本文内容已经过同行评议,以优先出版方式在线发表,可作为有效引用数据。由于优先发表的内容尚未完成规范的编校流程,《中华外科杂志》不保证其数据与正式版内容的完全一致。 【引用本文】彭淑牖,金赟,李江涛,等.膜解剖在肝胆胰脾外科的应用进展和现状[J].中华外科杂志,2023,61(7):535-539. 彭淑牖 金赟 李江涛 于源泉 {浙江大学医学院附属第二医院肝胆胰外科} 蔡秀军 洪德飞 梁霄 {浙江大学医学院附属邵逸夫医院普外科} 刘颖斌 王许安 {上海交通大学医学院附属仁济医院胆胰外科} 各种膜性结构遍布人体全身,认识和了解这些膜性结构对外科医师具有重要意义。近年来随着膜学说的兴起,膜解剖在腹部肿瘤特别是胃肠道肿瘤的治疗中得到广泛认可。临床实践中根据需要合理选择膜内或膜外解剖,能更好地实现精准手术。本文结合现阶段研究成果,综述膜解剖在肝胆胰脾外科领域的应用现状和进展,希望能为临床研究提供思路。 19世纪末期,肠系膜被认为是一个分散在腹部的非连续结构。2016年爱尔兰学者Coffey等[1]发现腹部系膜是一个连续的组织,与腹部器官、韧带之间相延续,并将其定义为人体第79个器官。基于这一发现,《格雷氏解剖学》对相关内容进行了更新[2]。目前认为,腹部系膜指包绕腹腔消化系统及其供养血管、悬挂并与后腹膜相连续的信封样结构[3]。从器官层面,腹部系膜与消化器官相互交联、衔接;在组织学层面,一侧的血管、神经等结缔组织与另一侧结缔组织相互连续。因此,腹部系膜与肠道、胰腺、脾脏、肝脏具有高度的整合性[3]。 系膜与系膜床之间存在天然间隙,间隙内仅存在少量纤维组织,在这一层面进行解剖不仅出血少,且可获得肿瘤学的根治。以系膜为基础的切除术,学者根据恶性肿瘤特定的生长、转移方式,认为肿瘤局部侵犯通常局限在系膜支配的区域内,切除肿瘤来源器官及其系膜可达到根治效果[3, 4]。以系膜切除为基础的手术已成为根治结直肠癌的标准手术方式[5],在胃癌、食管癌等肿瘤治疗中也被逐渐采用[6]。在临床实践中合理采用膜内或膜外解剖,可更好地实现精准手术[7, 8]。我们结合系膜理论和膜解剖的相关进展,对其在肝胆胰脾外科中的应用进行论述。 一、胰腺系膜及其发展 二、肝周韧带及其间隙 三、膜解剖在肝胆外科的实践 四、膜解剖在胰腺外科的实践 五、膜解剖在脾外科的实践 六、结论 参考文献 (在框内滑动手指即可浏览) [1]CoffeyJC,CulliganK,WalshLG,et al. An appraisal of the computed axial tomographic appearance of the human mesentery based on mesenteric contiguity from the duodenojejunal flexure to the mesorectal level[J].Eur Radiol,2016,26(3):714-721.DOI:10.1007/s00330-015-3883-0. [2]CoffeyJC,O′LearyDP. The mesentery: structure,function,and role in disease[J].Lancet Gastroenterol Hepatol,2016,1(3):238-247. DOI: 10.1016/S2468-1253(16)30026-7. [3]CoffeyJC,ByrnesKG,WalshDJ,et al. Update on the mesentery: structure,function,and role in disease[J].Lancet Gastroenterol Hepatol,2022,7(1):96-106. DOI: 10.1016/S2468-1253(21)00179-5. [4]ZhaoX,OuYangY. Demystifying membrane anatomy: toward a new era of abdominopelvic surgery[J].Innovation (Camb),2023,4(1):100370. DOI: 10.1016/j.xinn.2022.100370. [5]BunniJ,CoffeyJC,KaladyMF. Resectional surgery for malignant disease of abdominal digestive organs is not surgery of the organ itself,but also that of the mesenteric organ[J].Tech Coloproctol,2020,24(7):757-760. DOI: 10.1007/s10151-020-02197-7. [6]GongCZ,LiuW. Convergence of medicines: West meets East in newly-discovered organs and functions[J].Chin J Integr Med,2019,25(5):323-326. DOI: 10.1007/s11655-018-2570-9. [7]董家鸿,张宁. 精准外科[J].中华外科杂志,2015,53(5):321-323. DOI:10.3760/cma.j.issn.0529-5815.2015.05.001. [8]FanST. Precise hepatectomy guided by the middle hepatic vein[J].Hepatobiliary Pancreat Dis Int,2007,6(4):430-434. [9]GockelI,DomeyerM,WolloscheckT,et al. Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space[J].World J Surg Oncol,2007, 5:44. DOI: 10.1186/1477-7819-5-44. [10]AdhamM,SinghirunnusornJ. Surgical technique and results of total mesopancreas excision(TMpE) in pancreatic tumors[J].Eur J Surg Oncol,2012,38(4):340-345. DOI: 10.1016/j.ejso.2011.12.015. [11]HackertT,StrobelO,MichalskiCW,et al. The TRIANGLE operation-radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study[J].HPB (Oxford),2017,19(11):1001-1007. DOI: 10.1016/j.hpb.2017.07.007. [12]吴文广,吴向嵩,李茂岚,等. 