別是肝膽外科的發(fā)展進(jìn)入了全新的數(shù)字時(shí)代,也為“精準(zhǔn)外科”時(shí)代的來臨提供了支持。具體來說,優(yōu)質(zhì)的影像學(xué)技術(shù)為肝膽外科醫(yī)師在進(jìn)行活體肝移植,離體肝切除自體肝移植等高難度手術(shù)時(shí)提供了更深一步的解剖依據(jù)和數(shù)據(jù)基礎(chǔ)。近年來,基于解剖學(xué)和2D/3D影像學(xué)技術(shù)的發(fā)展,越來越多的外科醫(yī)師們認(rèn)識(shí)到了肝臟三維立體層面與二維之間的解剖學(xué)特異性和差異性,尤其是在第一肝門血管和膽管方面的變異對(duì)手術(shù)的設(shè)計(jì)和操作的影響。這些認(rèn)識(shí)改變一些傳統(tǒng)手術(shù)操作的理念,也增加了更多患者手術(shù)的可能性。然而,由于肝臟解剖與其它臟器的差異上,肝臟的出肝血流,如第二肝門和第三肝門的肝靜脈系統(tǒng)也存在著解剖學(xué)差異性和特異性,三維重建技術(shù)不僅能更為精確的分析各型肝靜脈的走形,引流區(qū)域,還能更好為手術(shù)的設(shè)計(jì)和操作提供幫助,最終使患者受益。鑒于目前這樣的文獻(xiàn)資料尚不全面,本實(shí)驗(yàn)就此類問題經(jīng)行全面的研究和探討。目的 結(jié)合三維影像學(xué)技術(shù),展開對(duì)肝臟靜脈系統(tǒng)的解剖變異,以及其具有的外科學(xué)意義進(jìn)行全面的回顧性研究并與傳統(tǒng)的肝靜脈分型進(jìn)行對(duì)比,探討肝靜脈損傷后對(duì)肝臟的影響。方法 連續(xù)性回顧98例病灶對(duì)靜脈系統(tǒng)無影響的患者的MSCT資料，，以IQQA-Liver軟件對(duì)肝靜脈系統(tǒng)經(jīng)行3D重建,結(jié)合2D資料進(jìn)行觀察,分析其特征以及引流區(qū)域的規(guī)律。結(jié)果 在納入研究的98例患者當(dāng)中,男性46例,女性52例,平均55.33±11.32歲。所有患者均無明顯肝硬化,或肝內(nèi)膽管擴(kuò)張和巨大腫瘤病灶等影響靜脈走形的疾病�；颊吒闻K的平均體積為1272.65±322.04 ml,其中三支主要肝靜脈的引流體積占總體積的百分比分別為肝右靜脈35.58±12.41%(443.51±190.27m1),肝中靜脈34.64±8.76%(445.53±173.71 m1)和最少的肝左靜脈21.13±5.41%(266.89±94.51 m1)。在第二肝門處約有52%的患者肝左靜脈與肝中靜脈匯合成一支長約12.54±4.29mm的共干后進(jìn)入肝后下腔靜脈,剩余的48%患者的三支主要肝靜脈則分別匯入腔靜脈,未形成明顯共干。除了經(jīng)典分型中三支主要肝靜脈以外,約43名患者擁有1支或更多的肝右后靜脈,變異率為43.9%。依據(jù)Nakamura和Tsuzuki的分型,Ⅰ型(無明顯肝右后靜脈),Ⅱ型(有明顯肝右后靜脈,但直徑小于肝右靜脈主干)和Ⅲ型(肝右后靜脈直徑大于肝右靜脈主干的)的出現(xiàn)率分別為56.1%,36.7%和7.1%。肝右后靜脈的平均直徑為4.65±1.14 mm,引流肝臟體積為179.27+128.79 ml(21.20-618.20 m1)占肝臟總體積的14.0±9.18%。其直徑的大小與引流體積呈明顯相關(guān)趨勢(shì)(y=80.388x-194.268,r=0.709,p0.01)。并且伴隨著右后靜脈的發(fā)育程度(由Ⅰ型向Ⅲ型遞增),肝右靜脈的引流區(qū)域呈遞減趨勢(shì)。根據(jù)研究結(jié)果,98名患者的肝中靜脈依據(jù)解剖學(xué)特征可分成經(jīng)典主干擁有雙分叉(A型),主干及單分叉型(B型),雙主干型(C型)和主干無明顯分叉型(D型)及,出現(xiàn)率分別為61.2%,24.5%,7.1%和7.1%。肝左靜脈同樣可以分為4型,單一主干型(A型,55.1%),雙主干型(B型,23.5%),無明顯分支型(C型,12.2%)和輻射型/無明顯主干型(D型,10.2%)。除了三支肝臟主要靜脈和肝右后靜脈外,研究發(fā)現(xiàn)大多數(shù)患者還存在一些特殊肝靜脈的解剖差異型。例如15.3%的患者存在著獨(dú)立的第4段回流靜脈,引流肝臟體積可達(dá)到139.49±52.51 ml，占全肝的9.84±2.53%。約76.5%的患者存在明顯的臍裂靜脈,而75.5%的患者存在著前裂靜脈,兩者在肝內(nèi)呈對(duì)稱形態(tài)。78.6%的病例有明顯的左右側(cè)淺靜脈。22.4%的患者CT在重建后可見明顯的尾狀葉引流靜脈。結(jié)論在基于傳統(tǒng)二維影像學(xué)和尸體解剖學(xué)方面的認(rèn)識(shí)對(duì)比下,肝靜脈的變異率較門靜脈系統(tǒng)更高,肝右后靜脈的出現(xiàn)會(huì)明顯影響肝右靜脈的引流體積及手術(shù)中對(duì)靜脈取舍的設(shè)計(jì)。部分病例中存在相對(duì)獨(dú)立的4段肝靜脈支,并引流相當(dāng)量的肝臟體積。肝中和肝左靜脈分型中的部分特殊類型,以及前裂和臍裂靜脈的出現(xiàn)對(duì)術(shù)前及術(shù)中的手術(shù)操作具有明確的定位指導(dǎo)意義。而3D技術(shù)在立體解剖學(xué)方面的優(yōu)勢(shì)可以更好的在復(fù)雜手術(shù)前提供重要依據(jù)。故在常規(guī)手術(shù)前,應(yīng)常規(guī)應(yīng)用三維影像學(xué)技術(shù),進(jìn)而規(guī)避靜脈損傷給患者帶來的損害,而當(dāng)同一肝葉內(nèi)存在多條肝靜脈時(shí)則可以降低術(shù)后靜脈淤血的可能,減少肝臟衰竭的風(fēng)險(xiǎn),為更多常規(guī)不可能完成的手術(shù)提供新的設(shè)計(jì)方案。
