Authors: Peng Shumu, Jin Yun, Li Jiangtao, Yu Yuanquan, Cai Xiujun, Hong Defei, Liang Xiao, Liu Yingbin, Wang Xu'an
Source: Chinese Journal of Surgery, 2023, 61(7)
summary
Various membranous structures are found throughout the human body, and it is important for surgeons to know and understand these membranous structures. In recent years, with the rise of membrane theory, membrane anatomy has been widely recognized in the treatment of abdominal tumors, especially gastrointestinal tumors. In clinical practice, the reasonable choice of intramembranous or extramembranous anatomy according to the needs can better achieve precise surgery. Based on the current research results, this article reviews the application status and progress of membrane anatomy in the field of hepatobiliary, pancreatic and spleen surgery, hoping to provide ideas for clinical research.
At the end of the 19th century, the mesentery was thought to be a discontinuous structure scattered in the abdomen. In 2016, Irish scholar Coffey et al. [1] found that the abdominal mesangium is a continuous tissue that continues with abdominal organs and ligaments, and defined it as the 79th organ of the human body. Based on this finding, Gray's Anatomy has been updated [2]. Mesangial abdomen is thought to refer to an envelope-like structure that surrounds the abdominal digestive system and its supporting vessels, hangs from the posterior peritoneum, and is continuous [3]. At the organ level, the abdominal mesangium and the digestive organs are cross-linked and connected. At the histological level, connective tissues such as blood vessels and nerves on one side are continuous with connective tissue on the other side. Therefore, the abdominal mesangium is highly integrated with the intestines, pancreas, spleen, and liver [3]. There is a natural gap between the mesangium and the mesangial bed, within which only a small amount of fibrous tissue is present, and dissection at this level not only reduces bleeding, but also allows for radical oncological cure. In mesangium-based resection, according to the specific growth and metastasis of malignant tumors, it is believed that local invasion of tumors is usually confined to the area innervated by the mesangium, and the radical effect can be achieved by resection of the tumor-derived organs and their mesangium [3, 4]. Mesangectomy-based surgery has become the standard surgical method for radical colorectal cancer [5], and is gradually being used in the treatment of gastric cancer, esophageal cancer, and other tumors [6]. Proper use of intramembranous or extramembranous dissection in clinical practice can lead to better precision surgery [7, 8]. Based on the relevant advances in mesangial theory and membrane anatomy, we discuss its application in hepatobiliary, pancreatic and spleen surgery.
1. Pancreatic mesangium and its development
In the past decade, the concept and scope of pancreatic total mesangial resection have been gradually standardized. In 2007, Gockel et al. [9] in Germany proposed the concept of mesangarily pancreatic resection for pancreatic cancer by dissecting fresh cadaver specimens, but the scope of mesangacecal resection was not elaborated. Five years later, Adham and Singhirunnusorn [10] in France defined the scope of total mesangial resection of the pancreas, including the triangular region formed by the portal-superior mesenteric vein, celiac trunk, and superior mesenteric artery. In 52 patients with resectable pancreatic malignant tumors, total mesangrectomy of pancreas was found to be the only site of tumor invasion. The core content of total mesangial pancreatic resection proposed by Adham and Singhirunnusorn [10] is similar to the radical pancreatic cancer resection proposed by Hackert et al. [11] to dissect the "Heidelberg Triangle".
In 2010, Yingbin Liu's team conducted a study on total mesangicile resection of the pancreas, and on the basis of the narrow mesangium and the membranous structure that only surrounds the arteriovenous arteries and veins from the uncinate process of the pancreas to the superior mesentery, the specific area of the mesangramis was further elaborated, from 2 cm above the celiac trunk to the inferior mesenteric artery, from the left to the edge of the inferior mesenteric vein, to the right edge of the inferior vena cava, and from the posterior to the inferior vena cava and the left edge of the abdominal aorta, including 16 groups of lymph nodes [12]. On this basis, Duan Weihong's team further proposed the concept of hepatopancreaticoduodenal spleen and gastric mesomembrane [13]. Our team has previously reported a strategy of radical resection of the retroperitoneal lymphofat lamina in radical resection of pancreatic head cancer, which is similar to the total mesangial region of the pancreas, but more clearly defines the mesangial region of the pancreas [14, 15]. Based on the mesangial theory, lymph node dissection for pancreatic cancer can be performed in a standardized and safe manner by using membrane dissection.
