直肠全系膜切除术中安全平面的解剖学观察

目的 明确直肠固有筋膜与周围结构的关系,寻找无血管、神经的间隙,为直肠全系膜切除术中＂安全平面＂的选择提供解剖学依据.方法 选择26例10%甲醛固定的成年男性盆腔标本进行研究,20例沿正中切开行局部解剖观察,6例行断层解剖观察.结果 直肠固有筋膜腹侧与Denonvilliers筋膜相邻,共同构成直肠膀胱隔,两者之间为无血管、神经的潜在间隙.直肠固有筋膜背侧与骶前筋膜水平走行,构成无血管、神经的骶前间隙,此间隙解剖变异较大,16例（80%）标本筋膜间隙明显,内有板层状直肠骶骨韧带走行（分层型） 4例（20%）无筋膜间隙,由肌肉样组织填充或骶前筋膜融合、增厚（融合型）.直肠固有筋膜外侧与盆腔壁层筋膜构成直肠外侧间隙,间隙内可见直肠侧韧带和盆腔神经丛,依据神经丛与直肠固有筋膜的关系分为紧密融合型（17例,85%）和疏松连接型（3例,15%）.结论 直肠腹侧的＂安全平面＂介于直肠固有筋膜与Denonvilliers筋膜之间,后外侧位于直肠固有筋膜与壁层筋膜之间.     

骶丛、坐骨神经盆腔段在磁共振神经成像术的解剖特征

[目的]应用磁共振神经成像序列,探讨骶丛、坐骨神经盆腔段MRI表现及解剖学特点。[方法]观察40例(80侧)健康成年志愿者骶丛、坐骨神经盆腔段在磁共振图像上的表现,并利用GE公司AW4.6工作站对磁共振3D-BRAVO序列、3D-FIESTA序列图像进行多平面重建(MPR),取得最佳显示层面,观察其影像学解剖特点。[结果] 3D-BRAVO序列、3D-FIESTA序列能够完成骶丛、坐骨神经盆腔段的显示,并且可以通过多平面重建清晰显示其与周围结构的毗邻关系。在MRI神经成像序列上测量双侧骶丛神经的长度,二者差异无统计学意义(P0.05)。测量双侧坐骨神经、梨状肌下孔的前后径、左右径,二者差异无统计学意义(P0.05)。[结论]利用MRI神经成像及多平面重建同层显示技术可以理想地显示骶丛、坐骨神经盆腔段的解剖特征,清晰地描述梨状肌下孔的形态及其毗邻结构组成。3D-BRAVO序列结合3D-FIESTA序列可以应用于外周神经的显示,对骶丛、坐骨神经正常解剖、相关病变的影像学诊断具有重要意义。     

陈旧性Denis Ⅱ型骶骨骨折合并骶神经损伤的诊断与治疗

目的：探讨陈旧性Denis Ⅱ型骶骨骨折合并骶神经损伤的诊断及手术方法。方法：取60具骶骨干标本及26具完整骨盆标本，测量S1棘突与S1后孔同位置关系、骶前区血管、骶神经及梨状肌之间关系；对14例陈旧性DenisⅡ型骶骨骨折合并骶神经损伤患者，在常规骨盆X线片，CT，螺旋CT三维重建的同时，又采用显示骶神经全长的骶骨斜冠状位MR扫描，观察神经走向及眦领关系。11例行自行设计的后略骶神经管扩大减压术，3例行非手术治疗。结果：S1棘突于S1后孔中上1/3者占90%，骶前区主要血管有骶外侧动静脉和骶外侧血管、骶正中血管及臀上血管进入骶前孔的分支。血管位于骶丛神经腹侧，骶外侧斑管距离S1前孔大于10mm，S2前孔大于5mm。骶骨斜冠状位MR扫描可以显示骶神经全长及周围眦领关系。骶神经损伤时，发现有神经根走行改变(13例），损伤处神经很周围脂肪消失（11例），神经根管狭窄(10例)。14例均获得随访。随访时间6--12个月。平均7.1个月，术后改善情况，优9例，无变化1例。结论螺旋CT三维重建及骶骨斜冠状位MR扫描对于骶神经损伤的定位及定性诊断有重要价值。后路骶神经管扩大减压术是针对骶神经管、骶前孔处神经损伤的较理想手术方法。     

