髂腹股沟入路相关解剖学研究

目的：为髂腹股沟入路如何避免易损伤结构提供解剖学依据。方法：对20侧成尸骨盆标本,按照手术进路的层次对相关结构和神经血管进行解剖观测。结果：（1）髂外血管与闭孔血管的吻合支直径为（2.56±0.72）mm,与耻骨联合的距离为（52.41±8.12）mm。（2）股神经由腰大肌和髂肌间穿出处至腹股沟韧带间的距离为（32.58±3.97）mm,在穿腹股沟韧带处与腹股沟韧带的垂直距离为（14.33±3.00）mm。（3）坐骨神经出骨盆时,与坐骨大切迹的距离为（15.53±3.6）mm。结论：在手术先后显露耻骨上支、髂窝及坐骨大切迹时,注意不要损伤髂外血管与闭孔血管的吻合支、股神经和坐骨神经。     

经腹直肌外侧切口入路治疗髋臼骨折的解剖学研究

目的　探讨经腹直肌外侧切口入路治疗髋臼骨折的安全性及临床应用价值。方法 新鲜成人尸体标本5具（3男2女）,同一尸体右侧腹壁行大体解剖,熟悉入路周围的解剖结构,左侧应用腹直肌外侧切口入路,模拟术中操作,显露骨盆环,进行解剖学观察,重点测量记录死亡冠血管相关解剖学参数。结果 （1）经腹直肌外侧入路的显露范围包括：耻骨联合至骶髂关节在内的真性骨盆环、髂骨翼、髋臼方形区和坐骨体内侧的髋臼后柱大部分。（2）根据对5具10侧骨盆的死亡冠统计分析发现,死亡冠的出现率为80%（8侧）,直径为（2.1±1.9）mm,长为（4.7±0.5）cm,距离耻骨联合的距离为（4.9±0.4）cm。男女之间差异无明显统计学意义。结论 经腹直肌外侧切口入路治疗髋臼骨折能够在不损伤重要神经血管的条件下,经腹膜外间隙对包括骶髂关节在内的大部分骨盆环结构进行显露。尤其方便显露结扎死亡冠,对髋臼后柱及髋臼内侧方形区的显露较传统入路有明显优势。     

经腹直肌外侧切口入路治疗髋臼骨折的解剖学研究

目的　探讨经腹直肌外侧切口入路治疗髋臼骨折的安全性及临床应用价值。方法 新鲜成人尸体标本5具（3男2女）,同一尸体右侧腹壁行大体解剖,熟悉入路周围的解剖结构,左侧应用腹直肌外侧切口入路,模拟术中操作,显露骨盆环,进行解剖学观察,重点测量记录死亡冠血管相关解剖学参数。结果 （1）经腹直肌外侧入路的显露范围包括：耻骨联合至骶髂关节在内的真性骨盆环、髂骨翼、髋臼方形区和坐骨体内侧的髋臼后柱大部分。（2）根据对5具10侧骨盆的死亡冠统计分析发现,死亡冠的出现率为80%（8侧）,直径为（2.1±1.9）mm,长为（4.7±0.5）cm,距离耻骨联合的距离为（4.9±0.4）cm。男女之间差异无明显统计学意义。结论 经腹直肌外侧切口入路治疗髋臼骨折能够在不损伤重要神经血管的条件下,经腹膜外间隙对包括骶髂关节在内的大部分骨盆环结构进行显露。尤其方便显露结扎死亡冠,对髋臼后柱及髋臼内侧方形区的显露较传统入路有明显优势。     

术前应用螺旋CT个体化测量在骶髂关节置钉中的意义

目的　探讨切开复位骶髂螺钉内固定术前应用螺旋CT个体化测量健侧螺钉钉道参数,指导术中置钉的可行性。 方法　⑴对10例冰冻正常成人骨盆标本进行螺旋CT扫描与多平面重组,在不同重组图像中依次测量左右侧S1螺钉的进针方向、进针点与髂后上、下棘的距离、钉道的长度与安全角度等参数;⑵将10例骨盆标本左右侧骶髂关节制成垂直不稳定贩折模型,然后左右侧骶髂关节分别根据对侧的CT测量结果进行个体化置钉验证。 结果　⑴进针方向与冠状面、水平面的夹角分别为（25.95±　1.39）°与（19.61±2.97）°,进针点与髂后上、下棘的距离分别为(37.17±2.90)mm与(38.23±1.69)mm,冠、轴状面上的安全角度分别为(19.87±1.61)°与(23.84±2.08) °;⑵左侧骶髂关节所置10枚螺钉均安全、准确地到达S1椎体预定位置;右侧骶髂关节所置螺钉除1枚偏离突出骨质外,其余9枚均安全到达S1椎体预定位置。 结论　切开复位骶髂螺钉内固定术前应用螺旋CT个体化测量健侧螺钉钉道参数,指导术中置钉的方法是可靠的。     