胰头癌行胰腺全系膜切除75例报告[J].中国实用外科杂志,2013,33(10):859-862. [13]来运钢,吕伟,成娣,等. 肝胰十二指肠系膜概念的基础与临床思考[J].医学与哲学,2018,39(12):79-82. DOI: 10.12014/j.issn.1002-0772.2018.06b.22. [14]彭淑牖,李江涛,秦仁义,等. 腹膜后淋巴脂肪板层根治性切除术——胰头癌根治术的新策略[J].中华肝胆外科杂志,2015,21(7):437-441. DOI:10.3760/cma.j.issn.1007-8118.2015.07.002. [15]金赟,李江涛,彭淑牖. 胰头癌患者扩大淋巴结清扫的研究进展及争议[J].中华肝胆外科杂志,2017,23(6):423-425. DOI: 10.3760/cma.j.issn.1007-8118.2017.06.018. [16]IbukuroK,FukudaH,TobeK,et al. The vascular anatomy of the ligaments of the liver: gross anatomy,imaging and clinical applications[J].Br J Radiol,2016,89(1064):20150925. DOI: 10.1259/bjr.20150925. [17]MajnoPE,MenthaG,MorelP,et al. Arantius′ ligament approach to the left hepatic vein and to the common trunk[J].J Am Coll Surg,2002,195(5):737-739. DOI: 10.1016/s1072-7515(02)01324-8. [18]IkegamiT,OndaS,TaniaiT,et al. Arantius′ ligament approach to middle hepatic vein in laparoscopic extended medial segmentectomy (with video)[J].Ann Surg Oncol,2021,28(13):8242-8243. DOI:10.1245/s10434-021-10415-1. [19]GaujouxS,DouardR,EttorreGM,et al. Liver hanging maneuver: an anatomic and clinical review[J].Am J Surg,2007,193(4):488-492. DOI:10.1016/j.amjsurg.2006.04.006. [20]彭淑牖,曹利平,李江涛,等. 肝后隧道的建立与绕肝带的使用在高难度肝切除术中的作用[J].中华医学杂志,2003,83(19):1644-1647. [21]BelghitiJ,GuevaraOA,NounR,et al. Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization[J].J Am Coll Surg,2001,193(1):109-111. DOI: 10.1016/s1072-7515(01)00909-7. [22]ChenXP,ZhangWG,LauWY,et al. Right hepatectomy using the liver double-hanging maneuver through the retrohepatic avascular tunnel on the right of the inferior vena cava[J].Surgery,2008,144(5):830-833. DOI: 10.1016/j.surg.2008.08.006. [23]LiuCL,FanST,LoCM,et al. Anterior approach for major right hepatic resection for large hepatocellular carcinoma[J].Ann Surg,2000,232(1):25-31. DOI: 10.1097/00000658-200007000-00004. [24]FanST,LiuCL. Anterior approach for major right hepatic resection[J].J Hepatobiliary Pancreat Surg,2005,12(5):356-361. DOI: 10.1007/s00534-005-1000-5. [25]CouinaudC. Le foie-Etudes anatomiques et chirurgicales[M]. Paris: Masso,1957. [26]KawaradaY,DasBC,TaokaH. Anatomy of the hepatic hilar area: the plate system[J].J Hepatobiliary Pancreat Surg,2000,7(6):580-586. DOI: 10.1007/s005340070007. [27]KikuchiY,MatuyamaR,HiroshimaY,et al. Surgical and histological boundary of the hepatic hilar plate system: basic study relevant to surgery for hilar cholangiocarcinoma regarding the 'true' proximal ductal margin[J].J Hepatobiliary Pancreat Sci,2019,26(5):159-168. DOI: 10.1002/jhbp.617. [28]陈应军,甄作均,吴志鹏,等. 腹腔镜下降肝门板半肝血流阻断在解剖性肝切除术中的应用[J].中华消化外科杂志,2015,14(4):339-343. DOI:10.3760/cma.j.issn.1673-9752.2015.04.016. [29]WeiZW,XiaGK,WuY,et al. Evaluation of skeletonization of the hepatoduodenal ligament for the lower third gastric cancer by propensity score analysis[J].Hepatogastroenterology,2013,60(127):1789-1796. [30]ShenBY,ZhanQ,DengXX,et al. Radical resection of gallbladder cancer: could it be robotic?