腹壁解剖及操作.ppt

局部解剖学 十四 腹部的局部解剖与操作 1 主要内容MainContent 境界与分区Theboundaryandregion表面解剖Thesurfaceanatomy腹前外侧壁TheAnterolateralAbdominalWall 一 境界与分区BoundaryandRegion 1 腹部的境界 上界 为胸廓下口 即剑突 肋弓 第11肋前端 第12肋下缘和第12胸椎围成 下界 为耻骨联合上缘 耻骨嵴 耻骨结节 腹股沟韧带 髂嵴至第5腰椎下缘的连线 2 固有 腹腔的境界 上界 膈下界 骨盆上口 3A 腹部的分区 九分法 3B 腹部的分区 四分法 二 表面解剖TheSurfaceAnatomy 体表标志Surfacelandmark表面投影Surfaceprojection Xiphoidprocess剑突 Costalarch肋弓 Iliaccrest髂嵴 Anteriorsuperioriliacspine髂前上棘 Pubictubercle耻骨结节 Superioredgeofpubicsymphysis耻骨联合上缘 Pubiccrest耻骨嵴 1 骨性标志 2 软组织标志 Locationofinguinalligament 3 体表投影 三 腹前外侧壁TheAnterolateralAbdominalWall 浅层结构Superficialstructures深层结构Deepstructures 皮肤 浅筋膜 腹膜下筋膜 深筋膜和肌肉 Thelayersoftheanterolateralabdominalwall 1 Skin2 Superficialfascia3 Deepfasciaandmuscles4 Transversefascia5 Extraperitonealfascia6 Parietalfascia 腹横筋膜 壁腹膜 一 浅层结构Thesuperficialstructures 皮肤Skin浅筋膜Superficialfascia 1 Skin thinnerandmoreelastic薄而富有弹性 2 Superficialfascia 主要由脂肪和疏松结缔组织组成 Camper筋膜 在腹壁下部 约在脐平面以下 浅筋膜分为两层 浅层称为Camper sfascia 含有丰富的脂肪组织 又称脂肪层 向下与股部的浅筋膜相互延续 深层称为Scarpa fascia 是富有弹性纤维的膜性层 在中线附于白线 向下在腹股沟下方约一横指处 紧附于股部的深筋膜 在耻骨结节之间 越过耻骨联合向下至会阴 与会阴浅筋膜 Colles筋膜 相延续 Scarpa筋膜 浅筋膜 Skin Superficialfasica Scarpa sfascia Musclesofanteriorabdominal Camper sfascia Transversalisfascia wall 2 Superficialfascia Superficialfasciaconsistsofalayerofconnectivetissuethatcontainsavariableamountoffat Abovethelevelofumbilicus itisafattylayer Intheinferiorpartoftheanterolateralwall thesubcutaneoustissueiscomposedoftwolayers thefattyouterlayer knownasCamper sfascia andthemembranousinnerlayer theScarpa fascia TheScarpa fascia 1 isattachedtolineaalbamedially 2 continusedownwardscrosstheinguinalligamenttoblendwiththefascialataofthethighabout1 5cmbelowtheinguinalligament 3 iscontinuouswiththesuperficialfasciaoftheperineum Colles fascia 浅动脉 浅静脉 皮神经 髂腹股沟区和下腹部的皮瓣Theilioinguinalandthelowerabdominalflaps 二 深层结构TheDeepStructures 肌肉层次Muscularlayer血管 淋巴及神经Vessels lymphandnerve腹横筋膜Transversalisfascia腹膜下筋膜Extraperitonealfascia壁腹膜Parietalperitoneum 1 肌层TheMuscularlayer 前外侧群TheAnterolateralGroupThethreeflatmusclesarethe 腹外斜肌externalobliquemuscle腹内斜肌internalobliquemuscle腹横肌transversusabdominis 腹直肌rectusabdominis锥状肌pyramidalis 1 腹外斜肌externalobliquemuscle 腹股沟管皮下环superficialinguinalring 内侧脚medialcrus 外侧脚lateralcrus 脚间纤维intercruralfibers 腹外斜肌Externaloblique 腹外斜肌腱膜Externaloblique aponeurosis Intercruralfibers Medialcrus 腹股沟管皮下环superficialinguinalring 内侧脚medialcrus 外侧脚lateralcrus 脚间纤维intercruralfibers 返转韧带reflectedligament 腹股沟韧带inguinalligament 