肝右静脉解剖及CT三维重建在活体肝移植中的应用
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摘要
目的和意义
肝移植是治疗终末期肝病公认的有效方法,LDLT解决了日益尖锐的供肝需求矛盾,特别是右叶部分LDLT的发展解决了成人患者供肝短缺的矛盾,成为成人间LDLT的主要术式。然而,右半肝肝内血管解剖的复杂性及多变性给右叶部分LDLT带来了许多不可预见性。因此,术前准确掌握有关RHV的解剖信息,将有助于右叶部分LDLT术式选择和受体肝静脉的重建。本研究从临床右叶部分LDLT手术应用角度出发,采用大体解剖与MSCT影像对照的方法,观测了RHV的形态学规律,旨在为右叶部分LDLT提供有关RHV的形态学资料。并在此基础上运用计算机三维重建软件重建了1例LDLT供体的肝脏及肝血管三维模型,旨在为LDLT虚拟手术奠定基础。
材料与方法
1利用50例成人无病变尸肝标本对肝静脉进行解剖剥离,对RHV和AHV进行观测,采集相关数据进行统计分析。
2采用100例无肝病成人64-MSCT增强扫描肝静脉期数据,利用CT自带的GE ADW 4.2工作站对肝静脉进行三维重建,观测RHV和aRHV,采集相关数据进行统计分析,并结合大体解剖标本所测结果进行对比分析。
3选用1例LDLT供体肝脏64-MSCT增强扫描数据,利用Mimics医学三维重建软件,重建肝脏及肝血管的三维模型。
结果
第一部分肝右静脉的大体形态学及CT研究
大体标本中,RHV 80.0%开口于IVC肝后段上份10:00位,CT标本中,RHV 60.0%开口于IVC肝后段上份9:00位。RHV汇入口上缘距膈腔静脉裂孔的距离在大体标本中测得为(10.27±6.62)mm。50例解剖标本中,RHV肝外段长度为(5.83±3.45)mm。大体标本和CT标本中,RHV外科干长分别为(6.99±5.52)mm和(13.01±6.10)mm,二者行对照分析P<0.05;RHV主干长分别为(68.29±30.24)mm和(66.31±30.91)mm,二者对照分析P>0.05。大体标本中,RHV主干汇合起始处、主干中点及其汇入IVC处的管径分别为(6.26±1.69)mm、(7.57±1.79)mm和(10.74±2.36)mm,CT标本中其对应管径分别为(6.62±1.59)mm、(7.96±1.64)mm和(10.10±2.58)mm,二者行对照分析均为P>0.05。大体标本中RHV主干在距IVC 1cm、2 cm、3 cm、4 cm处与主干汇合起始处距肝膈面的距离分别为(10.81±5.33)mm、(22.67±7.00)mm、(32.91±8.28)mm、(39.69±7.78)mm和(33.43±9.79)mm,CT标本中其对应距离分别为(13.23±6.79)mm、(24.73±8.20)mm、(32.63±7.76)mm、(39.03±7.24)mm和(30.68±10.20)mm,两组结果间对照分析1cm处P<0.05,余均为P>0.05。大体标本和CT标本中,RHV与IVC的夹角分别为(40.54±9.43)°和(46.22±12.33)°,二者对照分析P<0.05;RHV与MHV开口处间的距离分别为(12.12±4.10)mm和(12.09±4.19)mm,对照分析P>0.05。本文RHV分型中,大体标本和CT标本中A1型分别占64.0%和63.0%,A2型分别为10.0%和8.0%,B1型分别为4.0%和9.0%,B2型分别为22.0%和20.0%。
本研究将RHV主干属支汇合形式分为四型,在50例解剖标本中,其树状、两支型和三支型分别为90.0%、8.0%和2.0%,未见单独一支型;100例活体标本中,其树状、两支型和单独一支型分别为83.0%、11.0%和6.0%,而未见三支型。两组标本中,RHV主要属支数分别为(5.88±2.26)支和(5.23±2.04)支,其中A型RHV的主要属支数分别为(6.76±1.89)支和(5.83±1.86)支,B型RHV的主要属支数分别为(3.38±0.96)支和(3.39±1.41)支;大体标本中,Ⅴ段、Ⅵ段、Ⅶ段和Ⅷ段的主要属支数分别为(1.00±0.90)支、(1.04±0.86)支、(1.92±0.72)支和(1.92±0.90)支;CT标本中,其相应肝段的主要属支数分别为(0.87±0.74)支、(1.16±0.93)支、(2.15±0.94)支和(1.05±0.72)支,两组结果间对照分析A型RHV和Ⅷ段P<0.05,余均为P>0.05。50例解剖标本中,RHVⅤ段、Ⅵ段、Ⅶ段和Ⅷ段主要属支直径分别为(4.05±1.06)mm、(3.96±0.86)mm、(4.64±1.57)mm和(4.46±1.30)mm,CT标本中分别为(4.69±1.26)mm、(4.57±1.15)mm、(4.61±1.18)mm和(4.58±1.15)mm,两组间对照分析Ⅴ段和Ⅵ段P<0.05,Ⅶ段和Ⅷ段P>0.05。大体标本中RHVⅤ段、Ⅵ段、Ⅶ段和Ⅷ段主要属支长度分别为(21.51±11.24)mm、(28.94±15.90)mm、(30.14±14.41)mm和(23.03±11.14)mm,CT标本中分别为(22.71±12.32)mm、(23.44±14.70)mm、(26.29±11.74)mm和(19.84±8.65)mm,两组结果间对照分析Ⅴ段P>0.05,余均为P<0.05。大体标本中RHVⅤ段、Ⅵ段、Ⅶ段和Ⅷ段主要属支汇入RHV处距RHV汇入IVC处的距离分别为(79.51±17.89)mm、(80.11±17.82)mm、(25.93±17.32)mm和(25.04±17.16)mm,CT标本中分别为(78.49±22.12)mm、(74.85±22.47)mm、(28.13±17.22)mm和(32.71±18.14)mm,两组结果间对照分析Ⅷ段P<0.05,余均为P>0.05。50例解剖标本中,RHV右后上缘支的出现率为38.0%,其中2例右后上缘支直接汇入IVC。通过对大体标本中右半肝各肝段静脉回流情况的观察,结果肝Ⅴ段和Ⅷ段同时由RHV和MHV引流者分别为66.0%和88.0%,22.0%的肝Ⅵ段静脉血部分或全部汇入MHV,见1例肝Ⅶ段仅由aRHV引流。
