The Three-Dimensional Anatomic Study Of Vivo Female Variations Of Vessels Related To Pelvic And Para-aortic Lymphadenectomy

BackgroudAt present,the incidence of uterine malignant tumors has increased year by year.Cervical cancer has become the most common malignant tumor in gynecology.About 200,000 women die each year from the world,which poses a serious threat to women's life and health.Lymphatic metastasis is an important pathway for the metastasis of uterine malignant tumors and an important independent risk factor for prognosis.Because lymph nodes are associated with large vessel distribution,Pelvic and Para-aortic Lymphadenectomy requires continuous resection of lymphatic adipose tissue around the vascular,and finally the blood vessels are "naked".The abdominal and pelvic vessels are complicated and have anatomical variations,so it is easy to damage to the vascular and nerve,in severe cases can endanger the patient's life.The rate of vascular injury in laparoscopic pelvic lymphadenectomy is 1.08-4.71%.The most common vascular injury is venous injury,especially in the common iliac vein,internal iliac vein and external iliac veins.There are many factors of injury,such as unfamiliar anatomical or anatomical variations,so it is necessary to study the variation of abdominal and pelvic vessels.There is currently no clear definition of variant blood vessels.Systematic Anatomy mentions that the initiation or influx,branching,diameter,number,and stroke of a blood vessel will often vary due to certain factors.Therefore,the shape and value of blood vessels are not all the same,and sometimes variation or even abnormality(malformation).The traditional methods of abdominal and pelvic vascular research are autopsy and vascular casting,but the amount of cadaver specimens is limited,and the anatomical parameters of the cadaver are different from those of the living body.In recent years,DSA,CTA and MRA technologies have developed rapidly,among which CTA technology is relatively non-invasive with short scanning time;but in two dimensions,it is hard to intuitively understand the opening and walking of blood vessels.Based on personalization and digital obstetrics of three-dimensional visualization,Gynecology combines imaging equipment with digital software to obtain a complete and highly simulated 3D anatomical image.At present,there are few reports on the study of variation in abdominal and pelvic vessels by CTA digital three-dimensional reconstruction.Part one The Three-dimensional anatomic study of vivo female variations of vessels related to pelvic lymphadenectomy[Objective]To observe the structural features of variations of vessels related to pelvic lymphadenectomy through the constructed digital three-dimensional model in vivo for pelvic arteriovenous network of female based on CTA.[Method]1.Collect data on 1,623 patients who underwent thin-layer(?1mm)CTA examinations from December 2009 to December 2018 in the the Southern Hospital of Southern Medical University.Patients with large pelvic masses,pelvic lymphadenectomy,pelvic vascular imaging and artifacts were excluded.All collected data is saved in DICOM 3.0 format.2.The continuous tomography CTA raw data set was imported into the medical 3D reconstruction software,and the pelvic three-dimensional model was established by using the plain scan data.The arterial phase data was used to establish a three-dimensional model of the pelvic region arterial network,and the venous data was used to establish a three-dimensional model of the pelvic region venous network.The built models are exported and saved in STL format.3.Digitalized three-dimensional models of venous blood vessels in the pelvis and pelvic region were introduced into the arterial phase data for confluence registration.The characteristics of pelvic varicose arteries and veins were observed and classified in the three-dimensional view window of Mimics.[Results]1.Iliac artery variability:rare(6.96%,113/1623),the total left variability of the internal iliac artery was more than that of the right side(P=0.043),and the difference was statistically significant.There was no significant difference in the total left and right varnability between the common iliac artery and the external iliac artery(P=0.084,P = 0.118).Type ?(abnormal route)mainly(91.15%,103/113),mainly refers to the tortuous vessel(99.03%,102/103).There were 5 cases(0.31%,5/1623)of common iliac artery type ?(abnormal diameter).There were 5 cases of type III(other)variation(0.31%,5/1623):2 cases of absence of common iliac artery,2 cases of abnormal communicating branch between left common iliac artery with inferior pole of left kidney,and 1 case of abnormal branch from the left internal iliac artery.2.The variation of obturator arteries:more common,the number of variants on the right side is more than the left side,and one side is more than the double-sided,the overall mutation rate is 23.48%(381/1623)according to the number of cases,and 15.13%(491/3246)of the variation rate is calculated according to one side.The type is mainly type ?(various obturator artery),that the variable obturator artery replaces the normal obturator artery.3.Variation of iliac veins:complex and common(51.57%,837/1623).The total variability of common iliac vein was 20.33%(330/1623),the variability was 10.35%(336/3246)on one side,85.15%(281/330)on the left side,and the type ? was mainly.The overall variation and type ? and type III variations were more common on the left side(P<0.001,P<0.001,P=0.002).The common iliac venous variation type ?(abnormal number)is mainly due to the absence of common iliac vein.Type ?