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中华肝脏外科手术学电子杂志 ›› 2025, Vol. 14 ›› Issue (02) : 209 -216. doi: 10.3877/cma.j.issn.2095-3232.2025032

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基于亚段水平出入肝血流特征的肝脏外科解剖和手术入路
周迪1, 孙伟1, 龚健1, 王健东2, 全志伟2, 李俊1,()   
  1. 1. 200072 同济大学附属第十人民医院(上海市第十人民医院)肝胆外科
    2. 200090 上海交通大学医学院附属新华医院普外科
  • 收稿日期:2024-11-25 出版日期:2025-04-10
  • 通信作者: 李俊

Hepatic surgical anatomy and approach based on the characteristics of hepatic inflow and outflow at subsegmental level

Di Zhou1, Wei Sun1, Jian Gong1, Jiandong Wang2, Zhiwei Quan2, Jun Li1,()   

  1. 1. Department of Hepatobiliary Surgery, Tenth People’s Hospital Affiliated to Tongji University (Shanghai Tenth People’s Hospital), Shanghai 200072, China
    2. Department of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200090, China
  • Received:2024-11-25 Published:2025-04-10
  • Corresponding author: Jun Li
引用本文:

周迪, 孙伟, 龚健, 王健东, 全志伟, 李俊. 基于亚段水平出入肝血流特征的肝脏外科解剖和手术入路[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(02): 209-216.

Di Zhou, Wei Sun, Jian Gong, Jiandong Wang, Zhiwei Quan, Jun Li. Hepatic surgical anatomy and approach based on the characteristics of hepatic inflow and outflow at subsegmental level[J/OL]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(02): 209-216.

Couinaud 提出的肝段划分体系是现代肝脏外科的基石。近年来,随着腹腔镜解剖性肝切除技术正迅速迈向规范化和定型化,人们逐渐认识到Couinaud 体系的一些缺陷,并依托现代影像学技术提出了肝脏流域的概念。在技术层面,解剖性肝切除的范围应包括具有完整门静脉血供及肝静脉回流的流域。因此,肝段的划分和命名不仅需要明确其供血门静脉,更要关注肝静脉的回流途径。笔者建议在亚段水平对门静脉、肝静脉进行命名,并提倡兼顾门静脉血供及肝静脉回流归属方式考察肝叶和肝段的划分,期望有助于达成正确的术前规划,便于手术入路的选择。

The liver segmentation system described by Couinaud is the cornerstone of modern liver surgery.In recent years, with rapid standardization and maturation of laparoscopic anatomical hepatectomy, certain defects of Couinaud system have been gradually identified, and the concept of dynamic watershed theory has been proposed based on modern imaging technology.At the technical level, the scope of anatomical hepatectomy should include the watershed with complete portal vein blood supply and hepatic vein reflux.Therefore, the segmentation and naming of hepatic segments should not only clarify the supplying portal veins, but also emphasize the reflux path of hepatic veins.In this article, we suggest naming portal and hepatic veins at the subsegmental level, and recommend considering the blood supply of portal veins and the path of hepatic vein reflux to investigate the segmentation of hepatic lobes and segments, aiming to help achieve correct preoperative planning and facilitate the selection of surgical approach.

图1 Couinaud 肝脏分段示意图
图2 肝S2 及S3 段呈背侧及腹侧的关系(左侧视角)三维重建图像 注:a 示P2 与P3 分支呈背侧与腹侧分布,b 示S2 段,c 示S3 段,d 示S2 及S3 两者为背侧及腹侧的毗邻关系;*示S2 及S3 相接面为垂直面,而非图1 中经典Couinaud 肝脏分段法所示的水平面
图3 S4 门静脉分支的分布及亚段流域的排列形式(左侧视角)三维重建图像 注:a 示自矢状部的盲端囊部→矢状部主干(腹侧→背侧)的方向依次发出多个P4 分支;b 示S4 是自腹侧→背侧依次排列的亚肝段流域“拼接”而成
图4 肝S6v-1 的静脉回流途径三维重建图 注:a 示经V6v-1 回流入RHV,b 示经V5d(V6v-1)回流入MHV;RHV 为肝右静脉,V6v-1 为Ⅵ段腹侧第一亚段(S6v-1)回流肝静脉分支,MHV 为肝中静脉,P6v-1 为S6 段腹侧第一亚段(S6v-1)门静脉分支,V4b 为S4b 回流肝静脉分支,V5v-1 为S5 段腹侧第一亚段(S5v-1)回流肝静脉分支,V5v-2 为S5 段腹侧第二亚段(S5v-2)回流肝静脉分支,V5d 为V 段背侧亚段回流肝静脉分支
图5 肝S8lat 亚段与S6v 亚段的解剖毗邻关系三维重建图 注:S8lat 为S8 段外侧亚段,P8lat 为S8 段外侧亚段的门静脉分支,P8lat-inf 为S8 段外侧亚段下部门静脉分支,S6v-1 为S6 段腹侧第一亚段,P6v-1 为S6 段腹侧第一亚段的门静脉分支
图6 肝右前腹侧流域及右前背侧流域三维重建图像 注:a 为“右前叶”各亚肝段的门静脉分支,b 为右前背侧流域的亚肝段S5d、S8lat 及S8d,c 为右前腹侧流域的亚肝段S8v、S5v-1 及S5v-2;S5d为S5 段背侧亚段,S8lat 为S8 段外侧亚段,S8d 为S8 段背侧亚段;S8v 为S8 段腹侧亚段,S5v-1 为S5 段腹侧亚段-1,S5v-2 为S5 段腹侧亚段-2,P5d为S5 段背侧亚段门静脉,P8lat 为S8 段外侧亚段门静脉,P8d 为S8 段背侧亚段门静脉,P8v 为S8 段腹侧亚段门静脉,P5v-1 为S5 段腹侧亚段门静脉分支-1,P5v-2 为S5 段腹侧亚段门静脉分支-2,RHV 为肝右静脉,MHV 为肝中静脉
图7 肝MHV 属支V8v-inf 与P8 主干解剖关系三维重建图 注:由V4b、V5v 以及V8v-inf 汇合形成MHV 主干,汇合点称为B点(白色*号),V8v-inf(黄色三角)背侧深面1 ~2 cm 可寻及P8 主干(红色箭头);P8v 为S8 段腹侧亚段门静脉,P8d 为S8 段背侧亚段门静脉,P5v 为S5V 段腹侧亚段门静脉分支,MHV 为肝中静脉,V8v-sup为S8 段腹侧亚段(S8v)上部回流肝静脉分支,V8v-inf 为S8 段腹侧亚段(S8v)下部回流肝静脉分支
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