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

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

宋达疆1 李赞1 章一新2 周波1 吕春柳1 唐园园1 易亮1 罗振华1

本文来源：《中华整形外科杂志》2023年4月第39卷第4期

DOI:10. 3760 / cma.j.cn114453-20220508-00141

作者单位：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

通信作者：李赞，Email：zzanli@163.com

引用本文

宋达疆, 李赞, 章一新, 等. 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 [J] . 中华整形外科杂志, 2023, 39(4) : 351-358. DOI: 10.3760/cma.j.cn114453-20220508-00141.

【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，调整为方式2进行吻合后，卡压情况解除；其余4例所采用的静脉吻合方式包括方式2有1例，方式3有1例，方式4有2例，均通过及时调整血管蒂摆放位置解除了血管卡压情况。术后发生皮瓣坏死1例，采用的静脉吻合方式是Y形静脉直接吻合方法；其余172例皮瓣完全成活。随访10~36个月，平均18.7个月，再造乳房外形可，质地柔软，无皮瓣挛缩变形；皮瓣供区仅遗留线性瘢痕，对腹壁功能无明显影响，未见肿瘤复发病例。

结论根据腹壁下动脉伴行静脉分型制定较为完善的血管吻合策略，灵活调整血管吻合方式，可以最大程度确保游离下腹部皮瓣用于乳房再造血运的安全性。

【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

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

Song Dajiang1, Li Zan1, Zhang Yixin2, Zhou Bo1, Lyu Chunliu1, Tang Yuanyuan1, Yi Liang1, Luo Zhenhua1

1Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha 410008,China; 2Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011,China

Corresponding author: Li Zan, Email: zzanli@163.com

【Abstract】

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 muscle-sparing rectus abdominis musculocutaneous flap were harvested. The length of the flap was (26.9±1.9) cm, the width of the flap was (11.3±0.7) cm, the length of the vascular pedicle was (10.5±0.4) cm. The anatomical type of the deep inferior epigastric artery with only one accompanying vein accounted for 16 cases, and the veins were anastomosed directly. The anatomical type of Y-shaped accompanying vein accounted for 14 cases, of which 5 cases were anastomosed directly using method 1, 3 cases were anastomosed directly using method 1 after partial resection of the third costal cartilage to create a groove, and 6 cases were anastomosed using method 2. The H-shaped accompanying vein of the deep inferior epigastric artery was found in 143 cases. In 96 cases, vascular anastomosis were accomplished using method 3, 19 cases were anastomosed using method 4 and 28 cases were anastomosed using method 5. In 97 cases, the excessively long segment of the deep inferior epigastric artery were trimmed before vascular anastomosis. The average length of the trimmed segment was (2.7±0.7) mm. There were 6 cases of vascular anastomotic complications during operation, of which 2 patients were treated with method 1. Venous entrapment occurred during operation and was relieved after changing into method 2. The venous anastomosis methods adopted in the other 4 cases included 1 case of method 2, 1 case of method 3, and 2 cases of method 4, all of which were relieved of vessel entrapment by timely adjusting the placement of vessel pedicles. Postoperative flap necrosis occurred in 1 case. The vein anastomosis was direct Y-shaped vein anastomosis. The remaining 172 cases were completely successful. The patients were followed up for 10 to 36 months, with an average of 18.7 months. The reconstructed breast shape was good, the texture was soft, without flap contracture and deformation. Only linear scar remained in the donor site of the flap, which had no significant effect on the function of the abdominal wall. No tumor recurrence was observed.

Conclusion By flexibly adjusting the vascular anastomosis strategy according to the classification of the accompanying vein of the deep inferior epigastric artery, the blood supply of the free lower abdominal flap transfer in breast reconstruction can be guaranteed to the greatest extent.

【Key words】Mastectomy; Breast reconstruction; Lower abdominal flap; Vascular anastomosis; Deep inferior epigastric artery; Free flap

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Hunan Cancer Hospital (202260).

