腹腔镜远端胃癌D2手术解剖课件

1、腔镜远端胃癌D2手术相关解剖南方医科大学微创外科解剖学研究所南方医科大学附属南方医院普外科李国新腹腔镜远端胃癌D2手术解剖腔镜远端胃癌D2手术相关解剖南方医科大学微创外科解剖学研究所形态、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）腹腔镜远端胃癌D2手术解剖形态、位置与毗邻形态腹腔镜远端胃癌D2手术解剖Fig.1 Overall view of the stomach腹腔

2、镜远端胃癌D2手术解剖Fig.1 Overall view of the stomFig.2 Visceral projections on the gastric wallLiverCostal archTransvers mesocolonDiaphragmSpleenAdrenal glandLeft kidneyPancreas腹腔镜远端胃癌D2手术解剖Fig.2 Visceral projections on 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cardisc incisure第10肋软骨平面4部贲门部：贲门周

3、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腹腔镜远端胃癌D2手术解剖分部2口腹腔镜远端胃癌D2手术解剖Fig.3 Gastric districts腹腔镜远端胃癌D2手术解剖Fig.3 Gastric districts腹腔镜远端胃癌胃的动脉胃左动脉：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：

4、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腹腔镜远端胃癌D2手术解剖胃的动脉胃左动脉：腹腔干终支与胃右动脉吻合。肝固有动脉左Fig.4 Perfusion sample of the gastric arteriesFig.5 3D reconstruction image of the perigastric arteries腹腔镜远端胃癌D2手术解剖Fig.4 Perfusion sample of the Fig.6 Celiac trunksto

5、machleft gastirc mon hepatic a.right gastroepiploic a.superior mesenteric a.celiac trunkspleen a.pancreasduodenum腹腔镜远端胃癌D2手术解剖Fig.6 Celiac trunkstomachleft Fig.7 Vessels of the stomach (anterior view)腹腔镜远端胃癌D2手术解剖Fig.7 Vessels of the stomach (Fig.8 Vessels of the stomach (posterior view)腹腔镜远端胃癌D2手术解

6、剖Fig.8 Vessels of the stomach (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： 注入脾静脉腹腔镜远端胃癌D2手术解剖胃的静脉胃右静脉：注入门静脉，途中收纳幽门前静脉腹腔镜远端胃胃的淋巴胃左、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

7、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腹腔镜远端胃癌D2手术解剖胃的淋巴胃左、右淋巴结：沿同名血管排列，收纳小弯侧淋巴，注入Fig.9 Lymphatics of the stomach腹腔镜远端胃癌D2手术解剖Fig.9 Lymphatics of the stomac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Fi

8、g.10 Layers of the gastric wall腹腔镜远端胃癌D2手术解剖胃壁浆膜：脏腹膜Fig.10 Layers of the gFig.11 Histology of the gastric musoca腹腔镜远端胃癌D2手术解剖Fig.11 Histology of the gastri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

9、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腹腔镜远端胃癌D2手术解剖胃的神经交感神经：T610胸节交感干内脏神经腹Fig.12 Innervations of the stomach腹腔镜远端胃癌D2手术解剖Fig.12 Innervations of the sto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腹腔镜远端胃癌D2手术解剖胃周腹膜与筋膜结构大网膜：切开胃结肠韧带，勿损伤中结肠动脉腹Fig.1

10、3 Development of the gastrointestinal tract腹腔镜远端胃癌D2手术解剖Fig.13 Development of the gastFig.14 Cadaveric observations on the dorsal mesogastriumleft gastropancreatic fold and hepatopancreatic fold dorsal mesogastrium formed gastrolienal ligamentfusion fascia between anterior and posterior capsula panc

11、reaticfusion fascia between posterior capsula pancreatic and perirenal fascia腹腔镜远端胃癌D2手术解剖Fig.14 Cadaveric observations Fig.15 Configurations of the dorsal mesogastrium胃背系膜前层后层胃膈韧带大网膜胃脾韧带后叶前叶胰腺后筋膜胃胰襞肝胰襞胰腺前筋膜脾肾韧带在横结肠系膜内融合腹腔镜远端胃癌D2手术解剖Fig.15 Configurations of the dFig.16 Fusion fascia posterior to pan