在50例解剖标本中,AHV的出现率为100%,其中aRHV的出现率为96.0%,直径≥3.00mm和直径≥5.00mm的aRHV的出现率分别为60.0%和32.0%,其开口部位主要集中于IVC肝后段下份8:00～9:00位;CT标本中,直径≥3.00mm和直径≥5.00mm的aRHV的出现率分别为37.0%和28.0%,与大体标本组结果行对照分析分别为P<0.05和P>0.05,其开口部位主要集中于IVC肝后段下份7:00～8:00处。大体标本中,aRHV引流肝Ⅵ段、Ⅶ段、Ⅵ+Ⅶ段或Ⅷ段,其管径分别为(6.30±2.20)mm、(4.49±1.22)mm、(6.38±1.45)mm、(4.30±1.56)mm;CT标本中,aRHV亦引流肝Ⅵ段、Ⅶ段、Ⅵ+Ⅶ段或Ⅷ段,其管径分别为(6.41±1.85)mm、(4.28±1.14)mm、(6.93±1.38)mm、4.50mm,并见1例aRHV引流Ⅴ+Ⅵ+Ⅶ段,其管径为8.00mm,两组标本对应结果间行对照分析均为P>0.05。两组标本中,aRHV最大直径均与RHV管径大小呈负相关(P<0.05)。
第二部分肝脏及肝血管的三维重建及可视化研究
建立的肝动脉、门静脉、肝静脉和肝脏的三维模型几何外型逼真、解剖标志明显,可以不同颜色、任意组合显示,通过调节肝脏的透明度,可以同时显示肝脏和肝内血管。可对模型进行放大、缩小和旋转等全方位观察。利用Mimics的仿真模块能对模型进行任意切割,模拟出肝部分切除术平面,且能自动显示切除或未切除部分的肝体积。可将三维模型图像保存为BMP或JPEG格式,或录制成AVI格式的电影输出动态显示,其播放画面清晰流畅。
主要结论
1.通过解剖大体标本和64-MSCTA三维重建对肝静脉进行研究,两种方法各有利弊,互为补充;CT研究结果与大体标本观测结果基本一致,是一种可靠的临床检测方法,可为LDLT术前提供肝静脉的具体走行,指导制定合理的手术方案和对不同类型肝静脉的处理。
2.RHV多开口于IVC肝后段上份右侧壁,位置较深,其外科干短、主干长、管径粗;其主干在肝实质内呈近似斜向后内上的直线,起、止处较浅,中段较深;RHV主要属支数目不恒定,以Ⅶ段属支最多,管径亦最粗。
3.RHV的引流范围不仅与aRHV有关,同时亦与MHV关系密切,LDLT术前应结合肝右叶体积的大小和与MHV的关系来施行右半肝LDLT供肝的切取。
4.aRHV出现率较高,主要集中于IVC肝后段下份右后壁;LDLT术中对AHV的处理不应拘于现有模式,对单独引流某一肝段的AHV建议重建。
5.采用肝脏CT增强扫描数据,利用Mimics软件可以快速提取肝血管,重建肝内血管三维模型,但对于肝脏的分割较费时;重建的肝脏及肝血管三维模型有助于解剖教学和制定合理的肝脏手术方案,并为进一步行肝脏虚拟手术提供了条件。
Objective
Liver transplantation is the effective treatment of terminal stage liver disease. LDLT solved the increasingly acute contradiction of demand for donor liver, especially the development of right partial LDLT solved the contradiction of liver shortage in adult patient and has become the main modus operandi in adult-to-adult LDLT. However, the complexity and variability of anatomy to intra-hepatic blood vessels in right hemi-liver brought much non-prediction for right partial LDLT. Therefore, the anatomy information of RHV should be accurately mastered before operation, which is helpful for selecting modus operandi of LDLT and the reconstruction of hepatic vein in acceptor. From the clinical application of right partial LDLT surgery, this research observed the morph rules of RHV using compared method between gross anatomy and MSCT image, to provide morph data about RHV for right partial LDLT. And the three-dimensional models of liver and hepatic blood vessels of a donor for LDLT were reconstructed using computer three-dimensional reconstruction software, which is to establish foundation for virtual surgery of LDLT.
Materials and methods
1. 50 non-illness adult cadaveric hepatic vein were anatomied, RHV and AHV were observed, the correlated data were collected and analyzed statistically.
2. 100 non-illness adult livers were enhancedly scanned by 64-MSCT, the hepatic vein stage data were used. The hepatic vein was three-dimensional reconstructed by GE ADW 4.2 workstation of CT machine, RHV and aRHV were observed, the correlated data were collected and analyzed statistically, and the results were contrast analyzed combining with the results of gross anatomy.
3. The 64-MSCT enhanced scanning data of a donor’s liver for LDLT were used, the three-dimensional models of liver and hepatic blood vessels were reconstructed by medical three-dimensional reconstruction software.
