肝臓の総論 Central vein はじめに Hepatic artery 1,200 25 75 80 20 25 peribiliary vascular plexus 1 3 A B Sinusoid Peribiliary plexus Pbp Pbp Ha 図 1 肝内微細血管構造 A 肝内微細血管構造模式図 B Rat の血管鋳型走査電顕像 Sinusoid Portal vein Glisson s capsule 1 Pv 111(191) 186 174
図 2 門脈と肝静脈との関係を示す模式図 ( 文献 2 より引用改変 ) A ヒト肝臓における関係 (Glisson, 1657) B 分葉肝にみられる関係 C 非分葉肝 ( イルカ, 反芻動物, ヒト ) にみられる関係 A B C 3 1 1 2mm 1 2mm Glisson 1 Rex 2 2 29 3 70 85 3 56 肝臓および脈管の発生 1. 肝臓の発生 13 3 3A 3B ductus venosus 112(192) 187 175
静脈洞 左肝心臓路 肝静脈 ( 右卵黄嚢静脈 ) 下大静脈肝部 肝静脈 ( 左卵黄嚢静脈 ) 主静脈 肝シヌソイド 静脈管 肝芽 門脈 十二指腸 左臍静脈 右臍静脈 十二指腸 左臍静脈 上腸間膜静脈 脾静脈 A B 図 3 肝臓の血管の発生 ( 文献 3 より引用改変 ) A 胎生第 5 週 B 胎生第 3 カ月 ligamentum teres hepatis ligamentum venosum 18 19) 2. 肝内脈管の発生 3 3 ramus angularis 4A ramus arcuatus 4A 2 Mall 19 Sappey 20 1 4 7 9 113(193) 188 176
下大静脈 肝静脈 下大静脈 肝静脈 下大静脈 肝静脈 臍静脈 腸間膜静脈 臍静脈 胆囊 A B C 胆囊 門脈 臍静脈 図 4 肝内脈管の発生 19 A 7mm 胚 B 11mm 胚 C 24mm 胚 5 4B paramedian sector 24mm 4C 5 10 10 肝臓と腸間膜および脈管の通路 5 13 114(194) 189 177
神経管 体表外胚葉 横隔膜 背側胃間膜 ( 後胃間膜 ) 小網 脊索 大動脈 肝鎌状間膜 肝臓 胃 背側十二指腸間膜 卵黄腸管 尿膜 上腸間膜動脈 背側腸間膜 腸 胚内体腔 臍動脈 下腸間膜動脈 固有腸間膜 A B 図 5 肝臓と腸間膜 腹膜 脈管との関連. 背側および腹側腸間膜 ( 文献 13 より引用改変 ) A 4 B 2 2 2 2 115(195) 190 178
図 6 副左肝動脈 A DSA 像 : B Dynamic CT 動脈優位相 MIP 像 :CT A B 図 7 副右肝動脈 dynamic CT 動脈優位相 MIP 像 図 8 Inferior veins of Sappey CT MPVR multi projection volume reconstruction S4 inferior veins of Sappey paraumbilical veins 6 2 7 2 2 116(196) 191 179
A B 図 9 鎌状靭帯動脈 A DSA 像 : B 肝動脈造影下 CT MIP 像 : CT MIP 8 9 14 paraumbilical vein 15 20 19 1 16 8 Nordenson 17 肝の形態と周囲構造 1. 分葉肝と非分葉肝 2. 肝臓の周囲構造 117(197) 192 180
表 1 肝の区分の名称の大まかな対照表 ( 文献 4 より引用改変 ) 解剖学名外科的肝区域 クイノー肝区域 右葉尾状葉右葉の一部左葉 後区前区尾状葉内側区外側区 S7 S6 ( 上 )( 下 ) 外科的右葉 S8 S5 ( 上 )( 下 ) S9 S1 ( 右 )( 左 ) 外科的左葉 S4 S3 S2 ( 前下 )( 後上 ) porta hepatis porta 3. 肝臓の外景 4 2 1 4 22 30 5 10 2 4 process branch paracaval 118(198) 193 181
図 10 カントリー線 ( 面 ) CT 3D Ivc Rhv Lhv Pcb Mhv Lpv Slb Pb Pv Ivc 図 11 尾状葉解剖模式図 ( 文献 6 より引用改変 ) branch Spiegel s lobe 3 6 11 4. 形態の変異 7 8 64.5 10.5 7.9 5.3 5.3 2.6 2.6 1.3 9 5 119(199) 194 182
A B 図 12 右肝円索 A CT B CT MIP 4,500 5 0.1 10 11 12 12 肝臓の機能的区域 Galen 130 200 5 16 Glisson 1654 Glisson Rex 2 2 Cantlie 21 Rex- Cantlie Cantlie Hjorstö 22 Healey Schroy 23 Hjorstö 22 2 5 Couinaud 24 Goldsmith Woodburne 25 Goldsmith Woodburne 25 4 2 Couinaud 24 3 8 Couinaud 26 2 9 27 120(200) 195 183