腔隙韧带lacunarligament 耻骨梳韧带pectinealligament 腹股沟韧带inguinalligament 腔隙韧带lacunarligament 耻骨梳韧带pectinealligament 2 腹内斜肌及其腱膜internalobliquemuscle aponeurosis 参与构成腹直肌鞘前 后层 结合腱和提睾肌 Internalobliquemuscle Internalobliquem aponeurosis Transversusabdominis aponeurosis Transversusabdominis 3 腹横肌及其腱膜transversusmuscle aponeurosis 参与构成腹直肌鞘前层 弓状线以下 后层 弓状线以上 结合腱和提睾肌 提睾肌Cremastermuscle 腹股沟镰Inquinalfalx联合腱Conjoinedtendon 腹横肌下缘 腹内斜肌及其腱膜和腹横肌及其腱膜形成的结构 Rectussheath posteriorlayer 腱划tendinousintersections Rectusabdominis 弓状线Arcuateline Pyramidalm 4 腹直肌rectusabdominis 5 锥状肌pyramidalmuscle tendinousintersections Rectussheath anteriorlayer 腹直肌鞘 腹直肌鞘rectussheath 腹直肌鞘Rectussheath 腹直肌鞘包绕腹直肌 由腹外侧壁三个扁肌的腱膜构成 分为前 后两层 在弓状线以上 腹直肌鞘前层anteriorlayeroftherectussheath由腹外斜肌腱膜和腹内斜肌腱膜前层构成 腹直肌鞘后层posteriorlayeroftherectussheath由腹内斜肌腱膜的后层和腹横肌腱膜构成 在弓状线以下 腹直肌鞘前层由三个扁肌的腱膜构成 腹直肌鞘后层缺如 2 血管 淋巴及神经Vessels LymphandNerve 1 动脉 2 静脉 3 神经 3 腹横筋膜 TransversalisFascia 腹横筋膜Transversefascia 精索内筋膜internalspermaticfascia 腹股沟深环deepinguinalring窝间韧带interfoveolarligament 腹横筋膜Transversefascia 腹前壁内面的皱襞及凹窝 4 壁腹膜Parietalperitoneum 5 腹前壁手术常用切口 Thoracoabdominalincision Superiormedianincision Transrectusincision Pararectusincision Paramedianincision Subcostalincision Superiortransverseincision McBurney sincision Inferiormedianincision Inferiortransverseincision Abovethearcuateline Belowthearcuateline 四 腹股沟区TheInguinalRegion 境界Theboundary层次与特点Thelayersandcharacteristics腹股沟管Theinguinalcanal腹股沟三角Theinguinaltriangle疝hernias 腹股沟直疝Directinguinalhernias 腹股沟斜疝indirectinguinalhernias 股疝femoralhernias 一 境界Boundary 1 皮肤skin2 浅筋膜superficialfascia3 腹外斜肌aponeurosisofexternalobliquusabdominis 二 腹股沟区层次结构TheLayersoftheInguinalRegion 4 髂腹下神经Iliohypogastricn 和髂腹股沟神经ilioinguinaln 5 腹内斜肌Obliquusinternusabdominis6 腹横肌Transversusabdominis 二 腹股沟区层次结构TheLayersoftheInguinalRegion 7 腹横筋膜Transversefascia8 腹膜外筋膜Extraperitonealfascia9 腹璧下动脉Inferiorepigastrica and旋髂深动脉deepcircumflexiliaca 10 璧腹膜Parietalperitoneum 特点 腹外斜肌在此区移行为腱膜 并在下部形成一裂口 浅环 腹内斜肌与腹横肌的下缘未达腹股沟韧带的内侧部 两者间无肌层覆盖 有精索或子宫圆韧带通过 形成了一潜在性裂隙 在人体站立时 该区所承受的腹内压力比平卧时高3倍 因此 腹股沟区为腹壁的薄弱区 是腹壁疝的多发部位 三 腹股沟管Theinguinalcanal 位置Position通过的结构Structurespassingthroughit两口 四璧Twoopeningandfourwalls精索Formingofthespermaticcord腹股沟斜疝Indirectinguinalhernia 三 腹股沟管InguinalCanal 1 位置2 内容3 构成4 临床意义 Theinguinalcanalisanoblique inferomediallypassage betweenthesuperficialanddeepinguinialrings throughtheinferiorpartoftheanteriorabdominalwall 3 5cmlong Theinguinalcanalliesparallelandjustsuperiortothemedialhalfoftheinguinalligament