围肝门部及肝段门静脉和胆管的计算机3D应用解剖研究
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摘要
背景进行精准的外科手术之前必须对局域的解剖具有精确的了解。近年来，随着科技的快速进展，肝脏外科已经进入了“精准肝外科”时代。活体肝移植术、解剖性肝段/亚段切除术、肝门部胆管癌根治术、先天性胆管囊张扩张症大范围肝切除术等高难度解剖性手术的开展，需要外科医生深入了解围肝门部和肝段水平的解剖知识。然而，近年来进行的肝脏局部解剖学研究，基本基于尸体肝脏解剖或2D影像学技术的方法，不够符合外科临床应用习惯，或缺乏与3D影像的对照，得出的结果不够有说服力,并且目前为止尚缺乏对肝段水平的脉管结构的系统性研究。另外，根据近年来的研究结果，很多肝内门静脉结构并不完全遵从传统的Couinaud分段，因此有必要对这个问题进行进一步讨论。
目的对围肝门部和肝段水平的门静脉和胆管解剖，以及两者间具有外科意义的位置关系进行系统性研究。对Couinaud分段的进展和意义进行再讨论。
方法选取连续128例梗阻性黄疸的患者的MSCT影像，以Myrian软件对肝脏、门静脉、胆管进行3D重建，而后对目标区域进行2D与3D结合的观察。
结果100例患者纳入研究，其中男性73例，女性27例，平均年龄58.2±12.9岁。肝门区的门静脉变异率为21%，典型分支形式（A型）、三叉型（B型）、工字型（C型）和其它类型（D型）的出现率分别为79%、9%、9%和3%。P2有1-3支，其中1支者占92%，其发出位置为LPV角部；2-3支P2中，其分支可能从UP左侧发出。P3有1-4支，其中1支者占88%，其起源点为LPV囊部，多支P3可能起自UP左侧（10%）、腹尾侧（1%）或头背侧（1%）。P4可分为P4a和P4b，分别有1-3支分支（88%，89%）。P4a和P4b单独由LPV发出或存在共干发出的概率分别为53%和47%；P4总是从LPV囊部分支，但也可能有分支从UP头背侧（31%）和右侧缘（17%）发出。P5多为2-4支血管（87%），发自RAPV，异位的发出点包括RPPV主干（57%），P8v（54%），P8d或P8（l11%）和RAPV/RPPV分叉部（7%）。P8可分为P8v（100%），P8d（100%），P8l（73%）和P8m（49%），其中85%的P8d延伸到RHV后方。12%的病例无RPPV主干，存在主干的RPPV可分为弓状型（62.5%），2支型（28.4%）和羽毛型（8.0%）。从以上的解剖描述，可见肝段水平门静脉的解剖不完全遵从Couinaud的经典描述，最常见的变异是1）P8d延伸到RHV后方支配S7区域；2）P5分支源于RPPV主干（57%）和P8v（54%）。
围肝门部胆管的变异发生率为36%。可分为典型型（A型），三叉型（B型），RASD/RPSD低位汇合型（C型），RASD/RPSD汇合入LHD型（D型）和特殊类型（E型），其出现率分别为64%，9%，2%，17%和8%。左肝胆管系统的总体变异率为56%。B2与B3汇合成为正常LHD主干者75%，B3与B4首先汇合者25%。B4分为B4a和B4b，形成主干者66%，不形成主干者34%。其汇合点的Onishi分型的Ⅰ、Ⅱ、Ⅲ型出现率分别为17%、72%和11%。右肝系统的总体变异率为85%。常见的变异形式为B5分支汇入RPSD（61%），B8分支汇入RPSD（14%），RASD主干缺失（13%）和副肝管（5%）。B3和RPSD可能出现Infraportal型，其出现率分别为4%和18%。所有的C2型和D1型胆管都是Infraportal型。Infraportal型胆管在2D影像（从头侧向尾侧连续读片）上的特征为1）以RAPV-RPSD-RPPV的顺序出现；2）与RPV主干基本平行的RPSD主干。以门静脉形态分组，ABCD组门静脉中Infraportal型胆管的发生率为16.7%、22.2%、22.2%和33.3%，组间比较差异无统计学显著意义（P>0.05）。
以门静脉形态将病例分为正常组（n=79）和变异组（n=21），两组肝门部胆管的变异率分别为30.4%和57.1%，组间比较差异有统计学显著意义（P<0.05）。
结论围肝门部的胆管变异与门静脉变异有关。在门静脉变异的情况下，肝门部胆管变异的发生率升高，但Infraportal型胆管的出现率并不升高。肝段水平门静脉和胆管变异发生率高，且其解剖分布不完全遵从经典的Couinaud分段法的定义。Couinaud分段法应进行修正，但并不影响其在肝脏外科的价值；3D技术在立体解剖评价方面具有优势，能够提供重要解剖信息，应在复杂肝脏手术前常规应用。
Background Precise anatomy knowledge must be conducted before precise surgery.Recent years, with the rapid development of science and technology, liver surgery hasentered the era of “Precise Liver Surgery”. Surgeons need to have deep command ofanatomy on perihilar region and segmental horizon to perform the most complicatedprocedures, such as living donor liver transplantation, anatomical segmentectomy/subsegmentectomy, radical resection of hilar cholangiocarcinoma and major liverresection for congenital bile ducts dilation. However, studies in recent years on regionalliver anatomy are basically conducted by the methods of cadaveric liver or2D imaging,which are either in conformity with the clinical application habit or lack of contrast with3D models. Therefore, the results are not convincing enough. So far, it is still lack ofsystemic study on segmental vessels. In addition, according to recently researchingresults, many of the intrahepatic portal vein structure does not fully comply with thetraditional Couinaud segments, so it is necessary to take further discussion on thisquestion.
