基于肝内肝门静脉解剖的肝脏右前叶分段新概念

目的根据肝内肝门静脉的走形分布,提出肝脏分段的新概念,为影像学和肝脏外科提供资料。方法采用60例正常的活体肝移植供肝影像资料,研究右前叶肝内肝门静脉的走形和分布以及肝静脉及其属支的回流范围,10例Mevis三维软件重建图像,探讨两者之间的关系。结果 Couinaud分段中的Ⅷ段门脉支可大致分为腹侧支和背侧支,最多可达4支;约90%的背侧支越过肝右静脉分布到Couinaud分段中的VII段。V段的门脉分支大多来自右前叶或Ⅷ段门脉的腹侧支。因此,可将右前叶分为腹侧段:Couinaud分段中的Ⅷ段的腹侧段(S8v)和V段(S5)背侧段:Couinaud分段中的Ⅷ段的背侧段(S8d)两个部分。结论新的划分方法不仅有利于肝内病变的精确定位,而且便于肝脏外科实施新的、更安全的术式。     

右半肝肝段解剖研究进展

对肝内血管解剖结构及肝段的准确认识是肝切除术前评估和活体肝移植肝段选择的基础。特别是活体肝移植供体肝段的选择,需要考虑到肝段的体积、门脉及动脉血供和静脉回流,更需要对肝内各管道的解剖结构有精确的把握。右半肝管道立体交叉关系复杂,门静脉及肝静脉变异均多见。国际上通用的Couinaud肝段划分法,将右半肝分为4段,段Ⅷ、段Ⅴ为上下关系,段Ⅶ,段Ⅵ为上下关系。但随着肝脏手术的进展,影像学技术的提高,人们对右半肝肝段解剖划分提出质疑并有了新的观点。大部分学者倾向于以肝内门静脉3级分支分布形式作为划分右半肝肝段的主要依据,同时肝静脉引流情况也是重要的辅助依据,但分段方式并未形成统一。     

左半肝段的解剖观察及临床意义

目的观察左中肝外侧叶的分段情况及肝动脉、门静脉在左半肝的走行,分支和分布规律、为临床开展左半肝活体肝移植提供应用解剖学资料。方法解剖经福尔马林固定灌注红色乳胶的尸体肝脏标本30例,观察左半肝动脉、门静脉的走行、分支和分布规律,并测量有关数据;在15个肝脏铸型标本(6例全管道综合灌注、9例经门静和肝静脉分别进行单一管道灌注),进一步对比观察左半肝左外侧叶、段的内部结构特点。结果左半肝由左叶间裂分成左外叶和左内叶,左外叶以左外间裂分为外叶上段和下段:肝左动脉起始外径为(0.351±0.23)cm,于长(3.64±1.30)cm,左外叶动脉起始肝左动脉2l例(占70%),起始其它动脉9例(占30%);门静脉左干起始外径(1.1±0.12)cm,干长(2.10±0.240)cm;门静脉左干从门静脉主干发出后向左横行,发出分支分布于左内叶、左外叶上、下段。结论左外叶上段比左外叶下段小,分别占全肝的5%～7%和8%～10%左右,适合1～3个月和6～12月龄患儿肝脏移植。在活体肝脏移植时,外科医生熟悉肝动脉、门静脉的解剖结构和变异情况,在供肝的切取,选用适宜的重建方式,设计合理的手术方法有重要的临床意义。     

Couinaud肝段在矢状断面上的划分

为给肝内占位性病变的MRI定位诊断提供解剖学依据，利用30例腹部连续矢状断面标本和41例胎肝管道铸型，研究了肝内门静脉和肝静脉的矢状断面表现及Couinaud肝段在矢状断面上的划分，还详细讨论了易致错分肝段的一些因素。     

肝Ⅳa、Ⅳb亚段的门脉分支类型及径线测量

目的:进一步了解肝Ⅳa、Ⅳb两亚段门脉分支的解剖学资料。方法:对肝铸型标本供应第Ⅳ段的门静脉分支进行详细地观察和测量。结果:肝门静脉左支横部可发出供应肝Ⅳa亚段的分支;肝门静脉左支发出供应第Ⅳ段的分支数日为3～10支,供应Ⅳa亚段的分支为1～4支,供应Ⅳb亚段的分支为1～8支;门脉左支供应第Ⅳ段的分支直径平均为(2.95±0.98)mm;Ⅳa亚段的门脉分支类型只有一种,Ⅳb的分支类型有两种。结论:肝Ⅳa、Ⅳb两亚段的肝门静脉分支解剖学数据,可为临床上肝第Ⅳ段疾病的术前影像学诊断及亚段手术提供参考。     

