《腹壁解剖及操作》課件

1、腹壁解剖及操作,局部解剖學(xué)（十四）,腹部的局部解剖與操作（1）,腹壁解剖及操作,主要內(nèi)容 Main Content,境 界 與 分 區(qū) The boundary and region 表 面 解 剖 The surface anatomy 腹 前 外 側(cè) 壁 The Anterolateral Abdominal Wall,腹壁解剖及操作,一、境界與分區(qū)Boundary and Region,腹壁解剖及操作,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。,腹壁解剖及操

2、作,2. (固有)腹腔的境界,上界：膈 下界：骨盆上口,腹壁解剖及操作,3A. 腹部的分區(qū),(九分法),腹壁解剖及操作,3B. 腹部的分區(qū),(四分法),腹壁解剖及操作,二、表 面 解 剖The Surface Anatomy,體表標(biāo)志 Surface landmark 表面投影 Surface projection,腹壁解剖及操作,Xiphoid process劍 突,Costal arch肋 弓,Iliac crest髂嵴,Anterior superior iliac spine 髂前上棘,Pubic tubercle 恥骨結(jié)節(jié),Superior edge of pubic symphys

3、is 恥骨聯(lián)合上緣,Pubic crest 恥骨嵴,1.骨性標(biāo)志,腹壁解剖及操作,2. 軟 組 織 標(biāo) 志,Location of inguinal ligament,腹壁解剖及操作,3.體表投影,腹壁解剖及操作,三、腹 前 外 側(cè) 壁The Anterolateral Abdominal Wall,淺層結(jié)構(gòu) Superficial structures 深層結(jié)構(gòu) Deep structures,腹壁解剖及操作,皮膚,淺筋膜,腹膜下筋膜,深筋膜和肌肉,The layers of the anterolateral abdominal wall,1.Skin 2.Superficial fasc

4、ia 3.Deep fascia and muscles 4.Transverse fascia 5.Extraperitoneal fascia 6.Parietal fascia,腹橫筋膜,壁腹膜,腹壁解剖及操作,（一）淺 層 結(jié) 構(gòu)The superficial structures,皮膚 Skin 淺筋膜 Superficial fascia,腹壁解剖及操作,1. Skin: thinner and more elastic 薄而富有彈性,腹壁解剖及操作,2. Superficial fascia：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

5、分為兩層：淺層稱為 Campers fascia,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)；,腹壁解剖及操作,深層稱為Scarpa fascia，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,腹壁解剖及操作,淺 筋膜,Skin,Superficial fasica,Scarpas fascia,Muscles of anterior abdominal,Campers fascia,Transversalis fascia,wall,

6、腹壁解剖及操作,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 laye

7、r, 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 su

8、perficial fascia of the perineum (Colles fascia).,腹壁解剖及操作,淺動(dòng)脈、淺靜脈、皮神經(jīng),腹壁解剖及操作,髂腹股溝區(qū)和下腹部的皮瓣 The ilioinguinal and the lower abdominal flaps,腹壁解剖及操作,（二）深層結(jié)構(gòu) The Deep Structures,肌肉層次 Muscular layer 血管、淋巴及神經(jīng) Vessels, lymph and nerve 腹橫筋膜 Transversalis fascia 腹膜下筋膜 Extraperitoneal fascia 壁腹膜 Parietal peri

9、toneum,腹壁解剖及操作,1. 肌層 The Muscular layer,前外側(cè)群 The Anterolateral Group The three flat muscles are the: 腹外斜肌 external oblique muscle 腹內(nèi)斜肌 internal oblique muscle 腹橫肌 transversus abdominis： 腹直肌 rectus abdominis 錐狀肌 pyramidalis,腹壁解剖及操作,（1）腹外斜肌 external oblique muscle,腹股溝管皮下環(huán) superficial inguinal ring:內(nèi)側(cè)腳