Results
The first part The morph and CT study of RHV
In the group of gross anatomy, RHV was 80.0% opening to the upper part of IVC behind liver at 10:00 o’clock. In CT group, RHV was 60.0% opening to the upper part of IVC behind liver at 9:00 o’clock. The distance between the superior border of RHV abouchement opening and vena cava slit pore in diaphragm was (10.27±6.62)mm in gross specimens. In 50 anatomied specimens, the extrahepatic length of RHV was (5.83±3.45)mm. In gross specimens and CT specimens, the surgical trunk of RHV were (6.99±5.52)mm and (13.01±6.10)mm, respectively, the compared result was P < 0.05. The main trunk of RHV were respectively (68.29±30.24)mm and (66.31±30.91)mm, the compared result was P>0.05. In gross specimens, the diameter of RHV at the confluent beginning, the midpoint of main trunk and it inflowing to IVC were (6.26±1.69)mm(,7.57±1.79)mm and (10.74±2.36)mm, respectively. In CT specimens, the corresponding diameter were respectively(6.62±1.59)mm(,7.96±1.64)mm and (10.10±2.58)mm, the compared results were all P > 0.05. In gross specimens, the depth to facies diaphragmatica hepatis at 1cm, 2cm, 3cm, 4cm from the place RHV injecting to IVC and the confluent beginning of the superior wall of main trunk were (10.81±5.33)mm,(22.67±7.00)mm,(32.91±8.28)mm,(39.69±7.78)mm and (33.43±9.79)mm. In CT specimens, the corresponding depth were ( 13.23±6.79 ) mm, ( 24.73±8.20 ) mm,(32.63±7.76)mm,(39.03±7.24)mm and (30.68±10.20)mm, respectively, the compared result at the place of 1cm was P<0.05, others were all P>0.05. In gross specimens and CT specimens, the angle between RHV and IVC were respectively ( 40.54±9.43 )°and (46.22±12.33)°, the compared result was P<0.05. The distance between RHV and MHV were (12.12±4.10)mm,(12.09±4.19)mm, respectively, the compared result was P>0.05. In the RHV types of gross specimens and CT specimens, the percentage of A1 type were 64.0% and 63.0%, the percentage of A2 type were 10.0% and 8.0%, the percentage of B1 type were 4.0% and 9.0%, the percentage of B2 type were 22.0% and 20.0%.
In this study, the confluent pattern of tributaries of main trunk of RHV was divided into four types. In 50 anatomied specimens, the percentage of arborescence, dipl-ramus type and tri-ramus type were 90.0%, 8.0% and 2.0%, respectively, the alone type was not found. In 100 vivo specimens, the percentage of arborescence, dipl-ramus type and alone type were 83.0%, 11.0% and 6.0%, respectively, the tri-ramus type was not found. In two group specimens, the number of main tributaries of RHV were respectively(5.88±2.26) and (5.23±2.04), in which the number of main tributaries in type A RHV were respectively (6.76±1.89) and (5.83±1.86), the number of main tributaries in type B RHV were respectively (3.38±0.96) and (3.39±1.41). In gross specimens, the number of main tributaries of RHV in liver segmentⅤ,Ⅵ,ⅦandⅧwere (1.00±0.90),(1.04±0.86),(1.92±0.72) and (1.92±0.90), respectively. In CT specimens, the number of main tributaries of RHV in corresponding liver segment were respectively (0.87±0.74)(,1.16±0.93), (2.15±0.94) and (1.05±0.72), the compared results in type A RHV and segmentⅧwere P<0.05, others were P>0.05. In 50 anatomied specimens, the diameter of main tributaries of RHV in liver segmentⅤ,Ⅵ,ⅦandⅧwere (4.05±1.06)mm,(3.96±0.86)mm,(4.64±1.57)mm and (4.46±1.30)mm, respectively. In CT specimens, the diameter were respectively (4.69±1.26)mm,(4.57±1.15)mm,(4.61±1.18)mm and (4.58±1.15)mm, the compared results of segmentⅤandⅥwere P<0.05, the compared results of segmentⅦandⅧwere P>0.05. In gross specimens, the length of main tributaries of RHV in liver segmentⅤ,Ⅵ,ⅦandⅧwere (21.51±11.24)mm,(28.94±15.90)mm,(30.14±14.41)mm and (23.03±11.14)mm, respectively. In CT specimens, the length were respectively ( 22.71±12.32 ) mm,(23.44±14.70)mm,(26.29±11.74)mm and (19.84±8.65)mm, the compared result of segmentⅤwas P>0.05, others were all P<0.05. In gross specimens, the distance between the place of main tributaries of RHV inflowing to RHV and the place of RHV inflowing to IVC in liver segmentⅤ,Ⅵ,ⅦandⅧwere respectively (79.51±17.89)mm,(80.11±17.82)mm,(25.93±17.32)mm and(25.04±17.16)mm. In CT specimens, the distance were respectively ( 78.49±22.12 ) mm,(74.85±22.47)mm,(28.13±17.22)mm and (32.71±18.14)mm, the compared result of segmentⅧwas P<0.05, others were P>0.05. In 50 anatomied specimens, the frequency of the post-right upper tributary of RHV was 38.0%, in which there were two cases that the post-right upper tributary injected to IVC directly. The backstreaming information of each segment in right hemi-liver were observed, The rates of venous blood of segmentⅤandⅧinflowing to RHV and MHV simultaneously were 66.0% and 88.0%, respectively. The rate of venous blood of segmentⅥinflowing to MHV fully or partly was 22.0%, and the segmentⅦbeing drained only by aRHV was found in one case.
In 50 anatomied specimens, the frequency of AHV was 100%, in which the frequency of aRHV was 96.0%, the frequency of aRHV the diameter exceeding 3.00mm and 5.00mm were respectively 60.0% and 32.0%, the results compared with that of gross specimens were respectively P<0.05 and P>0.05. The opening position of aRHV was principally at 7:00～8:00 o’clock in the lower part of IVC behind liver. In gross specimens, aRHV drained segmentⅥ,Ⅶ,Ⅵ+ⅦorⅧ, the corresponding diameter of aRHV were (6.30±2.20)mm,(4.49±1.22)mm,(6.38±1.45)mm,(4.30±1.56)mm, respectively. In CT specimens, aRHV also drained segmentⅥ,Ⅶ,Ⅵ+ⅦorⅧ, the corresponding diameter of aRHV were respectively (6.41±1.85)mm,(4.28±1.14)mm,(6.93±1.38)mm, 4.50mm, and the aRHV draining segmentⅤ+Ⅵ+Ⅶwas found in one case, the diameter of which was 8.00mm, the compared results were all P>0.05. In two groups, the thickest diameter of aRHV was negative correlated to the diameter of RHV (P<0.05).
