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通讯作者:

陆峰,E-mail:lufeng770910@163.com;

王科,lancetwk@163.com

中图分类号:R657.3

文献标识码:A

文章编号:1007-4368(2022)05-658-07

DOI:10.7655/NYDXBNS20220509

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目录contents

    摘要

    目的:基于三维可视化技术构建肝右静脉系统的解剖路径图用于指导手术规划。方法:回顾性分析南京医科大学第一附属医院2018年7月—2021年6月的上腹部增强CT资料,导入海信计算机辅助系统行三维重建,模拟肝右静脉(right he⁃ patic vein,RHV)引导的解剖性肝切除,测量并记录肝体积、RHV及各段属支的分布情况、解剖变异等数据。结果:纳入336例正常肝脏受检者,中位年龄59岁。全肝体积为1255.65(1071.43~1450.078)mL,男性的全肝体积显著大于女性(P < 0.05)。 336例受检者的RHV直径与全肝体积呈正向弱相关(r =0.242,P < 0.05)。44.6%的受检者发现1(1~2)根右后下静脉(inferior right hepatic vein,IRHV)。RHV的标准化直径与是否伴有IRHV之间呈极弱负相关(r =-0.109,P < 0.05)。比较伴有IRHV的 RHV和不伴有IRHV的RHV的直径,两组之间存在显著差异(P < 0.05),分别为7.95(6.51~10.40)mm和9.33(7.37~11.23)mm。 15.8%受检者以IRHV为主导,RHV较短小,无法在肝断面上全程显露。最终选取283例RHV解剖正常的受检者构建解剖路径图。6段属支(hepatic veins draining segment Ⅵ,V6)、7段属支(hepatic veins draining segment Ⅶ,V7)主要分布在右后叶肝切除断面全长的 0.45(0.33~0.55)和 0.78(0.71~0.84)处,V6 的数目显著多于 V7 的数目(P < 0.05);5 段属支(hepatic veins draining segment Ⅴ,V5)、8段属支(hepatic veins draining segment Ⅷ,V8)主要分布在左三叶肝切除断面全长的0.41(0.32~0.50)和0.78 (0.70~0.86)处,V5的数目显著多于V8的数目(P < 0.05)。V6的直径显著大于V5的直径(P < 0.05)。结论:三维可视化技术有助于构建肝右静脉系统解剖路径图,对指导精准解剖性肝切除具有重要意义。

    Abstract

    Objective:This study aims to develop a novel roadmap of right hepatic vein(RHV)tributaries for surgical planning based on three⁃dimensional(3D)visualization. Methods:3D simulated anatomical liver resection(ALR)of healthy participants who underwent contrast⁃enhanced computed tomography(CECT)of the upper abdomen from July 2018 to June2021 in the First Affiliated Hospital of Nanjing Medical University were retrospectively reviewed. Liver volume,distributions of RHV and its tributaries,incidence of the inferior right hepatic vein(IRHV)were estimated. Results:Total336 eligible participants were assessed,with a median age of 59 (48~67)years. The total liver volume was 1255.65(1071.43~1450.078)mL,which was significantly larger in males than in females (P < 0.05). The Person correlation analysis revealed a positive and weak correlation between the diameter of RHV and the liver volume (r =0.242,P < 0.05).1(1~2)IRHV was detected in 44.6% of volunteers. A negative and poor correlation was noted between the standardized diameter of RHV and the incidence of IRHV(r =-0.109,P < 0.05). The diameter of RHV without IRHV was significantly larger than that of RHV with IRHV(P < 0.05),which were7.95(6.51~10.40)mm and 9.33(7.37~11.23)mm,respectively. There were15.8% of the participants excluded,whose RHV was short and unable to be fully exposed on the transection plane. Virtual RHV⁃oriented ALR of 283 participants with normal RHV was assessed to develop the roadmap of RHV tributaries. Hepatic veins draining segment Ⅵ(V6)and segment Ⅶ(V7)were concentrated at 0.45(0.33~0.55)and 0.78(0.71~0.84)of the transection plane in virtual right posterior sectionectomy respectively,where the number of V6 was significantly more than that of V7(P < 0.05). Hepatic veins draining segment Ⅴ(V5)and segment Ⅷ(V8)were concentrated at 0.41(0.32~0.50)and 0.78(0.70~0.86)of that in simulated left trisectionectomy respectively,where the number of V5 was significantly more than that of V8(P < 0.05). The diameter of V6 was significantly larger than that of V5(P < 0.05). Conclusion:Virtual roadmap of RHV tributaries is of great significance to guide precise anatomical liver resection.