Aim To carry on a systemic study on the perihilar and segmental portal veins and bileducts, and on the anatomical relationship of surgical significance in between, and todiscuss the development and significance of Couinaud’s segmentation.
Methods The research involved consecuative128obstuctive jaundice cases in ourhospital, and MSCT of these cases were analysed. Liver, portal vein and biliary tractwere reconstructed3-dimensionally using Intrasense Myrian. The researcher observedthe region of interest with2D images combined3D models.
Result28cases were excluded accoding to our criteria, and100cases were enrolled inthis study, among which73male and27female, mean age58.2±12.9yrs. The variationrate of portal vein in hilar region is was21%. The occurance rate of typical branch form (Type A), trifurcation type (Type B), I-shaped type (Type C), and other rare types (TypeD) was79%,9%,9%and3%respectively. P2had1to3branches, where1branch typetook92%and always originated from Rex Recess; Among2-3branches type, thebranches may originate from the left margin of UP. P3has1to4branches, where1branch type took88%and its original point was LPV cystic portion. Multi-branch typeP3might originate from the left (10%), ventro-caudal(1%) or cranial-dorsal (1%)margin of UP. P4could be divided into P4a and P4b, with1to3branches respectively(88%,89%). P4a and P4b originated seperately or jointly, with a frequency of53%and47%respectively; P4always originated from LPV cystic portion, but there might bebranches originated from cranial dorsal (31%) and the right side (17%) of the UP. P5comprised mostly2-4branches (87%), originated from RAPV. Ectopic originations ofP5include RPPV trunk (57%), P8v (54%), P8d or P8l (11%) and RAPV/RPPVbifurcation (7%). P8could be divided into P8v (100%), P8d (100%), P8l (73%) andP8m (49%).85%of P8d extended to the dorsal part of RHV. RPPV trunk was absent in12%of the cases. Besides the variation, the RPPV trunk could be divided into threetypes, which are arcuate type (62.5%),2-branch type (28.4%) and feather-shaped type(8.0%). Segmental anatomy of portal vein does not obey traditional Couinaudsegmentation strictly. The most common variations are1) P8d extended to the dorsalpart of RHV, where belongs to S7and2) the branches of P5originate from RPPV trunk(57%) and P8v (54%).