Themainoccupantoftheinguinalcanalisthespermaticcordinmalesandtheroundligamentoftheuterusinfemales Italsocontainsbloodandlymphaticvesselsandtheilioinguinalnerveinbothsexes Thedeep internal inguinalring entrancetoinguinalcanal isanoutpouchingofthetransversalisfasciaapproximately1 25cmsuperiortothemiddleoftheinguinalligamentandlateraltotheinferiorepigastricvessels Theanteriorwalloftheinguinalcanalisformedbytheexternalobliqueaponeurosisthroughoutthelengthofthecanal withtheanteriorwallofthelateralpartofthecanalbeingreinforcedbyfibersofinternusoblique Theposteriorwalloftheinguinalcanalisformedbythetransversalisfasciawiththeposteriorwallofthemedialpartofthecanalbeingreinforcedtheconjointtendon Roof superiorwall isformedbythearchingfibersoftheinternalobliqueandtransverseabdominalmuscles Floor inferiorwall isformedbytheinguinalligament Thesuperficial external inguinalring exitfrominguinalcanal isaslitlikeopeningbetweenthediagonalfibersoftheaponeurosisfotheexternaloblique superolateraltothepubictubercle 腹股沟三角InguinalTriangle 海氏三角Hesselbach striangle 构成 腹壁下动脉 腹直肌外侧缘和腹股沟韧带内侧半所围成的三角形区域 临床意义 由腹股沟三角突出的疝 称腹股沟直疝 腹股沟三角 腹股沟直疝 腹股沟斜疝 股疝 IndirectHernia DirectHernia 股疝femoralhernia 睾丸下降过程 卵巢下降过程 睾丸下降过程descendingprocessofthetestis 先天性腹股沟斜疝Acongenitalindirectinguinalhernia 后天性腹股沟斜疝Aacquiredindirectinguinalhernia 先天性腹股沟斜疝Acongenitalindirectinguinalhernia 后天性腹股沟斜疝Aacquiredindirectinguinalhernia 精索的被膜与腹前外侧壁层次的关系 精索或睾丸被膜与腹前外侧壁层次的关系 解剖与观察DissectionandObservation 浅层结构superficialstructures三层阔肌 血管和神经Threeflatmuscles vesselsandnerves腹直肌rectusabdominis腹直肌rectussheath腹股沟区inguinalregion腹股沟管inguinalcanal腹股沟三角inguinaltriangle 1 切口Incision 2 将皮瓣翻向外侧reflectskinflapslaterally 3 Identifythefattylayerofthesuperificialfascia 4 Identifythesuperficialepigastricvessels 5 Removethesuperficialfascia 6 Identifythemembranouslayerofthesuperficialfascia 7 Identifyseveralanteriorcutaneousbranchesofthelowestfiveintercostalnerves T7 T11 andthesubcostalnerve T12 8 Identifytheterminalbranchesoftheiliohypogastricnerve L1 andtheilioinguinalnerve L1 9 Removedeepinvestingcoveringtheexternalabdominalobliquemuscle 10 Identifythedirectionofthefibersandtheaponeurosisoftheexternalabdominalobliquemuscle 11 Identifytheinguinalligament thesuperficialinguinalring themedialcrus thelateralcrusandtheintercruralfibers 12 Reflecttheexternalabdominalobliqueandexposetheinternalabdominaloblique Reflecttheinternalabdominalobliqueandexposethetransversalismuscle 13 Identifythevesselsandnerves 14 Cutthroughtheanteriorlaye