  • 断肝平面的确定一直是精准实施解剖性肝切除的技术难点[1]。Makuuchi首先提出将主肝静脉作为确定断肝平面的肝内标志,是解剖性肝切除的主流方式之一[2-3]。因此,肝右静脉(right hepatic vein, RHV)在引导右后叶切除、左三叶切除中具有重要的临床意义。肝右静脉的解剖相对于肝中静脉和肝左静脉来说,更为复杂,变异也相对较多,常伴有右后下静脉(inferior right hepatic vein,IRHV)[4]。且肝右静脉的属支很少像肝中静脉一样呈“人”字合流,在切肝过程中遇到的肝右静脉属支多而细小,大大增加了手术难度和出血风险。现有的肝右静脉的解剖学研究主要包括肝右静脉在下腔静脉的开口情况、肝右静脉的流域占比、右后下静脉的发生情况等方面[4-9],对于肝右静脉及其属支分布的研究较少。因此,本研究希望通过三维可视化技术模拟肝右静脉引导的肝切除术,构建肝右静脉解剖路径图,以指导实际手术操作。

  • 1 对象和方法

  • 1.1 对象

  • 回顾性分析南京医科大学第一附属医院2018年9月—2021年6月的上腹部增强CT数据。纳入标准:①无肝胆疾病史;②CT层厚≤1.5mm;③CT图像对比度明显;排除标准:①肝内病变;②肝内血管栓塞性疾病;③肝脏手术史;④CT图像质量差。该研究经南京医科大学第一附属医院伦理委员会审批通过(伦理号:2020⁃SR⁃444)。

  • 1.2 方法

  • 将符合纳入标准的原始CT数据导入到海信计算机辅助系统中,提取肝脏、肝静脉、门静脉等数据,进行肝脏、血管等结构的重建,构建三维立体模型。测量全肝体积,测量RHV直径并记录其是否与肝中静脉(middle hepatic vein,MHV)共干,IRHV的发生情况及其直径。将RHV直径与全肝体积的比值记为RHV的标准化直径,并用科学记数法表示。将RHV左右两侧属支分别染色,行肝静脉流域分析,以肝右静脉主干为引导模拟解剖性右后叶肝切除或左三叶肝切除,探究两侧肝断面上RHV属支的分布情况。将流域边界与肝下缘的相交点记为切肝起始点;测量切肝起始点至肝右静脉根部的距离,记为肝断面长度。记录并测量RHV各段属支的数目和直径,包括5段属支(hepatic veins draining segment Ⅴ,V5)、6段属支(hepatic veins draining seg⁃ ment Ⅵ,V6)、7段属支(hepatic veins draining seg⁃ ment Ⅶ,V7)和8段属支(hepatic veins draining seg⁃ ment Ⅷ,V8),测量各属支距离切肝起始点的长度,计算其标准化距离(图1)。

  • 1.3 统计学方法

  • 应用SPSS Statistics 26.0统计软件进行统计学分析。首先进行正态性检验,正态分布的计量资料以均数±标准差(x-±s)表示,偏态分布的计量资料以中位数(四分位数)[MP25P75)]表示,两组偏态分布资料的组间比较用Mann⁃Whitney U检验。计数资料以相对数表示。对两变量之间的相关性分析采用Person相关性分析。双侧P <0.05为差异有统计学意义。

  • 2 结果

  • 2.1 一般资料

  • 本研究共纳入336例正常肝脏受检者行三维重建,其中男167例,女169例,中位年龄59(48,67) 岁,两组之间无显著差异(表1)。

  • 2.2 全肝体积

  • 336例正常肝脏受检者的中位全肝体积为1 255.65(1 071.43,1 450.078)mL,男性的全肝体积显著大于女性,分别为1 339.3(1 151.5,1 540.8)mL和1 193.1(1 023.7,1 350.9)mL,(P< 0.05,表1)。

  • 2.3 肝右静脉的解剖情况

  • 336例正常肝脏受检者的RHV中位直径为8.75 (6.97~10.82)mm,与全肝体积呈正向弱相关(r=0.242,P< 0.05)。336例RHV的标准化直径为6.82 (5.34~8.64)× 10-3 mm/mL。其中仅2%(7/336)的RHV与MHV共同开口于下腔静脉。

  • 图1 模拟肝右静脉引导的右后叶切除或左三叶切除的方法模式图

  • Fig.1 Diagram of simulating the right posterior sectionectomy or left trihepatectomy guided by RHV

  • 表1 336例正常肝脏受检者基本数据的性别差异分析

  • Table1 Gender difference analysis of basic data of 336normal liver participants

