腹壁解剖及操作.ppt

局部解剖學(xué)（十四）,腹部的局部解剖與操作（1）,主要內(nèi)容MainContent,境界與分區(qū)Theboundaryandregion表面解剖Thesurfaceanatomy腹前外側(cè)壁TheAnterolateralAbdominalWall,一、境界與分區(qū)BoundaryandRegion,1.腹部的境界,上界：為胸廓下口，即劍突、肋弓、第11肋前端、第12肋下緣和第12胸椎圍成；,下界：為恥骨聯(lián)合上緣、恥骨嵴、恥骨結(jié)節(jié)、腹股溝韌帶、髂嵴至第5腰椎下緣的連線。,2.(固有)腹腔的境界,上界：膈下界：骨盆上口,3A.腹部的分區(qū),(九分法),3B.腹部的分區(qū),(四分法),二、表面解剖TheSurfaceAnatomy,體表標(biāo)志Surfacelandmark表面投影Surfaceprojection,Xiphoidprocess劍突,Costalarch肋弓,Iliaccrest髂嵴,Anteriorsuperioriliacspine髂前上棘,Pubictubercle恥骨結(jié)節(jié),Superioredgeofpubicsymphysis恥骨聯(lián)合上緣,Pubiccrest恥骨嵴,1.骨性標(biāo)志,2.軟組織標(biāo)志,Locationofinguinalligament,3.體表投影,三、腹前外側(cè)壁TheAnterolateralAbdominalWall,淺層結(jié)構(gòu)Superficialstructures深層結(jié)構(gòu)Deepstructures,皮膚,淺筋膜,腹膜下筋膜,深筋膜和肌肉,Thelayersoftheanterolateralabdominalwall,1.Skin2.Superficialfascia3.Deepfasciaandmuscles4.Transversefascia5.Extraperitonealfascia6.Parietalfascia,腹橫筋膜,壁腹膜,（一）淺層結(jié)構(gòu)Thesuperficialstructures,皮膚Skin淺筋膜Superficialfascia,1.Skin:thinnerandmoreelastic薄而富有彈性,2.Superficialfascia：主要由脂肪和疏松結(jié)締組織組成。,Camper筋膜,在腹壁下部（約在臍平面以下），淺筋膜分為兩層：淺層稱為Campersfascia,含有豐富的脂肪組織，又稱脂肪層，向下與股部的淺筋膜相互延續(xù)；,深層稱為Scarpafascia，是富有彈性纖維的膜性層，在中線附于白線，向下在腹股溝下方約一橫指處，緊附于股部的深筋膜，在恥骨結(jié)節(jié)之間，越過(guò)恥骨聯(lián)合向下至?xí)?，與會(huì)陰淺筋膜（Colles筋膜）相延續(xù)。,Scarpa筋膜,淺筋膜,Skin,Superficialfasica,Scarpasfascia,Musclesofanteriorabdominal,Campersfascia,Transversalisfascia,wall,2.Superficialfascia,Superficialfasciaconsistsofalayerofconnectivetissuethatcontainsavariableamountoffat.Abovethelevelofumbilicus,itisafattylayer.Intheinferiorpartoftheanterolateralwall,thesubcutaneoustissueiscomposedoftwolayers,thefattyouterlayer,knownasCampersfascia,andthemembranousinnerlayer,theScarpafascia.TheScarpafascia:1)isattachedtolineaalbamedially.2)continusedownwardscrosstheinguinalligamenttoblendwiththefascialataofthethighabout1.5cmbelowtheinguinalligament.3)iscontinuouswiththesuperficialfasciaoftheperineum(Collesfascia).,淺動(dòng)脈、淺靜脈、皮神經(jīng),髂腹股溝區(qū)和下腹部的皮瓣Theilioinguinalandthelowerabdominalflaps,（二）深層結(jié)構(gòu)TheDeepStructures,肌肉層次Muscularlayer血管、淋巴及神經(jīng)Vessels,lymphandnerve腹橫筋膜Transversalisfascia腹膜下筋膜Extraperitonealfascia壁腹膜Parietalperitoneum,1.肌層TheMuscularlayer,前外側(cè)群TheAnterolateralGroupThethreeflatmusclesarethe:腹外斜肌externalobliquemuscle腹內(nèi)斜肌internalobliquemuscle腹橫肌transversusabdominis：腹直肌rectusabdominis錐狀肌pyramidalis,（1）腹外斜肌externalobliquemuscle,腹股溝管皮下環(huán)superficialinguinalring:內(nèi)側(cè)腳medialcrus、外側(cè)腳lateralcrus、腳間纖維intercruralfibers.,腹外斜肌Externaloblique,腹外斜肌腱膜Externaloblique，aponeurosis,Intercruralfibers,Medialcrus,腹股溝管皮下環(huán)superficialinguinalring:內(nèi)側(cè)腳medialcrus、外側(cè)腳lateralcrus、腳間纖維intercruralfibers.,返轉(zhuǎn)韌帶reflectedligament、腹股溝韌帶inguinalligament、腔隙韌帶lacunarligament、恥骨梳韌帶pectinealligament,腹股溝韌帶inguinalligament、腔隙韌帶lacunarligament、恥骨梳韌帶pectinealligament,（2）腹內(nèi)斜肌及其腱膜internalobliquemuscle&aponeurosis：參與構(gòu)成腹直肌鞘前、后層，結(jié)合腱和提睪肌。