한인(韓人) 간내혈관 및 담관계의 형태학적 연구

Abstract

[한글]

[영문]

Although many visible progresses have been made in recent years in the filed of liver surgery, there still exists many unsolved problems, primarily due to the uncertainly with regard to the anatomy of the liver. In the present investigation, attempts have been made to clerarify the anatomical complex of the liver, with

special reference to the threedimensional interrelationship among the intrachepatic blood vessels and biliary ducts.

Colored vinylite acetone corrosion casts of 140 human livers (mostly of the cadavers of children) were prepared for this study and the results are summarized as follows :

1. The anatomical course and the pattern of ramification were first studied for the oportaliveins and them the similar studies were made for the hepatic artery. Further more, the pattern of confluence of intrahepatice biliary ducts into the hepatic duct have been followed, with the portal vein as the reference points.

2. The boundary of the interlobar plane between the left and right lobes was along a ling which pass through the long axis of the fassa for the gall bladder and toward the middle of interior vena cave as it lies in contact with the liver posterioly in agreement with the earlier description by Cantlie.

Sinve this Oantlies line consists of avascular and abiliary zone, it si felt that this boundary line may be considered to be ideal from both surgical and functional view point.

3. On the basis of these observations, the following classifcation of the liver is proposed ; the liver consists of two lobes, five segments and ten subsegments as judged by the pattern of distribution of the intrahepatic vesselsand the biliary ducts.

a. Classification of the lobes

Ⅰ) Left lobe

Ⅱ) Right lobe

b. Classification of the segments :

1) Lateral segment of the left lobe

2) Medial segment of the left lobe

3) Anterior sefment of the left lobe

4) Posterior segment of the left lobe

5) Medioposterior sefment for the Caudate lobe in classic anatomical use

Classification of the subsegments :

ⅰ) Laterosuperior subsegment of the lateral segment.

ⅱ) Lateroinferior subsegment of the lateral segment.

ⅲ) Mediosuperior subsegment of the medial segment.

ⅳ) Medioinferior subsegment of the medial segment.

ⅴ) Anteriosuperior subsegment of the anterior segment.

ⅵ) Anterioinferior subsegment of the antorior segment.

ⅶ) Posteriosuperior subsegment of the pesterior segment.

ⅷ) Posterioinforior subsegment of the posterior segment.

ⅸ) Left medioposterior subsegment of the medioposterior segment.

ⅹ) Right medioposterior subsegment of the medioposterior segment.

4. The bifurcation of the left and right trunks of the portal vein at the hilar rigon was found to occur either extrhepatically (in ca 80%) or intrahe-patically

(in ca 20%). With thses trunks of the portal vein as the reference point, regional correlations of the respective branches of the hepatic artery and the hepatic duct were also investigated.

5. On the basis of the general inspection of the portal vein in various segments of the liver from surgical viewpoint, it was found that there exists 2 to 8 branches in the lateral segment and also 3 to 8 in the medial. Moreover, in case of the absence of the anterior and posterior main branches of the portal vein the anteriosuperior, anterioinferior, posteriosuperior, posterioinferior subsefmental main branches were originated from the right grunk of the portal vein. This type of ramification has never been reported before.

6. Two rare cases of double portal veiens observed (in 1.7%)

7. In addition to the normally present celiac hepatics replaced artery and accessory artery were studied either extrahepatically or intrahepatically. Beyond any question this sample casts prove conclusively that, if functionally considered, the term "accessory" is misleading because the so-called accessory artery, whatever its source, has a selective distribution to a specific area of the liver parenchyma.

8. In contrast to the conventional view, a number of intrahepatic arterial anastomosis were observed in 21.9% of cases.

Anastomosis of arterial radicals even between components of the right and left lobe were demonstrable.

9. There were two types of abnormal drainage of the hepatic ducts, one with the accessory hepatic duct and the other with the aberrant hepatic duct. This observation is believed to clarify some confusion which exists among previous workers concerning the above abnormal hapatic ducts.

10. The pattern of distribution of the hepatic artery and of the drainage of biliary ducts in the lateral segment of the liver were studies, with special emphasis on the modes of the bifurcation and form of the confluence with the umbilical part of the portal vein as the reference point. (i.e. the left segmental

fissure)

11. Branches of the 3 main hepatic veins (i.e. left, meddle and right) seem to drain blood from certain segments or subsegments in the liver on the basis of the present classification following Glissonian triad.

12. Although its existence was some what ignored the right inferior hepatic vein was found to exist in 88.3% of cases, among which 28.3% were well developed and the rest of 50% were underdeveloped.

13. In the present work, the hilar region and the boundaries between the medial-and the lateral, and between the anterior-and the posterior segments were defined, the occurrence of the typical and atypical types were also indicated. These informations are very valuable in carrying out liver surgery.

14. In the basis of the present investigation, it is considered to be feasible to perform left hepatic lobectomy with or without including anterior segment of the right lobe and posterior segmental resection.

It is recommended that surgeons must be well aware of all the normal as well as certain abnormal anatomical arrangements of the blood vessels and biliary systems in carrying out the liver surgeries. A special emphasis should be given to the pattern of the distribution of the portal vein and then to the hepatic artery and the biliary structure.