局部解剖PBL（原题+翻译+答案）(3)

are next to it .

2.the neck of pancreas is above pylorus and superior mesenteric vein is behind it. 3. the body of pancreas is next to the back of stomach ,abdominal aorta ,left suprarenal gland ,left kidney and splenic artery. 4.the tail of pancreas reaches spleen. 试述胰腺的位置及毗邻）

胰位于腹上区和左季肋区，横过第1、2腰椎前方。通常将胰分为头、颈、体、尾四部分。

1）胰头 位于第二腰椎右侧，为胰中最宽大部分，被十二指肠从上方、右侧和下方“C”型环绕。胰头前面有横结肠系膜根越过，后方有上腔静脉、右肾静脉以及胆总管；右上方与幽门和十二指肠相邻，左侧由前向后有肝固有动脉、肝门动脉、门腔淋巴结及网膜孔。

2） 胰颈 位于胃幽门后下方，其后有肠系膜上静脉通过，并与脾静脉在胰颈后汇合成肝门静脉。 3） 胰体 位于第一腰椎平面，脊柱前方。胰体前隔网膜囊与胃后壁相邻；后有腹主动脉，右肾上

腺动脉，右肾动脉及脾动脉。后借疏松结缔组织和脂肪附于腹后壁，上与腹腔干、腹腔丛相邻。 4） 胰尾 末端到达脾处，常有胰管行于此处。

根据胰的位置和毗邻关系，胰腺手术时切开腹壁进入腹膜腔后，到达胰腺的途径有哪些？

9. How to approach the pancreas after opening the peritoneal cavity according to the position and relationship of pancreas?

胰（pancreas）位于上腹部(superior abdomen)的腹膜(peritoneum)后，位置深在。根据胰的解剖特点，可选择以下途径显露胰：①经胃结肠韧带(gastrocolic ligament)途径。②经肝胃韧带(hepatogastricum ligament)途径。③经横结肠系膜(transverse mesocolon)途径，切开横结肠系膜的无血管处，再剪开胰上缘被膜，可充分游离胰体胰尾直至脾门(hilum of spleen)。④经腹膜后（retroperitoneum）径路，取左或右十二肋下缘切口，依次切开背阔肌(latissimus dorse)﹑胸腰筋膜(thracolumbar fascia)和腹内斜肌(obliquus internus abdominis)，在切开肾筋膜(renal fascia)后层进入肾囊(renal capsule)后，推开肾脏到达胰。⑤经十二指肠前壁（anterior wall of duodenum）径路，在经胃结肠韧带径路显露胰前表面的基础上，斜行切开十二指肠降部(descending part of duodenum)前壁可显露十二指肠大﹑小乳头(major/minus duodenal papilla)和胰管开口(the opening of pancreatic duct)

10. Why the head of pancreas, duodenum and parts of common bile duct have to be removed when the patient with cancer of head or ampulla of pancreas considering the anatomy here.

根据局解知识回答为什么胰头部或肝胰壶腹部癌需要根治切除时必须同时切除胰头、十二指

肠及一段胆总管?

答：The head of pancreas, duodenum and common bile duct are adjacent.

(胰管在胰头处与胆总管汇合形成肝胰壶腹，经十二指肠大乳头开口于十二指肠腔)

11. How to distinguish the large intestine and small intestine in an operation?

12. How to recognize the duodenojejunal flexure in an operation? 13. How to distinguish the jejunum and ileum in an operation? (1) the jejunum is thicker and wider（粗细）

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(2) the color the jejunum is fresh red,but the ileum is dim.（颜色）

(3) there are little blood vessel arch and fat in jejunum than in ileum.（血管）

14. Try to locate the vermiform appendix. How to recognize the appendix in an operation? Why suppurative appendicitis can cause the liver abscess?

