| Liver surgery has achieved rapid development since the first case of the world elective liver resection successfully completed by the surgeon of German Langenbuch in 1888.Liver surgery technology has developed at a tremendous speed especially after Hjortsjo segmentation, Healey arteriobiliary segmentation, Couinaud portal and hepatic vein segmentation and more than ten other liver anatomy segmentations appeared in the anatomy of the liver in the late 1950s. In the 21st century, the precision hepatectomy, as a new theory and technology system, requires more detailed and precise requirements for having relatively complex anatomy of the liver. There are many disputes for the original segmentation methods based on each part of the intrahepatic Glisson sheath, even if the most widely used Healey arteriobiliary segmentation and Couinaud portal and hepatic vein segmentation have not been completely unified on the understanding so far. With the development of liver anatomical techniques (such as iconography and virtual digital technique) and the constantly updating knowledge about segmentation of the liver lobe, the understanding of the anatomy have raised some new issues:There are many contradictions on the original liver anatomical segmentation methods. The intrahepatic Glisson sheath as a sheath wrapped by the general is rarely treated its three components hepatic portal vein, artery, bile duct separately in the practice of surgery. The professor Takasaki K of Japan divided the liver gross anatomy into three roughly equal parts, left, middle, right (30% each) and caudate lobe which is based on the Glisson sheath secondary branch and thus proposed the theory and techniques of Glissonean Pedicle Transection Method for Hepatic Resection,which has greatly raised the level of the control of regional blood flow and Anatomic resection of the lesion in the liver. However,Takasaki K’s"Glissonean Pedicle Transection Method for Hepatic Resection" and his technical theory system stayed its understanding on the secondary Glisson sheath and did not research furtherly,which resulted in a lack of theoretical basis of anatomy for implementing of "precision Glissonean Pedicle Transection Method for Hepatic Resection" based on Glisson sheath.This study intends to provide the liver anatomy basis for "precision Glissonean Pedicle Transection Method for Hepatic Resection" in nowadays by retrospecting the old ways of segmentation of the liver, understanding the features of various segmentation methods,observing the third branches of the structure,distribution and shape characteristics of intrahepatic Glisson sheath from the view of anatomy and combining comparative anatomy, embryologyand iconography of the liver.Materials and methods1、Specimen acquisition and productionTo random select 20 cases of adult corpses without liver pathological changes by macroscopic observation which were fixed in 10% formalin(Specimens from Kunming Medical University Department of Anatomy),either sex. Pierce the liver form facies inferior hepatism and diaphragmatic surface and remove the four level and above branches of intrahepatic Glisson system with a carving knife, using artificial carving method. Then the intrahepatic Glisson system can be fully displayed. Paint the different anatomical regions with the different colours of the pigment of Mali brand, paint Ⅱ/Ⅵ segment of Glisson System of the Couniaud Ⅷ segment violet, paint Ⅲ/Ⅶ segment of Glisson System white,paint Ⅳ segment of Glisson System green,paint GRA red, paint GRP main black,paint the first porta hepatic yellow and paint hepatic vein blue.2、MeasurementMeasure each index of the intrahepatic Glisson system of 20 cases of adult cor pses with vernier caliper, stainless steel ruler, compasses, a protractor,etc:traveling f-orm,space anatomical location,the number of three level branches and distribution r-ange of intrahepatic of the Glisson system.3、Statistical analysisThe data were processed with SPSS13.0 software.Measurement data results are represented with "mean ± standard deviation (x ± S)".4、 Theoretical explanations, demonstration and practiceBy studying the morphological features of tintrahepatic Glisson system and com-bining comparative anatomy, embryology of the liver,we have tried to demonstrate the reasonableness of dividing the liver into the left, middle and right lobe and elaborate that the liver is actually the axis of symmetry organ by the middle of Glisson backbone. We have tried to take the accurate Glisson cross-secti onal liver resection by the method of line Kelly clamps from the dissection anato-my,embryonic anatomy and comparative anatomy according