肝脏膜结构再认识及在腹腔镜肝切除术中的应用
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中南大学湘雅医院 肝脏外科,湖南 长沙 410008

作者简介:

周乐杜,中南大学湘雅医院主任医师,主要从事肝脏外科方面的研究。

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湖南省卫健委科研计划基金资助项目(202104010072)。


Re-understanding of liver membrane structure and its application in laparoscopic hepatectomy
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Department of Liver Surgery, Xiangya Hospital, Central South University, Changsha 410008, China

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    摘要:

    现代外科学的诞生源于对人体解剖学知识的不断积累,而外科学的飞速发展也促进了对脏器精细解剖的深入认识。肝脏作为人体最大的实质性脏器,其独特的双重血供、复杂的肝内脉管结构,使得手术过程中容易发生难以控制的出血。因此,长期以来肝脏手术都是普通外科难度较大的手术之一,需要较长的学习曲线。近30年来,随着腹腔镜肝切除术(LH)的迅速普及,外科医师发现利用以前未被充分重视的肝脏膜结构能够更便利、精准地解剖肝内、外脉管,定位切肝平面,减少术中出血。目前对肝脏膜结构在LH中应用的系统性阐述不多,笔者针对这一领域进行探讨。

    Abstract:

    The birth of modern surgery is attributed to the continuous accumulation of knowledge in human anatomy, and the rapid development of surgery also promotes in-depth understanding of fine organ anatomy. The liver as the largest solid organ in the human body has a unique dual blood supply system and complex intrahepatic vascular structures, make it prone to uncontrollable bleeding during surgery. Therefore, liver surgery has long been one of the most difficult operations in general surgery and requires a longer learning curve. In the past 30 years, with the rapid popularity of laparoscopic hepatectomy (LH), surgeons have discovered that the use of liver membrane structures, to which insufficient attention has been paid previously, can more conveniently and accurately dissect the internal and external vessels of the liver and locate the liver plane, and reduce intraoperative bleeding. At present, there are not many systematic explanations focusing on the application of liver membrane structure in LH. Therefore, the authors address the issues in this field.

    图1 常用肝蒂解剖方法 A:“鞘内解剖法”须打开Glisson鞘,将其中的门静脉,肝动脉和胆管分别解剖;B:“鞘外解剖法”在Glisson鞘外将其中的门脉三联结构整体解剖Fig.1 Commonly used methods for hepatic pedicle dissection A: Intra-sheath approach respectively dissecting the portal vein, hepatic artery and bile duct after incision of the Glissons capsule; B: Extra-sheath approach dissecting the entire tri-branch structure of the portal vein outside the Glissons capsule
    图2 利用Laennec膜行ALH A:吸引器头钝性分离出右后叶肝蒂Glisson鞘膜;B-C:胃钳紧贴右后叶肝蒂的Glisson鞘膜小心撑开其与肝实质表面Laennec膜之间的间隙,以便显露出VII段肝蒂分支;D:胃钳紧贴右肝静脉主干小心撑开其与肝实质表面Laennec膜之间的间隙以便探查静脉主干走行方向,指导切肝平面;E-F:半肝切除术中,胃钳紧贴中肝静脉主干小心撑开其与肝实质表面Laennec膜之间的间隙以便探查静脉主干走行方向,指导切肝平面;G-H:紧贴肝实质表面的Laennec膜钝性解剖,显露出其与肝后下腔静脉之间的潜在间隙Fig.2 Performing ALH using Laennecs capsule A: Blunt dissection of Glissons capsule in the posterior right hepatic pedicle with the head of the aspirator; B-C: Using the gastric forceps close to the Glissons capsule in the posterior right hepatic pedicle to carefully separate the space between it and the Laennecs capsule on the liver parenchyma to expose the hepatic pedicle branch of segment VII; D: Using the gastric forceps close to the main truck of the right hepatic vein to carefully separate the fissure between it and the Laennecs capsule on the liver parenchyma to determine the running direction of the main truck, so as to provide a guidance for the resection plane; E-F: In hemihepatectomy, using the gastric forceps close to the main truck of the middle hepatic vein to carefully separate the fissure between it and the Laennecs capsule on the liver parenchyma to determine the running direction of the main truck, so as to provide a guidance for the resection plane; G-H: Blunt dissection close to Laennecs capsule on the liver parenchyma to expose the latent space between it and retrohepatic inferior vena cava
    图3 利用肝脏“门板结构”行ALH A:半肝切除术前探查肝脏面;B:用不同颜色标记出胆囊板,肝门板及脐静脉板;C-D:肠钳钝性分离肝门板,以显露出其后方的左、右肝蒂汇合部;E:朝肝蒂汇合部用电钩标记半肝分界线;F:沿半肝分界线离断肝实质;G:脐静脉板与左肝蒂;H:Arantian板Fig.3 Performing ALH using the hilar area plate system A: Exploration of the liver surface before hemihepatectomy; B: Marking the cystic plate, the hilar plate, and umbilical plate with different colors; C-D: Blunt dissection of the hilar plate to expose the junction of the left and right hepatic pedicles behind it; E: Marking the left and right hepatic demarcation line on the junction of the hepatic pedicles using an electric hook; F: Liver parenchymal transection along the demarcation line; G: The umbilical plate and the left hepatic pedicle; H: The Arantian plate
    图4 “胆囊板入路”腹腔镜下右肝前叶切除 A:术前三维成像定位右肝肿块与肝内脉管之间的关系;B:分离胆囊板与肝实质表面的Laennec膜,可方便地显露出胆囊板深面的右前叶肝蒂,并有助于显露右后叶肝蒂Fig.4 Laparoscopic right anterior lobectomy using cystic plate approach A: Determining the relationship between the right liver tumor and the intrahepatic vessels by three-dimensional imaging before operation; B: Separating the cystic plate from the Laennecs capsule on the liver parenchyma for convenient exposure of the right anterior pedicle in the deep side of the cystic plate and for helping exposure of the right posterior pedicle
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肖亮,周乐杜.肝脏膜结构再认识及在腹腔镜肝切除术中的应用[J].中国普通外科杂志,2022,31(1):1-7.
DOI:10.7659/j. issn.1005-6947.2022.01.001

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  • 收稿日期:2021-12-28
  • 最后修改日期:2022-01-17
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  • 在线发布日期: 2022-01-27