The variation rate of perihilar bile ducts was36%. The occurrence rate of typicaltype (type A), trifurcation type (type B), RASD/RPSD low converging type (type C),RASD/RPSD converging into LHD type (type D) and rare type (type E) was64%,9%,2%,17%and8%respectively. The overall variation rate of left biliary system was56%. In75%cases, B2and B3converge to form the main trunk of LHD as the classicalanatomy. And in other25%cases, B4converge into B3prior to B2, as the variation. B4could be divided into B4a and B4b, among which66%form the trunk and34%did not. Onishi typeⅠ, Ⅱ, Ⅲ of the convergence was17%,72%and11%, respectively. Theoverall variation rate of right biliary system was85%. The most common variation wereB5branch converging into RPSD (61%), B8branch converging into RPSD (14%),RASD trunk absent (13%) and accessory hepatic duct (5%). The occurrence rate ofinfrapotal type in B3and RPSD was4%and18%respectively. All of the type C2andD1type bile ducts were infraportal type. The features of infraportal type bile ducts in2D images (continuous analysis from head to feet) were1) occurred in RAPV-RPSD-RPPV order;2) long RPSD trunk paralleled with RPV trunk. According to portal veinform, the proportion of infraportal bile ducts in A, B, C and D type portal vein groupwere16.7%,22.2%,22.2%and33.3%respectively. No statistical significance werereached between these groups (P<0.05).
According to portal vein form, the patients were divided into normal group (n=79)and variation group (n=21). The variation rate of biliary tract in two groups was30.4%and57.1%respectively. There was statistical significance to make a contrast betweengroups (P <0.05).
Conclusion The variations of hilar bile ducts are correlated with that of hilar portalveins. In portal vein variation group, the variation rate of hilar bile ducts elevates, butthe occurrence rate of infraportal type bile ducts does not. The rate of variation insegmental vessels is higher than that of perihilar region, and the segmental vessels’distribution does not obey the Couinaud’s segmentation. Couinaud’s segmentationshould be modified, but it is still valuable in liver surgery.3D technology hasadvantages on the three-dimensional anatomic assessment and can provide importantanatomical information, which should be applied routinely before complex liversurgery.
目的对围肝门部和肝段水平的门静脉和胆管解剖，以及两者间具有外科意义的位置关系进行系统性研究。对Couinaud分段的进展和意义进行再讨论。
方法选取连续128例梗阻性黄疸的患者的MSCT影像，以Myrian软件对肝脏、门静脉、胆管进行3D重建，而后对目标区域进行2D与3D结合的观察。
