腹壁下动脉伴行静脉分型及吻合策略在乳房再造中的应用  

Application of classification of the accompanying vein of deep inferior epigastric artery and vascular anastomosis strategy in breast reconstruction

作　　者：宋达疆[1] 李赞[1] 章一新[2] 周波[1] 吕春柳[1] 唐园园 易亮 罗振华 Song Dajiang;Li Zan;Zhang Yixin;Zhou Bo;Lyu Chunliu;Tang Yuanyuan;Yi Liang;Luo Zhenhua(Department of Oncology Plastic Surgery,Hunan Cancer Hospital,Changsha 410008,China;Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China)

机构地区：[1]湖南省肿瘤医院肿瘤整形外科,长沙410008 [2]上海交通大学医学院附属第九人民医院整形外科,上海200011

出　　处：《中华整形外科杂志》2023年第4期351-358,共8页Chinese Journal of Plastic Surgery

摘　　要：目的探讨腹壁下动脉伴行静脉分型及吻合策略在乳房再造中的应用。方法回顾性分析2015年10月至2021年1月湖南省肿瘤医院采用单侧游离下腹部皮瓣移植完成乳腺癌术后乳房再造的患者资料。术中采用游离腹壁下动脉穿支(DIEP)皮瓣或携带部分腹直肌的游离腹直肌肌皮瓣进行乳房再造,受区血管均选择胸廓内血管。腹壁下动脉伴行静脉的解剖结构分为3类:独立型,包括1支型和2支型;Y形结构;H形结构。独立型静脉采用直接吻合。Y形结构和H形结构伴行静脉吻合方式共分5种:(1)直接吻合;(2)去除Y形结构的共干节段后,将2条伴行静脉分别吻合;(3)结扎交通支后,将2条伴行静脉分别吻合;(4)保留交通支,将2条伴行静脉分别吻合;(5)结扎较细伴行静脉,吻合较粗的伴行静脉。方式1、2适用于Y形结构的伴行静脉,方式3~5适用于H形结构的伴行静脉。术中需将过长的腹壁下动脉节段去除。统计术中血管吻合并发症的发生情况,随访皮瓣成活、再造乳房外形、肿瘤复发情况。结果共纳入173例女性患者,年龄26~60岁,平均41.2岁。其中,即刻乳房再造92例,延期乳房再造81例。109例采用游离DIEP皮瓣,64例采用携带部分腹直肌的游离腹直肌肌皮瓣。皮瓣长(26.9±1.9) cm,皮岛宽(11.3±0.7) cm,血管蒂长度(10.5±0.4) cm。腹壁下动脉只有1条伴行静脉的解剖类型16例,伴行静脉直接吻合;伴行静脉呈Y形结构者14例,5例采用方式1直接吻合,3例先槽形切除部分第3肋软骨后再用方式1直接吻合,6例采用方式2完成吻合;伴行静脉呈H形结构者143例,96例采用方式3完成吻合,19例采用方式4完成吻合,28例采用方式5完成吻合。97例患者在血管吻合前对腹壁下动脉过长节段进行了修剪,去除长度为(2.7±0.7) mm。术中发生血管吻合相关并发症6例,其中2例患者采用的静脉吻合方式是Y形静脉直接吻合方法(方式1),术中出现静脉卡压,调�Objective To explore the application of the classification of the accompanying vein of deep inferior epigastric artery and vascular anastomotic strategy in breast reconstruction.Methods The data of patients who underwent breast reconstruction after breast cancer surgery with unilateral free lower abdominal flap transplantation in Hunan Cancer Hospital from October 2015 to January 2021 were retrospectively analyzed.During surgery,free deep inferior epigastric artery perforator(DIEP)flap or free muscle-sparing rectus abdominis musculocutaneous flap was used for breast reconstruction,and the recipient vessel was internal mammary vessel.The anatomy of the accompanying vein of the deep inferior epigastric artery can be divided into three types:independent type,including one branch type and two branch type;Y-shaped structure;H-shaped structure.Direct anastomosis was used for independent veins.There were five methods of vascular anastomoses for Y-shaped and H-shaped accompanying vein:(1)direct anastomosis;(2)the Y-shaped common stem segment was removed and the two accompanying veins were anastomosed respectively;(3)ligate the communicating branch and anastomose the two accompanying veins respectively;(4)the communicating branch was reserved and the two accompanying veins were anastomosed respectively;(5)ligate the smaller accompanying vein and anastomose the larger accompanying vein.Methods 1 and 2 were suitable for Y-shaped accompanying veins,and methods 3 to 5 were suitable for H-shaped accompanying veins.The excessively long inferior abdominal artery segment was removed during the operation.The complications of intraoperative vascular anastomosis were counted,and the survival of flap,aesthetics of breast reconstruction and tumor recurrence were followed up.Results A total of 173 female patients were included,ranging from 26 to 60 years,with an average age of 41.2 years.There were 92 cases of immediate breast reconstruction and 81 cases of delayed breast reconstruction.109 cases of free DIEP flap and 64 cases of free

关 键 词：乳房切除术 乳房再造 下腹部皮瓣 血管吻合 腹壁下动脉 游离皮瓣 

分 类 号：R655.8[医药卫生—外科学]