,Internalobliquemuscle,Internalobliquem.aponeurosis,Transversusabdominis,aponeurosis,Transversusabdominis,（3）腹橫肌及其腱膜transversusmuscle&aponeurosis：參與構(gòu)成腹直肌鞘前層（弓狀線以下）、后層（弓狀線以上），結(jié)合腱和提睪肌。,提睪肌Cremastermuscle,腹股溝鐮I(yíng)nquinalfalx聯(lián)合腱Conjoinedtendon,腹橫肌下緣,腹內(nèi)斜肌及其腱膜和腹橫肌及其腱膜形成的結(jié)構(gòu),Rectussheath,posteriorlayer,腱劃tendinousintersections,Rectusabdominis,弓狀線Arcuateline,Pyramidalm.,（4）腹直肌rectusabdominis（5）錐狀肌pyramidalmuscle,tendinousintersections,Rectussheath,anteriorlayer,腹直肌鞘,腹直肌鞘rectussheath,腹直肌鞘Rectussheath,腹直肌鞘包繞腹直肌，由腹外側(cè)壁三個(gè)扁肌的腱膜構(gòu)成，分為前、后兩層。在弓狀線以上：腹直肌鞘前層anteriorlayeroftherectussheath由腹外斜肌腱膜和腹內(nèi)斜肌腱膜前層構(gòu)成；腹直肌鞘后層posteriorlayeroftherectussheath由腹內(nèi)斜肌腱膜的后層和腹橫肌腱膜構(gòu)成。在弓狀線以下：腹直肌鞘前層由三個(gè)扁肌的腱膜構(gòu)成；腹直肌鞘后層缺如。,2.血管、淋巴及神經(jīng)Vessels,LymphandNerve,(1)動(dòng)脈,(2)靜脈,(3)神經(jīng),3.腹橫筋膜,TransversalisFascia,腹橫筋膜Transversefascia,精索內(nèi)筋膜internalspermaticfascia,腹股溝深環(huán)deepinguinalring窩間韌帶interfoveolarligament,腹橫筋膜Transversefascia,腹前壁內(nèi)面的皺襞及凹窩,4.壁腹膜Parietalperitoneum,5.腹前壁手術(shù)常用切口,Thoracoabdominalincision,Superiormedianincision,Transrectusincision,Pararectusincision,Paramedianincision,Subcostalincision,Superiortransverseincision,McBurneysincision,Inferiormedianincision,Inferiortransverseincision,Abovethearcuateline,Belowthearcuateline,四、腹股溝區(qū)TheInguinalRegion,境界Theboundary層次與特點(diǎn)Thelayersandcharacteristics腹股溝管Theinguinalcanal腹股溝三角Theinguinaltriangle疝hernias：腹股溝直疝D(zhuǎn)irectinguinalhernias、腹股溝斜疝indirectinguinalhernias、股疝femoralhernias,（一）境界Boundary,1.皮膚skin2.淺筋膜superficialfascia3.腹外斜肌aponeurosisofexternalobliquusabdominis,（二）腹股溝區(qū)層次結(jié)構(gòu)TheLayersoftheInguinalRegion,4.髂腹下神經(jīng)Iliohypogastricn.和髂腹股溝神經(jīng)ilioinguinaln.5.腹內(nèi)斜肌Obliquusinternusabdominis6.腹橫肌Transversusabdominis,（二）腹股溝區(qū)層次結(jié)構(gòu)TheLayersoftheInguinalRegion,7.腹橫筋膜Transversefascia8.腹膜外筋膜Extraperitonealfascia9.腹璧下動(dòng)脈Inferiorepigastrica.and旋髂深動(dòng)脈deepcircumflexiliaca.10.璧腹膜Parietalperitoneum,特點(diǎn)：腹外斜肌在此區(qū)移行為腱膜，并在下部形成一裂口(淺環(huán))；腹內(nèi)斜肌與腹橫肌的下緣未達(dá)腹股溝韌帶的內(nèi)側(cè)部，兩者間無(wú)肌層覆蓋；有精索或子宮圓韌帶通過(guò)，形成了一潛在性裂隙；在人體站立時(shí)，該區(qū)所承受的腹內(nèi)壓力比平臥時(shí)高3倍。因此，腹股溝區(qū)為腹壁的薄弱區(qū)，是腹壁疝的多發(fā)部位。,（三）腹股溝管Theinguinalcanal,位置Position通過(guò)的結(jié)構(gòu)Structurespassingthroughit兩口、四璧Twoopeningandfourwalls精索Formingofthespermaticcord腹股溝斜疝Indirectinguinalhernia,（三）腹股溝管InguinalCanal,1.位置2.內(nèi)容3.構(gòu)成4.