臀部肌肉注射避免损伤坐骨神经的探讨

臀部肌肉注射是常见的给药途径,如果忽视了严格的操作规程,或只注意个体的一般性,而忽视了个体的特殊性,会损伤坐骨神经引起瘫痪。本文就臀部肌肉注射损伤坐骨神经的可能性及预防讨论如下: 一、从臀部解剖看坐骨神经损伤的可能性臀部的肌肉由浅入深依次为臀大肌、臀中肌、梨状肌和臀小肌等。经梨状肌上孔穿出骨盆的有臀上血管、臀上神经;通过梨状肌下孔穿出骨盆的血管神经,由外侧向内侧依次为:坐骨神经、股后皮神经、臀下血管、臀下神经、阴部内血管和阴部神经。大约有60.5％的坐骨神经从梨状肌下孔穿出后,在大转子与坐骨结节之间垂直下降至股后部,分为胫神经和腓总神经;另有39.5％的坐骨神经分支很高,胫神经从梨状肌下孔穿出,而腓总神经则经梨状肌上孔或穿过梨状肌。由于坐骨神经的变异型较     

臀下动脉的解剖学研究

目的 研究臀下动脉的走行及变异情况，为临床手术应用该动脉供养的臀大肌肌皮瓣提供解剖依据。方法 选用10具18侧经红色乳胶液动脉灌注的标本，直视下解剖标本，显露臀下动脉及其周围组织，观察其走行情况。其中男性11侧，女性7侧，左9侧，右9侧。结果 臀下动脉通常自梨状肌下孔出骨盆，沿坐骨神经内侧向下走行，在出骨盆后平均于17．3、33．2及51.8mm处依次发出髋关节支、坐骨神经支及臀大肌支分别营养其支配区组织。18侧中共有7侧(其中女性5侧)属变异。结论 臀下动脉走行相对比较稳定，但变异较多，故术前宜行相关检查如彩色多普勒超声以大致确定动脉走行及分布情况。     

腰骶部骨筋膜室综合征针刀疗法应用解剖

我们对成年尸体腰骶部标本的胸腰筋膜、竖脊肌等有关结构进行了解剖观测 ,探讨产生腰骶部骨筋膜室高压症以及腰骶部筋膜脂肪疝等损伤症的解剖学机制 ,据此讨论了针刀治疗此综合征的手术入路 ,即相应的入刀点定位及其操作方向选择 ,应注意避免损伤的结构 ,供临床参考。1　材料和方法成年尸体 15具 ,其中男性 13具 ,女性 2具 ,左右共 30侧。以卡尺、手术放大镜等 ,自第 1腰椎平面至臀部解剖观测以下内容 :①腰骶部骨筋膜室的构成 ;②腰骶部竖脊肌以及腰骶神经后外支筋膜下段 ;③腰骶部神经后外支及其伴行血管的出筋膜点的体表定位。2　结果2 …     

前臂内侧皮神经的血供特点及其在皮瓣设计中的意义

目的 为临床设计前臂内侧皮神经营养血管皮瓣提供形态学依据。方法 用量微解剖和标本透明法研究３７侧上肢人侧上神经解剖及其与贵要静脉的关系以及营养血管的来源、位置、口径、对皮神经的营养形式等。结果 前臂内侧皮神经全程由神经旁血管营养。神经旁血管由来源于肱动脉与尺动脉的皮肤动脉分支吻合形成。前臂内侧皮神经与贵要静脉在１ｃｍ左右范围内伴行。结论 顺沿贵要静脉,可切取前臂内侧皮神经、神经旁血管或神经皮肤穿支     

