發(fā)布時(shí)間：2018-03-31 10:25

  本文選題：下腔靜脈肝后段　切入點(diǎn)：應(yīng)用解剖　出處：《南方醫(yī)科大學(xué)》2008年碩士論文

【摘要】： 研究背景和目的: 原發(fā)性肝癌是我國最常見惡性腫瘤之一,嚴(yán)重威脅人民健康。其治療方法首選外科手術(shù)治療。同肝臟其他部分一樣,尾狀葉可以發(fā)生良性腫瘤和原發(fā)性或轉(zhuǎn)移性的惡性腫瘤。以往,多是因?yàn)榧夹g(shù)上的原因,尾狀葉切除一般是連同肝左葉或肝右葉切除。然而,我國的肝細(xì)胞癌85%是發(fā)生在肝硬化的基礎(chǔ)上,若單純由于技術(shù)上的原因,尾狀葉癌切除時(shí)切除過多的肝組織,顯然是不利的。全尾狀葉切除是20世紀(jì)90年代肝臟外科技術(shù)發(fā)展的結(jié)果。同時(shí)隨著腹腔鏡手術(shù)的開展,腹腔鏡尾狀葉切除術(shù)也成為許多學(xué)者研究的熱點(diǎn),其技術(shù)要求高、風(fēng)險(xiǎn)大,對(duì)肝臟外科醫(yī)師來說是一種挑戰(zhàn)。但在熟悉尾狀葉解剖學(xué)結(jié)構(gòu)的前提下,手術(shù)仍是安全、可行的。事實(shí)上,外科醫(yī)生只是進(jìn)行解剖學(xué)的臨床演繹。國外關(guān)于尾狀葉方面的研究有報(bào)道。日本學(xué)者做得比較多,他們主要采用大體解剖與灌注結(jié)合,有時(shí)也采用組織學(xué)切片,但很少與影像方面結(jié)合。國內(nèi)也有報(bào)道,但尚不夠系統(tǒng)和全面,特別是與腹腔鏡肝尾狀葉切除術(shù)中涉及到的尾狀葉靜脈、門靜脈分布規(guī)律的解剖學(xué)和影像學(xué)研究較少。因而對(duì)其作詳盡的顯微解剖與影像學(xué)研究非常必要。 隨著微創(chuàng)診療技術(shù)的不斷提高以及計(jì)算機(jī)輔助三維重建技術(shù)的迅猛發(fā)展,三維重建技術(shù)在醫(yī)學(xué)領(lǐng)域的應(yīng)用日益廣泛。肝臟及其內(nèi)部管道系統(tǒng)是三維立體的結(jié)構(gòu),而以往肝臟影像檢查手段所提供的多為二維平面信息,不能完全、真實(shí)地反應(yīng)肝臟及其內(nèi)部管道系統(tǒng)和病變的三維立體、全方位的信息,存在一定的局限性,因此不利于術(shù)前的精確定位和手術(shù)方案的制定。 本課題采用了大體解剖、鑄型標(biāo)本和影像學(xué)手段的三者結(jié)合,進(jìn)一步闡述尾狀葉靜脈、門靜脈的位置、走行和相互毗鄰關(guān)系,并對(duì)尾狀葉靜脈回流到下腔靜脈肝后段的具體位置做了詳細(xì)描述,進(jìn)行了分區(qū),以期為腹腔鏡尾狀葉切除術(shù)提供形態(tài)學(xué)理論基礎(chǔ)。 材料和方法: 1.大體解剖觀察:①用32具成人肝臟標(biāo)本。肉眼觀察無病理改變,觀察尾狀葉的位置形態(tài)及邊界。②以雕琢法向第一肝門方向解剖,解剖觀測(cè)尾狀葉靜脈、門靜脈的來源、行程及肝外長(zhǎng)度。③將下腔靜脈肝后段(the retrohepaticsegment of the inferior vena cava,HIVC)從右后側(cè)縱形剖開,將其平均橫行分成3段,每一段又縱行分成4區(qū),形成12個(gè)區(qū)。