肠系膜上血管系统解剖特点的临床研究

Clinical anatomy study of superior mesenteric vessels and its branches

目的探讨肠系膜上血管及分支的解剖结构或变异情况。方法本研究为前瞻性观察研究(注册号:ChiCTR 1800014610)。收集2016年7月至2018年12月于北京协和医院基本外科接受腹腔镜根治性右半结肠切除术的100例患者的术中解剖资料。男性52例,女性48例,年龄(61.0±12.3)岁(范围:31~82岁),体重指数(23.3±3.5)kg/m^2(范围:16.0~34.2 kg/m2)。分析肠系膜上血管各属支(回结肠动静脉、右结肠动静脉、中结肠动静脉)的出现概率和走行情况;分析Henle干的组成情况。结果回结肠动静脉的出现概率分别为97.0%(97/100,95%CI:91.5%~99.4%,下同)和98.0%(98/100,93.0%~99.8%),回结肠静脉走行于前方者占52.6%(51/97,42.7%~62.5%)。右结肠动脉直接发自肠系膜上动脉者占42.0%(42/100,32.3%~51.7%),右结肠静脉直接汇入肠系膜上静脉者占19.0%(19/100,11.3%~26.7%)。中结肠动静脉出现概率分别为95.0%(95/100,90.7%~99.3%)和90.0%(90/100,84.1%~95.9%);中结肠动脉主干长度为(2.6±1.6)cm(范围:0.1~7.2 cm);中结肠静脉汇入肠系膜上静脉和Henle干的比例分别为87.8%(79/90,81.0%~94.6%)和12.2%(11/90,5.4%~19.0%)。存在Henle主干者占93.0%(93/100,88.0%~98.0%),主干长度为(1.0±0.6)cm(范围:0.1~2.4 cm),其下缘距胰头与十二指肠水平部交界处(2.7±0.7)cm(范围:1.3~4.5 cm)。由3支静脉汇合形成Henle主干者占54.8%(53/93,40.8%~61.2%);在以不同类型汇合形成Henle主干的各属支静脉中,出现概率由高及低分别为胃网膜右静脉98.0%(98/100,93.0%~99.8%)、上右结肠静脉82.0%(82/100,74.5%~89.5%)、胰十二指肠上前静脉78.0%(78/100,69.9%~86.1%)。结论回结肠血管出现概率最高,中结肠血管次之,这两组较为恒定的血管可以作为腹腔镜手术的切入点。Henle干的组成形式较多,手术解剖过程中需警惕。右结肠动静脉的出现概率较低,手术中无需特意解剖。

Objective To examine the anatomical relationships of tributaries to superior mesenteric artery and vein in surgical procedures.Methods A prospectively designed observational trial,registried to Chinese Clinical Trial Registry,ChiCTR 1800014610,was conducted in Department of General Surgery,Peking Union Medical College Hospital from July 2016 to Decmeber 2018 to record the relationships of ileocolic artery and vein,right colic artery and vein,middle colic artery and vein,and combinations to assemble Henle′s trunk,during the laparoscopic operation of radical right colectomy for right colon malignancies.The length of middle colic artery,length of Henle′s trunk,and distance from Henle′s trunk to the inferior margin of pancreatic head to duodenum were measured during operation.A total of 100 patients,52 male and 48 female,with right colon cancer,who underwent radical right colectomy,were enrolled in present study from July 2016 to December 2018,with age of(61.0±12.3)years(range:31 to 82 years),and body mass index of(23.3±3.5)kg/m^2(range:16.0 to 34.2 kg/m^2).Results The ileocolic artery and vein presented as rates of 97.0%(97/100,95%CI:91.5%to 99.4%,the same below)and 98.0%(98/100,93.0%to 99.8%),respectively.The ileocolic vein ran ventrally in 51 of 97 patients(52.6%,42.7%to 62.5%).The right colic artery,which raised from superior mesenteric artery directly,was found in 42 of 100 patients(42.0%,32.3%to 51.7%);and the right colic vein drained directly into superior mesenteric vein in 19 of 100 patients(19.0%,11.3%to 26.7%).The presence of middle colic artery and vein were 95.0%(95/100,90.7%to 99.3%)and 90.0%(90/100,84.1%to 95.9%)respectively.The average length of middle colic artery,from its origin to bifurcation into right and left branches,was(2.6±1.6)cm(range:0.1 to 7.2 cm).All the dissected middle colic vein drained into superior mesenteric vein(87.8%(79/90),81.0%to 94.6%)and Henle′s trunk(12.2%(11/90),5.4%to 19.0%).Henle′s trunk was found in 93 of 100 patients(93.0%,88.0%to 98.0%),with average length of(1.0±0.6)cm(range:0.1 to 2.4 cm).The distance between Henle′s trunk to the inferior margin of pancreatic head was(2.7±0.7)cm(range:1.3 to 4.5 cm).More than half of the Henle′s trunk were composed of 3 tributaries(54.8%(53/93),40.8%to 61.2%).The most frequently discovered tributaries to form Henle′s trunk were right gastroepiploic vein(98.0%(98/100),93.0%to 99.8%),superior right colic vein(82.0%(82/100),74.5%to 89.5%),and superior anterior pancreaticoduodenal vein(78.0%(78/100),69.9%to 86.1%).In present study,the right branch of middle colic vessels was often found to run closely with Henle′s trunk,veins drained from small intestine could be found to run over superior mesenteric artery to converge into superior mesenteric vein.There were 2 incidences,injuries to Henle′s trunk and middle colic vein,happened during the operation,which were overcomed by bipolar coagulation and dividing the vessels.Conclusions Ileocolic vessels and middle colic vessels could be used as landmarks for laparoscopic surgery based on their constant anatomical existence.In contrast,the chances are rare for the presence of right colic artery or right colic vein.Nearly half of the Henle′s trunk was consisted of right gastroepiploic vein,superior right colic vein and superior anterior pancreaticoduodenal vein.Exceptional cautions should be made for the variations of the Henle′s trunk during the operation.