腹腔镜辅助右半结肠癌根治性切除术中的血管解剖分析

Anatomic analysis of the right colonic vessels in the laparoscopic right hemicolectomy

目的分析腹腔镜辅助右半结肠癌根治性切除术中血管解剖情况。方法采用回顾性横断面研究方法。收集2013年3月至2016年10月福建医科大学附属第二医院收治的60例行腹腔镜辅助右半结肠癌根治性切除术患者的临床病理资料。患者均采用5孔法标准中间入路行腹腔镜辅助右半结肠癌根治性切除术。术中行完整结肠系膜切除术（CME），术后观察手术录像，准确辨别术中右半结肠的血管构成类别，对其起源、组成及相对空间位置关系统计并分析，分析过程中以录像截屏加以注释。观察指标：（1）肠系膜上动脉和上静脉：出现率及相对空间位置。（2）回结肠动脉和静脉：出现率及相对空间位置。（3）右结肠动脉和静脉：右结肠动脉的出现率和相对空间位置关系，右结肠静脉的出现率和汇入上级静脉的分布。（4）胃结肠静脉干：出现率及属支组成情况。（5）中结肠动脉和静脉：中结肠动脉的出现率和相对空间位置关系，中结肠静脉的出现率和汇入上级静脉的分布。计量资料采用构成比或百分率表示。结果（1）肠系膜上动脉和上静脉：60例患者均出现肠系膜上动脉和肠系膜上静脉，出现率均为100．0％（60／60）。60例患者中，肠系膜上动脉位于肠系膜上静脉左侧占95．0％（57／60），位于右侧占5．0％（3／60）。（2）回结肠动脉和静脉：60例患者中，回结肠动脉和静脉出现率分别为96．7％（58／60）和100．0％（60／60）。相对空间位置关系：58例出现回结肠动脉患者中，8．6％（5／58）回结肠动脉位于回结肠静脉正前、31．0％（18／58）位于前上、10．3％（6／58）位于前下、6．9％（4／58）位于正后、32．9％（19／58）位于后上、10．3％（6／58）位于后下；50．O％（29／58）回结肠动脉从前方跨越肠系膜上静脉，50．0％（29／58）走行于肠系膜上静脉后方。（3）右结肠动脉和静脉：①右结肠动脉：60例患者中，右结肠动脉出现率为55．0％（33／60），其中93．9％（31／33）存在1支右结肠动脉，6．1％（2／33）存在2支右结肠动脉。24．2％（8／33）右结肠动脉与中结肠动脉共干后汇入肠系膜上动脉，其中2／8存在2支右结肠动脉，6／8存在1支右结肠动脉。相对空间位置关系：33例出现右结肠动脉患者中，90．9％（30／33）右结肠动脉从肠系膜上静脉前方跨过；9．1％（3／33）肠系膜上动脉位于肠系膜上静脉右侧，导致右结肠动脉与肠系膜上静脉无前后相对空间位置关系。②右结肠静脉：60例患者中，右结肠静脉出现率为93．3％（56／60），其中87．5％（49／56）存在1支右结肠静脉（7例与右结肠动脉伴行）；12．5％（7／56）存在2支右结肠静脉。汇入上级静脉的分布：49例存在1支右结肠静脉患者中。73．5％（36／49）汇入胃结肠静脉干，26．5％（13／49）直接汇入肠系膜上静脉。7例存在2支右结肠静脉患者中，6／7分别汇入肠系膜上静脉和胃结肠静脉干，1／7均汇入胃结肠静脉干。（4）胃结肠静脉干：60例患者中，胃结肠静脉干出现率为88．3％（53／60）；11．7％（7／60）缺如胃结肠静脉干，其胃网膜右静脉直接汇入肠系膜上静脉。胃结肠静脉干属支组成情况：53例患者中，54．7％（29／53）由胃网膜右静脉、胰十二指肠上前静脉、右结肠静脉、中结肠静脉构成3支型或4支型胃胰结肠干；35．9％（19／53）由胃网膜右静脉和右结肠静脉、中结肠静脉构成2支型或3支型胃结肠干；9．4％（5／53）由胃网膜右静脉和胰十二指肠上前静脉构成2支型胃胰干。（5）中结肠动脉和静脉：①中结肠动脉：60例患者均有中结肠动脉，出现率为100．0％（60／60），其中1．7％（1／60）存在2支中结肠动脉；13．3％（8／60）与右结肠动脉共干；85．0％（51／60）存在1支中结肠动脉，其中15．7％（8／51）中结肠动脉出胰颈部走行≤1cm分叉，66．7％（34／51）出胰颈部走行〉1cm且≤2cm内分叉，17．6％（9／51）出胰颈部走行〉2cm后分又。②中结肠静脉：60例患者中，中结肠静脉出现率为93．3％（56／60），其中存在1、2、3支中结肠静脉分别占80．3％（45／56）、16．1％（9／56）、3．6％（2／56）。中结肠静脉汇入上级静脉的分布情况：45例存在1支中结肠静脉患者中。55．6％（25／45）汇入肠系膜上静脉，44．4％（20／45）汇入胃结肠静脉干。9例存在2支中结肠静脉患者中，7／9分别汇入肠系膜上静脉和胃结肠静脉干，2／9均汇入肠系膜上静脉。2例存在3支中结肠静脉患者中，1支汇入胃结肠静脉干，2支汇入肠系膜上静脉。结论腹腔镜辅助右半结肠根治性切除术中患者血管解剖复杂。外科干及Helen干的解剖处理是手术难点及核心。

Objective To analyze the anatomy of the right colonic vessels in the laparoscopic right hemieolectomy. Methods The retrospective cross-sectional study was conducted. The clinical data of 60 patients who underwent laparoscopic right hemicolectomies in the Second Affiliated Hospital of Fujian Medical University from March 2013 to October 2016 were collected. All the patients used central approach. Patients intraoperatively underwent complete mesocolic excision （CME）, and vascular anatomies of the right colon were precisely distinguished through postoperatively observing video. The starting