10、medial crus、外側(cè)腳lateral crus、腳間纖維intercrural fibers.,腹外斜肌 External oblique,腹外斜肌腱膜 External oblique，aponeurosis,Intercrural fibers,Medial crus,腹壁解剖及操作,腹股溝管皮下環(huán) superficial inguinal ring:內(nèi)側(cè)腳medial crus、外側(cè)腳lateral crus、腳間纖維intercrural fibers.,返轉(zhuǎn)韌帶reflected ligament、腹股溝韌帶inguinal ligament、腔隙韌帶lacunar liga

11、ment、恥骨梳韌帶pectineal ligament,腹壁解剖及操作,腹股溝韌帶inguinal ligament、腔隙韌帶lacunar ligament、恥骨梳韌帶pectineal ligament,腹壁解剖及操作,（2）腹內(nèi)斜肌及其腱膜 internal oblique muscle & aponeurosis ：參與構(gòu)成腹直肌鞘前、后層，結(jié)合腱 和提睪肌。,Internal oblique muscle,Internal oblique m. aponeurosis,腹壁解剖及操作,Transversus abdominis, aponeurosis,Transversus ab

12、dominis,（3）腹橫肌及其腱膜 transversus muscle & 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。,腹壁解剖及操作,提睪肌 Cremaster muscle,腹股溝鐮I(yíng)nquinal falx 聯(lián)合腱 Conjoined tendon,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),腹壁解剖及操作,Rectus sheath, posterior layer,腱 劃 tendinous intersections,Rectus abdominis,弓狀線 Arcuate line,Pyramidal m.

13、,（4）腹直肌 rectus abdominis （5）錐狀肌 pyramidal muscle,tendinous intersections,Rectus sheath, anterior layer,腹壁解剖及操作,腹直肌鞘,腹壁解剖及操作,腹直肌鞘 rectus sheath,腹壁解剖及操作, 腹直肌鞘 Rectus sheath,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 anterior layer of the rectus sheath 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 posterior layer o

14、f the rectus sheath 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。,腹壁解剖及操作,2.血管、淋巴及神經(jīng)Vessels, Lymph and Nerve,腹壁解剖及操作,(1)動(dòng)脈,腹壁解剖及操作,腹壁解剖及操作,(2)靜脈,腹壁解剖及操作,(3)神經(jīng),腹壁解剖及操作,3.腹橫筋膜,Transversalis Fascia,腹壁解剖及操作,腹橫筋膜 Transverse fascia,精索內(nèi)筋膜internal spermatic fascia,腹壁解剖及操作,腹股溝深環(huán)deep inguinal ring 窩

15、間韌帶 interfoveolar ligament,腹橫筋膜 Transverse fascia,腹壁解剖及操作,腹前壁內(nèi)面的皺襞及凹窩,4. 壁腹膜 Parietal peritoneum,腹壁解剖及操作,5. 腹前壁手術(shù)常用切口,Thoracoabdominal incision,Superior median incision,Transrectus incision,Pararectus incision,Paramedian incision,腹壁解剖及操作,Subcostal incision,Superior transverse incision,McBurneys inci

16、sion,Inferior median incision,Inferior transverse incision,腹壁解剖及操作,Above the arcuate line,Below the arcuate line,腹壁解剖及操作,四、腹 股 溝 區(qū)The Inguinal Region,境界 The boundary 層次與特點(diǎn) The layers and characteristics 腹股溝管 The inguinal canal 腹股溝三角 The inguinal triangle 疝 hernias ：腹股溝直疝 Direct inguinal hernias 、腹股溝

17、斜疝 indirect inguinal hernias、股疝 femoralhernias,腹壁解剖及操作,（一）境界 Boundary,1. 皮膚 skin 2. 淺筋膜 superficial fascia 3. 腹外斜肌 aponeurosis of external obliquus abdominis,（二）腹股溝區(qū)層次結(jié)構(gòu) The Layers of the Inguinal Region,腹壁解剖及操作,4. 髂腹下神經(jīng) Iliohypogastric n. 和髂腹股溝神經(jīng) ilioinguinal n. 5. 腹內(nèi)斜肌 Obliquus internus abdominis

