腹壁解剖及操作

局部解剖学（十四）,腹部的局部解剖与操作（1）,主要内容 Main Content,境 界 与 分 区 The boundary and region表 面 解 剖 The surface anatomy 腹 前 外 侧 壁 The Anterolateral Abdominal Wall,一、境界与分区Boundary and Region,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The Surface Anatomy,体表标志 Surface landmark表面投影 Surface projection,Xiphoid process剑 突,Costal arch肋 弓,Iliac crest髂嵴,Anterior superior iliac spine髂前上棘,Pubic tubercle耻骨结节,Superior edge of pubic symphysis 耻骨联合上缘,Pubic crest 耻骨嵴,1.骨性标志,2. 软 组 织 标 志,Location of inguinal ligament,3.体表投影,三、腹 前 外 侧 壁The Anterolateral Abdominal Wall,浅层结构 Superficial structures 深层结构 Deep structures,皮肤,浅筋膜,腹膜下筋膜,深筋膜和肌肉,The layers of the anterolateral abdominal wall,1.Skin2.Superficial fascia3.Deep fascia and muscles4.Transverse fascia5.Extraperitoneal fascia6.Parietal fascia,腹横筋膜,壁腹膜,（一）浅 层 结 构The superficial structures,皮肤 Skin浅筋膜 Superficial fascia,1. Skin: thinner and more elastic 薄而富有弹性,2. Superficial fascia：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 Campers fascia,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,Superficial fasica,Scarpas fascia,Muscles of anteriorabdominal,Campers fascia,Transversalis fascia,wall,2. Superficial fascia,Superficial fascia consists of a layer of connective tissue that contains a variable amount of fat.Above the level of umbilicus, it is a fatty layer.In the inferior part of the anterolateral wall, the subcutaneous tissue is composed of two layers, the fatty outer layer, known as Campers fascia, and the membranous inner layer, the Scarpa fascia. The Scarpa fascia:1) is attached to linea alba medially.2) continuse downwards cross the inguinal ligament to blend with the fascia lata of the thigh about 1.5cm below the inguinal ligament.3) is continuous with the superficial fascia of the perineum (Colles fascia).,浅动脉、浅静脉、皮神经,髂腹股沟区和下腹部的皮瓣The ilioinguinal and the lower abdominal flaps,（二）深层结构 The Deep Structures,肌肉层次 Muscular layer血管、淋巴及神经 Vessels, lymph and nerve 腹横筋膜 Transversalis fascia腹膜下筋膜 Extraperitoneal fascia壁腹膜 Parietal peritoneum,1. 肌层 The Muscular layer,前外侧群 The Anterolateral Group The three flat muscles are the:腹外斜肌 external oblique muscle腹内斜肌 internal oblique muscle腹横肌 transversus abdominis：腹直肌 rectus abdominis锥状肌 pyramidalis,（1）腹外斜肌 external oblique muscle,腹股沟管皮下环 superficial inguinal ring:内侧脚medial crus、外侧脚lateral crus、脚间纤维intercrural fibers.,腹外斜肌External oblique,腹外斜肌腱膜External oblique，aponeurosis,Intercrural fibers,Medial crus,腹股沟管皮下环 superficial inguinal ring:内侧脚medial crus、外侧脚lateral crus、脚间纤维intercrural fibers.,返转韧带reflected ligament、腹股沟韧带inguinal ligament、腔隙韧带lacunar ligament、耻骨梳韧带pectineal ligament,腹股沟韧带inguinal ligament、腔隙韧带lacunar ligament、耻骨梳韧带pectineal ligament,（2）腹内斜肌及其腱膜 internal oblique muscle & aponeurosis ：参与构成腹直肌鞘前、后层，结合腱 和提睾肌。,Internal oblique muscle,Internal oblique m. aponeurosis,Transversus abdominis, aponeurosis,Transversus abdominis,（3）腹横肌及其腱膜 transversus muscle & 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 Cremaster muscle,腹股沟镰Inquinal falx联合腱 Conjoined tendon,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,Rectus sheath, posterior layer,腱 划tendinous intersections,Rectus abdominis,弓状线Arcuate line,Pyramidal m.,（4）腹直肌 rectus abdominis（5）锥状肌 pyramidal muscle,tendinous intersections,Rectus sheath, anterior layer,腹直肌鞘,腹直肌鞘 rectus sheath, 腹直肌鞘 Rectus sheath,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 anterior layer of the rectus sheath 由腹外斜肌腱膜和腹内斜肌腱膜前层构成；腹直肌鞘后层 posterior layer of the rectus sheath 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, Lymph and Nerve,(1)动脉,(2)静脉,(3)神经,3.腹横筋膜,Transversalis Fascia,腹横筋膜 Transverse fascia,精索内筋膜internal spermatic fascia,腹股沟深环deep inguinal ring窝间韧带 interfoveolar ligament,腹横筋膜 Transverse fascia,腹前壁内面的皱襞及凹窝,4. 壁腹膜 Parietal peritoneum,5. 腹前壁手术常用切口,Thoracoabdominal incision,Superior median incision,Transrectus incision,Pararectus incision,Paramedian incision,Subcostal incision,Superior transverse incision,McBurneysincision,Inferiormedian incision,Inferiortransverse incision,Above the arcuate line,Below the arcuate line,四、腹 股 沟 区The Inguinal Region,境界 The boundary层次与特点 The layers and characteristics腹股沟管 The inguinal canal腹股沟三角 The inguinal triangle 疝 hernias ：腹股沟直疝 Direct inguinal hernias 、腹股沟斜疝 indirect inguinal hernias、股疝 femoralhernias,（一）境界 Boundary,1. 