经下腔静脉肝后段肝内穿刺介入的相关解剖学研究

Transhepatic puncture via retrohepatic inferior vena cava:applied anatomical study

目的:研究经下腔静脉肝后段(RIVC)肝内穿刺进行介入操作的安全性,为第2肝门重建术和直接肝内门腔分流术的临床应用提供解剖学基础。方法:对31例正常下腔静脉肝后段及肝脏的离体标本进行解剖学观察,了解下腔静脉肝后段和肝静脉的相关解剖结构特点。结果:(1)下腔静脉肝后段:长度(7.01±1.30)cm;经下腔静脉肝后段肝内穿刺安全范围是(5.43±1.23)cm,95%可信区间是3.02～7.84cm。(2)肝静脉:上组:肝右静脉、肝中静脉及肝左静脉的直径分别是(15.3±3.6)、(8.7±1.9)和(9.3±1.8)mm。肝左静脉与肝中静脉共同开口于下腔静脉90.3%(28例);3支静脉分别开口于下腔静脉9.7%(3例);下组肝小静脉:不同直径的肝小静脉(≥10mm、10～5mm、≤5mm)的肝小静脉构成比分别是5.0%(11条)、24.0%(52条)和71.0%;标本出现率分别是35.5%(11例)、87.1%(27例)和96.8%(30例);RIVC分布位置分别是右侧壁下份、右侧壁及前壁下份、前壁及左壁下份。(3)模拟测量比较常规TIPS穿刺距离和DIPS穿刺距离:经RHV和经MHV的TIPS穿刺距离分别是(38.6±8.1)mm和(46.6±8.2)mm。DIPS穿刺距离是(31.2±7.9)mm。TIPS与DIPS三组模拟测量穿刺距离之间差异有统计学意义(P<0.001),以DIPS穿刺距离最短,以经MHV的TIPS穿刺距离最长。结论:(1)在下腔静脉肝后段有(54.3±12.3)mm的安全穿刺范围;(2)下腔静脉肝后段下份不同直径的下组肝小静脉,其直径越小,出现率越高,数量越多;(3)DIPS的穿刺距离最短,经MHV常规TIPS穿刺距离最长。

Objective： To study the security of transhepatic puncture through retrohepatic inferior vena cava （RIVC）, and to provide the anatomical basis on the clinical application of reestablishing the second hepatic hlium （RSHH） and direct the intrahepatic portocaval shunt （DIPS）. Methods： Thirty-one normal specimens of livers and RIVC were anatomically observed for understanding the anatomic characteristics of the RIVC and the hepatic vein （HV）. Results： （1）length of Retrohepatic IVC： （7.01±1.30）cm; Safe area of the transhepatic puncture for the RIVC： （5.43±1.23） cm,95% confidence interval （CL）： 3.02-7.84 cm. 2. Hepatic vein： Upper group： diameters of the RHV, MHV and LHV are （5.3±3.6） mm, （8.7±1.9） mm and （9.3±1.8） mm respectively. LHV and MHV have the same port in 28 specimens （90.3%）. The three HVs has the independent port in 28 specimens （9.7%）; Lower group： for the different diameters of the small HVs （greater than 10mm, diameters in 10-5mm, and smaller than 5mm）, the percentage o f appearance o f the specimens was 35.5%, 87.1% and 96.8 % respectively; constituent ratio of the small HV was 5.0%, 71.0%, 24.0% respectively; distributing in right region of the lower RIVC, anterior and right region of the lower RIVC, and anterior and left region of the lower RIVC; （3）Transhepatic puncture distance of the routine TIPS and DIPS： TIPS via the RHV was （38.6±8.1） mm; TIPS via the MHV was （46.6±8.2） ram; and DIPS was （31.2±7.9） mm. The difference among the three groups were significant （P〈0.001）. The distance of the transhepatic puncture of DIPS was shortest, and that of TIPS via the MHV was longest. Conclusion： （1）（54.3±12.3） mm on RIVC are safe for the tvanshepatic puncture. （2） There are small HVs of different diameters on the lower part of RIVC. The samller the diameter is, the higher the appearance percentage is, and the more of the small HVs are. （3）The distance of the transhepatic puncture of DIPS is shortest, and the TIPS via the MHV is longest.