梨状肌综合征的影像学与临床特点分析

目的探讨梨状肌综合征的影像学与临床特点。方法回顾性分析2例梨状肌综合征患者的影像学和临床资料,复习相关文献,对梨状肌综合征的病因、临床表现、诊断方法、影像学特点及治疗方法进行讨论。结果 2例均有明确的外伤史,有臀部疼痛和腓总神经卡压等临床表现,梨状肌紧张试验(FAIR试验)阳性,而且骨盆MRI及CT检查分别表现出患侧梨状肌萎缩、脂肪变性等慢性损伤表现。1例予以局部微波、超声波治疗,进行梨状肌离心收缩训练,并辅以认知治疗后症状缓解。1例予以左侧梨状肌封闭治疗,辅以局部超声波治疗并进行梨状肌肌力训练后症状缓解,1周后疼痛复发,转骨科专科治疗。结论梨状肌的解剖变异及坐骨神经的解剖特点导致梨状肌综合征多产生腓总神经卡压症状;MRI和CT检查可以清楚显示梨状肌的形态和结构改变,是诊断梨状肌综合征必要的辅助检查。     

足底内侧皮瓣的应用解剖及修复足跟组织缺损的临床应用

目的 报道带神经血管蒂足底内侧皮瓣的解剖特点及修复足跟缺损的应用效果.方法 10具成年人体标本(20侧下肢),解剖观测其足底内侧动脉起源、分支、走行和分布以及该皮瓣的支配神经情况.临床应用带神经血管蒂足底内侧皮瓣修复同侧及对侧足跟皮肤缺损8例,供区植皮.结果 足底内侧动脉深支平均长度(8.9±0.2)cm,3～5条皮支.足底内侧神经的分支5～8支.它包含分布足底皮肤直接皮支3～5支和分布足趾皮肤的趾底固有神经2～4支.8例共用8个皮瓣.皮瓣大小为4 cm×3 cm～5 cm×6 cm,6例带蒂转移修复,2例游离移植.8个皮瓣完全成活,所有病例获随访1个月～1年,皮瓣功能、外形良好.结论 足底内侧皮瓣解剖变异少,血供可靠,不牺牲主要血管,转移后能恢复较好的感觉,是修复足跟皮肤缺损的理想皮瓣     

不同形式足内侧皮瓣修复前足软组织缺损

目的探讨不同形式足内侧皮瓣的血供来源及修复前足软组织缺损的临床效果。方法对12侧成人足标本的动脉内灌注红色乳胶进行解剖,观察拇趾胫侧底动脉与足内侧皮神经营养血管以及第1跖底动脉、足底内侧动脉浅支、内踝前动脉、跗内侧动脉间吻合关系。根据解剖的实际情况,对临床12例患者设计足内侧皮瓣,分别切取穿支螺旋桨皮瓣(5例)、皮神经营养血管筋膜蒂皮瓣(4例)、穿支+皮神经营养血管筋膜蒂皮瓣(3例)修复前足软组织缺损。结果解剖显示拇趾胫侧底动脉与足底内侧动脉浅支、内踝前动脉、跗内侧动脉间的血管吻合以及与足内侧皮神经营养血管的吻合,共同构成足内侧皮瓣的血运基础。所有患者的皮瓣及植皮区均成活,供区创缘一期愈合。随访6～24个月,皮瓣外形及功能较满意,皮瓣色泽与周围皮肤一致,无溃疡发生,均恢复保护性感觉;其穿鞋行走及负重等功能均未受到影响。结论根据足内侧穿支血管的实际情况,灵活设计并切取不同形式的足内侧皮瓣修复足前部皮肤缺损,血供可靠,操作简单,供区损伤较小,是修复前足软组织缺损较理想的皮瓣供区。     

The prevalence of anatomical variations that can cause inadvertent dural puncture when performing caudal block in Koreans: a study using magnetic resonance imaging

The purpose of this study was to investigate the prevalence of the anatomical abnormalities that can induce inadvertent dural puncture when performing caudal block. The anatomy of the lumbo-sacral area was evaluated using magnetic resonance imaging. In 2462 of the 2669 patients imaged, the dural sac terminal was located between the upper half of the 1st sacral vertebra and the lower half of the 2nd sacral vertebra. In 22 cases (0.8%), the dural sac terminal and the spinal canal were located at or below the 3rd sacral vertebra, and these were cases of simple anatomical variations. As regards pathologic conditions, there was one case of sacral meningocoele and 46 cases of sacral perineural cyst. In 21 cases (0.8%) out of the 46 perineural cyst cases, the cyst could be found at or below the 3rd sacral vertebra level. Inadvertent dural puncture may happen when performing caudal block in patients with such abnormal anatomy.     