皮肤 skin2. 浅筋膜 superficial fascia3. 腹外斜肌 aponeurosis of external obliquus abdominis,（二）腹股沟区层次结构The Layers of the Inguinal Region,4. 髂腹下神经 Iliohypogastric n. 和髂腹股沟神经 ilioinguinal n.5. 腹内斜肌 Obliquus internus abdominis6. 腹横肌 Transversus abdominis,（二）腹股沟区层次结构The Layers of the Inguinal Region,7. 腹横筋膜 Transverse fascia8. 腹膜外筋膜 Extraperitoneal fascia9. 腹璧下动脉Inferior epigastric a. and 旋髂深动脉 deep circumflex iliac a.10.璧腹膜 Parietal peritoneum,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The inguinal canal,位置 Position 通过的结构 Structures passing through it两口、四璧 Two opening and four walls精索 Forming of the spermatic cord腹股沟斜疝 Indirect inguinal hernia,（三）腹股沟管 Inguinal Canal,1.位置2.内容3.构成4.临床意义,The inguinal canal is an oblique, inferomedially passage(between the superficial and deep inguinial rings) through the inferior part of the anterior abdominal wall), 35cm long. The inguinal canal lies parallel and just superior to the medial half of the inguinal ligament.,The main occupant of the inguinal canal is the spermatic cord in males and the round ligament of the uterus in females. It also contains blood and lymphatic vessels and the ilioinguinal nerve in both sexes.,The deep ( internal ) inguinal ring, entrance to inguinal canal , is an outpouching of the transversalis fascia approximately 1.25cm superior to the middle of the inguinal ligament and lateral to the inferior epigastric vessels.,The anterior wall of the inguinal canal is formed by the external oblique aponeurosis throughout the length of the canal, with the anterior wall of the lateral part of the canal being reinforced by fibers of internus oblique.,The posterior wall of the inguinal canal is formed by the transversalis fascia with the posterior wall of the medial part of the canal being reinforced the conjoint tendon.,Roof ( superior wall) is formed by the arching fibers of the internal oblique and transverse abdominal muscles.Floor( inferior wall ) is formed by the inguinal ligament.,The superficial ( external ) inguinal ring-exit from inguinal canal- is a slitlike opening between the diagonal fibers of the aponeurosis fo the external oblique, superolateral to the pubic tubercle.,腹股沟三角 Inguinal Triangle （海氏三角 Hesselbachs triangle）,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,Indirect Hernia,Direct Hernia,股疝 femoral hernia,睾丸下降过程,卵巢下降过程,睾丸下降过程 descending process of the testis,先天性腹股沟斜疝A congenital indirect inguinal hernia,后天性腹股沟斜疝 A acquired indirect inguinal hernia,先天性腹股沟斜疝A congenital indirect inguinal hernia,后天性腹股沟斜疝 A acquired indirect inguinal hernia,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Dissection and Observation,浅层结构 superficial structures三层阔肌、血管和神经 Three flat muscles , vessels and nerves腹直肌 rectus abdominis腹直肌 rectus sheath腹股沟区 inguinal region腹股沟管 inguinal canal腹股沟三角 inguinal triangle,1.切口 Incision,2.将皮瓣翻向外侧 reflect skin flaps laterally.,3. Identify the fatty layer of the superificial fascia.,4.Identify the superficial epigastric vessels.,5.Remove the superficial fascia.,6. Identify the membranous layer of the superficial fascia.,7. Identify several anterior cutaneous branches of the lowest five intercostal nerves (T7T11)and the subcostal nerve (T12).,8. Identify the terminal branches of the iliohypogastric nerve (L1) and the ilioinguinal nerve (L1).,9. Remove deep investing covering the external abdominal oblique muscle. 10.Identify the direction of the fibers and the aponeurosis of the external abdominal oblique muscle.,11.Identify the inguinal ligament, the superficial inguinal ring, the medial crus, the lateral crus and the intercrural fibers.,12.Reflect the external abdominal oblique and expose the internal abdominal oblique. Reflect the internal abdominal oblique and expose the transversalis muscle.13.Identify the vessels and nerves.,14.Cut through the anterior