  • 2.4 右后下静脉的发生情况

  • 336例正常肝脏受检者肝右静脉系统的重建中, 44.6%(150/336)的受检者发现合并1(1~2)根右后下静脉,共195根,中位直径为4.43(3.18,6.91)mm,主要引流S7段背侧或S6段。RHV的标准化直径与是否伴有IRHV之间呈极弱负相关,点二列相关系数为-0.109(P< 0.05)。比较伴有IRHV和不伴有IRHV的RHV的标准化直径,两者存在显著差异 (P< 0.05),分别为6.290(4.754,8.374)×10-3 mm/mL和7.182(5.789,8.731)×10-3 mm/mL。两组RHV的实际测量直径分别为7.95(6.51,10.4)mm和9.33 (7.37,11.23)mm,两组之间存在显著差异(P< 0.05)。15.8%受检者的IRHV较为粗大,是右后叶的主要回流静脉,与短小的RHV共同引流右后叶。

  • 2.5 肝右静脉的属支情况

  • 336例正常肝脏受检者中,84.2%(283/336)受检者的RHV解剖正常,可全程显露在保留侧肝断面上。每例受检者的RHV右侧属支数目[5(3,6)]显著高于左侧属支数目[4(3,5)],差异有统计学意义(P< 0.05);V5、V6、V7、V8属支各685支、698支、 602支和469支,合计2 454支;每例受检者的V5、 V6、V7、V8数目分别为2(2,3)支、2(2,3)支、2(1,3) 支、2(1,2)支。

  • 15.8%(53/336)受检者的RHV较为短小,仅引流右肝上段,即S7、S8段,S6段和部分S7段背侧由粗大的IRHV引流。在此类IRHV主导型的受检者中,S6和S7的段间血管相对较少,段间间隙较明显 (图2)。该53例受检者的RHV中位直径为7.00 (5.46,8.27)mm。每例受检者有1(1,2)支IRHV,中位直径为6.68(4.64,8.64)mm。比较该53例受检者的RHV直径和IRHV直径,Mann⁃Whitney U检验显示两者之间无显著差异(P> 0.05)。每例受检者的V7、V8数目为2(1,3)支、2(1,2)支,共112支、96支,中位直径分别为4.28(3.38,5.86)mm、4.16(3.03, 5.67)mm(表2)。

  • 2.6 肝右静脉的路径图

  • 为了构建肝右静脉的路径图,本研究选取了283例RHV解剖正常的受检者,模拟以RHV为导向的右后叶肝切除和左三叶肝切除。283例受检者的RHV中位直径为9.14(7.29,11.12)mm,34.3%伴有1根IRHV,共117根,中位直径为3.94(2.74,5.38)mm。 RHV的标准化直径与是否伴有IRHV之间无相关性,点二列相关系数为0.022(P> 0.05)。比较伴有IRHV和不伴有IRHV的RHV的标准化直径,两组之间无显著差异(P> 0.05)。两组RHV的实际测量直径分别为9.09(7.15,1.09)mm和9.33(7.37,11.23)mm,差异无统计学意义(P> 0.05)。肝断面的中位长度为149.6(138.7,160.3)mm。V5、V6、V7、V8的中位直径分别为3.86(3.03,4.83)mm、4.31(3.25,5.51)mm、 4.48(3.36,5.58)mm、4.03(3.07,5.31)mm,V6的直径显著大于V5的直径(P< 0.05)。该283例受检者肝右静脉的属支数据见表3。

  • 图2 1例以右后下静脉为右后叶主要流出血管的典型病例

  • Fig.2 A typical case whose right posterior lobe was mainly drained by the inferior right hepatic vein

  • 表2 53例右后下静脉主导型受检者的肝右静脉系统解剖情况

  • Table2 Anatomy of the right hepatic vein system in 53volunteers with well⁃developed inferior right he⁃ patic vein

  • 在模拟右后叶切除的保留侧肝断面上,V6、V7主要分布在肝断面的0.45(0.33,0.55)和0.78(0.71, 0.84)处,V6的数目显著多于V7的数目(P< 0.05)。右后叶切除的保留侧断面上RHV属支的解剖路径图见图3A。直径在3.0~5.5mm之间的V6数量最多 (55.44%),5.0~10.0mm的次之(24.50%),<3.0mm的占19.48%,极少数(0.57%)的V6直径大于10.0mm (图3B)。大部分V7的直径在3.0~5.5mm,5.5~10.0mm和<3.0mm的V7分别占24.92%和18.11%,仅1.83%的V7直径大于10.0mm(图3C)。

