腹腔镜远端胃癌D2手术解剖ppt课件.ppt

腔镜远端胃癌D2手术相关解剖,1,形态、位置与毗邻,形态中等充盈时，长2530cm，容量1500ml位置大部：左季肋区，小部：腹上区。贲门在T11左侧，幽门在L1右侧，胃大弯最低点平脐。毗邻前壁右侧份：肝左叶左侧份：上为膈，下为腹前壁（游离区）后壁：膈左侧半、脾脏、左肾和肾上腺、胰腺、横结肠及其系膜（胃床）,2,Fig.1Overallviewofthestomach,3,Fig.2Visceralprojectionsonthegastricwall,Liver,Costalarch,Transversmesocolon,Diaphragm,Spleen,Adrenalgland,Leftkidney,Pancreas,4,分部,2口贲门：上口，接食管幽门：下口，通十二指肠2弯胃小弯：胃的右上缘，贲门幽门胃大弯：胃的左缘，贲门切迹cardiscincisure第10肋软骨平面4部贲门部：贲门周围的部分，因粘膜内贲门腺区别于他部胃底：贲门切迹平面以上的部分，胃泡胃体：胃底角切迹（小弯）水平部（大弯）幽门部：居胃体下界和幽门之间。幽门窦：幽门的左侧份，较为扩大，胃窦幽门管：右侧份呈长管状，管腔变窄，23cm,5,Fig.3Gastricdistricts,6,胃的动脉,胃左动脉：腹腔干终支与胃右动脉吻合。肝固有动脉左支或副肝左动脉偶起于胃左动脉胃右动脉：肝固有动脉或其左支、肝总动脉、胃十二指肠动脉，多与胃左动脉吻合，形成胃小弯动脉弓胃网膜右动脉：胃十二指肠动脉，与胃网膜左动脉吻合胃网膜左动脉：脾动脉末端或其脾支，与胃网膜右动脉吻合胃短动脉：脾动脉末端胃后动脉：72，脾动脉或其上极支，至胃底后壁左隔下动脉：可分布于胃底上部和贲门,7,Fig.4Perfusionsampleofthegastricarteries,Fig.53Dreconstructionimageoftheperigastricarteries,8,Fig.6Celiactrunk,stomach,leftgastirca.,commonhepatica.,rightgastroepiploica.,superiormesenterica.,celiactrunk,spleena.,pancreas,duodenum,9,Fig.7Vesselsofthestomach(anteriorview),10,Fig.8Vesselsofthestomach(posteriorview),11,胃的静脉,胃右静脉：注入门静脉，途中收纳幽门前静脉胃左静脉（冠状静脉）：汇入门静脉或牌静脉胃网膜右静脉：注入肠系膜上静脉胃网膜左静脉：注入脾静脉胃短静脉：经胃脾韧带注入牌静脉胃后静脉：注入脾静脉,12,胃的淋巴,胃左、右淋巴结：沿同名血管排列，收纳小弯侧淋巴，注入腹腔淋巴结胃网膜左、右淋巴结：沿同名血管排列，收纳大弯侧淋巴。胃网膜左淋巴结输出管至脾淋巴结，胃网膜右淋巴结至幽门下淋巴结贲门淋巴结：常归入胃左淋巴结内，位于贲门周围，收集贲门附近的淋巴，注入腹腔淋巴结幽门上、了淋巴结：在幽门上、下，收集胃幽门部的淋巴，幽门下淋巴结还收集胃网膜右淋巴结以及十二指肠上部和胰头的淋巴。汇入腹腔淋巴结脾淋巴结：在脾门附近，收纳胃底部和胃网膜左淋巴结的淋巴，通过沿胰上缘脾动脉分布的胰上淋巴结汇入腹腔淋巴结,13,Fig.9Lymphaticsofthestomach,14,胃壁,浆膜：脏腹膜肌层：外纵、中环、内斜。环行肌在幽门处增厚形成幽门括约肌粘膜下层：疏松结缔组织，富含血管粘膜：胃路、幽门瓣,Fig.10Layersofthegastricwall,15,Fig.11Histologyofthegastricmusoca,16,胃的神经,交感神经：T610胸节交感干内脏神经腹腔神经丛内腹腔神经节换元节后纤维腹腔干胃壁副交感神经：迷走神经胃壁神经丛节后纤维胃腺、肌层前干肝支：在小网膜内有行入肝丛胃前支：发支至胃前壁，在角切迹附近的鸦爪支分布于幽门窦及幽门管的前壁后干腹腔支：腹腔丛胃后支：分布于胃后壁，以鸦爪形分支分布于幽门窦及幽门管的后壁感觉神经：交感、副交感神经脊髓和延髓痛觉交感神经腹腔丛、交感干T610胸节牵拉感和饥饿感迷走神经延髓,17,Fig.12Innervationsofthestomach,18,胃周腹膜与筋膜结构,大网膜：切开胃结肠韧带，勿损伤中结肠动脉胃脾韧带：内有胃短血管胃膈韧带：内有胃后动脉肝胃韧带：小网膜之左侧部胃胰襞：内有胃左静脉胃胰韧带,19,Fig.13Developmentofthegastrointestinaltract,20,Fig.14Cadavericobservationsonthedorsalmesogastrium,leftgastropancreaticfoldandhepatopancreaticfold,dorsalmesogastriumformedgastrolienalligament,fusionfasciabetweenanteriorandposteriorcapsulapancreatic,fusionfasciabetweenposteriorcapsulapancreaticandperirenalfascia,21,Fig.15Configurationsofthedorsalmesogastrium,22,Fig.16Fusionfasciaposteriortopancreasandstomach,23,Fig.17Approachesingastriccancersuregery,24,Fig.18Clearanceofthe14VGroupoftheLNs,dissectionplaneanteriortothepacreatichead,surgicalplanein14VgroupoftheLNsdissection,completionofthe14VgroupoftheLNsclearance,completionofthe14VgroupoftheLNsclearance,25,Fig.19Clearanceofthe6GroupoftheLNs,thegastrocolonalhenletrunk,thegastroduodenalarteryanditsbranches,therightgastroepiploicartery,completionofthe6groupoftheLNsclearance,26,Fig.20Clearanceofthe7.8.9GroupsoftheLNs,thegastroduodenalartery,theleftgastropancreaticfold,theceliactrunkanditsbranches,completionofthe7.8.9groupsoftheLNsclearance,27,Step1紧靠横结肠切断胃结肠韧带,28,Step2在横结肠系膜前叶后方层面向上游离,29,Step3横结肠系膜前叶左侧向上翻转显露胰体尾部,30,Step4在胰尾上缘脾血管发出胃网膜左血管处离断,31,Step5打开横结肠系膜前叶正中可清除14v及第6组淋巴结,32,Step6横结肠系膜前叶右侧向上翻转显露十二指肠球部及降段,33,Step7掀起胰腺被膜，在胰腺上缘游离肝总动脉,34,Step8打开肝总、胃十二指肠动脉鞘,35,Step9结扎切断胃右血管，清扫12a和第5组淋巴结,36,Step10清扫第7、8、9组淋巴结,37,Step11清扫第1、3、4组淋巴结,38,Thanksforyourattention!,39,40,dissectionplaneanteriortothepacreatichead,41,surgicalplanein14VgroupoftheLNsdissection,42,completionofthe14VgroupoftheLNsclearance1,43,completionofthe14VgroupoftheLNsclearance2,44,thegastrocolonalhenletrunk,45,thegastroduodenalarteryanditsbranches,46,therightgastroepiploicartery