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3Dシミュレーションを用いた肝尾状葉の解剖学的解析と合理的な切除方法の検討

真木, 治文 東京大学 DOI:10.15083/0002002484

2021.10.15

概要

造影CTの画像を元に、3Dシミュレーションソフトウェアを用いて肝尾状葉を描出し、頭側と右側の境界について解析した。頭側境界について、尾状葉傍下大静脈領域は約3分の1の症例において肝横隔膜面にまで達していた。右側境界について、傍下大静脈領域静脈は全例で描出され、うち約2分の1の症例において尾状葉傍下大静脈領域の右側境界に一致しており、解剖学的切除のメルクマールとなり得ることが示唆された。残りの症例では、尾状葉傍下大静脈領域静脈と尾状葉右側境界との間に前区域または後区域グリソン鞘に由来する脈管が介在し、尾状葉全切除に際して、これらのグリソン鞘の損傷に留意すべきと考えられた。

 上記の知見を元に、肝臓の深部に位置する尾状葉を切除するための、肝門アプローチを用いた肝中央切除術の手術手技と成績を検討した。肝門アプローチとは、肝実質を前方から離断し、肝門板を広く露出して左右のグリソン鞘をテーピングすることと定義した。過去4年間の肝切除673例のうち、本術式は6例(0.89%)に適用された。主要脈管への浸潤をきたしていた症例や腫瘍径10cmを超える症例も含まれていたが、切除肝容量の全肝容量に対する割合の中央値は12.0(範囲4.7~39.5)%であり、十分な残肝容量が確保され術後肝不全を認めなかった。肝門アプローチを用いた肝中央切除術は視野が良好であり、根治性と術後肝機能の保持を両立させる手技として有用であると思われた。

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