腹腔镜下小儿腹股沟内环口周围的应用解剖学研究

目的　为腹腔镜下小儿腹股沟斜疝修补术提供解剖学依据。 方法　对16具（32侧）经防腐处理的小儿尸体标本内环口周围血管神经进行观测。 结果　（1）髂腹下神经与腹壁下动脉在腹前壁的交点与内环口上缘的距离：男左侧为（16.77±1.36）mm,男右侧为(17.77±2.39)mm;女左侧为(16.41±2.23) 　mm,女右侧为（15.81±0.57）mm。（2）髂腹下神经与腹壁下动脉的夹角：男左侧为(107.75±11.59)°,男右侧为（106.29±8.87)°,女左侧为（106.42±9.46)°,女右侧为(110.23±9.42)°。各测量数据在性别间差异无统计学意义（P >0.05）,各测量数据在双侧无显著性差异（P>0.05）。 结论　（1）在腹前壁髂腹下神经与腹壁下动脉之间有一个没有神经和血管的“安全区域”,该区可为IPOM手术中腹腔镜下补片固定提供足够的安全范围。（2）以腹壁下动脉为参考标志,可减少髂腹下神经的损伤,减少慢性疼痛的发生率。     

内镜下经阴道肾切除术中髂外动脉及其毗邻结构的应用解剖

目的　通过对内镜下腹盆部髂外动脉与卵巢血管、生殖股神经及腰大肌位置关系的解剖学观测,为内镜下经阴道肾切除术的临床应用提供解剖学依据。 方法　选取8例成年女性腹盆部标本,在大体解剖后在内镜下进行观测,确定髂外动脉与卵巢血管的交点为内镜下的标志点,测量其与生殖股神经的距离,确定内镜下经阴道肾切除手术通过盆腔后在腹部到达腹膜后间隙的相对安全区域。 结果　（1）确立了以卵巢血管与髂外动脉的交点为内镜下手术入路观察的标志点;左右侧卵巢血管束与髂外动脉相交处的角度,左侧为(20.68±3.14)°,右侧为(29.48±2.47)°;（2）交点处与生殖股神经的距离左侧为(11.84±0.80) mm,右侧为(12.60±1.32) mm。 结论　在卵巢血管与髂外动脉相交平面,在髂外动脉外侧,沿腰大肌的外侧缘进入腹膜后间隙,此范围是一个相对安全区域。     

骨盆骨折髂腹股沟入路避免神经血管损伤的临床解剖学

目的　为髂腹股沟入路在骨盆骨折手术中避免神经血管损伤提供解剖学依据。  方法    在15具(男9具,女6具)30侧成尸标本上选择髂前上棘、耻骨结节和腹股沟韧带为标志观测股外侧皮神经(Lateral femoral cutaneous nerve,LFCN)、髂腹股沟神经(Ilioinguinal nerve,IN)、股神经耻骨肌支和闭孔动脉(Obturator artery,OA)的走形特点,所测数据统计学处理。  结果     ① LFCN在髂前上棘内侧穿出腹股沟韧带占96.67% (29/30侧),距髂前上棘中心点(20.01±0.32)mm;被腹股沟韧带纵横纤维所包裹的占33.33% (10/30侧);在阔筋膜形成的筋膜鞘中走行占46.67%(14/30侧)。② IN穿出腹内斜肌部位距离髂前上棘中心点为(5.41±0.50)mm,穿出腹外斜肌腱膜部位距离耻骨结节中心点为(18.04±0.21)mm。  结论　在显露髂骨翼内侧面和骶髂关节时,应在LFCN走行的阔筋膜和腹股沟韧带部位进行显露和预防性松解,以免牵拉损伤;切开腹外斜肌腱膜时应从腹股沟韧带两端上方5 mm处开始,防止损伤深面的IN。在显露髂耻隆起时先寻找和结扎闭孔血管耻骨支,以免引起不可控制的出血。     