  • 在模拟左三叶切除的保留侧肝断面上,V5、V8主要分布在肝段面的0.41(0.32,0.50)和0.78(0.70, 0.86)处,V5的数目显著多于V8的数目(P< 0.05)。左三叶切除的保留侧断面上RHV属支的解剖路径图见图4A。大部分V5的直径在3.0~5.5mm,高达60.29%,<3.0mm和>5.0mm的V5分别占24.23%和15.47%(图4B)。直径在3.0~5.5mm之间的V8占54.80%,<3mm的次之(23.45%),>5.5mm的占21.75%(图4C)。

  • 3 讨论

  • 在解剖性肝切除术中,切肝平面的确定主要依赖于肝脏表面解剖学标志、肝蒂血流阻断的缺血线、术中超声引导门静脉穿刺染色、术中ICG荧光染色、循肝静脉切除等方法[710-15]。但由于在肝内实质的离断过程中缺血分界不明显、染色剂渗漏等原因[1],很容易迷失方向,主肝静脉是肝实质内部肝段划分的重要依据[2-3],因此常作为准确离断肝实质的肝内解剖学标志,持续显露在断肝平面上[16-20]。大量研究表明,经肝静脉入路的解剖性肝切除可有效减少术中出血和术后并发症的发生,改善患者预后[21-23]。因此,如何快速找到RHV主干,以及如何避免在离断过程中造成肝静脉的撕裂,在安全实施解剖性右后叶切除术或左三叶切除术中显得尤为重要。

  • 表3 283例模拟肝右静脉引导的解剖性肝切除的肝右静脉属支情况

  • Table3 Tributaries of the right hepatic vein in 283cases of virtual anatomical liver resection

  • *:V6直径显著大于V5直径,Z值-4.871,P <0.001。※:肝右静脉右侧属支总数目显著多于其左侧属支总数目,Z值-4.015,P <0.001。

  • 随着肝脏外科技术的进步和手术器械的更新,术中肝实质引起的出血已大大减少,肝静脉损伤是肝内出血的主要原因[24]。因此,术中对段间肝静脉的准确定位以及精准解剖对于控制术中出血的发生显得尤为重要[25]。传统的术前评估肿瘤、血管的方式主要通过B超、CT、MRI等二维影像手段,对外科医生的专业要求较高。三维可视化技术通过构建立体直观的三维图像,可有效降低专业壁垒,对断肝过程中可能遇到的肝内管道形成一定的预判,减少术中意外损伤引起的出血[26-27]

  • 对336例受检者RHV属支的形态进行观察后发现,RHV的属支回流很少会像MHV一样形成 “人”字回流,大多数是呈鱼骨状汇入RHV主干。术中对肝静脉的显露主要分为尾侧入路和头侧入路。尾侧入路是从肝静脉末梢逆行向静脉根部进行解剖,头侧入路是显露肝静脉根部后顺行向末梢解剖肝静脉[28-30]。研究结果表明,V6分支明显多于V7分支,因此在经尾背侧入路切肝的过程中需仔细小心离断RHV尾侧的V6分支。而在第一肝门解剖困难或巨大肝癌难以搬动肝脏的情况下,经头侧入路暴露RHV根部后沿RHV主干进行切肝不失为一种选择[2831]。不少研究表明,循肝静脉根部逆行切肝可降低肝静脉撕裂导致出血的风险[2030-31]

  • 在对283例肝断面上的RHV属支进行统计分析后发现,肝断面前1/3处的静脉分支较为细小疏散,在此段区域内可快速离断肝实质。V6主要集中分布于断面的1/3~1/2处,大部分V6的直径在3.0mm以上(80.52%),少数<3.0mm,离断尾侧肝实质时应缓慢小心离断肝静脉,警惕V6损伤所致的出血。在肝断面头侧的1/5~1/3处,81.90%的V7直径大于3mm,极少数会在近肝静脉根部1~2cm处遇到10mm以上的分支。因此,虽然头侧的V7显著少于尾侧的V6,可加快离断肝实质,但仍应小心近肝静脉根部的大分支静脉。同理,在经尾背侧入路行左三叶肝切除的过程中,可快速离断前1/3的肝实质。84.52%的V5和78.25%的V8直径小于5.5mm,离断肝实质时的出血几率较右后叶切除会有一定程度的降低。但是,在前1/3~1/2处和近肝右静脉根部1/5~1/3处仍应警惕可能会出现5mm以上的分支。除此之外,V6的数目显著多于V5,且大多为3mm以上的静脉。相较于少而细的V5,离断多而粗的V6的手术难度显然有所增加。即单从静脉属支的离断来看,左三叶切除的手术难度一定程度上是低于右后叶切除的。因此,术前精准把控肝右静脉属支的分布情况、术中仔细解剖以上两大“静脉危险区域”,避免静脉分支的撕裂,或许可以降低术中出血发生的概率。