游离下腹部皮瓣移植乳房再造手术越来越受到术者和患者的欢迎，得到了普遍推广应用[1]。然而其并发症较多，尤其是血管吻合质量不高导致的血管危象和皮瓣坏死仍然是临床上不可忽视的问题[2,3]。皮瓣血管危象中最常见的是静脉危象，确保皮瓣静脉回流通畅有几个重要环节必须完善：第一，高质量的血管吻合；第二，尽可能多地增加静脉吻合数量；第三，确保静脉顺行摆放，无卡压、折叠、迂曲和扭转。尽量确保动静脉之间没有互相干扰[4,5,6]。笔者结合国内外既往研究报道，认为确保游离皮瓣安全成活必须要将多个环节做好，尤其是血管吻合的方式设计和灵活调整，结合过去多年的临床经验和资料，总结制定了腹壁下动脉伴行静脉吻合的策略方式，供同道参考。

资料与方法

一、资料选择

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。纳入标准：(1)无法或拒绝保乳，拟行乳房切除或乳房已缺失，且患者乳房再造意愿强烈；(2)患者腹部皮下脂肪较多，适合采用下腹部皮瓣；(3)所有皮瓣都只携带一侧腹壁下血管蒂，皮瓣Ⅳ区远端全部去除，单纯选择胸廓内血管作为受区血管[7]。排除标准：(1)对手术效果要求不切实际的患者；(2)有精神抑郁病史的患者。

本研究经湖南省肿瘤医院伦理委员会批准[2022年科研快审(60)号]，所有患者及家属已签署知情同意书。

二、手术方法

术前详细评估患者全身及局部情况，确定采用游离下腹部皮瓣移植完成乳房再造。手术分2组同时进行，受区准备组完成乳腺癌改良根治手术或瘢痕切除皮袋分离，分离胸廓内血管作为受区血管；皮瓣制备组以单侧腹壁下血管为蒂制备游离下腹部皮瓣，根据穿支实际管径、位置及数量，确定制备游离腹壁下动脉穿支(deep inferior epigastric artery perforator，DIEP)皮瓣或者携带部分腹直肌的游离腹直肌肌皮瓣。详细评估胸廓内血管的实际解剖情况，在显微镜下完成胸廓内血管和腹壁下血管蒂的修剪，进一步完成血管吻合和皮瓣血运重建。

血管吻合全部采用端端吻合方法。腹壁下动脉与胸廓内动脉近心端吻合。静脉吻合方式相对多变，腹壁下动脉的伴行静脉为1条时，直接将伴行静脉与胸廓内静脉近心端吻合；若有2条伴行静脉，则充分利用胸廓内静脉的近心端和远心端，或者与2条胸廓内静脉的近心端完成吻合。腹壁下动脉伴行静脉的解剖结构可以分为3种：独立型，包括1支型和2支型；Y形结构；H形结构。术中根据伴行静脉的解剖结构，决定采用何种方式进行吻合，以最大程度避免静脉回流不畅的情况发生。在所有病例中，共采用5种静脉吻合方式完成皮瓣的静脉回流重建(表1，图1)。

鉴于以往发生并发症的经验，若直接将Y形伴行静脉的共干段与胸廓内静脉进行吻合，发生并发症的风险相对较高，主要原因是靠近血管吻合口区域容易发生扭转、卡压，导致静脉阻塞和静脉危象(图2，图3A)。因此，针对具有共干结构的Y形伴行静脉，可以采用以下2种方式吻合，并完善手术细节，有利于确保安全性：(1)在直接吻合之前，槽形切除部分肋软骨或直接去除完整的第3肋软骨，使得静脉摆放更加顺行(图3B)；(2)去除Y形共干部分的静脉节段，直接将2条伴行静脉分别与胸廓内静脉的近心端和远心端吻合，或者均与2条胸廓内静脉的近心端吻合(图3C)。

血管吻合过程中需重视的1个关键点是动脉长度的调整。由于动脉较粗、管壁较厚，且弹性较好，因此其分离完毕后缩短的程度明显小于静脉，导致动脉的实际有效长度明显超过静脉，如果不加调整而直接完成血管吻合，则动脉局部成角较为明显，有可能造成动脉的迂曲卡压，同时也会增加对静脉卡压的风险。因此根据我们的经验，动脉吻合前一定要精确判断动脉比伴行静脉超出的长度，适当去除一定节段的动脉(图4)。