[Abstract]:With the development of science and technology, especially the maturation of imaging technology, the development of surgery, especially in the Department of hepatobiliary surgery, has entered a new digital age. It also provides support for the advent of the "precision surgery" era. Specifically, high quality imaging techniques are for living liver transplantation and isolated hepatectomy for physicians in Department of hepatobiliary surgery. In recent years, more and more surgeons have recognized the anatomical specificity and difference between the three-dimensional and the two-dimensional liver, especially in the first hepatic portal blood vessels and bile ducts, based on the development of anatomy and 2D/3D imaging technology. The effects of variation on the design and operation of the operation. These ideas change the concept of some traditional operations and increase the possibility of more patients. However, the hepatic blood flow, such as the second hepatic portal and the hepatic portal system of the third hilum, has an anatomical difference, as the liver anatomy is different from other organs. The three-dimensional reconstruction technique can not only analyze the shape of the hepatic veins more accurately, but also provide the help for the design and operation of the operation, and finally benefit the patient. The anatomical variations of the hepatic venous system, as well as the surgical significance of the hepatic vein, were reviewed and compared with the traditional hepatic vein classification, and the effects of hepatic vein injury on the liver were investigated. Methods the MSCT data of 98 patients with no influence on the venous system were reviewed, and IQQA-Liver The software was used to observe the 3D reconstruction of the hepatic vein system and the 2D data, and analyze its characteristics and the law of the drainage area. Among the 98 patients who were included in the study, 46 males and 52 females, with an average of 55.33 + 11.32 years, all had no obvious cirrhosis, or the hepatic biliary Guan Kuozhang and the huge tumor lesions affected the venous form. The average volume of the liver was 1272.65 + 322.04 ml, and the percentage of the total volume of the drainage volume of the three main hepatic veins was 35.58 + 12.41% (443.51 + 190.27m1) of the right hepatic vein, 34.64 + 8.76% (445.53 + 173.71 M1) of the middle hepatic vein and the least left hepatic vein 21.13 + 5.41% (266.89 + M1). In% of the patients, the left hepatic vein and the middle hepatic vein were used to synthesize a total of about 12.54 + 4.29mm of the hepatic vein into the posterior inferior vena cava. The remaining three main hepatic veins of the remaining 48% patients were remitted to the vena cava, and there was no obvious common dry. In addition to the three main hepatic veins, about 43 patients had 1 or more right posterior hepatic veins in the classical classification. The rate of variation was 43.9%. based on the typing of Nakamura and Tsuzuki, type I (no obvious right posterior vein of the liver), type II (with obvious right posterior hepatic vein, but smaller than the