15. Try to describe the blood supply of the large intestine.

Case3 A 42-year-old business executive was admitted to the hospital after visiting the emergency room complaining of severe epigastric pain and pain over her right shoulder. She had a history of gastric ulcer which had been treated previously with medication, but on questioning, she admitted that she had been so busy recently that she had forgotten to refill her prescription and had not taken her medication in some time. As a result of the history and physical findings, the physician suspected that she was suffering from a perforated gastric ulcer. Gastroscopy was performed which confirmed the diagnosis. When the surgeon examined the patient's stomach during the surgery, she found a small perforation on the posterior aspect of the body of the stomach near the lesser curvature. The surgeon found it necessary to cut the left gastric artery, but at the same time, he also found that the common hepatic artery was from the left gastric artery. After treat it carefully, he had the stomach cut and anastomose the left stomach with the jejunum. Then the surgeon also determined to do vagotomy to reduce the acid secretion. 12 days after the operation, the patient left the hospital and back to work.

一位42岁的商业行政主管在急诊室说自己剧烈上腹痛，疼痛向右肩放射后入院。她有既往胃溃疡史，之前进行药物治疗，但在问诊时，她承认由于近期工作繁忙未能按时服药。根据病史和体格检查，医生怀疑胃溃疡穿孔。胃镜检查证实该诊断。手术中医生检查病人的胃发现胃后壁近小弯侧有穿孔。医生发现有必要切断胃左动脉，但同时也发现肝总动脉发于胃左动脉。经过仔细治疗后医生将胃切除并使左胃和空肠吻合。医生还进行了迷走神经切断术以减少胃酸的分泌。手术12天后，病人出院回到了工作中。

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Assignments:

1. Complete the learning module entitled liver.

2. Complete the learning module entitled extrahepatic bile ducts. 3. Complete the learning module entitled pancreas. 4. Complete the learning module entitled spleen.

5. Complete the learning module entitled portal venous system. Objectives:

1. Describe the position of the liver. 2. Master the three porta hepatic.

3. Recognize the interhepatic ducts: Glisson’s system. Hepatic venous. 4. Master the eight liver segments and how to divide it? 5. Recognize the structure of the extrahepatic bile ducts. 6. Recognize the relationship of the gallbladder 7. Master the Calot’s triangle.

8. Recognize common bile duct, bile drainage.

9. Describe the position, relationship and division of pancreas, pancreatic duct, blood supply of pancreas.

10. Describe the position of spleen and blood supply of spleen.

11. Master the relationship (diaphragmatic surface, visceral surface) of spleen.

12. Recognize the portal venous system.

13. Recognize communications between the portal venous system and caval venous system. Questions:

1. How to divide the liver? Why? People divide liver by intrahepatic ducts.

Glisson system consists of hepatic portal vein, hepatic artery and bile duct.

According to Glisson system, liver is usually divided into 5 lobes and 6 segments. Three interlobar fissures and intersegmental fissures are the boundaries.

Liver is divided into two parts by median fissure—left and right half liver.

Left half liver is divided into two lobes by left interlobar fissure—left medial lobe and left lateral lobe. Right half liver is divided into two lobes by right interlobar fissure—right anterior lobe and right posterior lobe.

Left lateral lobe is divided into two segments by left intersegmental fissure—superior segment and inferior segment.

Right posterior lobe is divided into two segments by right intersegmental fissure—superior segment and inferior segment.

Caudate lobe is divided into two segments by median fissure—left segment and right segment.

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There are three structures in hepatoduodenal ligament, namely common bile duct in the right ahead,

proper hepatic vein in the left ahead, and between the two of them back is the hepatic portal vein . In the right edge of hepatoduodenal ligament, is the slightly blue common bile duct,, cutting across the peritoneal on the surface, slightly more dissection, we can find the common bile duct. Puncture surgery routinely in the operation, such as taking out of bile, may be recognized as a common bile duct. As a result of inflammation, the changes in regional relationships, the hepatic artery may help to determine the location of the common bile duct by touching.

2. What are important structures in the hepatoduodenal ligament? How they are arranged? How to recognize the common bile duct in an operation?

