气管前筋膜的再认识及其在甲状腺癌手术中的意义

目的从应用解剖学的角度重新认识气管前筋膜及其周围间隙,为甲状腺癌手术提供解剖学依据。方法对福尔马林固定的尸体标本进行解剖以及术中甲状腺癌患者的气管前筋膜进行观察,观察气管前筋膜及气管前间隙的特点。结果气管前筋膜分为前后两层,两层筋膜之间是甲状腺峡部、脂肪、气管前淋巴结、甲状腺最下动脉、胸腺,甲状腺下静脉等。前层筋膜与舌骨下肌筋膜之间存在一间隙,为舌骨下肌后间隙;后层筋膜与气管之间存在一个无血管的间隙,为气管前间隙,该间隙向下通向纵膈,向上经甲状腺峡部后方通向喉前,向两侧延伸至气管食管沟。结论气管前筋膜分为前后两层,分离显露甲状腺及气管前脂肪淋巴组织时应该保持气管前筋膜前层的完整性;气管前间隙是处理峡部和气管前淋巴结的外科层面。     

腹膜后间隙筋膜分层及筋膜间隙的临床解剖学研究

目的:观察研究肾周腹膜后间隙的筋膜分层及筋膜间隙.方法:综合采用微创解剖、断层解剖、影像解剖和临床腹腔镜手术研究.包括断层标本1例;新鲜冰冻尸体手术解剖3例(左侧模拟腹腔镜左肾游离手术,右侧模拟开放肾游离手术);CT/MRI肾、肾上腺平扫十三维重建25例;腹腔镜手术55例.结果:肾前筋膜分3层,包括结肠融合筋膜、肾前融合筋膜和肾筋膜前叶.肾后筋膜分两层,包括侧锥筋膜和肾筋膜后叶.肾前、后筋膜光滑延续,形成肾筋膜间隙,其内容纳肾周脂肪、肾和肾盂输尿管鞘.肾盂输尿管鞘内容纳肾盂输尿管和肾盂输尿管周围脂肪.侧锥筋膜与腹横筋膜形成肾旁间隙,其内填充肾旁脂肪.肾前融合筋膜、腰肌筋膜和侧锥筋膜包绕形成肾周间隙,该间隙包括肾筋膜间隙及其上、下方的肾上腺间隙和生殖血管间隙.结肠系膜的脏腹膜和结肠融合筋膜形成结肠间隙.胰十二指肠前、后融合筋膜形成胰十二指肠间隙.肾周间隙和肾旁间隙为原生腹膜后间隙,胰十二指肠间隙和结肠间隙为次生腹膜后间隙.结论:肾前、后筋膜均为多层膜结构.腹膜后间隙借各层筋膜形成层叠状的空间.     

翼状筋膜解剖学研究进展及其在甲状腺外科膜解剖中的意义

翼状筋膜是连接两侧颈动脉鞘的冠状位走行的筋膜。目前翼状筋膜在甲状腺外科中的研究较少,本文通过检索国内外文献对翼状筋膜的相关解剖研究进展进行综述,探讨翼状筋膜在甲状腺系膜膜解剖中的意义及其在右侧喉返神经保护、右侧中央区淋巴结清扫中的作用。     

腹腔镜下远端胃癌根治术中胃背系膜及系膜间隙的解剖形态特点

目的:探讨腹腔镜胃癌根治术中相关系膜及系膜间隙的镜下解剖学特点,为腹腔镜下解剖定位和操作入路提供解剖学依据。方法:通过大体解剖观察并在腹腔镜下于新鲜尸体标本上模拟进展期胃癌根治术,对胚胎期胃背系膜形成的胰腺筋膜、胃脾韧带和腹后壁筋膜间隙在腹腔镜下的解剖层次和形态特点进行观察和描述。结果:胃背系膜后层衍化形成的胃脾韧带、胰腺筋膜、胰十二指肠筋膜和横结肠系膜前叶是相互延续的一个整体;胰腺前筋膜形成的胃胰襞和肝胰襞是镜下确定胃左血管根部和肝总动脉的解剖标志;胰腺后筋膜与肾前筋膜之间的融合筋膜间隙是进行胰后淋巴结清扫的安全平面,而肾前筋膜是确保安全操作平面的后界。结论:(1)胚胎时期由于肠管旋转形成胃周广泛存在的筋膜和筋膜间隙,是腹腔镜胃癌根治术中进行解剖定位、系膜游离和淋巴结清扫的关键;(2)循筋膜间隙进行分离有助于提高腹腔镜下操作的安全性和根治的彻底性;建立腹腔镜下筋膜层次解剖的整体观念可为腹腔镜手术的设计和规范提供形态学依据。     