The second part Study of three-dimensional reconstruction and visualization of liver and intra-hepatic blood vessels
The three-dimensional models of liver and intra-hepatic blood vessels were reconstructed, the morph of which was vivid and the anatomy signal was transparent. The models could be displayed by different colors and combined randomly. The liver and intra-hepatic blood vessels could be diaplayed simultaneously through adjusting the transparency of liver. The models could be viewed at any directions by amplified, zoomed down, rotated and so on. Using the simulation module of Mimics, the model could be cut at random and the plane of liver partial resection could be simulated. And the liver volume of resected or non-resected could be displayed automatically. The image of three-dimensional model could be preserved by BMP or JPEG form, or be recorded by AVI form to export for displaying dynamically. The film picture was clear and fluent.
Conclusions
1. Hepatic vein was studied through dissecting gross specimens and 64-MSCTA three-dimensional reconstruction, the two methods all had advantage and disadvantage, and supplied each other. The results of CT research were basically coincident to that of gross specimens. CT was a reliable clinical detecting method, which could provide concrete courser of hepatic vein before LDLT, to guide planning reasonable surgical program and handling different hepatic vein.
2. RHV was mostly opening to the right wall of the upper part of IVC behind liver and the position was deep. The surgical trunk of RHV was short, the main trunk was long, and the diameter was thick. The main trunk of RHV was approximately a inclined line to post-intra- upper direction, of which the beginning and ending were superficial, the middle section was deep. The number of main tributaries of RHV was not constant, the tributaries in segmentⅦwas most and thickest.
3. The draining scope of RHV was not only concerned with aRHV, but also closely relevant to MHV. Before LDLT, the right lobe liver volume and the relationship between RHV and MHV should be considered to resect the donor liver for right hemi-liver LDLT.
4. The frequency of aRHV was high, aRHV was mainly concentrated at post-right wall of lower part of IVC behind liver. In the operation of LDLT, the processing to AHV should not be limited at present mode. AHV which was the only vein draining one liver segment was suggested to be reconstructed.
5. The intra-hepatic blood vessels could be obtained quickly to reconstruct the three-dimensional model by using Mimics software and the enhanced CT scanning data of liver, but the division of liver was time consuming. The reconstructed three-dimensional models of liver and intra-hepatic blood vessels were helpful for anatomy teaching and designing reasonable hepatic surgery, and provided condition for virtual hepatic surgery.
肝移植是治疗终末期肝病公认的有效方法,LDLT解决了日益尖锐的供肝需求矛盾,特别是右叶部分LDLT的发展解决了成人患者供肝短缺的矛盾,成为成人间LDLT的主要术式。然而,右半肝肝内血管解剖的复杂性及多变性给右叶部分LDLT带来了许多不可预见性。因此,术前准确掌握有关RHV的解剖信息,将有助于右叶部分LDLT术式选择和受体肝静脉的重建。本研究从临床右叶部分LDLT手术应用角度出发,采用大体解剖与MSCT影像对照的方法,观测了RHV的形态学规律,旨在为右叶部分LDLT提供有关RHV的形态学资料。并在此基础上运用计算机三维重建软件重建了1例LDLT供体的肝脏及肝血管三维模型,旨在为LDLT虚拟手术奠定基础。
材料与方法
1利用50例成人无病变尸肝标本对肝静脉进行解剖剥离,对RHV和AHV进行观测,采集相关数据进行统计分析。
2采用100例无肝病成人64-MSCT增强扫描肝静脉期数据,利用CT自带的GE ADW 4.2工作站对肝静脉进行三维重建,观测RHV和aRHV,采集相关数据进行统计分析,并结合大体解剖标本所测结果进行对比分析。
3选用1例LDLT供体肝脏64-MSCT增强扫描数据,利用Mimics医学三维重建软件,重建肝脏及肝血管的三维模型。
结果
第一部分肝右静脉的大体形态学及CT研究
大体标本中,RHV 80.0%开口于IVC肝后段上份10:00位,CT标本中,RHV 60.0%开口于IVC肝后段上份9:00位。RHV汇入口上缘距膈腔静脉裂孔的距离在大体标本中测得为(10.27±6.62)mm。50例解剖标本中,RHV肝外段长度为(5.83±3.45)mm。大体标本和CT标本中,RHV外科干长分别为(6.99±5.52)mm和(13.01±6.10)mm,二者行对照分析P<0.05;RHV主干长分别为(68.29±30.24)mm和(66.31±30.91)mm,二者对照分析P>0.05。大体标本中,RHV主干汇合起始处、主干中点及其汇入IVC处的管径分别为(6.26±1.69)mm、(7.57±1.79)mm和(10.74±2.36)mm,CT标本中其对应管径分别为(6.62±1.59)mm、(7.96±1.64)mm和(10.10±2.58)mm,二者行对照分析均为P>0.05。大体标本中RHV主干在距IVC 1cm、2 cm、3 cm、4 cm处与主干汇合起始处距肝膈面的距离分别为(10.81±5.33)mm、(22.67±7.00)mm、(32.91±8.28)mm、(39.69±7.78)mm和(33.43±9.79)mm,CT标本中其对应距离分别为(13.23±6.79)mm、(24.73±8.20)mm、(32.63±7.76)mm、(39.03±7.24)mm和(30.68±10.20)mm,两组结果间对照分析1cm处P<0.05,余均为P>0.05。大体标本和CT标本中,RHV与IVC的夹角分别为(40.54±9.43)°和(46.22±12.33)°,二者对照分析P<0.05;RHV与MHV开口处间的距离分别为(12.12±4.10)mm和(12.09±4.19)mm,对照分析P>0.05。本文RHV分型中,大体标本和CT标本中A1型分别占64.0%和63.0%,A2型分别为10.0%和8.0%,B1型分别为4.0%和9.0%,B2型分别为22.0%和20.0%。