直肠癌根治术中保留骨盆自主神经的神经解剖学基础及临床意义

目的　探讨直肠癌根治术中保留神经的解剖学基础。　方法　解剖 6例完整尸体标本(男 4例 ,女 2例 )和 4例直肠及盆腔未受破坏的矢状半骨盆标本 ,观察骨盆神经组成及走行。　结果　显露下腹神经干 ,确定其在第 5腰椎处分为左、右下腹神经。其特点是较为粗大 ,位置固定 ,在腹主动脉分叉处易找到 ,呈网状联系 ,质地较实 ,为灰白色 ,与腹主动脉较近。分叉后左右下腹神经还有较粗大分支。骨盆内脏神经在大体标本上较难辨认 ,在矢状半骨盆标本中见到发自骶前孔 2～ 4的骨盆内脏神经 ,该神经较纤细 ,在侧韧带处呈丛状的细小纤维。　结论　保留下腹神经临床上较易完成。保留骨盆内脏神经则须细心操作 ,预保留神经的一侧在侧韧带水平的手术操作应尽量贴近直肠进行。     

CT引导微创注射生物蛋白胶治疗骶管囊肿围手术期异常事件的防治

目的探讨CT引导微创注射生物蛋白胶治疗骶管囊肿围手术期异常事件产生的原因,提出防治措施。方法2006年1月-2007年10月行CT引导微创注射生物蛋白胶治疗骶管囊肿37例,其中L5S17例,S1-212例,S2-318例。回顾分析围手术期出现的异常事件和产生的原因。结果血性囊液13例,抽不出囊液4例,骶管内积气28例,骶神经根刺伤2例,术后发热8例,剧烈头痛,呕吐3例,症状无缓解3例,除骶管内积气外,上述并发症多发生于该微创技术早期应用的病例中,与术中穿刺和抽液技术,病例选择不当有关。结论CT导向下的穿刺和抽液技术有一个学习和熟练的过程,掌握技巧,正确选择病例和完善围手术期处理是防治围手术期异常事件的关键。     

骶前静脉的解剖及在骨盆骨折大出血中的临床意义

目的探讨骶前区静脉的解剖和骨盆骨折大出血的关系。方法结合50例骨盆骨折伴盆腔内血管损伤出血临床病例救治，选成年尸体标本5具，研究骶前区静脉走行，骶骨的解剖学特点，骨折部位与出血的关系。结果骶前区静脉由骶前静脉丛和骶椎椎体静脉组成，有广泛的侧支循环，骶骨C区骨折及严重的B区骨折易损伤骶前静脉丛。临床骶前静脉出血者经剖腹探查证实、止血。结论骶骨C区骨折及严重的B区骨折易引起骶前静脉丛损伤。一旦确诊应立即恢复骨盆环的完整性，腹外加压止血，非必要时不能行剖腹探查止血。     

Laparoscopic ovarian cystectomy using a single umbilical puncture method

To establish a minimally invasive technique to perform ovarian cystectomy, the authors applied a single umbilical puncture method. A 2-month old female infant was admitted to the hospital because of an ovarian cyst that showed no spontaneous shrinkage after her birth. An umbilical semicircular incision was made to insert a 10-mm trocar, into which a 3-mm laparoscope was inserted. The ovarian cyst was grasped using forceps inserted through an operating channel of the scope, and the cyst was removed through the incision. After aspiration of the cyst, the free cyst wall was resected, leaving the intact ovarian tissue. The operation was performed without difficulty or complication. The postoperative course was uneventful. The wound was inconspicuous, and the result was cosmetically excellent. The case demonstrated the feasibility of the minimally invasive technique using a single umbilical puncture for ovarian cystectomy in an infant.     