18、6. 腹橫肌 Transversus abdominis,（二）腹股溝區(qū)層次結(jié)構(gòu)The Layers of the Inguinal Region,腹壁解剖及操作,7. 腹橫筋膜 Transverse fascia 8. 腹膜外筋膜 Extraperitoneal fascia 9. 腹璧下動(dòng)脈Inferior epigastric a. and 旋髂深動(dòng)脈 deep circumflex iliac a. 10.璧腹膜 Parietal peritoneum,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

19、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。,腹壁解剖及操作,（三）腹股溝管The inguinal canal,位置 Position 通過(guò)的結(jié)構(gòu) Structures passing through it 兩口、四璧 Two opening and four walls 精索 Forming of the spermatic cord 腹股溝斜疝 Indirect inguinal hernia,腹壁解剖及操作,（三）腹股溝管 Inguinal Canal,1.位置 2.內(nèi)容 3.構(gòu)成 4.臨床意義

20、,腹壁解剖及操作,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

21、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.,腹壁解剖及操作,腹壁解剖及操作,The deep ( internal ) inguinal ring, entrance to inguinal canal , is an outpouching of the tran

22、sversalis 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 o

23、f 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 intern

24、al 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 tuberc

25、le.,腹壁解剖及操作,腹股溝三角 Inguinal Triangle （海氏三角 Hesselbachs triangle）,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。,腹壁解剖及操作,腹股溝三角,腹股溝直疝、腹股溝斜疝、股疝,腹壁解剖及操作,Indirect Hernia,Direct Hernia,股疝 femoral hernia,腹壁解剖及操作,睪丸下降過(guò)程,腹壁解剖及操作,卵巢下降過(guò)程,腹壁解剖及操作,睪丸下降過(guò)程 descending process of the testis,腹壁解剖及操作,先天性腹股溝斜

26、疝 A congenital indirect inguinal hernia,后天性腹股溝斜疝 A acquired indirect inguinal hernia,腹壁解剖及操作,先天性腹股溝斜疝 A congenital indirect inguinal hernia,后天性腹股溝斜疝 A acquired indirect inguinal hernia,腹壁解剖及操作,精索的被膜與腹前外側(cè)壁層次的關(guān)系,腹壁解剖及操作,精索或睪丸被膜與腹前外側(cè)壁層次的關(guān)系,腹壁解剖及操作,解剖與觀察Dissection and Observation,淺層結(jié)構(gòu) superficial struct

27、ures 三層闊肌、血管和神經(jīng) Three flat muscles , vessels and nerves 腹直肌 rectus abdominis 腹直肌 rectus sheath 腹股溝區(qū) inguinal region 腹股溝管 inguinal canal 腹股溝三角 inguinal triangle,腹壁解剖及操作,1.切口 Incision,腹壁解剖及操作,2.將皮瓣翻向外側(cè) reflect skin flaps laterally.,腹壁解剖及操作,3. Identify the fatty layer of the superificial fascia.,腹壁解剖及操

28、作,4.Identify the superficial epigastric vessels.,腹壁解剖及操作,5.Remove the superficial fascia.,腹壁解剖及操作,6. Identify the membranous layer of the superficial fascia.,腹壁解剖及操作,7. Identify several anterior cutaneous branches of the lowest five intercostal nerves (T7T11)and the subcostal nerve (T12).,腹壁解剖及操作,8.

29、 Identify the terminal branches of the iliohypogastric nerve (L1) and the ilioinguinal nerve (L1).,腹壁解剖及操作,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.,腹壁解剖及操作,11.Identif

30、y the inguinal ligament, the superficial inguinal ring, the medial crus, the lateral crus and the intercrural fibers.,腹壁解剖及操作,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.,腹壁解剖及操作,14.Cut thr