两种经口腔镜下甲状腺切除手术入路的解剖学比较研究

目的　探讨经口入路腔镜下甲状腺切除术不同手术路径的解剖学结构,评价手术的安全性和可行性。  方法　对5具新鲜人体标本口底结构进行解剖,明确经口颈前正中路径（eMIT）和经口气管旁路径（TOPP）的解剖通路及其相关结构,模拟经口入路腔镜下甲状腺切除术,术后观察相关解剖结构的损伤情况。   结果　eMIT经口底肌中线能够顺利到达颈前区,手术路径无重要血管、神经组织。口腔前庭切口需注意颏神经的保护。TOPP术中需注意舌下神经的保护。eMIT和TOPP均能成功实施甲状腺切除,术后解剖标本观察,无重要神经、血管等相关解剖结构损伤。TOPP手术创伤更小,但限于单侧手术,手术视野小,手术耗时（3h）较eMIT（1h）明显延长,对手术技术及器械要求较高。  结论　经口入路腔镜下甲状腺切除术具有解剖学的安全性和可行性,合理地选择手术路径是手术成功的关键因素。eMIT目前更适合临床推广。     

直肠系膜的形态学特点及其临床意义

目的：以直肠系膜为中心，探讨直肠癌手术切除术的最佳的解剖层次。方法：应用尸体标本27例、新鲜尸体标本10例、临床取材标本10例，分别进行解剖、测量及灌注。结果：直肠系膜是由直肠周围包裹在盆脏筋膜周围之内的脂肪组织、神经、血管、淋巴管等组成。直肠系膜上端与乙状结肠系膜相连续，下端与直肠肛管相连接，盆腔内的生殖管道，髂内血管，盆自主神经及盆腔侧壁的肌肉均为壁层筋膜覆盖，外面是一层光滑的盆脏筋膜，长8～10cm，宽6～8cm，直视下清晰可见脂肪、毛细血管等。结论：直肠系膜是被盆筋膜脏层完整地包裹着的脂肪、血管和淋巴即称为直肠系膜，是一独立的解剖单位；从常规病理可见直肠系膜是由脂肪、血管和淋巴组织组成；MRI及VCH上直肠系膜清晰可见。     

前列腺周围筋膜及其毗邻结构的三维断层解剖研究

目的阐明前列腺周围筋膜及其毗邻结构的形态特点,为前列腺癌根治术手术分离平面的选择提供解剖学基础。方法 6例福尔马林固定的成年男性盆腔标本,制成横、矢、冠状连续断层切片,观察前列腺周围筋膜及其毗邻结构的形态学特点。结果①盆腔壁层筋膜在前列腺前方增厚形成耻骨前列腺韧带;背深静脉复合体位于两侧耻骨前列腺韧带之间、耻骨尿道韧带之上,前缘与前列腺筋膜、后缘与前列腺连接紧密;前列腺筋膜前方为填充脂肪组织的耻骨后间隙。②前列腺包囊、前列腺静脉丛和前列腺筋膜三者在前列腺两侧相互融合形成前列腺纤维鞘,纤维鞘内侧缘与前列腺连接紧密,外侧缘与盆腔壁层筋膜之间为一疏松的、无血管神经的筋膜间隙。③Denonvilliers筋膜和直肠固有筋膜在前列腺后方构成直肠膀胱隔,两层筋膜之间为一无血管神经的间隙;在前列腺后外侧,两层筋膜分离走行,与外侧的盆腔壁层筋膜构成神经血管束三角。结论前列腺根治术手术中紧贴前列腺筋膜和Denonvilliers筋膜的外侧面分离,有利于减少手术中神经、血管的损伤。     