[J].Surg Endosc,2012,26(11):3245-3250. DOI:10.1007/s00464-012-2330-4. [31]姜小清,张柏和,易滨,等. 肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌[J].中华外科杂志,2004,42(4):210-212. DOI: 10.3760/j.issn.0529-5815.2004.04.006. [32]彭淑牖,刘付宝. 胰十二指肠切除中的淋巴结清扫术[J].临床外科杂志,2005,13(4):203-205. DOI:10.3969/j.issn.1005-6483.2005.04.008. [33]彭淑牖,刘颖斌,许斌,等. 肝静脉和下腔静脉血流控制在高难度肝肿瘤切除中的应用[J].中华外科杂志,2004,42(5):260-264. DOI: 10.3760/j.issn.0529-5815.2004.05.002. [34]彭淑牖,蔡秀军,牟一平,等. 肝癌合并下腔静脉癌栓的外科治疗[J].中华外科杂志,2006,44(13):878-881. DOI: 10.3760/j.issn.0529-5815.2006.13.006. [35]WangY,YuanL,GeRL,et al. Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: results of a retrospective cohort study[J].Ann Surg Oncol,2013,20(3):914-922. DOI: 10.1245/s10434-012-2646-2. [36]SakamotoK,NaganoH. Outcomes of surgery for hepatocellular carcinoma with tumor thrombus in the inferior vena cava or right atrium[J].Surg Today,2018,48(9):819-824. DOI: 10.1007/s00595-017-1619-2. [37]GaoJ,ZhengJ,ZhuZ,et al. Laparoscopic orthotopic right hemihepatectomy by anterior approach combined with inferior vena cava thrombectomy[J].Ann Surg Oncol,2022,29(9):5548-5549. DOI: 10.1245/s10434-022-11710-1. [38]JinY,WangL,YuYQ,et al. Anatomic isolated caudate lobectomy: is it possible to establish a standard surgical flow?[J].World J Gastroenterol,2017,23(41):7433-7439. DOI: 10.3748/wjg.v23.i41.7433. [39]彭淑牖,洪德飞,许斌,等. 经正中裂入路单独完整肝尾状叶切除术的策略探讨(附19例报告)[J].中华外科杂志,2007,45(19):1321-1324. DOI:10.3760/j.issn.0529-5815.2007.19.009. [40]TakayamaT,MakuuchiM,WatanabeK,et al. A new method for mapping hepatic subsegment: counterstaining identification technique[J].Surgery,1991,109(2):226-229. [41]彭淑牖,冯雪冬,刘颖斌,等. 肝尾状叶原发性肝细胞肝癌的外科治疗[J].中华外科杂志,2005,43(1):49-52. DOI: 10.3760/j.issn.0529-5815.2005.01.015. [42]HayashiS,MurakamiG,OhtsukaA,et al. Connective tissue configuration in the human liver hilar region with special reference to the liver capsule and vascular sheath[J].J Hepatobiliary Pancreat Surg,2008,15(6):640-647. DOI: 10.1007/s00534-008-1336-8. [43]SugiokaA,KatoY,TanahashiY. Systematic extrahepatic Glissonean pedicle isolation for anatomical liver resection based on Laennec′s capsule: proposal of a novel comprehensive surgical anatomy of the liver[J]. J Hepatobiliary Pancreat Sci,2017,24(1):17-23. DOI: 10.1002/jhbp.410. [44]余德才. 肝脏膜性解剖及Laennec入路解剖性肝切除[J/CD].中华腔镜外科杂志(电子版),2019,12(6):332-336. DOI: 10.3877/cma.j.issn.1674-6899.2019.06.005. [45]彭淑牖,洪德飞,许斌,等. 简易胰门三头控制技术在困难型胰十二指肠切除术中的应用[J].中华外科杂志,2007,45(21):1466-1468. DOI:10.3760/j.issn.0529-5815.2007.21.011. [46]李志斌,肖冬生,宋伟. 一级脾蒂离断法与二级脾蒂离断法脾切除治疗脾脏疾病的Meta分析[J].中国老年学杂志,2018,38(14):3389-3392. DOI:10.3969/j.issn.1005-9202.2018.14.024. |
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