腹腔镜Kasai手术中门静脉分支解剖的经验探讨

Distribution anatomy of portal vein branches during laparoscopic Kasai surgery

目的:探讨腹腔镜kasai术中门静脉向肝门纤维块发出分支血管的特点,为胆道闭锁术中游离肝门纤维块提供解剖学经验。方法:回顾性分析2018年1月至2022年1月淮安市妇幼保健院小儿外科采用腹腔镜Kasai手术治疗Ⅲ型胆道闭锁患儿24例,并对所有患儿的手术全程进行录像。仔细分离门静脉左右支向纤维块发出所有静脉分支,并对分支数量及发出方向进行分析。将目测下直径大于1.5 mm的分支命名为危险分支。比较不同分支数量差异及危险分支占比差异,符合正态分布的计量资料用t检验,不符合正态分布的计量资料采用wilcoxon秩和检验,多组间独立样本采用Kruskal-Wallis检验。结果:24例患儿发向肝门纤维块的门静脉分支数量为(4.9±1.7)支,范围在2~10支。24例分支数量总计118支,其中门静脉左半弧分支占61.0%(72/118),分支数量为(3.0±1.1)支,范围在1~6支;门静脉右半弧分支占32.2%(38/118),分支数量为(1.6±0.7)支,范围在1~3支。比较门静脉左右半弧分支血管数量,差异有统计学意义(t=5.27,P<0.001)。门静脉主干分叉处血管分支占6.8%(8/118)。门静脉各处分支血管数量比较,差异有统计学意义(χ^(2)=47.63,P<0.001)。门静脉左半弧的危险分支占44.4%(32/72),而右半弧的危险分支占7.9%(3/38),比较左右两侧半弧危险血管数量,差异有统计学意义(Z=4.06,P<0.001)。在门静脉左支的32个危险分支中,15支(46.9%,15/32)向2点钟方向发出,7支(21.9%,7/32)向4点钟方向发出,10支(31.3%,10/32)向5点钟方向发出。门静脉右支的3个危险分支均向7点钟方向发出。2例患儿腹腔镜手术中因左门静脉左半弧的分支血管损伤导致术中凶险出血,分别向2点钟方向、5点钟方向发出。门静脉右半弧分支未发生凶险出血。结论:外科医生在腹腔镜Kasai手术中必须熟知门静脉血管分支解剖,避免术中无法控制的出血。

Objective To summarize the characteristics of portal vein semi-arc emanating branching vessels towards fibrous mass of porta hepatis during laparoscopic Kasai to provide an anatomical basis for liberating fibrous mass of porta hepatis in children with biliary atresia(BA).Methods A total of 24 children with typeⅢBA undergoing laparoscopic Kasai were videotaped between January 2018 and January 2022.Small branches arising from transverse groove of portal vein towards fibrous tissue were thoroughly dissected.The branches>1.5 mm in diameter visually inspected were categorized as risky branches.The differences in distribution of portal vein branches and proportion of risky branches were compared.The data conforming to a normal distribution were processed with two independent sample t-test while the data not conforming to a normal distribution with Wilcoxon rank sum test.Kruskal-Wallis test was utilized for examining independent samples between multiple groups.Results There were a total of 118 small branches in transverse groove in 24 children.The mean count was(4.9±1.7)(2-10)branches for each of them.There were 61.0%(72/118)small branches from left branch of portal vein[mean(3.0±1.1)(1-6)branch]branches),whereas 32.2%(38/118)from right branch of portal vein[mean(1.6±0.7)(1-3)branches].The small branches derived from the bifurcation of main portal vein into its left/right branches were 6.8%(8/118).Small branch distribution of left and right portal vein was compared by two independent sample t-test(t=5.27,P<0.001).Kruskal-Wallis test was utilized for comparing the small branch distribution of left and right portal vein and bifurcation respectively(χ^(2)=47.63,P<0.001).There were 44.4%(32/72)risky branches in half transverse groove of left portal vein,whereas 7.9%(3/38)in right branches.Statistical analyses of risky left/right branches of portal vein were conducted with Wilcoxon's rank sum test(Z=4.06,P<0.001).Among 32 risky branches in left portal vein,15(46.9%)coursed towards fibrous tissue at 2 o'clock,7(21.9%)arised from 4 o'clock and 10(31.3%)originated from 5 o'clock.All 3 risky right-sided branches were derived from 7 o'clock.Excessive bleeding occurred(n=2)due to vascular injury of branches in half transverse groove of left portal vein at 2 and 5 o'clock respectively.Hemostasis was achieved cautiously by repeated low-power electrocautery in vascular ends.Conclusions Anatomical familiarity of small branches in transverse groove is essential for avoiding massive intraoperative bleeding.