腹腔镜下腹膜后筋膜间隙外科平面的解剖观察

目的 探讨在腹腔镜下升、降结肠或肾切除术相关的腹膜后筋膜和筋膜间隙的解剖学特点及毗邻关系,以便正确地寻找、识别和选择安全的筋膜间隙外科平面. 方法在腹腔镜下对5具成人新鲜腹部标本,30例腹腔镜下升、降结肠切除术和95例肾切除术中的腹膜后筋膜和筋膜间隙的位置、沟通和毗邻关系进行了观察.结果升、降结肠外侧缘的脏腹膜与壁腹膜之间有一条黄白交界线,沿此线切开腹膜、腹膜外组织,即可显露深面的融合筋膜.融合筋膜与肾前筋膜之间的潜在间隙为融合筋膜间隙.切开融合筋膜,沿此间隙向内分离,可将升结肠或降结肠及原始结肠系膜向内翻起,完成结肠游离;或显露后方的肾前筋膜.肾前筋膜、融合筋膜外侧部与侧锥筋膜之间的间隙为肾旁前筋膜间隙;肾后筋膜、侧锥筋膜与腰方肌筋膜之间的间隙为肾旁后筋膜间隙.肾旁前筋膜间隙与融合筋膜间隙和肾旁后筋膜间隙沟通,通过这些间隙分离,可将肾安全游离. 结论 黄白交界线为进入融合筋膜间隙的标志,融合筋膜间隙及肾旁前、后筋膜间隙内无重要血管,易于辨认和分离,为腹腔镜下升、降结肠或肾游离的理想外科平面.     

腹腔镜右半结肠切除术中完整结肠系膜切除的解剖学观察

目的探讨腹腔镜右半结肠切除术中完整结肠系膜切除(CME)的相关筋膜和间隙的局部解剖特点。方法采用尸体解剖和活体观察的方法描述和总结相关系膜、筋膜、间隙的解剖学特点。结果肠系膜上静脉是实施腹腔镜中间入路CME法的右半结肠切除术的解剖标志。其中主要的系膜为右半结肠系膜和回肠系膜,筋膜包括肾前筋膜及胰前筋膜,筋膜之间构成重要的解剖间隙为右结肠后间隙和横结肠后间隙,二者之间的融合筋膜间隙为手术的天然平面。结论腹腔镜右半结肠切除术中CME的腹腔系膜、筋膜和间隙组成的天然外科平面统一于结肠系膜与肾前筋膜之间,该术式临床上是可行的。     

腹横筋膜与腹膜前疝修补术103例分析

目的重新认识腹横筋膜的解剖特点,从解剖学角度探讨腹膜前疝修补术的合理性。方法对术中腹横筋膜以及腹膜前间隙的解剖观察,回顾性分析腹膜前修补腹股沟疝103例的临床资料。结果耻骨肌孔由腹横筋膜的前层覆盖,腹横筋膜由两层构成,腹壁下血管位于两层之间。3种方法放置的补片在不同的腹膜前间隙覆盖耻骨肌孔。103例均成功,无切口感染、髂腹股沟神经痛病例。术后随访1～6年无复发。结论从解剖学特点看,覆盖耻骨肌孔的腹膜前疝修补具有合理性。前后入路腹膜前疝修补补片放置的间隙不同。     

