腹腔镜下远端胃癌根治术中胃背系膜及系膜间隙的解剖形态特点

Anatomic features of dorsal mesogastrium and interfascial space in laparoscopic surgery for gastric cancer

目的:探讨腹腔镜胃癌根治术中相关系膜及系膜间隙的镜下解剖学特点,为腹腔镜下解剖定位和操作入路提供解剖学依据。方法:通过大体解剖观察并在腹腔镜下于新鲜尸体标本上模拟进展期胃癌根治术,对胚胎期胃背系膜形成的胰腺筋膜、胃脾韧带和腹后壁筋膜间隙在腹腔镜下的解剖层次和形态特点进行观察和描述。结果:胃背系膜后层衍化形成的胃脾韧带、胰腺筋膜、胰十二指肠筋膜和横结肠系膜前叶是相互延续的一个整体;胰腺前筋膜形成的胃胰襞和肝胰襞是镜下确定胃左血管根部和肝总动脉的解剖标志;胰腺后筋膜与肾前筋膜之间的融合筋膜间隙是进行胰后淋巴结清扫的安全平面,而肾前筋膜是确保安全操作平面的后界。结论:(1)胚胎时期由于肠管旋转形成胃周广泛存在的筋膜和筋膜间隙,是腹腔镜胃癌根治术中进行解剖定位、系膜游离和淋巴结清扫的关键;(2)循筋膜间隙进行分离有助于提高腹腔镜下操作的安全性和根治的彻底性;建立腹腔镜下筋膜层次解剖的整体观念可为腹腔镜手术的设计和规范提供形态学依据。

Objective：To study the anatomic features of fascia and interfascial space and provide visual mark points and safe surgical plane in laparoscopic surgery for gastric cancer. Methods： Laparoscopic gastrectomy was performed in 3 formalin fixed and 6 fresh cadavers. Transverse mesocolon, capsula pancreas and the potential interfascial space were observed in laparoscopic vision. The anatomic features of surgical plane and anatomic mark point for reorganization in laparoscopic vision were recorded. Results： Gastrolienal ligament, pancreatic fascia, pancreat-duodenum fascia and the anterior lobe of transverse mesocolon that came from dorsal mesogastrium were connected with each other. Gastropancreatic fold and hepatopancreatic fold formed by capsula pancreas can be marked to locate the root of left gastric artery and common hepatic artery in laparoscopic vision. The fusion fascia between the posterior lamella of capsula pancreas and the anterior lamella of Gerota＇s fascia was a vessel-free plane that can be used to make lymphadenectomy behind pancreas and duodenum. Gerota＇s fascia can be regarded as a safe posterior border to avoid hurting by mistake vessels and adrenal gland. Conclusions： Fascia and interfascial space formed in embryonic development is very important to locate the surgical plane for laparoscopic operation leaving from bleeding and organ injury. Operation following interfascial space is good in safety, as well in radical dissection. Full understanding of the laparoscopic anatomic features of the fascia around the stomach can provide anatomic basis for the design of laparoscopic operation.