Cystic triangle is surrounded by cystic duct , common hepatic duct and porta hepatis . Cystic artery

usually begins from the right branch of proper hepatic artery at cystic triangle , so it is often at cystic triangle to find and ligate cystic artery when doing cystic surgery . But there are often many variations in the origin of cystic artery and the numbers of branches , doctors must trace the artery in surgery to confirm that the artery has come into the cystic wall, and try to ligate and cut down the artery close to the cystic wall in order to avoid hurting the right branch of proper hepatic artery.

3. What is cystic triangle? What does it mean in clinic?

Because middle hepatic vein not only receives the venous blood of left medial lobe but also the

venous blood of right anterior lobe, so when doing the half hepatectomy, middle hepatic vein must be reserved . Otherwise, stasis hepatonecrosis will happen.

4. Why should the middle hepatic vein be reserved in the half hepatectomy, whatever left or right?

Solution: the main procedure of splenectomy are separating and cutting off the ligaments around the

5. What are the extrahepatic bile ducts? Try to describe the divisions and relationships of the common bile duct.

6. Which ligaments should be cut off in splenectomy? Which blood vessels should be ligated in spenectomy?

spleen and ligating the blood vessels:(1) gastrolienal ligament and inner short gastric vessels、left gastroepiploic vessels (2)lienorenal ligament and inner lineal artery、vein (3)phrenicosplenic ligament (4)lienocolic ligament.

Component: Usually, superior mesenteric vein join with splenic vein behind the neck

of pancreas which makes up the hepatic portal vein. hepatic portal vein is located up behind the pancreas, enters into the hepatoduodenal ligament via the deep area of the

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7. What collateral circulations are between portal and caval venous system in portal hypotension? What symptoms will exist?

8. Try to explain why the abscess is common in the right liver according to the anatomy of portal vein.

9. try to describe the constitues, relationship, main tributaries and features of portal vein.

superior part of duodenum, then goes up to the parta hepatic, hepatic portal vein is divided into two parts, left and right which go into the corresponding half liver respective. Adjoin: Hepatic portal vein go ahead in the hepatoduodenal ligament. On the right front near the lesser omentum is common hepatic duct, On the left front is hepatic artery proper, On the behind it opposites the inferior vena vein through the Winslow.

Main branches: superior mesenteric vein, splenic vein, left gastric vein, inferior mesenteric vein and paraumbillical veins. The blood finally goes into the hepatic portal vein mainly comes from digestive duct ,spleen and pancreas.

The feature of the structure: hepatic portal vein is different from other general veins, its top and terminal are all blood capillary. One side starts from the capillary network of the stomach, intestine, pancreas and spleen, the other side end at the hepatic sinusoid in the hepatic lobule. Hepatic portal vein and its branches are lack of valve. Because of these anatomical features , no matter whether the blocking happened within or outside the liver in hepatic portal vein, it would cause the blood flow back, which may cause portal hypertension.

Case4（93K）

A 48-year-old male with a history of alcoholism is brought into the ER with severe epigastric pain and hematemesis. Upon physical examination you find him to be jaundiced and tachycardic with low blood pressure. Other physical findings include spider nevi (hemangiomas) on the cheeks, neck, upper extremities, and torso; ascites; splenomegaly; and tortuous dilated veins radiating from the umbilicus (caput medusae). The patient also tells you that he often has bloody stools, which prompts you to perform a rectal examination during which you find internal hemorrhoids. After completing your work-up, you correctly make a diagnosis of alcoholic cirrhosis of the liver. Then according to the patient’s situation, you determine to create a shunt between left renal and splenic vein to reduce the portal hypertension.

一个48岁的男性患者有长期的酗酒史，由于上腹部剧烈疼痛且伴有呕血症状而被送入急诊。在身体检查中发现他有黄疸，心跳过速而且有低血压。其他检查中发现在脸颊，脖颈，上肢和躯干部可见蜘蛛痣。腹水，脾大。以脐为中心放射状迂曲扩张静脉（海蛇头）。患者还声称他经常便血，因此你对他进行肛门指检，并发现内痔。在检查完成后，诊断为酒精性肝硬化。根据患者情况，决定在其左肾和脾静脉之间引流来缓解门脉高压。

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