腹腔镜远端胃癌D2手术解剖ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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,形态、位置与毗邻,形态,中等充盈时，长,25,30cm,，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）,Fig.1 Overall view of the stomach,Fig.2 Visceral projections on the gastric wall,Liver,Costal arch,Transvers,mesocolon,Diaphragm,Spleen,Adrenal gland,Left kidney,Pancreas,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，,2,3cm,Fig.3 Gastric districts,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,Fig.4 Perfusion sample of the gastric arteries,Fig.5 3D reconstruction image of the,perigastric,arteries,Fig.6 Celiac trunk,stomach,left,gastirc,a.,common hepatic a.,right,gastroepiploic,a.,superior mesenteric a.,celiac trunk,spleen a.,pancreas,duodenum,Fig.7 Vessels of the stomach (anterior view),Fig.8 Vessels of the stomach (posterior view),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,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,Fig.9,Lymphatics,of the stomach,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.10 Layers of the gastric wall,Fig.11 Histology of the gastric,musoca,胃的神经,交感神经,：,T6,10,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,T6,10,胸节,牵拉感和饥饿感,迷走神经,延髓,Fig.12 Innervations of the stomach,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,Fig.13 Development of the gastrointestinal tract,Fig.14,Cadaveric,observations on the dorsal,mesogastrium,left,gastropancreatic,fold and,hepatopancreatic,fold,dorsal,mesogastrium,formed g,astrolienal,ligament,f,usion,fascia between anterior and posterior,capsula,pancreatic,f,usion,fascia between posterior,capsula,pancreatic and,perirenal,fascia,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,Fig.16 Fusion fascia posterior to pancreas and stomach,Fig.17 Approaches in gastric cancer,suregery,Fig.18 Clearance of the 14V Group of the,LNs,dissection plane anterior to the,pacreatic,head,surgical plane in 14V group of the,LNs,dissection,completion of the 14V group of the,LNs,clearance,completion of the 14V group of the,LNs,clearance,Fig.19 Clearance of the 6 Group of the,LNs,the,gastrocolonal,henle,trunk,the,gastroduodenal,artery and its branches,the right,gastroepiploic,artery,completion of the 6 group of,theLNs,clearance,Fig.20 Clearance of the 7.8.9 Groups of the,LNs,the,gastroduodenal,artery,the left,gastropancreatic,fold,the celiac trunk and its branches,completion of the 7.8.9 groups of the,LNs,clearance,Step1,紧靠横结肠切断胃结肠韧带,Step2,在横结肠系膜前叶后方层面向上游离,Step3,横结肠系膜前叶左侧向上翻转显露胰体尾部,Step4,在胰尾上缘脾血管发出胃网膜左血管处离断,Step5,打开横结肠系膜前叶正中可清除14,v,及第6组淋巴结,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,Step7,掀起胰腺被膜，在胰腺上缘游离肝总动脉,Step8,打开肝总、胃十二指肠动脉鞘,Step9,结扎切断胃右血管，清扫12,a,和第5组淋巴结,Step10,清扫第7、8、9组淋巴结,Step11,清扫第1、3、4组淋巴结,Thanks for your attention!,dissection plane anterior to the,pacreatic,head,surgical plane in 14V group of the,LNs,dissection,completion of the 14V group of the,LNs,clearance1,completion of the 14V group of the,LNs,clearance 2,the,gastrocolonal henle,trunk,the,gastroduodenal,artery and its branches,the right,gastroepiploic,artery,completion of the 6 group of,theLNs,clearance,the,gastroduodenal,artery,the left,gastropancreatic,fold,the celiac trunk and its branches,completion of the 7.8.9 groups of the,LNs,clearance,