基于Laennec膜理论的规范化腹腔镜肝段切除术的研究进展
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1.宁德师范学院附属宁德市医院 肝胆胰脾外科,福建 宁德 352100;2.福建医科大学宁德临床医学院,福建 宁德 352100

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林德新,宁德师范学院附属宁德市医院主任医师,主要从事肝胆胰脾外科方面的研究。

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福建省自然科学基金资助项目(2021J011164)。


Research progress of standardized laparoscopic segmentectomy based on Laennec's capsule theory
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1.Department of Hepatobiliary, Pancreatic and Splenic Surgery, Ningde Municipal Hospital, Ningde Normal University, Ningde, Fujian 352100, China;2.Ningde Clinical Medicine College of Fujian Medical University, Ningde, Fujian 352100, China

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    摘要:

    随着腹腔镜肝脏外科的迅速发展,腹腔镜肝切除术逐渐成为肝脏外科的主流术式,肝脏膜解剖在其中扮演着重要作用。肝Laennec膜包裹整个肝脏,并随着Glisson蒂和肝静脉进入肝实质,将肝实质与Glisson鞘膜、“六扇门”及肝门板系统、肝静脉和肝后下腔静脉隔开,是肝切除术中安全游离并寻找肝蒂的标准膜间隙。通过Laennec膜分离入肝的Glisson蒂和出肝的肝静脉,可以准确切除肝组织。目前严格按照标准腹腔镜肝段切除术的文献不多,结合Laennec膜解剖进行腹腔镜肝段切除的研究报告更少。组织学已证实Laennec膜的存在,其与肝门部的Glisson鞘是互相独立,不延续,二者之间存在间隙,并随着Glisson蒂深入肝实质。利用肝门部Glisson鞘与Laennec包膜之间的间隙,分离各肝段的Glisson蒂,并结扎阻断,是规范化肝段切除的解剖学基础。本文总结肝Laennec膜理论的相关研究,结合临床上腹腔镜肝段切除术的探索报告,为基于Laennec膜的规范化腹腔镜肝段切除术提供参考。

    Abstract:

    With the rapid development of laparoscopic liver surgery, laparoscopic hepatectomy has gradually become a mainstream procedure in liver surgery, and the anatomical understanding of the liver membrane plays a crucial role in this. The Laennec's capsule encapsulates the entire liver. It enters the liver parenchyma along with the Glisson's capsule and hepatic veins, separating the liver parenchyma from the Glisson's capsule, "six portal triads" system, hepatic veins, and the retrohepatic inferior vena cava. It is the standard intermembrane space for safe dissection and location of the hepatic pedicle during hepatectomy. Accurate liver tissue resection can be achieved by separating the Glisson's capsule that enters the liver and the hepatic veins that exit the liver through the Laennec's capsule. Currently, there is a scarcity of literature strictly adhering to the standard laparoscopic liver segmentectomy, and even fewer studies report on laparoscopic liver segmentectomy combined with Laennec's membrane anatomy. Histology has confirmed the existence of the Laennec's membrane, which is independent and not continuous with the Glisson's capsule at the hepatic hilum; there is a space between them that deepens into the liver parenchyma along with the Glisson's capsule. Utilizing the space between the Glisson's capsule at the hepatic hilum and the Laennec's capsule to separate and ligate the Glisson's capsule of each liver segment provides the anatomical basis for standardized liver segmentectomy. This paper summarizes relevant research on the theory of Laennec's capsule, combined with clinical exploration reports on laparoscopic segmental hepatectomy, to provide a reference for standardized laparoscopic liver segmentectomy based on Laennec's capsule.

    图1 肝脏Couinaud分段法[33]Fig.1 Couinauds segmentation of the liver[33]
    图2 肝Ⅰ段缺血表现[36]Fig.2 Ischemic manifestations of liver segment I[36]
    图3 肝门部六扇“门”的入路Fig.3 The entry routes of the six gates in the hepatic hilum
    图4 肝Ⅱ、Ⅲ、Ⅳ段缺血表现 A:左肝的入路点;B:肝Ⅱ段缺血区;C:肝Ⅲ段缺血区;D:肝Ⅳ段缺血区Fig.4 Ischemic manifestations of the liver segments Ⅱ, Ⅲ, and Ⅳ A: The entry point of the left liver; B: Ischemic manifestations of liver segment Ⅱ; C: Ischemic manifestations of liver segment Ⅲ; D: Ischemic manifestations of liver segment Ⅳ
    图5 规范化肝Ⅴ、Ⅷ段切除 A:肝Ⅴ、Ⅷ段缺血区;B:拓展肝门板右侧与Laennec膜的间隙,可见肝Ⅴ、Ⅷ段Glisson蒂Fig.5 Standardized resection of liver segments Ⅴ and Ⅷ A: The ischemic zone of liver segments Ⅴ and Ⅷ; B: Expanding the gap between the right side of the hepatic portal plate and the Laennecs capsule, with visible Glisson pedicle in liver segments Ⅴ and Ⅷ
    图6 规范化肝Ⅵ、Ⅶ段切除 A:阻断肝Ⅶ段Glisson蒂;B:肝Ⅵ、Ⅶ段切除缺血分界线Fig.6 Standardized resection of liver segments Ⅵ and Ⅶ A: Blocking the Glisson pedicle of liver segment Ⅶ; B: Ischemic boundary after resection of liver segments Ⅵ and Ⅶ
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林德新,常贵建,卓信斌,雷文俤,张勇,李旋.基于Laennec膜理论的规范化腹腔镜肝段切除术的研究进展[J].中国普通外科杂志,2024,33(7):1153-1161.
DOI:10.7659/j. issn.1005-6947.2024.07.014

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  • 收稿日期:2024-06-13
  • 最后修改日期:2024-07-15
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  • 在线发布日期: 2024-08-10