尾状葉 a b 前区 後区 A B 右葉 内側区 左葉 外側区 図 13 Healey 28) の肝区域 A 28 B 28 a b 1 2 3 4 posterior-superior area artery 5 posterior-inferior area artery 6 7 anterior-superior area artery 8 anterior-inferior area artery 9 10 11 medial-superior area arteries 12 medial-inferior area arteries 13 14 lateral-superior area artery 15 lateral-inferior area artery 16 1.HealeyとSchroy 23) の肝区域 Healey Schroy 23 Healey 28 13 lobar fissure Rex-Cantlie right lobe left lobe umbilical fossa fossa for ligamentum venosum left segmental fissure medial segment lateral segment right segmental fissure anterior segment posterior segment 4 superior area inferior area caudate lobe 4 1 caudate lobe proper left caudate process right left subsegment right subsegment 3 13A pars transversus pars umbilicus 29 cul-de-sac superior area branch inferior area branch superior area branch inferior area branch 2 anterior segmental branch posterior segmental branch 2 superior branch inferior branch 2 13B 3 4 lobar fissure Rex-Cantlie left segmental fissure right segmental fissure 121(201) 196 184
2 1 3 4 VIII VII VIII II Mhv IV VI V IV III Rhv Ivc 背側肝 7 6 5 26) 図 14 門脈による区域分けと背側肝 1 2 3 4 5 6 7 4 + 5 6 + 7 superior area inferior area inferior area superior area 2.Couinaud 24 26) の肝区域 Couinaud 24 26 left liver right liver main portal fissure Rex-Cantlie left portal fissure left lateral sector left paramedian sector right portal fissure right paramedian sector right lateral sector dorsal liver Couinaud I VIII segment 14 Segment I dorsal liver Segment II left lateral sector Segment III left paramedian sector Segment IV left paramedian sector Rex Recessus umbilicalis 2 umbilical fossa right paramedian sector right lateral sector main portal arch 15 Segment VIII Segment V Segment VII Segment VI Couinaud main portal fissure left portal fissure right portal fissure 30 main portal fissure left portal fissure right portal fissure porta Couinaud portal fissure main portal fissure left portal fissure Segment II Segment III Segment II Segment IV right portal fissure Segment V Segment VIII Segment VI Segment VII 122(202) 197 185
肝鎌状間膜 VIII Mhv IV Rhv IX L I VII IX R Ivc 下大静脈 図 15 肝臓の主門脈弓 ( 赤線 ) 33) 図 16 背側肝を下から見たところ 33) Segment I Filipponi Segment IX 3 Rhv Mhv portal fissure Couinaud left lateral sector left paramedian sector right paramedian sector right lateral sector 4 sector left lateral vein umbilical fossa left paramedian vein 14 Segment III P3 Segment IV P4 right paramedian vein right lateral vein sector P5 P8 2 P6 P7 2 main portal arch 15 Couinaud 26 S1l S1r 2 dorsal liver Couinaud 31 S1r Segment IX S9 S9 P7 26 31 32 7.5 42.5 S7 S8 47.5 S9 S7 S8 Couinaud Segment IX Segment IX R IX L 16 33 34 36 27) 3. 竜と趙の肝区域 Healey 1952 Couinaud 24 26 27 Couinaud 24 26 S2 S3 S4 Couinaud 24 26 anteroventral segment Avs antero-dorsal segment Ads posterior segment Ps 1 17 123(203) 198 186