臨床意義,Theinguinalcanalisanoblique,inferomediallypassage(betweenthesuperficialanddeepinguinialrings)throughtheinferiorpartoftheanteriorabdominalwall),35cmlong.Theinguinalcanalliesparallelandjustsuperiortothemedialhalfoftheinguinalligament.,Themainoccupantoftheinguinalcanalisthespermaticcordinmalesandtheroundligamentoftheuterusinfemales.Italsocontainsbloodandlymphaticvesselsandtheilioinguinalnerveinbothsexes.,Thedeep(internal)inguinalring,entrancetoinguinalcanal,isanoutpouchingofthetransversalisfasciaapproximately1.25cmsuperiortothemiddleoftheinguinalligamentandlateraltotheinferiorepigastricvessels.,Theanteriorwalloftheinguinalcanalisformedbytheexternalobliqueaponeurosisthroughoutthelengthofthecanal,withtheanteriorwallofthelateralpartofthecanalbeingreinforcedbyfibersofinternusoblique.,Theposteriorwalloftheinguinalcanalisformedbythetransversalisfasciawiththeposteriorwallofthemedialpartofthecanalbeingreinforcedtheconjointtendon.,Roof(superiorwall)isformedbythearchingfibersoftheinternalobliqueandtransverseabdominalmuscles.Floor(inferiorwall)isformedbytheinguinalligament.,Thesuperficial(external)inguinalring-exitfrominguinalcanal-isaslitlikeopeningbetweenthediagonalfibersoftheaponeurosisfotheexternaloblique,superolateraltothepubictubercle.,腹股溝三角InguinalTriangle（海氏三角Hesselbachstriangle）,構(gòu)成：腹壁下動(dòng)脈、腹直肌外側(cè)緣和腹股溝韌帶內(nèi)側(cè)半所圍成的三角形區(qū)域。臨床意義：由腹股溝三角突出的疝，稱腹股溝直疝。,腹股溝三角,腹股溝直疝、腹股溝斜疝、股疝,IndirectHernia,DirectHernia,股疝femoralhernia,睪丸下降過(guò)程,卵巢下降過(guò)程,睪丸下降過(guò)程descendingprocessofthetestis,先天性腹股溝斜疝Acongenitalindirectinguinalhernia,后天性腹股溝斜疝Aacquiredindirectinguinalhernia,先天性腹股溝斜疝Acongenitalindirectinguinalhernia,后天性腹股溝斜疝Aacquiredindirectinguinalhernia,精索的被膜與腹前外側(cè)壁層次的關(guān)系,精索或睪丸被膜與腹前外側(cè)壁層次的關(guān)系,解剖與觀察DissectionandObservation,淺層結(jié)構(gòu)superficialstructures三層闊肌、血管和神經(jīng)Threeflatmuscles,vesselsandnerves腹直肌rectusabdominis腹直肌rectussheath腹股溝區(qū)inguinalregion腹股溝管inguinalcanal腹股溝三角inguinaltriangle,1.切口Incision,2.將皮瓣翻向外側(cè)reflectskinflapslaterally.,3.Identifythefattylayerofthesuperificialfascia.,4.Identifythesuperficialepigastricvessels.,5.Removethesuperficialfascia.,6.Identifythemembranouslayerofthesuperficialfascia.,7.Identifyseveralanteriorcutaneousbranchesofthelowestfiveintercostalnerves(T7T11)andthesubcostalnerve(T12).,8.Identifytheterminalbranchesoftheiliohypogastricnerve(L1)andtheilioinguinalnerve(L1).,9.Removedeepinvestingcoveringtheexternalabdominalobliquemuscle.10.Identifythedirectionofthefibersandtheaponeurosisoftheexternalabdominalobliquemuscle.,11.Identifytheinguinalligament,thesuperficialinguinalring,themedialcrus,thelateralcrusandtheintercruralfibers.,12.Reflecttheexternalabdominalobliqueandexposetheinternalabdominaloblique.Reflecttheinternalabdominalobliqueandexposethetransversalismuscle.13.Identifythevesselsand