2. Perihepatic ligament and its interspace
The perihepatic ligament is formed by the retroflexion of the peritoneum and is continuously distributed around the liver. On the one hand, the perihepatic ligament can fix the liver, and on the other hand, it can guide and instruct during surgery. The sickle ligament connects the anterior abdomen to the ventral surface of the liver and the round ligament of the liver down to the umbilicus plane. The two layers of the sickle ligament surround the liver along the ventral and dorsal sides of the liver (except the bare area), forming the coronary ligament and deltoid ligament in the two layers of the peritoneum under the diaphragm. Perihepatic ligaments are home to blood vessels of different origins, and in the presence of portal hypertension or portal vein cancer thrombosis, the vessels within these ligaments dilate compensatorily to form collateral circulation, and should be clamped with an integral extramembranous forceps [16]. The sickle ligament is also the natural dividing line between the left lateral and left inner lobes on the liver surface, and is a commonly used surgical approach, especially in laparoscopic hepatectomy.
The perihepatic ligament has a close relationship with the perihepatic space, and this natural anatomical relationship provides the basis for intramembranous and extramembranous anatomy. The inferior vena cava ligament, also known as the Makuuchi ligament, is a connective tissue that originates from the right side of the superior and inferior vena cava and straddles the inferior vena cava. The hepatic venous ligament, also known as the Arantius ligament, is the conduit connecting the left portal vein and the inferior vena cava during the fetal period, and the apex is attached to the dorsal side of the left hepatic vein, which is the main reference for exposing the root of the left hepatic vein and the inferior vena cava. The ligament of Arantius is an important anatomical landmark during left lateral lobectomy, left hemiliver, and caudate lobectomy [17, 18].
The retrohepatic tunnel is a potential gap between the dorsal surface of the liver and the posterior inferior vena cava, with the superior border of the suprahepatic venous fossa (also known as the suprahepatic recess), the inferior inferior vena cava and caudate lobe of the lower border, the right border of the inferior vena cava on the right, and the left edge of the inferior vena cava on the left [19, 20]. The superior hepatic venous fossa is located at the second hepatic hila, with the right hepatic vein on the right and the middle hepatic vein and the left hepatic vein on the left. Since isolation is not possible under direct vision, extravenous separation is necessary to achieve precise anatomy in order to prevent injury to the inferior vena cava. Liver hanging maneuver (LHM) was reported in 2001 by French surgeon Belghiti et al. [21], and two years later, our team reported this technique and renamed it the liver wrapping method, and applied it to difficult liver resection surgeries such as radical cholangiocarcinectomy, and has since been widely used in caudate lobectomy and hemihepatectomy [20]. LHM combined with anterior approach resection can cleave the liver parenchyma without leaving the liver, avoid squeezing the tumor, shorten the operation time, and obtain a better view and accurate liver profile during surgery [19,22], with the greater advantage of avoiding cancer metastasis caused by crushing the liver [23, 24]. With the development of laparoscopic techniques, the success rate of laparoscopic LHM has gradually increased. In addition, a variety of improved LHMs are emerging, providing technical support for the safe and efficient implementation of surgery.
3. Membrane anatomy in the practice of hepatobiliary surgery
In 1957, Couinaud [25] proposed the concept of hepatic door plates. In 2000, Japanese scholar Kawarada et al. [26] named the area near the hepatic portal system, including the gallbladder plate on the right side, the hepatic portal plate in the center, and the umbilical plate on the left side. The hepatic portal plate is a fibrous connective tissue formed by the thickening of the liver capsule at the first hepatic hilum and continues with the Glisson sheath in the liver. With the continuous deepening of the dissection of the hepatic portal plate, researchers have found that the hepatic portal plate also includes structures such as blood vessels, nerves, and lymphatic vessels, so patients with hepatic hilar cholangiocarcinoma can have tumor invasion and metastasis in this area [27]. The upper boundary of the hepatic portal plate is the liver segment 4b, the right boundary is the Rouviere groove and gallbladder plate, the left boundary is the umbilical plate, and the lower boundary is the hepatoduodenal ligament [26]. The use of membrane dissection to blunt separation of the liver portal plate not only reduces bleeding, but also can well expose the left and right liver pedicles, and selectively suspend or block the target liver pedicles according to the needs of surgery. In addition, this technique is commonly used in laparoscopic anatomic hepatectomy [28].