Sacrum and sacral hiatus

The sacrum is a large triangular bone formed from the five fused sacral vertebrae (Figure 1). Two rows of foramina on its dorsal and pelvic surfaces divide it into a median portion, the body and two lateral masses. The paired pelvic and dorsal sacral foramina communicate by intervertebral foramina with the central sacral canal and convey the ventral and dorsal rami of the sacral nerves. The base, directed upwards and forwards is formed from the upper surface of the first sacral vertebra. Lateral to this, the lateral masses of the sacrum are at their widest and form the prominent ala. The protruding central part of the superior surface is known as the promontory.     

卵巢子宫内膜异位囊肿术后盆腔囊性包块分析

目的 探讨卵巢子宫内膜异位囊肿术后异位囊肿的复发和盆腔包裹积液发生的规律,以及合理有效的治疗方案.方法 比较两者发生的时间、手术范围,与年龄、服药、CA125的关系,以及影像学的特征.采用阴道超声引导下穿刺治疗,并就其囊液进行分析.结果 术后1～6月内,盆腔包裹积液发生率为41.7%（10/24）,没有发生卵巢子宫内膜异位囊肿复发,两者相比（P〈0.001）差异有统计学意义.术后18月以上出现的囊肿中,卵巢子宫内膜异位囊肿居多,发生率为40%（12/30）两者的发生率相比（P〈0.05）,差异有统计学意义.结论 子宫内膜异位症术后盆腔包裹积液出现一般早于卵巢子宫内膜异位囊肿的复发,且这种囊肿可以通过阴道超声进行介入治疗.     

Covered anus with anocutaneous fistula: the muscular sphincters

A rare specimen of a covered anus with anocutaneous fistula obtained from a newborn female baby was subjected to macroexamination and microexamination to determine the anatomy of the sphincters and the levatores musculature. The internal sphincter and the deep voluntary sphincters, albeit slightly modified, were well developed but the sphincters in the perineum were absent or rudimentary. The pelvic muscles were present even in the absence of the sacrum up to and including the second sacral vertebra.     

Safe corridor for iliosacral and trans-sacral screw placement in Indian population: A preliminary CT based anatomical study

ObjectivesNonsurgical management of unstable pelvic ring injuries is associated with poor outcomes. Posterior pelvic ring injuries include sacroiliac joint disruption and sacral fractures or a combination of the two. Morbidity is high in non-operatively managed patients. Screw fixation is being increasingly used to manage unstable posterior pelvic injuries. Limitations include a steep learning curve and potential for neurovascular injury. This is the first study in Indian population to describe the safe corridor for screw placement and check the feasibility of screw in both upper and lower sacral segments.MethodsThis study involved retrospective analysis of 105 pelvic CT scans of patients admitted to the emergency department of a Level 1 trauma centre. Vertical height at the level of constriction (vestibule) of S1 and S2 was measured in coronal sections and anteroposterior width of constrictions was measured in axial sections. We created a trajectory for 7.3 mm cylinder keeping additional 2 mm free bony corridor around it and confirmed that bony limits were not breached in axial, coronal and sagittal sections. Whenever there was breach in bony limit we checked applicability of 6.5 mm screw.ResultsThe vertical height and anteroposterior width of vestibule/constriction of S1 was significantly higher in males, whereas S2 vestibule height and width were similar in males and females. Both male and female pelves were amenable to S1 Trans-sacral and S1 Iliosacral screw fixation with a 7.3 mm screw when a safe corridor of 2 mm was kept on all sides. However, when S2 segment was analysed, only 42.9% of male pelves and 25.7% of female pelves were amenable to insertion of trans-sacral 7.3 mm screw.ConclusionAn individualized approach is necessary and each patient’s CT must be carefully studied before embarking on sacroiliac screw fixation in Indian population.