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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形态、位置与毗邻l形态形态l中等充盈时，长2530cm，容量1500ml l位置位置l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 。l毗邻毗邻l前壁l右侧份：肝左叶l左侧份：上为膈，下为腹前壁（游离区）l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 stomachFig.2 Visceral projections on the gastric wallLiverCostal archTran
2、svers mesocolonDiaphragmSpleenAdrenal glandLeft kidneyPancreas分部l2口口l贲门：上口，接食管 l幽门：下口，通十二指肠 l2弯弯l胃小弯：胃的右上缘，贲门幽门l胃大弯：胃的左缘，贲门切迹cardisc incisure第10肋软骨平面l4部部l贲门部：贲门周围的部分，因粘膜内贲门腺区别于他部l胃底：贲门切迹平面以上的部分，胃泡 l胃体：胃底角切迹（小弯）水平部（大弯）l幽门部：居胃体下界和幽门之间。l幽门窦 ：幽门的左侧份，较为扩大，胃窦l幽门管：右侧份呈长管状，管腔变窄，23cmFig.3 Gastric districts胃的
3、动脉l胃左动脉胃左动脉：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l胃右动脉胃右动脉：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l胃网膜右动脉胃网膜右动脉：胃十二指肠动脉，与胃网膜左动脉吻合l胃网膜左动脉胃网膜左动脉：脾动脉末端或其脾支，与胃网膜右动脉吻合l胃短动脉胃短动脉：脾动脉末端l胃后动脉胃后动脉：72，脾动脉或其上极支，至胃底后壁l左隔下动脉左隔下动脉：可分布于胃底上部和贲门Fig.4 Perfusion sample of the gastric arteriesFig.5 3D reconstruction image
4、 of the perigastric arteriesFig.6 Celiac trunkstomachleft gastirc mon hepatic a.right gastroepiploic a.superior mesenteric a.celiac trunkspleen a.pancreasduodenumFig.7 Vessels of the stomach (anterior view)Fig.8 Vessels of the stomach (posterior view)胃的静脉l胃右静脉胃右静脉：注入门静脉，途中收纳幽门前静脉l胃左静脉（冠状静脉）胃左静脉（冠状静脉
5、） ：汇入门静脉或牌静脉l胃网膜右静脉胃网膜右静脉：注入肠系膜上静脉l胃网膜左静脉胃网膜左静脉：注入脾静脉l胃短静脉胃短静脉：经胃脾韧带注入牌静脉l胃后静脉胃后静脉： 注入脾静脉胃的淋巴l胃左、右淋巴结胃左、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l胃网膜左、右淋巴结胃网膜左、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l贲门淋巴结贲门淋巴结：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l幽门上、了淋巴结幽门上、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
6、肠上部和胰头的淋巴。汇入腹腔 淋巴结l脾淋巴结脾淋巴结：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l浆膜浆膜：脏腹膜l肌层肌层：外纵、中环、内斜。环行肌在幽门处增厚形成幽门括约肌l粘膜下层粘膜下层：疏松结缔组织，富含血管l粘膜粘膜：胃路、幽门瓣Fig.10 Layers of the gastric wallFig.11 Histology of the gastric musoca胃的神经l交感神经交感神经：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
7、壁l副交感神经副交感神经：迷走神经胃壁神经丛节后纤维胃腺、肌层l前干l肝支：在小网膜内有行入肝丛l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l后干l腹腔支：腹腔丛l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l感觉神经感觉神经：交感、副交感神经脊髓和延髓l痛觉交感神经腹腔丛、交感干T610胸节l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l大网膜大网膜：切开胃结肠韧带，勿损伤中结肠动脉l胃脾韧带胃脾韧带：内有胃短血管l胃膈韧带胃膈韧带：内有胃后动脉l肝胃韧带肝胃韧带：小网膜之左侧部l
8、胃胰襞胃胰襞：内有胃左静脉l胃胰韧带胃胰韧带Fig.13 Development of the gastrointestinal tractFig.14 Cadaveric observations on the dorsal mesogastriumleft gastropancreatic fold and hepatopancreatic fold dorsal mesogastrium formed gastrolienal ligamentfusion fascia between anterior and posterior capsula pancreaticfusion fas
9、cia between posterior capsula pancreatic and perirenal fasciaFig.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在横结肠系膜内融合Fig.16 Fusion fascia posterior to pancreas and stomachFig.17 Approaches in gastric cancer suregeryFig.18 Clearance of the 14V Grou
10、p of the LNsdissection plane anterior to the pacreatic headsurgical plane in 14V group of the LNs dissectioncompletion of the 14V group of the LNs clearancecompletion of the 14V group of the LNs clearanceFig.19 Clearance of the 6 Group of the LNsthe gastrocolonal henle trunkthe gastroduodenal artery
11、 and its branchesthe right gastroepiploic arterycompletion of the 6 group of theLNs clearanceFig.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 clearanceStep1 紧靠横结肠切断胃结肠韧带紧靠横
12、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打开横结肠系膜前叶正中可清除14v及第及第6组淋巴结组淋巴结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
13、鞘打开肝总、胃十二指肠动脉鞘Step9 结扎切断胃右血管，清扫结扎切断胃右血管，清扫12a和第和第5组淋巴结组淋巴结Step10 清扫第清扫第7、8、9组淋巴结组淋巴结Step11 清扫第清扫第1、3、4组淋巴结组淋巴结Thanks for your attention!dissection plane anterior to the pacreatic headsurgical plane in 14V group of the LNs dissectioncompletion of the 14V group of the LNs clearance1completion of the 1
14、4V group of the LNs clearance 2the gastrocolonal henle trunkthe gastroduodenal artery and its branchesthe right gastroepiploic arterycompletion of the 6 group of theLNs clearancethe gastroduodenal arterythe left gastropancreatic foldthe celiac trunk and its branchescompletion of the 7.8.9 groups of the LNs clearance