国人肝段的再认识

目的:对肝内门静脉和肝静脉重新认识,提出一种新的国人肝段划分方法,为影像学和肝外科提供断层解剖学资料。方法:使用50例上腹部连续断层标本和20例多层螺旋CT图像及三维重建图像,研究了肝内门静脉的走行和分布以及肝静脉及其属支的回流范围及其两者之间的相互关系。结果:国人肝段新的划分方法:门静脉右支主干存在时,依肝中静脉所在的正中裂将肝分为左、右半肝。右半肝被一弯曲的右叶间裂分成右前上叶和右后下叶。右前上叶依垂直段间裂分为腹侧和背侧段。右前上叶的腹侧段被水平亚段间裂分为上、下两个亚段。右后下叶依水平段间裂分为上、下两段。肝左静脉主干存在时,依肝左静脉主干所在的左叶间裂将左半肝分成左后上叶和左前下叶。左前下叶依左段间裂分为内侧和外侧段。水平亚段间裂将左前下叶的内侧段分为上、下两个亚段。依弧形背裂分尾状叶和右前上叶及左前下叶内侧段。结论:国人肝段新的划分法不仅有利于肝内微小病变的精确定位,而且便于肝外科探索新的和更加安全的术式来施行各种肝切除和肝移植。     

COUINAUD肝段法在横断面上的划分及其在影像学中的应用

作者在30具男性成年尸体连续横断面上，追踪观察了肝静脉系统和肝门静脉鞘系在肝内的属支和分支，下腔静脉肝后段以及肝表面的沟，裂，探讨了如何按Couinaud肝段法划分横断面上的肝叶，肝段的问题，并讨论了在影像学诊断中的有关问题。     

左、右肝管全程剖开的应用解剖

用6个取自新鲜成人尸体的肝脏,注入ABS丙酮溶液制成铸型。另外还解剖了经固定的42例(成人32,儿童10)肝脏标本,测量左、右肝管长度、管径,并观察左、右肝管与肝动脉、门静脉及其分支的关系。提出了左、右肝管全程剖开的手术方法和注意事项。     

左,右肝管全程部开的应用解剖

用６个取自新鲜成人尸体的肝脏，注入ＡＢＳ丙酮溶液制成铸型。另外还解剖了经固定的４２例（成人３２，儿童１０）肝脏标本，测量左，右肝管长度，管径，并观察左，右脖管与肝动脉，门静脉及其分支的关系。提出了左，右肝管全程剖开的手术方法和注意事项。     

Reconfirmation of the right medial division of the portal venous system of liver

With the development of hepatic surgery and radiology, an increasing amount of researchers have reported discrepancies between the real distribution of the hepatic portal vein branches and Couinaud's segmentation, especially for further division of the right medial division. The present study investigated 25 cadaveric liver dissections and 30 three-dimensional reconstruction images of intrahepatic vessels. The ramifications, course, distribution and quantity of the portal branches were analyzed. An oblique fissure that had few vessels was found among third-order branches of the hepatic portal vein of the right medial division. The right medial division could be redivided into the ventral subsegment and dorsal subsegment by this oblique fissure. A hepatic vein coursed in the oblique fissure between the ventral subsegment and dorsal subsegment. The hepatic vein could serve as an anatomical landmark of the inter-subsegmental plane. This new method of identifying further division of the right medial division is a novel concept providing further information on conventional segmental anatomy.     

左外叶活体肝移植的解剖学研究

目的：模拟左外叶活体肝移植门静脉、肝动脉和胆管的切取方法。方法：解剖正常人肝脏标本30具，观察肝脏铸型标本30具，测量门静脉、肝动脉及胆管长度、管径及属支或分支分布情况。结果：左外叶门静脉的血供来自门静脉左支，主要为左外叶上段门静脉支、左外叶下段门静脉支；动脉主要来源于肝固有动脉、肝左动脉、肝中动脉，偶有迷走动脉支；胆道引流属支有左外叶上段胆管支、左外叶下段胆管支。结论：左外叶解剖变异较多，活体取肝前应仔细研究其结构特点，设计合理的切取模式；对门静脉、肝动脉和胆管支需行必要的整形，以便与受体相应的管道进行吻合。     

肝尾状叶脉管构筑的应用解剖

应用55例成人肝剥离标本及45例胎儿、新生儿肝管道铸型,研究了肝尾状叶的鞘系及静脉回流。尾状叶有两个恒定的蒂、接受左、右侧鞘系的双重供应,以左侧为主;而尾状突主要由右后叶鞘系分布。15例肝铸型标本的尾状叶左、右侧动脉形成吻合弓。尾状叶动脉供应形式可分为三种,静脉可分为三型并直接汇入下腔静脉。由于血管吻合的存在,在病理状态下,尾状叶也应是沟通门一腔静脉的桥梁。     