颈中央区淋巴结数目及分布的临床解剖学研究

目的　探讨颈中央区淋巴结的数目及分布规律。 方法　回顾分析2013年6月-2016年6月在我科行中央区淋巴结清扫术的甲状腺乳头状癌患者的临床资料。统计分析颈部中央区及各亚区淋巴结的数目。 结果　双侧中央区淋巴结(9.86±3.36) 枚（4~20枚）。左侧中央区淋巴结(6.24±2.23) 枚（2~14枚）。右侧中央区淋巴结(7.77±2.79) 枚（2~15枚）。喉前区淋巴结(1.29±0.75) 枚（0~4枚）,气管前区(2.62±1.26) 枚（0~7枚）,左侧气管旁区(2.38±1.34) 枚（0~6枚）,右侧气管旁区(3.97±1.97) 枚（0~10枚）。四个亚区淋巴结比例分别为：12.69%,24.47%,24.15%,38.47%。其中右侧气管旁区的两个亚区右侧喉返神经外侧区(1.35±1.27) 枚（0~6枚）,右侧喉返神经内侧区(2.64±1.75) 枚（0~9枚）。 结论　本研究报道颈中央区淋巴结的数目及分布结果,可为外科医生在行颈中央区淋巴结清扫术时提供解剖学依据。     

甲状腺的淋巴流向

在５０例新鲜童尸上，用普鲁士兰氯仿溶液向甲状腺实质内注射后，观察该器官的淋巴液向，甲状腺的淋巴管从器官内器官表面形成淋巴管网。自淋巴管网发出的淋巴管向外侧、向上、向下走行，注入颈内静脉淋巴结，喉前淋巴结，气管旁淋巴结和气管前淋巴结。     

A detailed appraisal of mesocolic lymphangiology – an immunohistochemical and stereological analysis

Inadequate resection of the adjoining mesentery is associated with adverse outcome for colon cancer. Disruption of the integrity of the mesenteric lymphatic package has been implicated in this, though not proven. Recent studies have determined mesenteric anatomy and histology and now provide an opportunity to determine accurately the distribution of lymphatic vessels. The aim of this study was to characterise the distribution of the lymphatic vessels (LV) within the small intestinal and colonic mesentery, and in Toldt's fascia, which lies between the mesocolon and underlying retroperitoneum. Mesenteric samples were harvested from 12 human cadavers. Samples were taken from the small bowel mesentery, ascending, transverse, descending mesocolon and from both apposed and non‐apposed portions of the mesosigmoid. Serial sections were stained immunohistochemically with monoclonal antibody D2‐40 (podoplanin), and Masson's Trichrome. Lymphatic vessel (LV) density and radius of diffusion were determined using a stereological approach. A lymphatic network was embedded within the mesenteric connective tissue lattice throughout each mesenteric region. LV were identifiable within the submesothelial connective tissue where they measured 10.2 ± 4.1 μm in diameter and had an average radius of diffusion of 174.72 ± 97.68 μm. Unexpectedly, LV were identified in Toldt's fascia, where they measured 4.3 ± 3.1 μm in diameter and had a radius of diffusion of 165.12 ± 66.26 μm. This is the first study systematically to determine and quantify the distribution of lymphatic vessels within the mesenteric organ and to demonstrate the presence of such vessels within Toldt's fascia. A rich lymphatic network occupies all levels of the mesenteric connective tissue lattice. Within the latter, they are found within 0.1 mm of peritonealised mesenteric surfaces and are separated by an average distance of 0.17 mm and may be particularly vulnerable during surgery.     

肾前筋膜间平面无血腹腔镜上尿路手术入路精准解剖与技巧

目的　探讨肾前筋膜间平面无血腹腔镜上尿路手术入路精准解剖与技巧（Inter-prerenal-fascia planes in urological laparoscopic operations,IpULO）。 方法　采用尸体解剖、320排CT影像解剖研究及临床病例活体腹腔镜手术研究,对IpULO手术中肾前筋膜间平面相关解剖标志在腹腔镜下的形态特点进行观察研究。 结果 肾前筋膜间平面是肾前间隙多层次的无血管筋膜结构,层面间充满蜘蛛丝网格状白色纤维组织,在IpULO手术过程中存在7个重要的外科平面：Told’t 筋膜间平面、结肠融合筋膜肾前融合筋膜间平面、结肠融合筋膜胰十二指肠前融合筋膜间平面、胰十二指肠后融合筋膜肾前融合筋膜间平面、肾前融合筋膜肾筋膜前叶间平面、肾筋膜前叶肾脂肪囊外平面、肾前肾筋膜前叶下平面。 结论 IpULO手术是基于层面外科的精准解剖入路,肾前筋膜间平面是IpULO手术的重要解剖层面,术中能推窗见景,避免解剖迷失。     