(abnormal communicating branch)mainly refers to the abnormal traffic branch between the common iliac vein and the internal iliac vein.The most common is the left common iliac vein and the right internal iliac vein(81.78%,211/258),and type III(other)showed bifurcation in the middle of the vein.The overall variability of external iliac vein was 36.66%(595/1623),and the variability was calculated by one side of 20.89%(678/3246).The overall variation rate of internal iliac vein was 49.60%(805/1623),and the variation rate by one side was 28.34%(920/3246).The internal and external venous variability was more common on the right side,and the type of variation was mainly type I(abnormal number).It was most common to divide the internal iliac vein into two branches with external iliac vein.4.Obturator vein variability:the most complex and common.The overall variation rate was 73.07%(1186/1623),and the variation rate was 53.76%(1745/3246)according to one side.The abnormality was mainly based on the point of entry and abnormal number.There was no significant difference in the left and right side variation.Obturator veins and variant obturator veins(into the external iliac vein or inferior epigastric vein)were the most common,and the type I was the largest variation(91.64%,1008/1100).[Conclusion]1.Pelvic artery variation is rare,and venous variation is more common.This also suggests why the vein is easily damaged during pelvic lymphadenectomy,especially the internal iliac vein.2.The variation of the iliac artery is rare,and the type of variation is mainly caused by tortuous vessel.3.Obturator arterial variability was more common.The right side was more than the left side,and the unilateral side was more than the bilateral side.The type was replaced by the variable obturator artery instead of the obturator artery.4.The variation of iliac veins is more common.The type of common iliac vein variability is mainly type ?(abnormal communicating branch),and the left side is more common.The internal and external iliac veins are more common with type ?(abnormal number)variation,more common on the right side;There is a de:ficiency in the common iliac vein,which is more common on one side.5.Obturator vein variability is the most complex and common,mainly due to abnormal numbers and abnormal points,and type ?(obturator vein and variant obturator vein)is the most common.Part two The Three-dimensional anatomic study of vivo female variations of vessels related to para-aortic lymphadenectomy[Objective]To observe the structural features of variations of vessels related to para-aortic lymphadenectomy through the constructed digital three-dimensional model in vivo for para-aortic arteriovenous network of female based on CTA.[Method]The method is the same as the first part(a total of 1400 cases are collected).[Results:]1.Abdominal aorta variation:rare(1.57%,22/1400),with type ?(abnormal route)most common(86.36%,19/22).2.Renal artery variability:common(44.57%,624/1400),the left and right side of the renal artery showed no statistically significant variation(P=0.280),the most common variation is the variation of the accessory renal artery.The rate of variation of multiple renal arteries(type ? and type ?)was 18.14%(254/1400),10.18%(285/2800),and the variation rate of the secondary renal artery(type ?,type ?,and type ?)was 28.79%(403/1400)and 17.32%(485/2800),respectively,according to the number of cases and the side.The variation of the accessory renal artery from the renal artery to the left upper segment of the kidney is most common(11.88%,285/2800),and the variation from the common iliac artery is rare(0.11%,3/2800),From the renal artery,abdominal aorta,iliac artery and other confluent to the lower segment of the kidney is also not uncommon(2.64%,74/2800).The incidence of low post renal artery or accessory renal artery(L3 and below)was 1.54%(43/2800).3.Inferior vena cava variability:rare(1.50%,21/1400),with type ?(double inferior vena cava)most common(57.14%,12/21),the equal diameter of the left and right inferior vena cava is the most common(58.33%,7/12),Iliac communicating branch often exists(75%,9/12).4.Renal vein variability:more common(11.93%,167/1400),the right renal vein variability is more common(5.33%,128/2400),and most of them were abnormal in number(2 renal veins,63.47%,106/167),the difference is statistically significant(P<0.001).The variation of left renal vein was mainly caused by abnormal walking.[Conclusion]1.Variant variation of abdominal aorta and inferior vena cava in abdominal region is rare,and renal arteriovenous variation is more common.2.Abdominal aortic variation is rare,with type ?(abnormal route).3.Variations in the inferior vena cava are rare,with type ?(double inferior vena cava)being the most common,type with equal diameters of left and right inferior vena cava being the most common,and iliac communicating branch often existing.4.Renal artery variability is common.The most common variation is the accessory renal artery.Variation of the upper segment of the left kidney from the renal artery to the left kidney is most common.The variation from the common iliac artery is rare.The incidence of renal artery or accessory renal artery from low position(L3 and below)is 1.54%(43/2800),which is a high-risk type and more likely to be damaged in para-aortic lymphadenectomy.5.Renal vein variability is also common,with right renal vein variability more common.Right side with abnormal number(2 renal veins)was the main,and left renal vein variation was mainly caused by abnormal walking.