trunk of the right hepatic vein) and type III (the diameter of the right posterior hepatic vein larger than the right trunk of the liver) was 56.1%, and the average diameter of the right posterior vein of the liver was 4.65 + 1.14 mm, 36.7% and 7.1%., respectively. The volume of the drainage liver is 179.27+128.79 ml (21.20-618.20 M1), which accounts for 14 + 9.18%. of the total liver volume. The diameter of the liver is significantly related to the volume of the drainage volume (y=80.388x-194.268, r=0.709, P0.01). And with the development of the right posterior vein (from type I to type III), the drainage area of the right hepatic vein is decreasing. Results of the 98 patients, the hepatic veins were divided into two branches (A type), trunk and single bifurcation type (B type), double trunk type (C type) and trunk no obvious bifurcation type (D type), and the incidence rate was 61.2%, 24.5%, 7.1% and 7.1%., respectively, 4 type, single trunk type (A type, 55.1%), double trunk type (B). Type, 23.5%), no obvious branching (type C, 12.2%) and radiated / unobvious trunk type (D type, 10.2%). In addition to three main hepatic veins and right posterior hepatic veins, the study found that most patients also have some special hepatic veins dissection. For example, 15.3% of patients have independent fourth reflux veins, and the volume of drainage liver can reach 1. 39.49 + 52.51 ml, accounting for 9.84 + 2.53%. about 76.5% of the whole liver, there were obvious cleft veins in the patients, and 75.5% of the patients had the anterior fissure veins. The two cases with symmetrical.78.6% in the liver were obviously.22.4% in the left and right lateral veins, and CT was visible after the reconstruction of the caudate lobe. In comparison with the cognitive and autopsy anatomy, the variation rate of the hepatic vein is higher than that of the portal vein system. The appearance of the right posterior hepatic vein obviously affects the drainage volume of the right hepatic vein and the design of the venous withdrawal during the operation. In some cases, there are relatively independent 4 segments of the hepatic vein, and the volume of the liver is drained. Some special types of venous typing, as well as the appearance of the anterior and umbilical fissure veins have a definite orientation for preoperative and intraoperative operation, and the advantages of 3D technique in stereoscopic anatomy can provide an important basis for the complicated surgery. While avoiding the damage caused by venous injury, the presence of multiple hepatic veins in the same liver can reduce the possibility of postoperative venous congestion, reduce the risk of liver failure, and provide a new design for more routinely uncompleted operations.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R322.47;R657.3

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