本研究将RHV主干属支汇合形式分为四型,在50例解剖标本中,其树状、两支型和三支型分别为90.0%、8.0%和2.0%,未见单独一支型;100例活体标本中,其树状、两支型和单独一支型分别为83.0%、11.0%和6.0%,而未见三支型。两组标本中,RHV主要属支数分别为(5.88±2.26)支和(5.23±2.04)支,其中A型RHV的主要属支数分别为(6.76±1.89)支和(5.83±1.86)支,B型RHV的主要属支数分别为(3.38±0.96)支和(3.39±1.41)支;大体标本中,Ⅴ段、Ⅵ段、Ⅶ段和Ⅷ段的主要属支数分别为(1.00±0.90)支、(1.04±0.86)支、(1.92±0.72)支和(1.92±0.90)支;CT标本中,其相应肝段的主要属支数分别为(0.87±0.74)支、(1.16±0.93)支、(2.15±0.94)支和(1.05±0.72)支,两组结果间对照分析A型RHV和Ⅷ段P<0.05,余均为P>0.05。50例解剖标本中,RHVⅤ段、Ⅵ段、Ⅶ段和Ⅷ段主要属支直径分别为(4.05±1.06)mm、(3.96±0.86)mm、(4.64±1.57)mm和(4.46±1.30)mm,CT标本中分别为(4.69±1.26)mm、(4.57±1.15)mm、(4.61±1.18)mm和(4.58±1.15)mm,两组间对照分析Ⅴ段和Ⅵ段P<0.05,Ⅶ段和Ⅷ段P>0.05。大体标本中RHVⅤ段、Ⅵ段、Ⅶ段和Ⅷ段主要属支长度分别为(21.51±11.24)mm、(28.94±15.90)mm、(30.14±14.41)mm和(23.03±11.14)mm,CT标本中分别为(22.71±12.32)mm、(23.44±14.70)mm、(26.29±11.74)mm和(19.84±8.65)mm,两组结果间对照分析Ⅴ段P>0.05,余均为P<0.05。大体标本中RHVⅤ段、Ⅵ段、Ⅶ段和Ⅷ段主要属支汇入RHV处距RHV汇入IVC处的距离分别为(79.51±17.89)mm、(80.11±17.82)mm、(25.93±17.32)mm和(25.04±17.16)mm,CT标本中分别为(78.49±22.12)mm、(74.85±22.47)mm、(28.13±17.22)mm和(32.71±18.14)mm,两组结果间对照分析Ⅷ段P<0.05,余均为P>0.05。50例解剖标本中,RHV右后上缘支的出现率为38.0%,其中2例右后上缘支直接汇入IVC。通过对大体标本中右半肝各肝段静脉回流情况的观察,结果肝Ⅴ段和Ⅷ段同时由RHV和MHV引流者分别为66.0%和88.0%,22.0%的肝Ⅵ段静脉血部分或全部汇入MHV,见1例肝Ⅶ段仅由aRHV引流。
在50例解剖标本中,AHV的出现率为100%,其中aRHV的出现率为96.0%,直径≥3.00mm和直径≥5.00mm的aRHV的出现率分别为60.0%和32.0%,其开口部位主要集中于IVC肝后段下份8:00～9:00位;CT标本中,直径≥3.00mm和直径≥5.00mm的aRHV的出现率分别为37.0%和28.0%,与大体标本组结果行对照分析分别为P<0.05和P>0.05,其开口部位主要集中于IVC肝后段下份7:00～8:00处。大体标本中,aRHV引流肝Ⅵ段、Ⅶ段、Ⅵ+Ⅶ段或Ⅷ段,其管径分别为(6.30±2.20)mm、(4.49±1.22)mm、(6.38±1.45)mm、(4.30±1.56)mm;CT标本中,aRHV亦引流肝Ⅵ段、Ⅶ段、Ⅵ+Ⅶ段或Ⅷ段,其管径分别为(6.41±1.85)mm、(4.28±1.14)mm、(6.93±1.38)mm、4.50mm,并见1例aRHV引流Ⅴ+Ⅵ+Ⅶ段,其管径为8.00mm,两组标本对应结果间行对照分析均为P>0.05。两组标本中,aRHV最大直径均与RHV管径大小呈负相关(P<0.05)。
第二部分肝脏及肝血管的三维重建及可视化研究
建立的肝动脉、门静脉、肝静脉和肝脏的三维模型几何外型逼真、解剖标志明显,可以不同颜色、任意组合显示,通过调节肝脏的透明度,可以同时显示肝脏和肝内血管。可对模型进行放大、缩小和旋转等全方位观察。利用Mimics的仿真模块能对模型进行任意切割,模拟出肝部分切除术平面,且能自动显示切除或未切除部分的肝体积。可将三维模型图像保存为BMP或JPEG格式,或录制成AVI格式的电影输出动态显示,其播放画面清晰流畅。
主要结论
1.通过解剖大体标本和64-MSCTA三维重建对肝静脉进行研究,两种方法各有利弊,互为补充;CT研究结果与大体标本观测结果基本一致,是一种可靠的临床检测方法,可为LDLT术前提供肝静脉的具体走行,指导制定合理的手术方案和对不同类型肝静脉的处理。
2.RHV多开口于IVC肝后段上份右侧壁,位置较深,其外科干短、主干长、管径粗;其主干在肝实质内呈近似斜向后内上的直线,起、止处较浅,中段较深;RHV主要属支数目不恒定,以Ⅶ段属支最多,管径亦最粗。
3.RHV的引流范围不仅与aRHV有关,同时亦与MHV关系密切,LDLT术前应结合肝右叶体积的大小和与MHV的关系来施行右半肝LDLT供肝的切取。
4.aRHV出现率较高,主要集中于IVC肝后段下份右后壁;LDLT术中对AHV的处理不应拘于现有模式,对单独引流某一肝段的AHV建议重建。
5.采用肝脏CT增强扫描数据,利用Mimics软件可以快速提取肝血管,重建肝内血管三维模型,但对于肝脏的分割较费时;重建的肝脏及肝血管三维模型有助于解剖教学和制定合理的肝脏手术方案,并为进一步行肝脏虚拟手术提供了条件。
Objective
Liver transplantation is the effective treatment of terminal stage liver disease. LDLT solved the increasingly acute contradiction of demand for donor liver, especially the development of right partial LDLT solved the contradiction of liver shortage in adult patient and has become the main modus operandi in adult-to-adult LDLT. However, the complexity and variability of anatomy to intra-hepatic blood vessels in right hemi-liver brought much non-prediction for right partial LDLT. Therefore, the anatomy information of RHV should be accurately mastered before operation, which is helpful for selecting modus operandi of LDLT and the reconstruction of hepatic vein in acceptor. From the clinical application of right partial LDLT surgery, this research observed the morph rules of RHV using compared method between gross anatomy and MSCT image, to provide morph data about RHV for right partial LDLT. And the three-dimensional models of liver and hepatic blood vessels of a donor for LDLT were reconstructed using computer three-dimensional reconstruction software, which is to establish foundation for virtual surgery of LDLT.
