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中华结直肠疾病电子杂志 ›› 2022, Vol. 11 ›› Issue (04) : 272 -280. doi: 10.3877/cma.j.issn.2095-3224.2022.04.002

解剖与手术专栏

横结肠癌根治术应用膜解剖
王枭杰1, 黄颖1,()   
  1. 1. 350001 福州,福建医科大学附属协和医院结直肠外科
  • 收稿日期:2022-04-16 出版日期:2022-08-25
  • 通信作者: 黄颖
  • 基金资助:
    福建省科技创新联合资金项目(2020Y9071); 福建省自然科学基金(2020J011030); 北京医卫健康公益基金会医学科学研究基金(B20062DS); 福建省卫生健康科技计划项目(2020CXA025); 白求恩公益基金(BCF-SY-0311-20190807-08)

Applied fascia anatomy for transverse colon cancer surgery

Xiaojie Wang1, Ying Huang1()   

  1. 1. Department of Colorectal Surgery, Fujian Medical University Union Hospital, 350001 Fuzhou, China
  • Received:2022-04-16 Published:2022-08-25
  • Corresponding author: Ying Huang
引用本文:

王枭杰, 黄颖. 横结肠癌根治术应用膜解剖[J/OL]. 中华结直肠疾病电子杂志, 2022, 11(04): 272-280.

Xiaojie Wang, Ying Huang. Applied fascia anatomy for transverse colon cancer surgery[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2022, 11(04): 272-280.

横结肠癌发病率低,手术难度大。该术式涉及的解剖学特征与要点包括:其一,横结肠的血管支配复杂、变异多,应沿着横结肠供血血管根部结扎,进行D3站淋巴结清扫。目前结肠中动脉(MCA)根部淋巴结(223组淋巴结)是公认的横结肠癌D3站淋巴结。此外,当右结肠动脉(RCA)存在时,仍应于RCA根部进行结扎。应熟悉横结肠的供血血管变异,特别是MCA、副结肠中动脉(aMCA)、RCA和Henle干的解剖特征,同时注意保护空肠静脉(JV)和肠系膜下静脉(IMV)。其二,横结肠位处胚胎发育时原肠旋转的中心,膜解剖原理复杂。为保证无张力吻合,常需同时游离脾曲与肝曲结肠。理解横结肠的胚胎发育过程和横结肠系膜根结构,有助于完成高效的“三路包抄”脾曲游离。其三,幽门下区结构本质上由胚胎时横结肠系膜、胃系膜和十二指肠系膜相交汇形成,拓扑结构混乱。针对T3~T4期的进展期横结肠癌,仍应行网膜弓淋巴结清扫,而T1~T2期患者可不清扫,理解幽门下区局部解剖关系和胃系膜横结肠系膜间隙等膜解剖结构有助于该区域分离。

The incidence of transverse colon cancer is low and surgery for transverse colon cancer is technically demanded. The anatomical structures that are relevant during transverse colon cancer surgery include: firstly, complicated structural variations in the vascular anatomy of the transverse colon and its implications for D3 lymph node dissection. Root positioning and ligation of the middle colic artery (MCA) as well as right colic artery (RCA) if exists should be performed to remove No. 223 lymph nodes, with an understanding of the variations in the vascular anatomy of MCA, accessory MCA, RCA, Henle's trunk, jejunal vein, and inferior mesenteric vein. Secondly, the transverse colon is located in the center of gastrula rotation during embryonic development, which resulted in complexity in fascia anatomy. However, mobilization of the splenic flexure and/or hepatic flexure colon would frequently be necessary to ensure a tension-free anastomosis. Understanding its embryonic development process as well as the root of transverse mesocolon would be beneficial for an efficient splenic flexure mobilization with "three-way encirclement". Thirdly, the transverse colon, which originates from the midgut and hindgut, and the gastrocolic ligament and greater omentum, which originate from the mesogastrium and mesoduodenum, are intertwined. The above-mentioned topological structure resulted in a difficulty in gastroepiploic lymph node resection, which was recommended for selected advanced cases with T3~T4 stage. Lymph node dissection may not be performed in patients with T1~T2 stage.Thus, it is of great importance to understand this topological structure area, especially the anatomical landmark of the space between transverse mesocolon and mesogastrium.

图1 横结肠癌胃网膜弓淋巴结清扫范围(冠状面)(改编自笔者论文16
图2 MCA的解剖学特征19。2A:Ⅰ型;2B:Ⅱ型;2C:Ⅲ型;2D:Ⅳ型
图3 aMCA的起源和走行的解剖学特征示意图(笔者绘制)。MCA:结肠中动脉,SMA:肠系膜上动脉,aMCA:副结肠中动脉
图4 aMCA的起源和走行的解剖学特征(术中图)。MCA:结肠中动脉,SMA:肠系膜上动脉,SMV:肠系膜上静脉,RCV:右结肠静脉,RCA:右结肠动脉,aMCV:副结肠中静脉,aMCA:副结肠中动脉
图5 Henle干属支规律21
图6 Henle干术中解剖图:胃胰结肠干
图7 JV横跨SMA前方示意图(笔者绘制)。MCV:结肠中静脉,ICV:回结肠静脉,SMV:肠系膜上静脉,JV:空肠静脉,MCA:结肠中动脉,ICA:回结肠动脉,SMA:肠系膜上动脉,JA:空肠动脉
图8 JV出现在D3站清扫术野中(术中图)。RCA:右结肠动脉,MCA:结肠中动脉,aRCV:副右结肠动脉
图9 aMCV直接汇入IMV(术中图)。IMV:肠系膜下静脉,aMCV:副结肠中静脉,aMCA:副结肠中动脉
图10 横结肠系膜脾曲侧膜解剖与“三路包抄”示意图(改编自笔者论文25)。红色线框示大网膜第四层与横结肠系膜背侧叶融合;蓝色线框示横结肠系膜根筋膜模式;黑色粗箭头示“三路包抄”分离路线
图11 横结肠系膜根与网膜囊、横结肠后间隙、Toldt间隙示意图(笔者绘制)
图12 中央入路脾曲游离(术中图)。IMV:肠系膜下静脉
图13 横结肠癌根治术脾曲游离与其他术式脾曲游离的异同示意图(笔者绘制)
图14 于IMV左侧(不离断IMV)由内向外游离左腹膜后间隙(术中图)。IMV:肠系膜下静脉
图15 网膜弓在胃大弯侧发出前支和后支供应胃壁模式图(笔者绘制)
图16 幽门下区膜解剖示意图(改编自笔者论文16)。16A:弓上游离和网膜弓淋巴结清扫,绿色虚线示胃系膜横结肠系膜间隙,黑色虚线示头侧和尾侧分离路线,蓝色虚线框示206组淋巴结;16B:弓下游离,黑色虚线示头侧和尾侧分离路线
图17 右原始后腹膜示意图(改编自笔者论文27
图18 右原始后腹膜(术中图)27
图19 右原始后腹膜(术中图)27
图20 胃大弯血供和超声刀的使用(术中图)
图21 肿大的网膜弓淋巴结(术中图)15
图22 胃系膜横结肠系膜间隙(术中图)
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