12、creas and stomach腹腔镜远端胃癌D2手术解剖Fig.16 Fusion fascia posteriorFig.17 Approaches in gastric cancer suregery腹腔镜远端胃癌D2手术解剖Fig.17 Approaches in gastric cFig.18 Clearance of the 14V Group of the LNsdissection plane anterior to the pacreatic headsurgical plane in 14V group of the LNs dissectioncompletion of

13、 the 14V group of the LNs clearancecompletion of the 14V group of the LNs clearance腹腔镜远端胃癌D2手术解剖Fig.18 Clearance of the 14V GrFig.19 Clearance of the 6 Group of the LNsthe gastrocolonal henle trunkthe gastroduodenal artery and its branchesthe right gastroepiploic arterycompletion of the 6 group of t

14、heLNs clearance腹腔镜远端胃癌D2手术解剖Fig.19 Clearance of the 6 GrouFig.20 Clearance of the 7.8.9 Groups of the LNsthe gastroduodenal arterythe left gastropancreatic foldthe celiac trunk and its branchescompletion of the 7.8.9 groups of the LNs clearance腹腔镜远端胃癌D2手术解剖Fig.20 Clearance of the 7.8.9 Step1 紧靠横结肠切断

15、胃结肠韧带腹腔镜远端胃癌D2手术解剖Step1 紧靠横结肠切断胃结肠韧带腹腔镜远端胃癌D2手术Step2 在横结肠系膜前叶后方层面向上游离腹腔镜远端胃癌D2手术解剖Step2 在横结肠系膜前叶后方层面向上游离腹腔镜远端胃癌Step3 横结肠系膜前叶左侧向上翻转显露胰体尾部腹腔镜远端胃癌D2手术解剖Step3 横结肠系膜前叶左侧向上翻转显露胰体尾部腹腔镜远Step4 在胰尾上缘脾血管发出胃网膜左血管处离断腹腔镜远端胃癌D2手术解剖Step4 在胰尾上缘脾血管发出胃网膜左血管处离断腹腔镜远Step5 打开横结肠系膜前叶正中可清除14v及第6组淋巴结腹腔镜远端胃癌D2手术解剖Step5 打开横结肠系

16、膜前叶正中可清除14v及第6组淋巴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 腹腔镜远端胃癌D2手术解剖Step6 横结肠系膜前叶右侧向上翻转显露十二指肠球部及降Step7 掀起胰腺被膜，在胰腺上缘游离肝总动脉腹腔镜远端胃癌D2手术解剖Step7 掀起胰腺被膜，在胰腺上缘游离肝总动脉腹腔镜远端Step8 打开肝总、胃十二指肠动脉鞘腹腔镜远端胃癌D2手术解剖Step8 打开肝总、胃十二指肠动脉鞘腹腔镜远端胃癌D2手Step9 结扎切断胃右血管，清扫12a和第5组淋巴结腹腔镜远端胃癌D2手术解剖Step9 结扎切断胃右血管，清扫12a和第5组淋巴结腹腔Step10 清扫第7、8、

17、9组淋巴结腹腔镜远端胃癌D2手术解剖Step10 清扫第7、8、9组淋巴结腹腔镜远端胃癌D2手Step11 清扫第1、3、4组淋巴结腹腔镜远端胃癌D2手术解剖Step11 清扫第1、3、4组淋巴结腹腔镜远端胃癌D2手Thanks for your attention!腹腔镜远端胃癌D2手术解剖Thanks for your attention!腹腔镜远dissection plane anterior to the pacreatic head腹腔镜远端胃癌D2手术解剖dissection plane anterior to tsurgical plane in 14V group of th

18、e LNs dissection腹腔镜远端胃癌D2手术解剖surgical plane in 14V group ofcompletion of the 14V group of the LNs clearance1腹腔镜远端胃癌D2手术解剖completion of the 14V group ocompletion of the 14V group of the LNs clearance 2腹腔镜远端胃癌D2手术解剖completion of the 14V group othe gastrocolonal henle trunk腹腔镜远端胃癌D2手术解剖the gastrocolonal henle trunk腹the gastroduodenal artery and its branches腹腔镜远端胃癌D2手术解剖the gastroduodenal artery and the right gastroepiploic artery腹腔镜远端胃癌D2手术解剖the right gastroepiploic artercompletion of the 6 group of theLNs clearance腹腔镜远端胃癌D2手术解剖completion of the 6 group of tthe gastroduo