position, formation and relative spatial location of vessels were counted and analyzed, and video screenshots were used as a comments during analysis. Observation indicators ： （ 1 ） superior mesenterie artery （SMA） and superior mesenterie vein （SMV） ： occurrence rate and relative spatial location; （2） ileocolie artery and vein： occurrence rate and relative spatial location; （3） right colonic artery and vein： occurrence rate and relative spatial location of right colonic artery, occurrence rate and distribution of right colonic vein flowed into superior vein ; （4） gastrocolie venous trunk： occurrence rate and composition of the branches ; （5） middle colonic artery and vein： occurrence rate and relative spatial location of middle colonic artery, occurrence rate and distritution of middle colonic vein flowed into superior vein. Measurement data were represented as proportion and percentage. Results （1） SMA and SMV： all the 60 patients appeared SMA and SMV, with an occurrence rate of 100. 0%（60/60）. Of 60 patients, 95.0%（57/60） and 5.0%（3/60） patients＇ SMAs respectively were located on the left side and right side of SMVs. （2） Ileoeolic artery and vein ： of 60 patients, the occurrence rates of ileocolie artery and vein were 96.7% （58/60） and 100. 0% （60/60）. Relative spatial location： of 58 patients with ileocolic artery, 8.6%（5/58）, 31.0%（ 18/58）, 10. 3% （ 6/58）, 6. 9% （ 4/58）, 32. 9% （19/58） and 10. 3% （6/58） patients＇ ileocolie arteries were respectively located on the right ahead, anterosuperior, inferoanterior, right behind, upper posterior and lower posterior of ileocolic veins; 50.0%（29/58） patients＇ ileocolic arteries crossed from the front of SMV, and 50. 0% （29/58） patients＇ ileocolie arteries ran behind the SMV. （3） Right colonic artery and vein ： （1） Right colonic artery ： of 60 patients, occurrence rate was 55.0%（33/60）, including 93.9%（31/33） with 1 right colonic artery and 6. 1%（2/33） with 2 right colonic arteries. A trunk made of right colonic artery and middle colonic artery was detected in 24. 2% （8/33） patients, and flowed into SMA, including 2/8 patients with 2 right colonic arteries and 6/8 with 1 right colonic artery. Relative spatial location ： of 33 patients, 90. 9% （30/33） occurred right colonic artery crossed from the front of SMV; 9. 1% （3/33） occurred SMA located on the right side of SMV that led to no relative spatial location between right colonic artery and SMV. （2） Right colonic vein ： of 60 patients, occurrence rate was 93.3% （56/60）, including 87.5% （49/56） with 1 right colonic vein （7 were accompanied by right colonic artery） and 12. 