腹壁解剖及操作ppt课件

.,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Campersfascia,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Scarpafascia，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,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).,.,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,McBurneysincision,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),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.,.,腹股沟三角InguinalTriangle（海氏三角Hesselbachstriangle）,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(T7T11)andthesubcostalnerve(T12).,.,8.Identifytheterminalbranchesoftheiliohypogastricnerve(L1)andtheilioinguinalnerve(L1).,.,9.Removedeepinvestingcoveringtheexternalabdominalobliquemuscle.10.Identifythedirectionofthefibersandtheaponeurosisoftheexternalabdominalobliquemuscle.,.,11.Identifytheinguinalligament,thesuperficialinguinalring,themedialcrus,thelateralcrusandtheintercruralfibers.,.,12.Reflecttheexternalabdominalobliqueandexposetheinternalabdominaloblique.Reflecttheinternalabdominalobliqueandexposethetransversalismuscle.13.Identifythevesselsan