Materials and methods
1. 50 non-illness adult cadaveric hepatic vein were anatomied, RHV and AHV were observed, the correlated data were collected and analyzed statistically.
2. 100 non-illness adult livers were enhancedly scanned by 64-MSCT, the hepatic vein stage data were used. The hepatic vein was three-dimensional reconstructed by GE ADW 4.2 workstation of CT machine, RHV and aRHV were observed, the correlated data were collected and analyzed statistically, and the results were contrast analyzed combining with the results of gross anatomy.
3. The 64-MSCT enhanced scanning data of a donor’s liver for LDLT were used, the three-dimensional models of liver and hepatic blood vessels were reconstructed by medical three-dimensional reconstruction software.
Results
The first part The morph and CT study of RHV
In the group of gross anatomy, RHV was 80.0% opening to the upper part of IVC behind liver at 10:00 o’clock. In CT group, RHV was 60.0% opening to the upper part of IVC behind liver at 9:00 o’clock. The distance between the superior border of RHV abouchement opening and vena cava slit pore in diaphragm was (10.27±6.62)mm in gross specimens. In 50 anatomied specimens, the extrahepatic length of RHV was (5.83±3.45)mm. In gross specimens and CT specimens, the surgical trunk of RHV were (6.99±5.52)mm and (13.01±6.10)mm, respectively, the compared result was P < 0.05. The main trunk of RHV were respectively (68.29±30.24)mm and (66.31±30.91)mm, the compared result was P>0.05. In gross specimens, the diameter of RHV at the confluent beginning, the midpoint of main trunk and it inflowing to IVC were (6.26±1.69)mm(,7.57±1.79)mm and (10.74±2.36)mm, respectively. In CT specimens, the corresponding diameter were respectively(6.62±1.59)mm(,7.96±1.64)mm and (10.10±2.58)mm, the compared results were all P > 0.05. In gross specimens, the depth to facies diaphragmatica hepatis at 1cm, 2cm, 3cm, 4cm from the place RHV injecting to IVC and the confluent beginning of the superior wall of main trunk were (10.81±5.33)mm,(22.67±7.00)mm,(32.91±8.28)mm,(39.69±7.78)mm and (33.43±9.79)mm. In CT specimens, the corresponding depth were ( 13.23±6.79 ) mm, ( 24.73±8.20 ) mm,(32.63±7.76)mm,(39.03±7.24)mm and (30.68±10.20)mm, respectively, the compared result at the place of 1cm was P<0.05, others were all P>0.05. In gross specimens and CT specimens, the angle between RHV and IVC were respectively ( 40.54±9.43 )°and (46.22±12.33)°, the compared result was P<0.05. The distance between RHV and MHV were (12.12±4.10)mm,(12.09±4.19)mm, respectively, the compared result was P>0.05. In the RHV types of gross specimens and CT specimens, the percentage of A1 type were 64.0% and 63.0%, the percentage of A2 type were 10.0% and 8.0%, the percentage of B1 type were 4.0% and 9.0%, the percentage of B2 type were 22.0% and 20.0%.
In this study, the confluent pattern of tributaries of main trunk of RHV was divided into four types. In 50 anatomied specimens, the percentage of arborescence, dipl-ramus type and tri-ramus type were 90.0%, 8.0% and 2.0%, respectively, the alone type was not found. In 100 vivo specimens, the percentage of arborescence, dipl-ramus type and alone type were 83.0%, 11.0% and 6.0%, respectively, the tri-ramus type was not found. In two group specimens, the number of main tributaries of RHV were respectively(5.88±2.26) and (5.23±2.04), in which the number of main tributaries in type A RHV were respectively (6.76±1.89) and (5.83±1.86), the number of main tributaries in type B RHV were respectively (3.38±0.96) and (3.39±1.41). In gross specimens, the number of main tributaries of RHV in liver segmentⅤ,Ⅵ,ⅦandⅧwere (1.00±0.90),(1.04±0.86),(1.92±0.72) and (1.92±0.90), respectively. In CT specimens, the number of main tributaries of RHV in corresponding liver segment were respectively (0.87±0.74)(,1.16±0.93), (2.15±0.94) and (1.05±0.72), the compared results in type A RHV and segmentⅧwere P<0.05, others were P>0.05. In 50 anatomied specimens, the diameter of main tributaries of RHV in liver segmentⅤ,Ⅵ,ⅦandⅧwere (4.05±1.06)mm,(3.96±0.86)mm,(4.64±1.57)mm and (4.46±1.30)mm, respectively. In CT specimens, the diameter were respectively (4.69±1.26)mm,(4.57±1.15)mm,(4.61±1.18)mm and (4.58±1.15)mm, the compared results of segmentⅤandⅥwere P<0.05, the compared results of segmentⅦandⅧwere P>0.05. In gross specimens, the length of main tributaries of RHV in liver segmentⅤ,Ⅵ,ⅦandⅧwere (21.51±11.24)mm,(28.94±15.90)mm,(30.14±14.41)mm and (23.03±11.14)mm, respectively. In CT specimens, the length were respectively ( 22.71±12.32 ) mm,(23.44±14.70)mm,(26.29±11.74)mm and (19.84±8.65)mm, the compared result of segmentⅤwas P>0.05, others were all P<0.05. In gross specimens, the distance between the place of main tributaries of RHV inflowing to RHV and the place of RHV inflowing to IVC in liver segmentⅤ,Ⅵ,ⅦandⅧwere respectively (79.51±17.89)mm,(80.11±17.82)mm,(25.93±17.32)mm and(25.04±17.16)mm. In CT specimens, the distance were respectively ( 78.49±22.12 ) mm,(74.85±22.47)mm,(28.13±17.22)mm and (32.71±18.14)mm, the compared result of segmentⅧwas P<0.05, others were P>0.05. In 50 anatomied specimens, the frequency of the post-right upper tributary of RHV was 38.0%, in which there were two cases that the post-right upper tributary injected to IVC directly. The backstreaming information of each segment in right hemi-liver were observed, The rates of venous blood of segmentⅤandⅧinflowing to RHV and MHV simultaneously were 66.0% and 88.0%, respectively. The rate of venous blood of segmentⅥinflowing to MHV fully or partly was 22.0%, and the segmentⅦbeing drained only by aRHV was found in one case.
