How should we treat short hepatic veins and paracaval branches in anterior hepatectomy using the hanging maneuver without mobilization of the liver? An anatomical and experimental study.
How should we treat short hepatic veins and paracaval branches in anterior hepatectomy using the hanging maneuver without mobilization of the liver? An anatomical and experimental study.
复制标题
前肝切除术中，在不动员肝脏的情况下，如何使用悬挂手法治疗肝短静脉和腔旁分支？
作者：
I. Hirai;G. Murakami;W. Kimura;T. Kanamura;I. Sato
本研究探讨了将悬挂手法应用于前路肝切除术的相关解剖学，因为前路肝切除术不可能动员肝脏。使用176个尸体肝脏，我们用形态计量学研究了下腔静脉（IVC）肝后部分静脉开口的分布；接下来，我们进行了一系列的实验，以确定插入镊子的哪个方向可以保存最厚的静脉。在肝前剥离后，我们在下腔静脉无静脉开口的区域内沿平面进行了前切口。最粗尾状静脉与右肝下静脉（IRHV）之间无静脉开口区，平均宽度为16.2 mm。当钳沿连接右叶右下角和中、右肝静脉终末之间的相同袋状空间的右方向插入时，尾状静脉很可能被保留，而IRHV则没有。相比之下，连接胆囊窝和袋状间隙的左侧路线则几乎相反。在沿无血管平面进行虚拟切口时，门静脉分支的门静脉区域最容易受损；左侧门脉起源尾状支损伤较少。在没有IRHV的情况下，向右的路径可能是插入钳的最佳方法。为保留尾状静脉和内下腔静脉，建议在内下腔静脉右侧包扎并向右收缩，或者当钳头在下腔静脉前方时，将钳的方向由左向右改变。前路悬吊术对于大肿瘤或肝硬化的右肝或左肝切除术是方便的。
This study investigates the relevant anatomy for applying the hanging maneuver to hepatectomy by an anterior approach, where liver mobilization is not possible. Using 176 cadaveric livers, we morphometrically investigated the distribution of venous openings within the retrohepatic portion of the inferior vena cava (IVC); next, we conducted a series of experiments to identify which course for insertion of a pair of forceps preserved the thickest of these veins. After anterior dissection of the liver, we carried out an anterior incision along a plane within an area free of venous openings in the IVC. The area free of venous openings was between the thickest caudate vein and the inferior right hepatic vein (IRHV), and averaged 16.2 mm in width. When forceps were inserted along the rightward course connecting the right inferior angle of the right lobe and the same pocket-like space between the terminals of the middle and right hepatic veins, the caudate vein was very likely to be preserved, whereas the IRHV was not. In contrast, the leftward course connecting the gallbladder fossa and the pocket-like space provided an almost opposite incidence of damage. The portal territory of the hilar bifurcation was most likely to be damaged during a virtual incision along an avascular plane; however, the caudate branch of left portal origin was rarely damaged. The rightward course may be the best method for forceps insertion in cases where there is no IRHV. To preserve the caudate vein and the IRHV, taping on the right side of the IRHV and retracting to the right, or changing the direction of the forceps from leftward to rightward when the tip of the forceps is anterior to the IVC is recommended. The hanging maneuver by an anterior approach without mobilization is convenient for right or left hepatectomy for large tumors or hardened liver.