Avs Ads At Adp Avp 右肝 At Pp 前 P4 P3 3 2 1 左肝 P2 左門脈 左門脈結合部分 右門脈 Ps Pp Ivc At Pp At Pp At Pp 図 17 門脈の文枝に基づく肝臓の区分 27) S1 S2 S3 S4 Couinaud 26 P1 P2 P3 P4 Couinaud 26 anterior trunk At Couinaud 24 26 2 37 38 37 3 antero-ventral portal branch Avp antero-dorsal portal branch Adp 2 17 Avs Ads Ps 39 40 1 79.8 2 8.7 3 11.5 41 1 2 3 図 18 肝門部の門脈分岐様式の変異形成についての仮説 27) 27 18 3 19 Couinaud 24 26 right lateral sector ramus arcuatus S6 S7 2 2 42 S6 S7 P6 P7 43 46 45 47 P5 P8 27 S6 S7 Couinaud 24 26 S5 S8 38 48 27 Segment Ir IX S7 124(204) 199 187
Apv Lpv Ppv Lpv Rpv 図 19 門脈分岐型 ( 経動脈性門脈造影下 CT MIP3D 像 ) A 通常型 B 右後区域門脈枝独立分岐型 C 同時 3 分岐型 A C B Apv 右葉 左葉 後区域前区域内側区域外側区域 Healey & Schroy による分類 下大静脈 肝静脈 Ppv Lpv Couinaud による分類 49 51 画像解剖 Couinaud Healey Schory Couinaud segment Couinaud sector hemiliver Healey Schroy segment lobe Couinaud subsegment 5 2008 20 21 CT Couinaud 門脈 図 20 肝癌取扱い規約分類 5 2008 Couinaud 125(205) 200 188
図 21 肝内門脈分枝,CTAP 像 (1 15) 126(206) 201 189
1 2 3 4 5 6 7 8 9 16 17 18 19 20 p127 10 11 12 13 14 15 p126 図 21 肝内門脈分枝,CTAP 像 (16 20) Pv Rpv Lpv Apv Ppv P1 right superior P1 right inferior P1 left superior P1 left medial P2 P3 P4a P4b P4 dorsal P5a P5b P6a P6b P6* P7a P7b P8a P8b P8c P8d 1. 肝内門脈起始部の分岐形式 19 3 71 90 4 17 5 12 12 2. 肝内門脈 Couinaud 22 P7 P6 2 20 P6 P6 P7 P8d 20 accessory anterior superior branch 23 S8 S1 paracaval portion branch PCPB 1 127(207) 202 190
Umbilical portion Transverse portion 1 r-sup r-inf l-sup l-med 2 3 4 a, b dor 5 a, b 6 a b * 7 a b 8 a b c d 図 22 高安分類模式図 図 23 Accessory anterior superior branch 2 Couinaud P5 Couinaud 27 17 Avs Ads Ps Avs Ads Ps S1 6 11 Spiegel s lobe paracaval portion Kogure 54 51 multidetector-row CT MDCT CT 24 128(208) 203 191
Pcb Pcb Pcb Slb Slb Slb Pb 図 24 尾状葉解剖 CT MIP Spiegel s lobe branch Slb paracaval branch Pcb process branch Pb 右肝静脈 左肝静脈 中肝静脈 左肝静脈 中肝静脈 右肝静脈 図 25 肝静脈解剖 ( 経動脈性門脈造影下 CT MIP 像 ) A B A B S4 Matsui 55 CT 20 18 14 3. 肝静脈 3 27 27 25 56 72 28 2 33 2 V2 V3 V2 129(209) 204 192
図 26 後下肝静脈 ( 経動脈性門脈造影下 CT MIP 冠状断像 ) A B accessory left hepatic vein superior left hepatic vein left marginal vein 3mm 7 S3 S8 3mm V8 35 5mm 24 26 S7 まとめ MDCT 4. 肝内動脈 27 S5 27 bare area S4 参考文献 1 Glisson F: Anatomia hepatis. 1642, O. pullein, London 2 Rex H: Beitrage zur Morphologie der Saugerleber. Morph Jb 14: 517-616, 1888 3 83 384-395 1982 4 4 721-734 2000 5 29 520-533 1966 6 26 1193-1199 1985 7 1 27 20-23 1952 8 Chiba S, Suzuki T, Kasai T: A tongue-like projection of the left lobe in human liver, accompanied with lienorenal venous shunt and intrahepatic arterial anastomosis. Okajimas Folia Anat Jpn 68: 51-66, 1991 130(210) 205 193
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