In 50 anatomied specimens, the frequency of AHV was 100%, in which the frequency of aRHV was 96.0%, the frequency of aRHV the diameter exceeding 3.00mm and 5.00mm were respectively 60.0% and 32.0%, the results compared with that of gross specimens were respectively P<0.05 and P>0.05. The opening position of aRHV was principally at 7:00～8:00 o’clock in the lower part of IVC behind liver. In gross specimens, aRHV drained segmentⅥ,Ⅶ,Ⅵ+ⅦorⅧ, the corresponding diameter of aRHV were (6.30±2.20)mm,(4.49±1.22)mm,(6.38±1.45)mm,(4.30±1.56)mm, respectively. In CT specimens, aRHV also drained segmentⅥ,Ⅶ,Ⅵ+ⅦorⅧ, the corresponding diameter of aRHV were respectively (6.41±1.85)mm,(4.28±1.14)mm,(6.93±1.38)mm, 4.50mm, and the aRHV draining segmentⅤ+Ⅵ+Ⅶwas found in one case, the diameter of which was 8.00mm, the compared results were all P>0.05. In two groups, the thickest diameter of aRHV was negative correlated to the diameter of RHV (P<0.05).
The second part Study of three-dimensional reconstruction and visualization of liver and intra-hepatic blood vessels
The three-dimensional models of liver and intra-hepatic blood vessels were reconstructed, the morph of which was vivid and the anatomy signal was transparent. The models could be displayed by different colors and combined randomly. The liver and intra-hepatic blood vessels could be diaplayed simultaneously through adjusting the transparency of liver. The models could be viewed at any directions by amplified, zoomed down, rotated and so on. Using the simulation module of Mimics, the model could be cut at random and the plane of liver partial resection could be simulated. And the liver volume of resected or non-resected could be displayed automatically. The image of three-dimensional model could be preserved by BMP or JPEG form, or be recorded by AVI form to export for displaying dynamically. The film picture was clear and fluent.
Conclusions
1. Hepatic vein was studied through dissecting gross specimens and 64-MSCTA three-dimensional reconstruction, the two methods all had advantage and disadvantage, and supplied each other. The results of CT research were basically coincident to that of gross specimens. CT was a reliable clinical detecting method, which could provide concrete courser of hepatic vein before LDLT, to guide planning reasonable surgical program and handling different hepatic vein.
2. RHV was mostly opening to the right wall of the upper part of IVC behind liver and the position was deep. The surgical trunk of RHV was short, the main trunk was long, and the diameter was thick. The main trunk of RHV was approximately a inclined line to post-intra- upper direction, of which the beginning and ending were superficial, the middle section was deep. The number of main tributaries of RHV was not constant, the tributaries in segmentⅦwas most and thickest.
3. The draining scope of RHV was not only concerned with aRHV, but also closely relevant to MHV. Before LDLT, the right lobe liver volume and the relationship between RHV and MHV should be considered to resect the donor liver for right hemi-liver LDLT.
4. The frequency of aRHV was high, aRHV was mainly concentrated at post-right wall of lower part of IVC behind liver. In the operation of LDLT, the processing to AHV should not be limited at present mode. AHV which was the only vein draining one liver segment was suggested to be reconstructed.
5. The intra-hepatic blood vessels could be obtained quickly to reconstruct the three-dimensional model by using Mimics software and the enhanced CT scanning data of liver, but the division of liver was time consuming. The reconstructed three-dimensional models of liver and intra-hepatic blood vessels were helpful for anatomy teaching and designing reasonable hepatic surgery, and provided condition for virtual hepatic surgery.
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[30] Nakamura T, Tanaka K, Kiuchi T, et al. Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases[J]. Transplantation, 2002, 73(12):1896-1903.
[31]扈延龄,金丹,苏秀云,等.基于三维CT数据的髋臼骨折计算机辅助虚拟手术设计[J].中华创伤骨科杂志,2008,10(2):135-137.
[32] Marchetti C,Bianchi A,Bassi M,et a1.Mathematical modeling and numerical simulation in maxillo-faeial virtual surgery (VISU) [J].J Craniofae Surg,2006,17(4):661-667.
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[36]方驰华,常旭,鲁朝敏,等.肝内外胆管结石64排CT数据三维重建及其临床意义[J].南方医科大学学报,2008,28(3):370-372.
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[38]李宏为.活体部分肝移植[J].上海交通大学学报(医学版),2006,26(6):559-560.
[1] Sugawara Y, Makuuchi M. Technical advances in living-related liver transplantation[J]. J Hepatobiliary Pancreat Surg, 1999,6(3):245-253.
