肝静脉解剖与肝移植技术规范的临床研究（附248例报道）

A clinical study on the anatomy of hepatic veins and its applications in liver transplantation： a report on 248 patients

目的研究肝静脉合干以及在下腔静脉（IVC）注入的解剖与分布，从规范背驮式肝移植技术角度将其分型。方法收集中南大学湘雅三医院卫生部移植工程技术研究中心2000年5月至2007年8月施行的248例背驮式肝移植（PBLT）资料。在移除病肝时观察每例患者肝静脉在第二肝门合干以及注入下腔静脉的解剖情况，观察肝短静脉在第三肝门注入下腔静脉的解剖情况。结果本组248例肝病切除术中观察到肝静脉合干及注入下腔静脉的解剖情况为：左中肝静脉合干142例、右中肝静脉合干54例、三支分别注入34例（18例非水平轴面注入IVC，16例同水平轴面注入IVC）、三支肝静脉合干14例、各肝段肝短静脉分别注入4例。作者按肝静脉合干及注入IVC解剖情况将其分为五型：I型（左中合干型）57．2％、Ⅱ型（右中合干型）21．7％、Ⅲ型（三支合干型）5．6％、Ⅳ型（分别汇入型）13．0％（其中Ⅳn型16例，占6％，为同轴水平汇入；Ⅳ。型18例，占7％，为非同轴水平汇入）、V型（肝段型）1．6％。结论I、Ⅱ、Ⅲ型可常规行经典式背驮式肝移植。Ⅳ型（IVA型）有近50％的肝静脉同轴水平注入IVC（同轴水平注入IVC占本组病例6％），可三支成型常规行经典背驮式肝移植（CPBLT）。IVA型常规行CPBLT效果好。部分Ⅳ型（1V。型）和V型仅能行供、受体IVC端侧或侧侧的改良背驮式肝移植（APBLT），或行经典式原位肝移植（classicorthotopiclivertransplanta-tion，COLT），亦可结扎或缝扎各HV分支，在供、受体IVC后、前正中行梭形切口或三角型开孔吻合。根据HV合干与非合干汇人IVC的解剖状况，将其分型，并根据HV分型可规范PBLT手术技巧。

Objective To investigate the anatomy and the variations of hepatic veins draining in- to the inferior vena eava （IVC）, and to classify the surgical techniques of piggyback liver transplanta- tion （PBLT） based on the anatomy of the hepatic veins. Method 248 PBLT were preformed in our hospital from May 2000 to Aug. 2007. The anatomy of the hepatic veins were noted on resection of the recipient livers. The anatomy of the 3 major hepatic veins （HV） and the short hepatic veins （SHV） draining into IVC was recorded. Results Of the 248 recipient livers, the left and middle he- patic veins joined as a single trunk in 142 patients （type I , 57.2%） ; the right and middle hepatic vein joined as a single trunk in 54 patients （type Ⅱ , 21.7%）; three hepatic veins joined as single trunk in 14 patients （type HI, 5.6%） ; the left, right and middle hepatic veins were all separate in 34 patients （16 patients in the same horizontal plane, typeⅣA, 6%; 18 patients in different horizontal planes type IVB, 7%）; and there were no major hepatic veins but only short hepatic veins which drained into IVC in 4 patients （type V , 1.6%）. Conclusions In patients who had type I , Ⅱ or Ⅲ hepatic vein anatomy, a classical piggyback liver transplantation （CPBLT） could be carried out. Innearly half of the type Ⅳr （type ⅣA） patients who had the hepatic veins draining into the IVC in the same horizontal plane, CPBLT could also be performed on these patients. For the type IVB and type V patients, ameliorative piggyback liver transplantation （APBLT） with an end to-side or a side-to-side cavo-caval anastomosis only could be carried out. The study showed that the classification of hepatic vein anatomy can help us to choose the type of PBLT.