胰腺和胰周间隙的活体解剖学特点及其对腹腔镜远端胃癌D2切除术的启示

Living anatomical observations on peripancreatic spaces and their implications on laparoscopic gastrectomy with D2 lymphadenectomy for distal gastric cancer

目的观察胰腺和胰周间隙的活体解剖学特点，为腹腔镜远端胃癌D2切除术提供技术指导。方法按照腹腔镜远端胃癌D2切除术的基本步骤，对132例胃癌患者进行腹腔镜下活体解剖学观察。结果患者的大网膜与横结肠系膜之间的间隙在胰腺下缘与胰前间隙和胰后间隙相通，后两者在胰腺上、下缘相互贯通并向周围延伸。在胰尾上缘的胰前间隙，可定位胃网膜左血管。在胰颈下缘的胰后间隙，可定位肠系膜上静脉；在胃窦下方的胃系膜和胰前间隙中，可定位胃网膜右血管。在胃窦-胰头间隙，可定位胃十二指肠动脉，并依此追溯肝总动脉。在胰体上缘的胰后间隙，可定位肝总动脉、胃左动脉、腹腔动脉和脾动脉。肝胰襞和胃胰襞是定位肝总动脉和胃左动脉的解剖标志。这些血管及其鞘内间隙是相互延续的整体。结论腹腔镜远端胃癌D2切除术中，胰腺是总的中心标志，胃周血管主干和分又是具体和局部标志，各向延伸的胰前间隙和胰后间隙是宏观外科平面，相互延续的胃周血管鞘内间隙是微观外科平面。

Objective To explore living anatomy of pancreas and peripancreatic spaces, as well as their implications on laparoscopic gastrectomy with D2 lymphadenectomy for distal gastric cancer. Methods Living observation was carried out in 132 patients diagnosed as distal gastric cancer and undergoing laparoscopie gastrectomy with D2 lymphadenectomy. Results Spaces between greater omentum and transverse mesocolon continued to pre-pancreatie and retro-pancreatie spaces at inferior margin of pancreas. The pre-pancreatic and retro-pancreatic spaces continued each other at inferior and superior margin of pancreas and extended in all directions. Left gastroepiploic vessels were located in pre-pancreatic spaces at superior margin of pancreatic tail. In retro-pancreatic space at inferior margin of pancreatic neck, superior mesenteric veins were located. In retro-pancreatic spaces or in gastric mesenteries inferior to gastric antrum, right gastroepiploic vessels were located. In spaces between gastric antrums and pancreatic heads, gastroduodenal arteries were located and traced to locate common hepatic arteries. In retro-pancreatie spaces at superior margin of pancreatic body, common hepatic arteries, left gastric arteries, celiac arteries and splenic arteries were located. Hepatopancreatic folds and gastropancreatic folds were landmarks respective to locate common hepatic arteries and left gastric arteries. The aforementioned vessels and spaces in their vagina vasorums continued each other and united as a whole. Conclusions Laparoscopic gastrectomy with D2 lymphadenectomy for distal gastric cancer is carried out in macroscopic surgical planes of pre-pancreatic space and retro-pancreatic space, as well as their extensions in all directions, and in microscopic surgical planes of spaces in vagina vasorums of perigastric vessels which continue each other, under the guidance of central landmards of pancreas and concrete landmarks of vessel trunks and their furcations.