左肝内血管可视化3D分型及其在精准肝切除术的临床应用

doi:10.12122/j.issn.1673-4254.2025.05.18

摘要/Abstract

摘要：

目的运用三维可视化技术探索左半肝的门静脉及肝静脉系统的空间解剖，并进行可视化3D分型，为左肝病灶的解剖性肝段、亚肝段切除提供解剖学依据。方法筛选244例肝脏增强CT的薄层数据，采用MI-3DV Works软件对左肝内门静脉系统及肝静脉系统进行分割及三维重建，统计左肝门静脉及肝静脉分支的起始位置、数目、空间走行及相对位置关系，分别进行3D分型和肝段划分，指导临床左肝段及亚肝段切除术。结果 244例肝脏增强CT薄层数据均可清晰重建出左肝门静脉3~4级分支和肝静脉3~4级属支，据其空间分布规律进行左肝内血管3D分型如下：左肝门静脉系统3D特点：242例（99.1%）左肝门静脉单独发出，2例（0.9%）门静脉右前支起自门静脉左支主干，据此将左肝门静脉分为两型。左肝门静脉进一步3D分型如下：II段门静脉据分支数量分为两型；III段门静脉根据分支分布的空间位置细分为三型；而左外叶门静脉根据Ⅱ、Ⅲ段门静脉分支起始点间距离长短进一步分为紧密型和离散型；IV段门静脉根据其分支数量及起始部位分为三型；而第四肝门血管分支（门静脉左支横部血管）据其供应肝段不同分为三型。左肝静脉系统3D分型如下：244例左肝静脉依据其汇入下腔静脉的情况可分为两型；脐裂静脉依据其汇入静脉及其汇入点与该静脉根部的距离可分为三型。基于上述门静脉和肝静脉的分型和肝段划分，分别制定相应部位的不同手术规划。结论基于三维可视化技术进行的左肝门静脉和左肝静脉的3D分型，对以肝段或亚肝段为解剖单位的左肝病灶的精准肝切除具有较好的临床指导意义。

关键词: 门静脉左支, 肝左肝静脉, 三维可视化, 3D分型

Abstract:

Objective To establish a three-dimensional (3D) visualization-based classification of the left hepatic portal vein (LHPV) and left hepatic vein (LHV) systems using 3D reconstruction technology to facilitate precise segmental/subsegmental resection of left liver lesions. Methods Thin-slice contrast-enhanced CT datasets from 244 patients were reconstructed using MI-3DV Works software. The spatial anatomy (origins, branching patterns, and spatial relationships) of the LHPV and LHV branches was analyzed to determine their 3D classifications and segmental liver divisions for guiding surgical planning for anatomical left liver resections. Results The 3D models of the third- and fourth-order branches of the LHPV and LHV were successfully reconstructed for all the 244 patients. Two types of the LHPV system were identified, where the LHPV either had independent origins [242 cases (99.1%)] or had right anterior portal branches arising from the LHPV trunk [2 cases (0.9%)]. 3D classifications identified two types of the Segment II of the LHPV (based on branch number), 3 types of the Segment III (by spatial distribution of the branches), compact vs dispersed types of the left lateral lobe (determined by Segment II/III branches proximity), 3 types of the Segment IV (by branch number and origin), and 3 types the fourth hilar vessels (transverse branches of the left portal vein) for their supplied segments. The LHV system had two drainage types into the inferior vena cava, and the umbilical fissure veins were classified into 3 types by drainage patterns and distance to the venous roots. These classifications combined with liver segmentations allowed individualized surgical planning for segment-specific resections. Conclusion The 3D classification of the LHPV and LHV provides valuable clinical guidance for precise anatomical resections of left liver lesions using liver segments or subsegments as anatomical units to enhance surgical accuracy and improve the outcomes of hepatobiliary surgery.

Key words: left portal vein, left hepatic vein, three-dimensional visualization, 3D classification

郑俊, 王志华, 胡小军, 何翔, 范应方. 左肝内血管可视化3D分型及其在精准肝切除术的临床应用[J]. 南方医科大学学报, 2025, 45(5): 1047-1055.

Jun ZHENG, Zhihua WANG, Xiaojun HU, Xiang HE, Yingfang FAN. 3D visualization-based classification of left intrahepatic vessels and its application in precision hepatectomy[J]. Journal of Southern Medical University, 2025, 45(5): 1047-1055.

图/表 9

图1 血管3D走向示意图

Fig.1 Schematic diagram of 3D directions of blood vessels. A: Schematic diagram of 3D space. B: Schematic diagram of the anatomical position. C: Schematic diagram of the vascular spatial orientation in the anatomical position.

图2 门静脉主干3D分型

Fig.2 3D classification of the main portal vein. A: The left hepatic portal vein has independent origin, and the yellow vessel is the right branch of the portal vein. B: The right anterior branch of the portal vein and the left branch of the portal vein have a common trunk, and the yellow vessel is the right anterior branch of the portal vein.

图3 II段门静脉3D分型

Fig.3 3D classification of portal vein segment II. The yellow vessel is the branch of the portal vein segment II. A: 1 branch. B, C: 2-3 branches.

图4 III段门静脉3D分型

Fig.4 3D classification of segment III of the portal vein. The yellow vessel is the branch of the segment III of the portal vein. A: Branched are distributed in the cephalad and ventral left quadrant. B: Branches are distributed in the foot and ventral left quadrant. C: Branches in both quadrants at the same time.

图5 左外叶门静脉3D分型

Fig.5 3D classification of the left lateral lobe of the portal vein. The yellow vessel is the branch of portal vein segment III, the green vessel is the branch of portal vein segment II, and the purple vessel has the shortest distance between them. A: The distance between the origins of the portal vein branch in segments II and III is less than 2 cm. B: The distance is more than 2 cm.

图6 IV段门静脉3D分型

Fig.6 3D classification of portal vein of segment IV. The yellow vessel is from the capsular part of the branch of segment IV, the green vessels is from the sagittal part of the branch of segment IV, and the purple vessel is from the transverse part of the branch of segment IV. A: The branch of the capsular part is clustered and there is no branch in the sagittal part. B: Capsular partial branch + sagittal partial branch. C: Capsular partial branch + sagittal partial branch + transverse partial branch.

图7 第四肝门血管3D分型

Fig.7 3D classification of the fourth hilar vessel. The yellow vessel is the short portal vessel, and the purple vessel is the transverse portal vein. A: The branches supplying the Spiegel lobes. B: The branches supplying caudate lobulocaval part. C: The branch supplying segment II. D: The branches supplying segment IVa.

图8 肝静脉3D分型

Fig.8 3D classification of the liver vein. The yellow vessel is the left liver vein, the green vessel is the middle liver vein, and the purple vessel is the right liver vein. A: The left liver vein and the middle liver vein drained into the inferior vena cava. B: The left, middle, and right hepatic veins join the inferior vena cava alone.

图9 脐裂静脉3D分型

Fig.9 3D classification of the umbilical fissure vein. The yellow vessel is the umbilical fissure vein. A: The umbilical fissure vein merges into the root of the left liver vein within 2 cm. B: The umbilical fissure vein merges 2 cm outside the root of the left hepatic vein. C: Umbilical fissure vein merges into the inferior vena cava. D: The umbilical fissure vein merges into the root of the middle liver vein within 2 cm. E: The umbilical fissure vein merges 2 cm from the root of the middle hepatic vein.

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