5% （7/56） with 2 right colonic veins. Distribution of right colonic vein flowed into superior vein： of 49 patients with 1 right colonic vein, right colonic vein respectively flowed into gastrocolic venous trunk and SMV were detected in 73.5% （36/49） and 26. 5% （13/49） patients. Of 7 patients with 2 right colonic veins, right colonic vein flowed into SMV and gastrocolic venous trunk were detected respectively in 6/7 patients and 1/7 patients. （4） Gastroeolic venous trunk： occurrence rate was 88.3% （53/60）; 11.7% （7/60） patients had absence of gastrocolie venous trunk, and right gastric epiploic vein directly flowed into SMV. Composition of the branches of gastrocolic venous trunk： of 53 patients, 3-branch or 4-branch stomach-pancreas-colon venous trunk in 54. 7% （29/53） patients was made up of right gastric epiploic vein, pancreaticodnodenal vein, right colonic vein and middle colonic vein; 2-branch or 3-branch gastroeolie venous trunk in 35.9% （19/53） patients was made up of right gastric epiploic vein, right colonic vein and middle colonic vein; 2-branch stomach-pancreas venous trunk in 9.4% （5/53） patients was made up of right gastric epiploic vein and pancreaticoduodenal vein. （5） Middle colonic artery and vein： （1） Middle colonic artery： 60 patients appeared middle colonic artery, with an occurrence rate of 100. 0% （60/60） and 1.7% （1/60） appeared 2 middle colonic arteries. Of 60 patients, 13. 3% （8/60） patients＇ middle colonic artery shared the same trunk together with right colonic artery that flowed into 1 middle colonic artery, and 85.0%（51/60） appeared 1 middle colonic artery. Middle colonic artery ≤ 1 cm, from 1 to 2 cm （excluding 1 cm） and 〉2 cm occurred branch at running out of neck of pancreas were detected in 15.7% （ 8/51 ）, 66. 7% （ 34/51 ） and 66. 7% （ 34/51 ） patients, respectively. （2） Middle colonic vein： 56 of 60 patients appeared middle colonic vein, with an occurrence rate of 93.3%（56/60）, and 80. 3%（45/56）, 16. 1%（9/56） and 3.6% （2/56） patients appeared respectively 1, 2 and 3 middle colonic veins. Distribution of middle colonic vein flowed into superior vein ： 45 patients appeared 1 middle colonic vein, 55.6% （25/45） and 44. 4% （20/45） middle colonic veins respectively flowed into SMV and gastrocolic venous trunk; 9 patients appeared 2 middle colonic veins, 7/9 middle colonic veins flowed into SMV and gastrocolic venous trunk and 2/9 middle colonic veins flowed into SMV; 2 patients appeared 3 middle colonic veins, 1 and 2 middle colonic veins respectively flowed into gastrocolic venous trunk and SMV. Conclusion Vascular anatomical variations of the fight colon are complex in the laparoscopic right hemicolectomy, and anatomies of the surgical thunk and Helen trunk are difficult and core issue in operation.