小腿后外侧穿支皮支链的解剖学研究

目的　探讨小腿后外侧穿支皮支链形成的具体区域，为临床切取小腿后外侧穿支皮支链皮瓣提供解剖学基础。 方法　新鲜成人尸体下肢标本15侧，（女性2侧，男性13侧），皮肤无外伤及手术史。13侧下肢经股动脉行红色乳胶灌注，手术显微镜下进行精细解剖，充分显示各穿支间的链状吻合，并于穿深筋膜处测量各穿支的外径。2侧下肢制做血管铸型标本，观察皮支链的构筑。 结果　小腿后外侧穿支数为67支，每侧(5.15±1.86)支，穿深筋膜处的直径为（0.92±0.25）mm；腓骨长度为（34.78±17.78）cm，参与构成小腿后外侧皮支链的穿支数为34支，每侧为（3.31±1.65）支，直径为（0.99±0.23）mm，占所在区域穿支的（28.33±17.79）%～(64.04±19.48) %。 结论　根据小腿后外侧穿支皮支链分布规律和形式切取皮瓣，不但可适当扩大皮瓣的切取面积，也使皮瓣的血供更加安全。     

L5/S1椎间孔内韧带的形态和分布规律

目的:探讨L5/S1椎间孔内韧带的形态、分布规律并评价其临床意义。方法:取5具防腐和5具新鲜冰冻正常成人腰骶部标本(年龄42~80岁,平均51岁)。仔细剔除脊柱周围的软组织,从正中矢状位锯开脊柱。找出L5/S1神经根并沿椎间孔小心去除周围脂肪和筋膜等软组织。在肉眼及手术显微镜下观察韧带的形态、走行、起始位置及分布特点,用游标卡尺在手术显微镜下测量其长度、宽度及直径或厚度。用HE染色和Masson三色染色法分析对比不同类型韧带的组织学类型。结果:在20个L5/S1椎间孔内共发现215条韧带,其中条带形90条,条索形125条;连接神经根到横突或椎间孔内壁的放射状韧带181条(84.2%),连接椎间孔周围组织横跨在椎间孔内的横跨状韧带34条(15.8%);放射状韧带出现率与横跨状韧带出现率的比较有统计学差异(Z=-3.928,P=0.000)。在L5/S1椎间孔内口(73条,34.0%)、中间(102条,47.4%)及外口(40条,18.6%)区域均有分布。韧带长度多变,为1.43~19.01mm;厚度最厚处达3.46mm。光镜下,HE染色提示椎间孔内韧带由纤维结缔组织构成且部分韧带内包含小血管组织,Masson三色法染色提示椎间孔内韧带由大量的胶原纤维和少量的弹性纤维构成。放射状韧带与横跨状韧带组织学表现无明显差异。结论:L5/S1椎间孔内韧带主要分为条带形和条索形两种形状。椎间孔内放射状韧带比横跨状韧带出现率高。经骶骨裂孔硬膜外腔导管粘连松解术前应掌握其分布规律并在术中辨别并予以正确松解,以减少并发症的发生。     

The urogenital-hypogastric sheath: an anatomical observation on the relationship between the inferomedial extension of renal fascia and the hypogastric nerves

Purpose

The study aimed to perform an anatomical observation on the inferomedial extension of the renal fascia (RF) to the pelvis and explore its relationship with the hypogastric nerves (HGNs).

Methods

Gross anatomy was performed on 12 formalin-fixed and 12 fresh cadavers. Sectional anatomy was performed on four formalin-fixed cadavers.

Results

Different from the traditional concept, both the anterior and posterior RF included the outer and inner layer with different inferomedial extensions. The multiple layers of RF extended downward to form a sandwich-like and compound fascia sheath with potential and expandable spaces which was named as “the urogenital-hypogastric sheath.” Below the level of the origin of the inferior mesenteric artery, the bilateral urogenital-hypogastric sheath communicated with the counterpart in front of the great vessels in the midline and the superior hypogastric plexus ran into the urogenital-hypogastric sheath which carried the HGNs, ureters, and genital vessels downward to their terminations in the pelvis. In the retrorectal space, the urogenital-hypogastric sheath surrounded the fascia propria of the rectum posterolaterally as a layer of coat containing HGNs.

Conclusion

The multiple layers of RF with different extensions are the anatomical basis of the formation of the urogenital-hypogastric sheath. As a special fascial structure in the retroperitoneal space and the pelvis, emphasis on its formation and morphology may be helpful for not only unifying the controversies about the relationship between the pelvic fascia and HGNs but also improving the intraoperative preservation of the HGNs by dissecting in the correct surgical plane.