【作者】 张策； 郑连生； 余江； 丁自海； 闻英； 李国新； 钟世镇；

【Author】 ZHANG Ce;Zheng Lian-sheng;Yu Jiang;DING Zi-hai;Wen Ying;LI Guo-xin;ZHONG Shi-zhen;Department of General surgery,Southern Medical University;Institute of Minimal Invasive Surgery Anatomy,Southern Medical University;

【机构】 南方医科大学南方医院普通外科； 南方医科大学微创外科解剖学研究所；

【摘要】 背景:切除11p、11d、10组淋巴结是所有中上部和部分下部胃癌D2切除术的要求,但腹腔镜下解剖脾动脉及其脾终支是困难的技术。目的:阐明与腹腔镜下解剖脾动脉及其脾终支外科入路有关的、胰体尾筋膜和间隙的局部解剖学特点。方法:对8具尸体和52例在腹腔镜胃癌D2手术中切除11p、11d、10组淋巴结的病人进行解剖学观察。结果:尸体解剖显示,胰前筋膜、胰后筋膜与胰的实质之间分别存在胰前间隙和胰后间隙。脾动脉起自腹腔动脉后转向左下至胰后间隙;于胰体尾交界处越过胰上缘至胰前间隙;于胰尾左缘入脾系膜并分支入脾。胰前筋膜和胰后筋膜在胰的上缘汇合续于胃胰韧带;在胰尾左缘汇合续于脾的系膜;在胰的下缘汇合续于大网膜后叶,并与横结肠系膜融合。胰后筋膜与肾前筋膜之间存在胰十二指肠后间隙;胃胰韧带与肾前筋膜之间存在胃后间隙。在手术中,沿胰的上缘游离胰前筋膜,可在胰前间隙内解剖脾动脉胰前段、门前段。沿胰的上缘切开胃胰韧带、沿胰的下缘游离横结肠系膜、游离脾膈韧带并将脾和胰体尾向左翻转,可分别从上、下和左侧进入胰十二指肠后间隙。继续游离胰后筋膜,可在胰后间隙内解剖脾动脉胰段。从而实施脾动脉干淋巴结(11p、11d)切除。沿前面或后面解剖脾系膜内的脾动脉终末支,即可切除脾门淋巴结(No.10)。结论:腹腔镜下脾动脉及其脾终支解剖的外科间隙是胰后间隙和胰前间隙这样的前肠系膜内间隙,其外科入路是胰体尾上缘、下缘和脾膈韧带左缘。更多还原

【Abstract】 Background:Resection of No.11p,11d and 10 lymph nodes is essential for gastrectomy with D2lymphadenectomy for all upper and middle and part of the lower gastric cancer,while dissection of the splenic artery(SA) and its terminal branches of the spleen is difficult technique in laparoscopy.Objective:To explore regional anatomy of fasciae and spaces around the pancreas body and tail,which related to surgical approaches of dissection of the SA and its terminal branches to the spleen in laparoscopy.Methods:Eight cadavers and 52 patients undergoing resection of No.11p,11d and 10 lymph nodes in laparoscopic gastrectomy with D2 lymphadenectomy for cancer were observed.Results:Dissection of the cadavers indicated that there were pre-pancreatic space(PPS) and retro-pancreatic space(RPS) respectively between parenchyma of pancreas and pre-pancreatic fascia(PPF),parenchyma and retro-pancreatic fascia(RPF).The SA originated from the celiac artery before turning left and inferior,into the RPS.It ran over the superior margin of the junction between pancreas body and tail and reached the PPS.It got into the mesentery of the spleen at the left margin of pancreas tail and branched to supply the spleen.The PPF and the RPF converged and continued to the gastro-pancreatic ligament(GPL) along the superior margin of the pancreas;to the mesentery of spleen at the left margin of pancreas tail;to the posterior layer of the greater omentum along the inferior margin of pancreas that fused to the transverse mesocolon(TMC).There were retro-pancreatico-duodenal space(RPDS) between the RPF and the pre-renal fascia,retro-gastric space between the GPL and the pre-renal fascia.In surgery,dissection of the PPF along the superior margin of pancreas revealed the PPS and facilitated dissection of the pre-pancreatic part and the pre-hilum part of the SA.Dividing the GPL along the surperior margin of pancreas,mobilization of the TMC along the pancreas body and tail,mobilization of the spleno-phrenic ligament before reversing left the spleen and the pancreas body and tail,revealed the RPDS respectively from the superior,inferior and left side,before dissection of the RPF that revealed the RPS and facilitated dissection of the pancreatic part of the SA.Lymph nodes along the SA(No.11p,11d) were removed while the artery was dissected.Lymph nodes at the splenic hilum(No.10) were removed along the terminal branches in the mesentery of the spleen from the anterior or the posterior side.Conclusions:Surgical spaces for laparoscopic dissection of the SA and its terminal branches of spleen were spaces in mesenteries of the foregut,such as the PPS and the RPS.Surgical approaches of these dissection are superior and inferior margins of the pancreas body and tail,as well as the left margin of the spleno-phrenic ligament.更多还原