  • 图3 模拟右后叶切除的肝断面上肝右静脉属支的分布图

  • Fig.3 Distribution of RHV tributaries on the transection plane of simulated right posterior sectionectomy

  • 图4 模拟左三叶切除的肝断面上肝右静脉属支的分布图

  • Fig.4 Distribution of RHV tributaries on the transection plane of simulated left trisectionectomy

  • 在336例健康受检者中,44.6%的受检者合并有1(1,2)根IRHV,主要引流S7背侧段和S6段。部分研究表明IRHV的存在会影响RHV的走行和引流范围,其直径与其引流的肝段体积成正比,与RHV的引流体积成反比[8-9]。比较336例中伴有IRHV和不伴有IRHV的RHV的标准化直径发现存在显著差异,比较两组的实际测量直径同样存在显著差异。在15.8%的以IRHV为主导的受检者中,IRHV和RHV的直径无显著差异,说明粗大的IRHV会对RHV产生影响,继而改变两根静脉的引流模式,与Hwang等[8] 的发现一致。剔除该53例对RHV有影响的病例后,对283例以RHV为主导的受检者行Person相关性分析,发现RHV的标准化直径与IRHV的发生情况之间无相关性。进一步比较283例中伴有IRHV和不伴有IRHV的RHV的标准化直径和实际测量直径,均无明显差异。结合以上分析,说明IRHV的直径越接近RHV的直径,对RHV的负向影响越大;当RHV占主导时,IRHV的影响较小。除此之外,本研究发现在以IRHV为主导的情况下, S6、S7段间是一个相对无血管的区域。对于局限于一段内的肝占位,实施单一的肝段切除术较右后叶切除术可能会减少术中出血、术后淤血甚至肝衰竭的风险。

  • 综上所述,术前采用三维重建技术,构建RHV的解剖路径图,对断肝过程中可能遇到的肝内管道进行精准的评估,术中显露肝实质时警惕两大危险区域,减少术中意外损伤引起的出血,对提高手术的安全性具有重要意义。

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    • [4] WATANABE A,YOSHIZUMI T,HARIMOTO N,et al.Right hepatic venous system variation in living donors:a three ⁃ dimensional CT analysis[J].Br J Surg,2020,107(9):1192-1198

    • [5] SATO F,IGAMI T,EBATA T,et al.A study of the right intersectional plane(right portal scissura)of the liver based on virtual left hepatic trisectionectomy[J].World J Surg,2014,38(12):3181-3185

    • [6] CHEN W,ZHAO L,WANG J,et al.Hepatic vascular vari⁃ ations and visual three ⁃ dimensional reconstruction tech⁃ nique in pediatric patients with choledochal cyst[J].Surg Radiol Anat,2020,42(12):1489-1499

    • [7] PRAVISANI R,SOYAMA A,TAKATSUKI M,et al.Im⁃ pact of the inferior right hepatic veins on right liver lobe regeneration in living⁃donor liver transplant:3⁃dimension⁃ al computed tomography scan analyses in donors and re⁃ cipients[J].Exp Clin Transplant,2019,17(6):768-774

    • [8] HWANG J W,PARK K M,KIM S C,et al.Surgical im⁃ pact of an inferior right hepatic vein on right anterior sec⁃ tionectomy and right posterior sectionectomy[J].ANZ J Surg,2014,84(1⁃2):59-62

    • [9] SHARMA M,SOOD D,SINGH CHAUHAN N,et al.Infe⁃ rior right hepatic vein on routine contrast⁃enhanced CT of the abdomen:prevalence and correlation with right hepat⁃ ic vein size[J].Clin Radiol,2019,74(9):735 e739-735 e714

    • [10] TAKASAKI K.Glissonean pedicle transection method for hepatic resection:a new concept of liver segmentation[J].J Hepatobiliary Pancreat Surg,1998,5(3):286-291

    • [11] OME Y,HONDA G,DOI M,et al.Laparoscopic anatomic liver resection of segment 8 using intrahepatic glissonean approach[J].J Am Coll Surg,2020,230(3):e13-e20

    • [12] PROCOPIO F,TORZILLI G,FRANCHI E,et al.Ultra⁃ sound⁃guided anatomical liver resection using a compres⁃ sion technique combined with indocyanine green fl uores⁃ cence imaging[J].Hpb,2021,23(2):206-211

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