Hepatic hilar ossified lymph node dissection is a key step in radical resection of abdominal tumors, which not only affects the accuracy of tumor staging, but also has an important impact on the long-term survival of patients after surgery [29, 30, 31]. We believe that the dissection of the hilar osstalgic lymph nodes is not a single procedure, and that the fibrous connective tissue in the area adjacent to the hilum and hepatoduodenal ligaments should be dissected as a whole. It is recommended to perform counterclockwise ossylomic dissection of the hila-hepatoduodenal lymph nodes, first by incising the superficial serous membrane at the first segment of the duodenum, with the right side contiguous to the Kocher incision and the left side to the beginning of the common hepatic artery; then along the hepatic propria artery sheath from bottom to top to the bifurcation of the left and right hepatic arteries; The hepatic hilum is then dissected from left to right in and out of the hepatic portal to the gallbladder plate; This was followed by top-down dissection along the right side of the bile duct and finally dissection of the posterior portal vein to remove the lymph nodes in groups 12a, 12b, 12p, and 8a and their surrounding fibrous tissue [32].
The inferior vena cava is formed by the confluence of the left and right iliac veins, ascends along the right side of the abdominal aorta through the diaphragmatic vena cava foramen into the thoracic cavity, and finally enters the right atrium. The control and management of the inferior vena cava is an important part of hepatobiliary surgery, including presetting of the suprahepatic and/or inferior inferior vena cava blocking band, incision and thrombectomy of the inferior vena cava with liver cancer, partial resection and reconstruction of the inferior vena cava, and liver transplantation [33, 34]. With the increasing diagnosis of liver cancer complicated with inferior vena cava cancer thrombosis, the therapeutic effect of combined inferior vena cava thrombectomy has also been affirmed [35, 36]. Gao et al. [37] reported a successful case of laparoscopy combined with thoracoscopy in the treatment of liver cancer complicated with inferior vena cava cancer thrombosis. In 2006, our team reported the experience of treating liver cancer complicated with inferior vena cava cancer thrombosis, and believed that surgery should be reasonably used according to the location of the cancer clot. If the cancer thrombus is located in the right atrium, the heart should be opened to remove the clot; If the cancer thrombus is located in the upper diaphragm but does not enter the right atrium, extradiaphragmatic or intrapericardial blockade can be used for thrombectomy; If the cancer thrombus is located in the inferior vena cava in the inferior diaphragm, thrombectomy can be performed with upper and lower hepatic vena cava occlusion [34].
The caudate lobe is located deep in the liver and adjacent to important blood vessels, and there are certain risks associated with surgical procedures in this area. Our team designed a standardized caudate lobectomy algorithm based on the anatomy and resection extent of the caudate lobe, with a one-year survival rate of 88.9 percent and a three-year survival rate of 49.4 percent for patients with resectable caudate lobe malignancy [38]. The positioning of the resection boundary in caudate lobectomy is difficult to identify, with the left border being easily identified due to the presence of the Arantius ligament, and the right border being difficult to define because the caudate lobe is connected to the liver parenchyma. We define the line from the tip of the caudate lobe (at the angle between the left hepatic vein and the inferior vena cava) to the caudate process as the right demarcation, also known as the Penn cut line [39]. With good blood flow control and boundary definition, caudate lobectomy can be performed safely and efficiently. Makuuchi's team used intraoperative ultrasound-guided injection of methylene blue into the right portal vein to mark the boundary between the caudate lobe and the right liver [40]. We first cut the hepatic portal plate, and then dissected several caudate lobes along the intermembranous space one by one at the lower edge of the first hepatic portal groove and ligate, and marked the caudate lobe boundary according to the ischemic line, which is simpler and more effective than Makuuchi's staining method [41].