胰周筋膜及筋膜间隙CT影像的解剖观察及临床意义

目的　探讨腹部CT影像胰周筋膜及胰周的筋膜间隙与新鲜成人尸体标本胰周筋膜与筋膜间隙相互对应关系,从而对微创胰腺外科相关的手术提供指导意义。 方法　本研究选取惠东县人民医院经临床确诊的急性胰腺炎病例156例,对其腹部CT扫描的胰周影像特点进行归纳总结。同时选取南方医科大学解剖教研室提供的5具新鲜成人尸体标本进行解剖,明确腹部CT影像胰周筋膜及筋膜间隙与尸体标本的对应关系。 结果　在少数急性胰腺炎患者腹部CT扫描影像上和新鲜成人尸体标本上可同时观察到胰腺前筋膜、胰腺后筋膜、肾前筋膜,左右肾前筋膜是相互延续的。胰前间隙位于胰腺实质和其前方的胰腺前筋膜之间,胰后间隙位于胰腺实质和其后方的胰腺后筋膜之间,胰腺后融合筋膜间隙位于胰腺后筋膜和肾前筋膜之间。 结论　少数急性胰腺炎患者的腹部CT扫描影像上能观察到胰周筋膜与胰周的筋膜间隙,与新鲜成人尸体标本存在着相互对应关系。     

小隐静脉旁淋巴管的应用解剖

目的　研究小隐静脉旁淋巴管的解剖特征,为临床应用提供解剖学基础。  方法　成人新鲜尸体3具,截取3对下肢。外踝后皮内注入少量双氧水,真皮下找到淋巴管,将显影剂经30G注射针注入,使其显影,追踪并显示小隐静脉旁淋巴管的走行,同时进行拍照及X线摄像,依次到达小腿及腘窝。  结果　小隐静脉旁均可见内侧支和外侧支集合淋巴管,有的始于外踝后区真皮下,有的始于小腿后下部。淋巴管沿小隐静脉两侧蜿蜒曲折向心性走行,管间有分支相连接。近腘窝时,淋巴管与小隐静脉一起穿过深筋膜进入腘窝,然后发出多个小分支汇入淋巴结。此组淋巴管管径在0.3~1.5 mm之间,近侧较粗,远侧稍细。  结论　精确描述了下肢小隐静脉旁淋巴管的分布与走行,为临床应用提供重要的解剖学参考。     

甲状腺乳头状癌合并桥本氏甲状腺炎右侧喉返神经深层淋巴结转移情况分析

目的：探讨甲状腺乳头状癌（PTC）合并桥本氏甲状腺炎（HT）患者右侧喉返神经深层淋巴结（LN-prRLN） 的转移情况。方法： 选取本院2015 年7 月至2019 年12 月收治的123 例PTC合并HT及150 例单纯PTC病例为研究 对象,分为观察组、对照组。所有患者均行中央区淋巴结完整清扫,比较2 组颈部中央区淋巴结转移情况,分析 观察组不同临床病理特征患者LN-prRLN 转移率,采用多因素logistic 回归分析探讨观察组发生LN-prRLN 转移的 独立影响因素。结果：术后病理结果提示观察组、对照组中央区淋巴结转移率、LN-prRLN 转移总转移率、单纯 转移率,分别为43.1%、48.0%,26.8%、30.0%,4.9%、9.3%,2 组比较差异均无统计学意义。单因素分析表明 观察组癌灶最大径>2.0 cm、癌灶数量≥ 2 个、癌灶位于甲状腺下极、肿瘤侵犯包膜、甲状腺周围组织、中央区 淋巴结清扫总数≥ 5 枚、合并其他中央区淋巴结转移、颈侧区淋巴结转移患者LN-prRLN 转移发生率显著升高, 差异均有统计学意义。多因素logistic 回归分析结果表明,癌灶数量≥ 2 个与肿瘤侵犯包膜是观察组LN-prRLN 转 移发生的独立危险因素（OR=1.986、3.338）。结论：1/4 的PTC合并HT患者会出现LN-prRLN 转移,在清扫右侧 中央区淋巴结时应常规探查LN-prRLN,当癌灶数量≥ 2 个与肿瘤侵犯包膜时推荐尽量完整清扫LN-prRLN。     

