以胰腺为轴心的相关筋膜及安全外科平面解剖研究

Relative Anatomic Research Around Pancreatic Interfascial Space and Safe Surgical Plane-Regard Pancreas as Axis

目的研究胰十二指肠区域血管的应用解剖、相关系膜及系膜间隙的解剖学特点,观察胰十二指肠区域解剖标志及安全外科平面,为临床上开展胰头及十二指肠、胆总管末端手术提供解剖学基础。方法对7具甲醛固定的成人尸体的十二指肠、胰腺周围供血血管及胆总管下段作了解剖学观察,对横结肠系膜构成的网膜囊及胰腺周围胚胎时期形成的潜在的筋膜间隙和解剖层次标志进行观察描述。结果准确定位胃左动脉和肝总动脉,由胰腺前筋膜形成的肝胰襞及胃胰襞是一个很好的标志。当进行胰腺游离及后方淋巴结清扫时,在胰腺后筋膜及肾前筋膜间有一无血管平面可以应用。肾前筋膜是避免损伤腹膜后血管、肾上腺的安全界面,为避免腹膜后血管及肾上腺的损伤,肾前筋膜应作为安全分离平面的后界。胰十二指肠前后动脉弓及分支主要供应十二指肠降部和水平部的血运,行保留十二指肠的胰头切除术时应注意保护胰十二指肠前后动脉弓。结论充分理解胚胎发育过程胰腺周围筋膜及筋膜间隙的形成,对于手术中正确理解、辨识解剖平面非常重要,沿着筋膜间隙的操作可避免出血及副损伤,也是肿瘤外科根治性切除的基本要求。

Objective To study the vascular applied anatomy,the anatomic features of fascial,and interfascial space around the pancreas and duodenum,observe marker and safe surgical plane of pancreaticoduodenal region,and provide clinical anatomy basis for surgery of duodenum,pancreatic head,and distal common bile duct.Methods Anatomical observations were performed in 7 formalin fixed cadavers on duodenum,distal common bile duct,and pancreatic peripheral blood supply.Transverse mesocolon,pancreatic capsule and potential interfascial space,surgical plane and anatomic marker for reorganization around pancreas were observed.ResultsGastropancreatic fold and hepatopancreatic fold formed by pancreatic capsule were good markers to locate the root of left gastric artery and common hepatic artery.A vessel-free plane between the behind pancreas and the anterior lamella of Gerota fascia could be used to make lymphadenectomy and pancreatic dissection behind pancreas and duodenum.Gerota fascia should be regarded as a safe posterior border to avoid injuring vessels and adrenal gland by mistake.The descending part and horizontal part of duodenum were mainly supplied by the anterior and posterior pancreaticoduodenal arterial arcade.The anterior and posterior pancreaticoduodenal arterial arcade should be protected in duodenum-preserving resection of pancreatic head.ConclusionsFull understanding of pancreatic fascial and interfascial space formed in embryonic development is very important.Operation along the interfascial spaces is safe without bleeding and organ injury,which is essential in oncosurgery.