[2]王学浩,李国强,李相成,等.活体肝移植手术经验回顾(附13例次报告)[J].中国实用外科杂志,2002,22(6):345-348.
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[4] Lo CM, Fan ST, Liu CL, et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts[J]. Ann Surg, 1997, 226(3):269-270.
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[6] Sugawara Y, Makuuchi M, Takayama T, et al. Liver transplantation using a right lateral sector graft from a living donor to her granddaughter[J]. Hepatogastroenterology, 2001, 48(37):261-263.
[7] Lee SG, Hwang S, Park KM, et al. Seventeen adult-to-adult living donor liver transplantations using dual grafts[J]. Transplant Proc, 2001, 33(728):3461-3463.
[8]严律南,曾勇,王文涛,等.成人间双供体活体肝脏移植成功2例报告[J].中国普外基础与临床杂志,2005,12(4):399-402.
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[7] Lee SG, Hwang S, Park KM, et al. Seventeen adult-to-adult living donor liver transplantations using dual grafts[J]. Transplant Proc, 2001, 33(728):3461-3463.
[8]严律南,曾勇,王文涛,等.成人间双供体活体肝脏移植成功2例报告[J].中国普外基础与临床杂志,2005,12(4):399-402.
[9]李立,李晓延,冉江华,等.成人间右三段加左半肝双供体活体肝移植1例报告[J].中国实用外科杂志,2007,27(1):97.
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[11]方驰华,李晓锋,鲁朝敏,等.可视化仿真手术在活体肝移植中的应用价值[J].中国组织工程与临床康复,2008,12(39):7751-7754.
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[29]王海全,邢雪,孙国锋.主肝静脉和肝短静脉的解剖学研究及其临床意义[J].中国普通外科杂志,2007,16(8):767-769.
[30] Nakamura T, Tanaka K, Kiuchi T, et al. Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases[J]. Transplantation, 2002, 73(12):1896-1903.
[31]扈延龄,金丹,苏秀云,等.基于三维CT数据的髋臼骨折计算机辅助虚拟手术设计[J].中华创伤骨科杂志,2008,10(2):135-137.
[32] Marchetti C,Bianchi A,Bassi M,et a1.Mathematical modeling and numerical simulation in maxillo-faeial virtual surgery (VISU) [J].J Craniofae Surg,2006,17(4):661-667.
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[34]程果,郭燕丽,张绍祥,等.人体可视化肝脏与肝脏超声影像学的对照研究[J].第三军医大学学报,2008,30(23):2157-2160.
[35]高宏建,吴水才,任新颖,等.利用Amira进行肝脏及其管道系统的三维重建[J].北京生物医学工程,2006,25(5):534-537.
[36]方驰华,常旭,鲁朝敏,等.肝内外胆管结石64排CT数据三维重建及其临床意义[J].南方医科大学学报,2008,28(3):370-372.
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[38]李宏为.活体部分肝移植[J].上海交通大学学报(医学版),2006,26(6):559-560.
[1] Sugawara Y, Makuuchi M. Technical advances in living-related liver transplantation[J]. J Hepatobiliary Pancreat Surg, 1999,6(3):245-253.
[2]王学浩,李国强,李相成,等.活体肝移植手术经验回顾(附13例次报告)[J].中国实用外科杂志,2002,22(6):345-348.
[3] Yamaoka Y,Washida M,Honda K,et a1.1iving liver transplantation using a right lobe graft from a living related donor[J]. Transplantation, 1994,57(7):1127-1130.
[4] Lo CM, Fan ST, Liu CL, et al. Adult-to-adult living donor liver transplantation using extended right lobe grafts[J]. Ann Surg, 1997, 226(3):269-270.
[5] Kim SH, Suh KS, Kim SB, et al. Adult living donor liver transplantation using right posterior segment[J]. Transpl Int, 2003,16(9):689-691.
[6] Sugawara Y, Makuuchi M, Takayama T, et al. Liver transplantation using a right lateral sector graft from a living donor to her granddaughter[J]. Hepatogastroenterology, 2001, 48(37):261-263.
[7] Lee SG, Hwang S, Park KM, et al. Seventeen adult-to-adult living donor liver transplantations using dual grafts[J]. Transplant Proc, 2001, 33(728):3461-3463.
[8]严律南,曾勇,王文涛,等.成人间双供体活体肝脏移植成功2例报告[J].中国普外基础与临床杂志,2005,12(4):399-402.
[9]李立,李晓延,冉江华,等.成人间右三段加左半肝双供体活体肝移植1例报告[J].中国实用外科杂志,2007,27(1):97.
[10]韩永坚,刘牧之.临床解剖学丛书(腹、盆部分册)[M].北京:人民卫生出版社,1992:265-266.
[11]安永林,黄明玉.肝静脉开口观测及其临床应用研究[J].青海医学院学报,2004,25(3):181-182.
[12]王海全,邢雪,孙国锋.主肝静脉和肝短静脉的解剖学研究及其临床意义[J].中国普通外科杂志,2007,16(8):767-769.
[13]张新锋,杨晓梅,韩长青.肝内门-腔静脉分流术的应用解剖[J].吉林医学院学报,1998,18(3):29-30.
[14]王现亮,董光,耿海,等.肝静脉分型与测量参数的多层螺旋CT研究[J].中华放射学杂志,2007,41(7):709-712.
[15]康健,佘永华.下腔静脉和肝静脉末段的应用解剖学[J].四川解剖学杂志,1997,5(3):148-151.
[16]吕衡发,孙天恩,张振有,等.经颈内静脉肝内门体分流术的应用解剖[J].白求恩医科大学学报,1997,23(4):369-371.
[17]宋庆轮,陈卫霞,陈军法.多层螺旋CT增强扫描显示肝静脉正常解剖及变异[J].中国临床解剖学杂志,2008,26(1):56-58.
[18]彭民浩,黄源,李启强,等.肝静脉在背驮式肝移植术中的应用[J].局部手术学杂志,1997,6(3):3-5.
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