The membrane dissection technique is suitable not only for the exposure of extrahepatic structures, but also for the exposure of intrahepatic ducts. More than two hundred years ago, Lannec reported a membranous structure that distinguishes it from the hepatic peritoneum, but it was not until the last decade, especially with the development of laparoscopic hepatectomy, that this structure gradually became valued by liver surgeons. Hayashi et al. [42] stained the cadaveric liver specimens by elastic fibers and lymphatic system, and found that there was a dense fibrous layer under the hepatic serosa and continued with the hepatic vein and Glisson sheath in the liver. On the one hand, the Lannec membrane approach allows for safe extrathecal dissection of the target liver pedicle and the dissection of the "gate structure" of the liver as required for surgery [43]. On the other hand, the Lannec membrane approach is also useful for exposing the hepatic vein. Yu [44] reported that there is a natural gap between the Lannec membrane and the hepatic vein, and that the hepatic vein can be safely visualized laparoscopically by cephalad, dorsal, or anterior approaches. In addition, the Lannec membrane approach has many advantages in anatomic liver resection, including shorter operative time and hospital stay.
IV. The practice of membrane anatomy in pancreatic surgery
In addition to the total mesangial resection of the pancreas mentioned above, many surgical techniques in pancreatic surgery also apply the concept of membrane anatomy. If a retropancreatic tunnel is required during pancreaticoduodenectomy, the procedure should be performed intramantially in the superior mesenteric vein to safely establish the retropancreatic tunnel. In most patients, the inferior border of the pancreas can be dissected to reveal the superior mesenteric vein, followed by the upper edge of the pancreas, which in turn reveals the common hepatic artery, the hepatic artery propria, and the gastroduodenal artery. Finally, the posterior pancreatic tunnel is bluntly separated from the bottom to the top in the superior mesenteric vein, and the small blood vessels in this area can be ligated and severed. If the tumor is large or the tumor is closely related to the portal vein or superior mesenteric vein due to local inflammation, the simple portal portal tricep control technique we reported earlier can be used, first separating the portal vein above the pancreatic neck and prefabricating a blocking band, then separating the superior mesenteric vascular space at the inferior edge of the uncinate process, prefabricating the superior mesenteric arteriovenous with a prefabricated blocking band, and finally controlling portal vein blood flow from the back of the mesenteric vein, behind the pancreatic head, and between the hepatogastric ligament [45].
5. The practice of membrane anatomy in spleen surgery
Splenectomy is a common procedure in general surgery, and the dissection of the spleen pedicle is a key step in this operation. In the past, the method of ligation and dissection of a large lump at the hilum of the spleen was often used, also known as the first-level spleen pedicle dissection. However, this approach is often associated with complications such as pancreatic fistula and spleen fever (fever due to splenectomy), and our team has reported that secondary splenic pedicle separation and ligation can effectively reduce the incidence of pancreatic fistula, spleen fever, and portal vein thrombosis [46]. We suggest that when performing splenectomy, it is best to cut the spleen and colonic ligament and then separate it to the superior pole of the spleen against the posterior wall of the spleen to support the spleen. When handling and ligating the secondary splenic pedicle, the space between the upper and lower poles of the spleen should be carefully separated, i.e., the secondary splenic pedicle space. Through this space, they are separated and ligated, but due to the large space, it is not necessary to separate and ligate in the vascular membrane.
VI. Conclusions
The many advantages of membrane anatomy have led to the widespread application of this concept in abdominal surgery. With the continuous development of laparoscopic technology and anatomy, membrane dissection techniques have also been gradually carried out in hepatobiliary, pancreatic and splenic surgery, such as pancreatic total mesangial resection, hepatic pedicle dissection, secondary splenic pedicle dissection, etc. Anatomy and surgery complement each other, surgery without anatomy cannot build a tall building, and anatomy without surgery has no clinical application value. Reasonable selection of intramembranous or extramembranous dissection during the operation process can achieve precise operation, and promote the steady progress of complex hepatobiliary and pancreatic surgery towards the goal of precision.
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