结果100例患者纳入研究，其中男性73例，女性27例，平均年龄58.2±12.9岁。肝门区的门静脉变异率为21%，典型分支形式（A型）、三叉型（B型）、工字型（C型）和其它类型（D型）的出现率分别为79%、9%、9%和3%。P2有1-3支，其中1支者占92%，其发出位置为LPV角部；2-3支P2中，其分支可能从UP左侧发出。P3有1-4支，其中1支者占88%，其起源点为LPV囊部，多支P3可能起自UP左侧（10%）、腹尾侧（1%）或头背侧（1%）。P4可分为P4a和P4b，分别有1-3支分支（88%，89%）。P4a和P4b单独由LPV发出或存在共干发出的概率分别为53%和47%；P4总是从LPV囊部分支，但也可能有分支从UP头背侧（31%）和右侧缘（17%）发出。P5多为2-4支血管（87%），发自RAPV，异位的发出点包括RPPV主干（57%），P8v（54%），P8d或P8（l11%）和RAPV/RPPV分叉部（7%）。P8可分为P8v（100%），P8d（100%），P8l（73%）和P8m（49%），其中85%的P8d延伸到RHV后方。12%的病例无RPPV主干，存在主干的RPPV可分为弓状型（62.5%），2支型（28.4%）和羽毛型（8.0%）。从以上的解剖描述，可见肝段水平门静脉的解剖不完全遵从Couinaud的经典描述，最常见的变异是1）P8d延伸到RHV后方支配S7区域；2）P5分支源于RPPV主干（57%）和P8v（54%）。
围肝门部胆管的变异发生率为36%。可分为典型型（A型），三叉型（B型），RASD/RPSD低位汇合型（C型），RASD/RPSD汇合入LHD型（D型）和特殊类型（E型），其出现率分别为64%，9%，2%，17%和8%。左肝胆管系统的总体变异率为56%。B2与B3汇合成为正常LHD主干者75%，B3与B4首先汇合者25%。B4分为B4a和B4b，形成主干者66%，不形成主干者34%。其汇合点的Onishi分型的Ⅰ、Ⅱ、Ⅲ型出现率分别为17%、72%和11%。右肝系统的总体变异率为85%。常见的变异形式为B5分支汇入RPSD（61%），B8分支汇入RPSD（14%），RASD主干缺失（13%）和副肝管（5%）。B3和RPSD可能出现Infraportal型，其出现率分别为4%和18%。所有的C2型和D1型胆管都是Infraportal型。Infraportal型胆管在2D影像（从头侧向尾侧连续读片）上的特征为1）以RAPV-RPSD-RPPV的顺序出现；2）与RPV主干基本平行的RPSD主干。以门静脉形态分组，ABCD组门静脉中Infraportal型胆管的发生率为16.7%、22.2%、22.2%和33.3%，组间比较差异无统计学显著意义（P>0.05）。
以门静脉形态将病例分为正常组（n=79）和变异组（n=21），两组肝门部胆管的变异率分别为30.4%和57.1%，组间比较差异有统计学显著意义（P<0.05）。
结论围肝门部的胆管变异与门静脉变异有关。在门静脉变异的情况下，肝门部胆管变异的发生率升高，但Infraportal型胆管的出现率并不升高。肝段水平门静脉和胆管变异发生率高，且其解剖分布不完全遵从经典的Couinaud分段法的定义。Couinaud分段法应进行修正，但并不影响其在肝脏外科的价值；3D技术在立体解剖评价方面具有优势，能够提供重要解剖信息，应在复杂肝脏手术前常规应用。
Background Precise anatomy knowledge must be conducted before precise surgery.Recent years, with the rapid development of science and technology, liver surgery hasentered the era of “Precise Liver Surgery”. Surgeons need to have deep command ofanatomy on perihilar region and segmental horizon to perform the most complicatedprocedures, such as living donor liver transplantation, anatomical segmentectomy/subsegmentectomy, radical resection of hilar cholangiocarcinoma and major liverresection for congenital bile ducts dilation. However, studies in recent years on regionalliver anatomy are basically conducted by the methods of cadaveric liver or2D imaging,which are either in conformity with the clinical application habit or lack of contrast with3D models. Therefore, the results are not convincing enough. So far, it is still lack ofsystemic study on segmental vessels. In addition, according to recently researchingresults, many of the intrahepatic portal vein structure does not fully comply with thetraditional Couinaud segments, so it is necessary to take further discussion on thisquestion.
Aim To carry on a systemic study on the perihilar and segmental portal veins and bileducts, and on the anatomical relationship of surgical significance in between, and todiscuss the development and significance of Couinaud’s segmentation.
Methods The research involved consecuative128obstuctive jaundice cases in ourhospital, and MSCT of these cases were analysed. Liver, portal vein and biliary tractwere reconstructed3-dimensionally using Intrasense Myrian. The researcher observedthe region of interest with2D images combined3D models.
