内容紹介
Summary
We report successful laparoscopic distal gastrectomy in a patient with early gastric cancer and an Adachi type Ⅵ arterial variant. The case is a male in his 50's who was detected a type 0-Ⅱc lesion on the antrum of the stomach and diagnosed as tub2. Laparoscopic distal gastrectomy was performed, with the pathologic diagnosis of cT1bN0M0, cStageⅠ. MD-CT showed absence of the common hepatic artery ventral to the portal vein, consistent with an Adachi type Ⅵ arterial variant. The interface between pancreatic and fatty tissue was separated in suprapancreatic dissection, and was extended between the hepatoduodenal ligament and splenic artery, with exposure of the surface of the portal vein. Thus, safe dissection of No. 8a area was achieved. Discussion: Adachi classified the celiac artery branches into 6 types and 28 groups. Type Ⅵ, a variant of the common hepatic artery located on the dorsal aspect of the portal vein, has a reported frequency of 2%. Because it is a variant of the hepatic artery, a landmark of suprapancreatic dissection, careful observation is required to determine the anatomy. Although tactile sensation is limited in laparoscopic surgery, arterial pulsation is clearly visible. To ensure a safe procedure, it is important to identify vessel anatomy both pre- and intraoperatively.
要旨
Adachi分類Ⅵ型破格を有する早期胃癌症例に対し,安全に腹腔鏡下幽門側胃切除術を施行できた1例を経験したので報告する。症例: 患者は50歳台,男性。前庭部に0-Ⅱc病変を認め,生検の結果はtub2,臨床病期はcT1bN0M0,cStageⅠの診断で腹腔鏡下幽門側胃切除術の方針となった。MD-CTで門脈前面に総肝動脈を認めず,Adachi分類Ⅵ型と判断した。膵上縁で膵実質と脂肪織の境界を切離し,門脈前面を露出しつつ肝十二指腸間膜および脾動脈方向へ郭清範囲を広げることで過不足のないNo. 8a郭清を安全に施行できた。考察: Adachiらは腹腔動脈の分岐形態を6型28群に分類している。総肝動脈が門脈背側を走行するⅥ型は約2%の頻度とされる。膵上縁のリンパ節郭清の際に道標となる総肝動脈の走行破格であるため,解剖の認識には細心の注意が必要である。鏡視下手術は触覚に頼ることはできないが,動脈の拍動は視認可能である。術前の血管走行の把握と術中の入念な観察が安全な手術施行に重要である。
目次
We report successful laparoscopic distal gastrectomy in a patient with early gastric cancer and an Adachi type Ⅵ arterial variant. The case is a male in his 50's who was detected a type 0-Ⅱc lesion on the antrum of the stomach and diagnosed as tub2. Laparoscopic distal gastrectomy was performed, with the pathologic diagnosis of cT1bN0M0, cStageⅠ. MD-CT showed absence of the common hepatic artery ventral to the portal vein, consistent with an Adachi type Ⅵ arterial variant. The interface between pancreatic and fatty tissue was separated in suprapancreatic dissection, and was extended between the hepatoduodenal ligament and splenic artery, with exposure of the surface of the portal vein. Thus, safe dissection of No. 8a area was achieved. Discussion: Adachi classified the celiac artery branches into 6 types and 28 groups. Type Ⅵ, a variant of the common hepatic artery located on the dorsal aspect of the portal vein, has a reported frequency of 2%. Because it is a variant of the hepatic artery, a landmark of suprapancreatic dissection, careful observation is required to determine the anatomy. Although tactile sensation is limited in laparoscopic surgery, arterial pulsation is clearly visible. To ensure a safe procedure, it is important to identify vessel anatomy both pre- and intraoperatively.
要旨
Adachi分類Ⅵ型破格を有する早期胃癌症例に対し,安全に腹腔鏡下幽門側胃切除術を施行できた1例を経験したので報告する。症例: 患者は50歳台,男性。前庭部に0-Ⅱc病変を認め,生検の結果はtub2,臨床病期はcT1bN0M0,cStageⅠの診断で腹腔鏡下幽門側胃切除術の方針となった。MD-CTで門脈前面に総肝動脈を認めず,Adachi分類Ⅵ型と判断した。膵上縁で膵実質と脂肪織の境界を切離し,門脈前面を露出しつつ肝十二指腸間膜および脾動脈方向へ郭清範囲を広げることで過不足のないNo. 8a郭清を安全に施行できた。考察: Adachiらは腹腔動脈の分岐形態を6型28群に分類している。総肝動脈が門脈背側を走行するⅥ型は約2%の頻度とされる。膵上縁のリンパ節郭清の際に道標となる総肝動脈の走行破格であるため,解剖の認識には細心の注意が必要である。鏡視下手術は触覚に頼ることはできないが,動脈の拍動は視認可能である。術前の血管走行の把握と術中の入念な観察が安全な手術施行に重要である。