Human liver caudate lobe and liver segment

Recently, the caudate lobe has seemed to be the final target for aggresive cancer surgery of the liver. This lobe has five surfaces: the dorsal, left and hilar-free surfaces and the right and ventral-border planes. Surgeons have divided the caudate lobe into three parts: Spiegel’s lobe, which is called the ‘caudate lobe and papillary process’ by anatomists, the caudate process, viewed as almost the same entity by anatomists, and the paracaval portion corresponding to the dorsally located parenchyma in front of the inferior vena cava. All three parts are supplied by primary branches originating from the left and right portal veins, including the hilar bifurcation area. The hilar bifurcation branch often (50%) supplies the paracaval portion and it sometimes (29%) extends its territory to Spiegel’s lobe. It was postulated by Couinaud that the paracaval portion or the S9 is not defined by its supplying portal vein branch but by its ‘dorsal location’ in the liver. Couinaud’s caudate lobe or dorsal-liver concept caused, and still now causes, great logical confusion for surgeons. We attempt here to describe the margins of the lobe, border branches of the portal vein, the left/ right territorial border of the portal vein or Cantlie’s line and other topics closely relating to the surgery within these contexts. Finally, the caudate lobe as a liver segment will be discussed.     

Boundaries between subsegments IVa and IVb in the human liver

Until now there has been no definitive anatomical study of the boundary between hepatic subsegments IVa and IVb. In this study, we used a multicolor segmental corrosion cast technique and a multicolor segmental technique on plastinated slices, in combination with helical CT three-dimensional (3D) reconstruction on 15 donated fresh isolated human liver specimens. The corrosion cast technique was carried out on eight of these specimens, and the remaining seven livers were used to make horizontal plastinated slices. Examination of these specimens and observation of 20 additional liver corrosion cast specimens showed that all boundaries between hepatic segments were complex, undulating scissures rather than simple, flat planes. We also found that there was an obvious boundary between subsegments IVa and IVb, such that subsegment IVa laid posterosuperior to subsegment IVb. A tributary of a hepatic vein passed through the boundary between subsegments IVa and IVb, and could serve as an anatomical landmark of this boundary.     

有关右叶部分肝移植的胆管临床应用解剖

目的：研究胆管的临床应用解剖,为右叶部分肝移植提供解剖基础。方法：在88个铸型标本中对胆管的分布、走行、汇合方式、分型中所占的比例、涉及右叶肝移植的胆管大小等内容作观察。结果：有47个标本清楚显示胆管,A型占76．6％;B型占8．5％;C型占2．1％;D型占10．6％;无E型;F型占2．1％。胆管的分型中A型远较国外高,E型、C型远比国外低。结论：本组结果有利于右叶部分肝移植,提示中国人胆管的结构较适合右叶肝移植。     

A combination method for preparing casting and transparent liver specimen

With the development of hepatic surgery and radiology, a more accurate understanding of intrahepatic vessels and hepatic segments is necessary. Previously, research in these fields was primarily by means of dissecting livers, preparing corrosion cast specimens, reconstructing three‐dimensional MSCT images of intrahepatic vessels, and so on. The aim of this study was to search for a new specimen preparing method, which could demonstrate intrahepatic vessels and the relationships between internal vessels and external structures of liver simultaneously. Rabbit livers were prepared with three different techniques in this study: (a) corrosion‐cast technique; (b) transparency technique; and (c) combination technique of cast and transparency. The results showed that the combination of casting and transparent liver specimens in group C could demonstrate both the intrahepatic vessels and the external structures clearly. The relationships between the internal vessels and external structures could also be observed clearly. In conclusion, the combination method for preparing casting and transparent liver specimen created a new approach for the research of intrahepatic vessels, especially for applied basic research of hepatic segments. Clin. Anat. 23:559–562, 2010. © 2010 Wiley‐Liss, Inc.     

左外叶活体肝移植肝静脉的临床应用解剖

目的 :观察肝左叶静脉解剖结构 ,模拟左外叶活体肝移植肝静脉切取方法。方法 :解剖正常人肝脏标本 30具 ,观察肝脏铸型标本 30具 ,测量肝左静脉长度、管径及属支分布情况。结果 :肝左静脉主要由左外叶上段静脉支和下段静脉支汇合并延续而成 ,主要接收或不接收较有意义的属支有左后上缘静脉支和左叶间裂静脉支。结论 :肝左外叶静脉血管解剖变异较多 ,活体取肝前应仔细研究其结构特点 ,设计合理的切取模式 ;移植前肝静脉需行必要的整形 ,以便与受体静脉进行吻合。少数情况下肝左外叶活体移植为禁忌证。