Result28cases were excluded accoding to our criteria, and100cases were enrolled inthis study, among which73male and27female, mean age58.2±12.9yrs. The variationrate of portal vein in hilar region is was21%. The occurance rate of typical branch form (Type A), trifurcation type (Type B), I-shaped type (Type C), and other rare types (TypeD) was79%,9%,9%and3%respectively. P2had1to3branches, where1branch typetook92%and always originated from Rex Recess; Among2-3branches type, thebranches may originate from the left margin of UP. P3has1to4branches, where1branch type took88%and its original point was LPV cystic portion. Multi-branch typeP3might originate from the left (10%), ventro-caudal(1%) or cranial-dorsal (1%)margin of UP. P4could be divided into P4a and P4b, with1to3branches respectively(88%,89%). P4a and P4b originated seperately or jointly, with a frequency of53%and47%respectively; P4always originated from LPV cystic portion, but there might bebranches originated from cranial dorsal (31%) and the right side (17%) of the UP. P5comprised mostly2-4branches (87%), originated from RAPV. Ectopic originations ofP5include RPPV trunk (57%), P8v (54%), P8d or P8l (11%) and RAPV/RPPVbifurcation (7%). P8could be divided into P8v (100%), P8d (100%), P8l (73%) andP8m (49%).85%of P8d extended to the dorsal part of RHV. RPPV trunk was absent in12%of the cases. Besides the variation, the RPPV trunk could be divided into threetypes, which are arcuate type (62.5%),2-branch type (28.4%) and feather-shaped type(8.0%). Segmental anatomy of portal vein does not obey traditional Couinaudsegmentation strictly. The most common variations are1) P8d extended to the dorsalpart of RHV, where belongs to S7and2) the branches of P5originate from RPPV trunk(57%) and P8v (54%).
The variation rate of perihilar bile ducts was36%. The occurrence rate of typicaltype (type A), trifurcation type (type B), RASD/RPSD low converging type (type C),RASD/RPSD converging into LHD type (type D) and rare type (type E) was64%,9%,2%,17%and8%respectively. The overall variation rate of left biliary system was56%. In75%cases, B2and B3converge to form the main trunk of LHD as the classicalanatomy. And in other25%cases, B4converge into B3prior to B2, as the variation. B4could be divided into B4a and B4b, among which66%form the trunk and34%did not. Onishi typeⅠ, Ⅱ, Ⅲ of the convergence was17%,72%and11%, respectively. Theoverall variation rate of right biliary system was85%. The most common variation wereB5branch converging into RPSD (61%), B8branch converging into RPSD (14%),RASD trunk absent (13%) and accessory hepatic duct (5%). The occurrence rate ofinfrapotal type in B3and RPSD was4%and18%respectively. All of the type C2andD1type bile ducts were infraportal type. The features of infraportal type bile ducts in2D images (continuous analysis from head to feet) were1) occurred in RAPV-RPSD-RPPV order;2) long RPSD trunk paralleled with RPV trunk. According to portal veinform, the proportion of infraportal bile ducts in A, B, C and D type portal vein groupwere16.7%,22.2%,22.2%and33.3%respectively. No statistical significance werereached between these groups (P<0.05).
According to portal vein form, the patients were divided into normal group (n=79)and variation group (n=21). The variation rate of biliary tract in two groups was30.4%and57.1%respectively. There was statistical significance to make a contrast betweengroups (P <0.05).
Conclusion The variations of hilar bile ducts are correlated with that of hilar portalveins. In portal vein variation group, the variation rate of hilar bile ducts elevates, butthe occurrence rate of infraportal type bile ducts does not. The rate of variation insegmental vessels is higher than that of perihilar region, and the segmental vessels’distribution does not obey the Couinaud’s segmentation. Couinaud’s segmentationshould be modified, but it is still valuable in liver surgery.3D technology hasadvantages on the three-dimensional anatomic assessment and can provide importantanatomical information, which should be applied routinely before complex liversurgery.
引文
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