從腔內(nèi)觀察靜脈開口的位置及口徑。 2.鑄型標(biāo)本觀察:觀察15例鑄型標(biāo)本(南方醫(yī)科大學(xué)陳列館)尾狀葉靜脈、門靜脈的屬性、位置及相互毗鄰關(guān)系。 3.放射造影觀測(cè):采用氧化鉛與明膠混懸液為造影劑,對(duì)10例新鮮肝標(biāo)本進(jìn)行灌注,而后行CT掃描,并應(yīng)用CT自帶軟件進(jìn)行三維重建。 結(jié)果: 1.下腔靜脈肝后段的解剖:①HIVC長(zhǎng)為(61.2±10.9)mm,下口口徑為(19.3±1.8)mm,上口口徑為(22.1±3.5)mm,在下腔靜脈肝后段上1/3與中1/3之間有一個(gè)無肝短靜脈區(qū),其長(zhǎng)度(16.4±7.4)mm。②肝左靜脈與肝中靜脈的開口都位于左上區(qū)(2區(qū)),其間距為0～5.0mm;肝右靜脈開口位于前上區(qū)(3區(qū))。③肝右下靜脈口徑為(5.7±2.4)mm,大于5.0 mm有16例。④尾狀葉靜脈開口大部分位于HIVC的中、下1/3段,且口徑大于5.0mm的尾狀葉靜脈位于HIVC中1/3段的左中區(qū)(6區(qū)),其它肝短靜脈匯入HIVC的位置集中在中、下1/3段,大部分位于10區(qū)和11區(qū)。⑤肝左靜脈或共干(肝左靜脈與肝中靜脈)開口上緣與肝右靜脈開口下緣之間的間距即第二肝門的高度為(21.2±5.9)mm。第三肝門的高度為(38.6±9.2)mm。 2.尾狀葉靜脈的解剖:①固有尾狀葉靜脈主要有1-3支,有34.4%(11例)出現(xiàn)固有尾狀葉上靜脈,90.6%(29例)出現(xiàn)固有尾狀葉中靜脈,59.4%例(19)出現(xiàn)固有尾狀葉下靜脈。②腔靜脈旁部靜脈為1支,主要回流至HIVC中、下1/3。③引流尾狀突的靜脈主要為1支,出現(xiàn)率34.4%(11例),主要回流至HIVC下1/3中的10區(qū)。④尾狀葉靜脈主要匯入到HIVC的左上區(qū)(2區(qū))、左中區(qū)(6區(qū))、左下區(qū)(10區(qū))。其游離部的長(zhǎng)度長(zhǎng)短不一。 3.尾狀葉門靜脈的解剖:①1支固有尾狀葉門靜脈的出現(xiàn)率為(31.1%),1支以上的固有尾狀葉門靜脈的出現(xiàn)率為68.9%,其中主要以固有尾狀葉門靜脈后支和前支為主(27.5%),另外也有固有尾狀葉門靜脈左支和右支(12.5%)。②腔靜脈旁部門靜脈主要為1支,10例腔靜脈旁部的實(shí)質(zhì)也有固有尾狀葉的分支(主要為右支或前支)。③尾狀突門靜脈主要為1支,來自于門靜脈左、右支。 4.尾狀葉靜脈、門靜脈的三維重建:重建的三維圖象可以直觀形象生動(dòng)的體現(xiàn)尾狀葉靜脈、門靜脈的空間位置關(guān)系,并可按各種方向任意旋轉(zhuǎn)演示。 結(jié)論: 本研究積累了尾狀葉的解剖學(xué)資料,對(duì)腹腔鏡尾狀葉切除術(shù)中提高操作的安全性具有一定的臨床意義。
[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?rùn)鑴夎倽鍚帉D電殑瑙ｅ墫:鈶燞IVC闀夸負(fù)(61.2鹵10.9)mm,涓嬪彛鍙ｅ緞涓，

本文編號(hào)：1690327