The vascular imageological anatomy anterior to L4/5 disc and laparoscopic surgical strategies
Liu Jinwei*, Guan Mingqiang, Li Wei, Ding Zihai
Lecong Clinical Base of Guangdong Traumatherapy Research Center. Department of Orthopedics, Affiliated Lecong Hospital of Guangzhou Medical University, Foshan 528315, China
Abstract：Objective To provide coping strategies for laparoscopic operation by observation and classification of the imaging morphology of large vessels in anterior to L4/5 disc.Methods The MRI axial images of L4/5 disc in 257 cases were collected and examined. The bifurcation of abdominal aorta (AB) and convergence of common iliac vein (CCIV) at the level of L4/5 disc was then identified and classified. Since the operation approach was especially complex for patients whose abdominal aorta has divaricated while iliac vein has not converged at the level of L4/5 disc ("ⅰ+α"combination), these patients were emphatically studied. Composition of "intervascular window"(IVW) was identified and the distance between vessels on both sides of IVW was measured in the axial image through the center of L4/5 disc. Differences of IVW value according to gender and age were further explored. The axial images of L4/5 disc were vertically divided into four equal parts. The operational space was quantified according to the relationship between the three dividing lines and the large vessels in anterior to L4/5. Patients were then divided into four types according to the size and location of the operation space. Laparoscopic L4/5 disc surgery could be performed on patients of A, B1, C1 type. Finally, the coping strategies for laparoscopic operation of different types were explored in accordance with Kleeman′s approach classification.Results At the level of L4/5 disc, abdominal aorta had divaricated in 82.49 %(212/257) of the cases while iliac vein had not converged in 43.58 %(112/257) of the cases. "ⅰ+α" combination was identified in 43.58%(112/257) of the cases. Both sides of the IVW, the common iliac vein accounted for 94.64% on the left side, While the iliac artery accounted for 93.75%. The IVW size of this combination was (0.42+0.70) cm. There was no significant difference between the sexes (t=-1.29, P>0.05), and no significant difference between the age too (χ2=0.065, P>0.05). There was no significant difference between the sexes(P＞0.05), significant difference existed between the age (P＜0.05). Morphological classification implied that laparoscopic L4/5 disc surgery could be performed only on 39.29% (44/112) cases (type A, type B1, and type C1). The IVW size of these patients is (1.03+0.79) cm. Operation space was identified between left common iliac artery and the left edge in 8.93% (10/112) cases. Anterior approach was not suitable in 51.78% (58/112) cases.Conclusions The vascular identification and classification based on the MRI axial images is valuable for preoperative plan of laparoscopic L4/5 disc surgery.
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Liu Jinwei, Guan Mingqiang, Li Wei, Ding Zihai. The vascular imageological anatomy anterior to L4/5 disc and laparoscopic surgical strategies. Chinese Journal of Anatomy and Clinics, 2015, 20(5): 399-404.
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2015, Vol. 20 