Enhanced study of facial soft tissues using a novel large scale histology technique

The safety and effectiveness of facial cosmetic surgery procedures are dependent on detailed 3D understanding of the complex surgical anatomy of the face. Traditional, small sample size anatomical dissection studies have limitations in providing definitive clarification of the fascial layers of the face, and especially in their relationship with the facial nerve, and their reaction to surgical manipulation. The objective study of large tissue areas is required to effectively demonstrate the broader architecture. Conventional histology techniques were modified to handle extraordinarily large tissue samples to fulfill this requirement. Full-thickness soft tissue samples (skin to bone) of maximum length 18 cm, width 4 cm, and tissue thickness 1 cm, were harvested from 20 hemifaces of 15 fresh human cadavers (mean age at death = 81 years). After fixation, the samples were processed with an automated processor using paraffin wax for 156 h, sectioned at 30 μm, collected on gelatin-chromium-coated glass slides, stained with a Masson's Trichrome technique and photographed. Using this technique, excellent visualization was obtained of the fascial connective tissue and its relationship with the facial mimetic muscles, muscles of mastication and salivary glands in 73 large histological slides. The resulting slides improved the study of the platysma and superficial musculo-aponeurotic system (SMAS), the spaces and ligaments, the malar fat pad, and the facial nerve in relations to the deep fascia. Additionally, surgically induced changes in the soft-tissue organization were successfully visualized. This technique enables improved insight into the broad structural architecture and histomorphology of large-scale facial tissues.     

Suprahyoid neck fascial configuration,especially in the posterior compartment of the parapharyngeal space: A histological study using late‐stage human fetuses

The fascial configuration in the suprahyoid parapharyngeal space was evaluated using semiserial sagittal sections of 15 late‐stage human fetal heads. The prevertebral fascia covered the longus colli, longus capitis, and rectus capitis lateralis muscles, but was most evident along the longus colli muscle. The carotid sheath and its extension were located around the internal and external carotid arteries and the lower cranial nerves. The superior cervical ganglion was also inside the sheath. Even near full term, the fetal suprahyoid neck was short, with the jugular foramen and hypoglossal canal located at the posterolateral side of the oropharynx. Thus, the glossopharyngeal and accessory nerves ran across the upper part of the carotid sheath. Fasciae of the stylopharyngeus, styloglossus, and stylohyoideus muscles were attached to and joined the anterosuperior aspect of the carotid sheath. All these neurovascular and muscle sheaths are communicated with the visceral fascia covering the pharynx at multiple sites, and, together, they formed a mesentery‐like bundle. This communication bundle was made narrow by the anteriorly protruding longus capitis muscle. The mesentery‐like bundle was covered by the posterior marginal fascia of the prestyloid compartment of the parapharyngeal space. The external carotid artery ran on the lateral and posterior sides of the posterior marginal fascia. Consequently, the typical carotid sheath configuration was modified by muscle sheaths from the styloid process, communicated with the visceral fascia and, anteriorly, constituted the posterior margin of the prestyloid space. Clin. Anat. 2013. © 2012 Wiley Periodicals, Inc.     

家兔甲状腺的淋巴流向

用活体淋巴管注射法，研究了４０只家兔甲状腺的淋巴流向。甲状腺的集合淋巴管多是注入颈深淋巴结，一部分汇入喉腹侧淋巴结及气管旁淋巴结。在６例有一条集合淋巴管直入颈内静脉或静脉角。