to the results of anato-mical observation of Glisson system in the liver.Results(1)Results of the study of applied anatomy about the Glisson pedicle of right anterior section are:95% of the Glissonean pedicle of the Right liver have been divided into the right anterior and posteriorbranches,and 5% have been divided into the right anterior,G6 and G7 branches. The length of the the Glisson pedicle of the stem of right liver is 2.36± 0.56cm.The length of the the Glisson pedicle of right anterior is 2.61±0.72cm.The depth between the Glisson pedicle of right anterior’s root and the visceral surface of liver is 1.99 ± 0.43cm; The depth between the Glisson pedicle of right anterior’s terminal to the diaphragmatic surface of liver is 4.84±1.95cm; The shortest distance between the Glisson pedicle of right anterior’s stem to MHV’s stem is 1.61±0.90cm; The shortest distance between the Glisson pedicle of right anteriors stem to RHV’s stem is 1.89 ± 0.80cm. Angles between GRA/MHVare 74.4±16.8°; angles between GRA/MHV are 73.1±19.6 °; The shapes of the 20% of the Glissonean pedicle of the Right anterior section are Couinaud’s type,65% are Cho As type,15% are compound type; the number of radial level 3 branches is between 2-6.(2)The results of the study of Applied anatomy about the Glisson pedicle of right posterior section are:95% of the Glissonean pedicle of the Right posterior section have shared branches,and 5% do not. Angles between GRL/GRA are81.4±13.8 °;30% of the Glissonean pedicle of the Right posterior section are in the shape of Y or V, and in Y, the angles between G6/G7 are 71 °±3.92°; 70% of the Glissonean pedicle of the Right posterior section are in the shape of C, the number of radial level 3 branches is between 3-8.(3) The results for the anatomy of symmetry research about the intrahepatic Glisson System are:Angles between GM/GL are 76.7±17.36 ° (The left Glisson system,GL; Glisson pedicle trunk,GT); Angles between GM/GR are 81.4±13.8° (The middle Glisson system. GM;The right Glisson system,GR); The length of the the Glisson pedicle of left hepatic is 3.1±0.76cm; The length of the the Glisson pedicle of middle hepatic is 2.61 ±0.72cm; The length of the the Glisson pedicle of right hepatic is 1.5 ± 0.50cm; The shapes of the Glissonean pedicle stem of the left hepatic arch, the number of radial level 3 branches is between 2-8. The Glissonean pedicle stem of the middle hepatic is a continuation of the main of Glissonean pedicle, the number of radial level 3 branches is between 2-6.30% of the Glissonean pedicle of the right hepatic are in the shape of Y or V, 70% of the Glissonean pedicle of the right hepatic are in the shape of C, the number of radial level 3 branches is between 3-8.(4) According to the observation of the anatomy of hepatic Glisson system, with the help of Kelly forceps clamping method all of the 10 patients were successfully operated by using precision Glissonean Pedicle Transection Method for Hepatic Resection without injury of the blood vessels or biliary ducts during operation. The average operative time was 4.6(3.2～6.5) h, and the mean blood loss was 440(150-800)ml.As a result, the patients had no serious postoperative complications and were all cured.Conclusion(1)The distribution of the Left.Right anterior and Right posterior section of the three branches Glissonean pedicle system does not entirely fit the description of Couinaud’s segment,obvious individual differences do exsit. Therefore,understanding the anatomical characteristics of intrahepatic Glisson system and designing the rational of surgical options before carrying out precise hepatectomy can be very helpful to reduce the surgical risks and postoperative complications..(2)In the light of morphology,embryology and comparative anatomy, it is reasonable to divide the liver into left,middle,right lobe by Glissonean pedicle of radial level 2 branches and this demonstrates that the liver is an axiality and symmetry organ.(3)It shows that with the help of Kelly forceps clamping method using precision Glissonean Pedicle Transection Method for Hepatic Resection is good to operate and it is precise, economical, simple, fast, safe and easy to implement according to the observation of the anatomy of hepatic Glisson system and the new understanding of surgical anatomy of the liver. It can be widely used in clinic.especially in the hospitals that are in the lack of CUSA or advanced equipment condition primary hospitals.So understanding the anatomy of the liver, especially the shape and distribution disciplinarian of the Glisson system is the basis of liver surgery,because of the complex... |
PDF Full Text Request