第2骶椎骶髂螺钉最佳进钉通道的分析

目的　利用数字化仿真技术确定并测量第二骶椎骶髂螺钉最佳进钉通道参数。 方法　将2011年4月至2011年7月入院的8例无骨盆病变患者（男性4例,女性4例,年龄25~53岁）的CT数据集导入Mimics10.01进行三维重建,利用数字化仿真技术生成骶椎阴模,利用透视骶椎阴模确定S2骶髂螺钉最佳进钉通道,利用空间解析几何测量相关参数。 结果　8例共16侧资料的S2骶髂螺钉最佳进钉通道均能以此方法确定。最佳进钉通道参数：最大半径男性为（6.38±0.54）mm,女性为（4.9±0.74）mm;深度男性为（68.93±3.49）mm,女性为（58.43±8.16）mm;与矢状面夹角男性为（73.48±8.57）°,女性为（79.93±　5.29）°;与横截面夹角男性为（14.07±6.22）°,女性为（6.95±4.81）°;与冠状面夹角男性为（7.12±7.11）°,女性为（5.87±5.01）°。最佳进钉点及最佳进钉终点的确定方法为：在骨盆出口位X线透视图像上,作一边长分别水平及垂直并恰好包围骨盆的矩形,以左下角顶点为原点,左上角顶点为（0,1）,右下角顶点为（1,0）建立二维直角坐标系,进钉点坐标男性为（0.5±0.26,0.52±0.04）,女性为（0.49±0.24,0.47±0.10）;进钉终点坐标男性为（0.5±0.01,0.59±0.07）,女性为（0.5±0.02,0.49±0.14）。在骨盆入口位X线透视图像上,用相同的方法作一矩形并定义坐标系,进钉点坐标男性为（0.5±0.26,0.52±0.04）,女性为（0.49±0.24,0.47±0.10）,进钉终点坐标男性为（0.5±0.01,0.78±0.01）,女性为（0.5±0.02,0.81±0.03）。S2骶髂螺钉最佳进钉通道参数男女对比“最大半径”、“深度”、“与横截面夹角”、“进钉点前后相对位置”有统计学差异（P<0.05）,余无统计学差异。 结论　数字化仿真技术能精确确定S2骶髂螺钉最佳进钉通道参数。     

经腹膜后间隙抢救骨盆骨折大出血的解剖研究及临床应用

目的　探讨髂腹股沟入路腹膜后间隙的解剖要点及在抢救骨盆骨折大出血中的应用。  方法    37具国人尸体标本左右两侧髂腹股沟入路显露腹膜后间隙,观测血管、输尿管走行关系及肠系膜下动脉和输尿管、睾丸（卵巢）动静脉的前移距离。并临床应用该入路抢救12例骨盆骨折大出血患者,男10例,女2例。  结果    腹膜后间隙内腹主动脉、下腔静脉、髂总动静脉等紧贴盆壁与壁腹膜间有腹膜外脂肪相隔;肠系膜下动脉、睾丸（卵巢）动静脉与壁腹膜之间有致密结缔组织连接,易随壁腹膜掀起,输尿管上部与壁腹膜有连接,下部连接松弛;在L4椎体平面肠系膜下动脉可前移19.3 mm,睾丸（卵巢）动静脉可前移26.4 mm(右)和28.0 mm(左);输尿管可前移37.0 mm(左)和41.0 mm(右)。临床应用该入路抢救12例骨盆骨折大出血患者,术中对腹主动脉临时压迫阻断控制出血,抢救休克,修复或结扎损伤血管,复位固定骨折。11例成功,1例死亡;无血管、神经再损伤发生。  结论    经髂腹股沟腹膜后间隙入路手术可充分显露盆腔大血管,对腹主动脉临时压迫阻断可快速控制出血,纠正休克,提高了骨盆骨折大出血抢救成功率,是救治骨盆骨折大出血的理想入路。     

髂腹股沟神经皮支营养血管皮瓣的应用解剖

目的:为髂腹股沟神经皮支及其营养血管为蒂岛状皮瓣的临床应用提供解剖学基础。方法:在27侧经红色乳胶液灌注的会阴及下肢标本上解剖观测髂腹股沟神经皮支及其营养血管的来源、走行、分布、吻合及外径,2侧成人新鲜标本灌注墨汁,观测营养血管的墨染范围。结果:髂腹股沟神经来源于第1腰神经腹侧支,其皮支从腹股沟管浅环穿深筋膜,穿出点横径为(1.89±0.47)mm,穿出时位于精索或子宫圆韧带下方。髂腹股沟神经皮支营养血管主要来源于阴部外浅动脉的升支、降支及股内侧支,并沿途发出皮支营养周围皮肤。结论:可以设计以髂腹股沟神经营养血管为蒂的岛状皮瓣。     

Deep and superficial circumflex iliac arteries and their relationship to the ultrasound‐guided femoral nerve block procedure: A cadaver study

The in‐plane lateral to medial approach is a standard technique for ultrasound‐guided femoral nerve block (USG‐FNB). The first bifurcation of the femoral artery, which consists of the deep artery of the thigh (DAT) or occasionally the lateral circumflex femoral artery (LCFA), is regarded as the distal border for this procedure. We sometimes detect arteries along the estimated needle trajectory for USG‐FNB. The superficial (SCIA) and deep (DCIA) circumflex iliac arteries run laterally parallel to the inguinal ligament from the femoral or external iliac artery. The relationship between the SCIA and DCIA and other anatomical structures related to USG‐FNB around the femoral triangle region was studied by gross anatomical examination of 100 formalin‐fixed adult cadavers. At least one SCIA and one DCIA were identified around each femoral triangle; 81.8% of SCIA and 58% of DCIA originated from the femoral artery. All DCIA coursed between the fascia lata and fascia iliaca and 80% of SCIA penetrated the fascia lata. In 94% of femoral triangles, at least one arterial branch heading towards the lateral part of the thigh originated from the femoral artery from the level of the inguinal ligament to the first bifurcation of the femoral artery. The presence of SCIA and DCIA should be considered during USG‐FNB using the in‐plane lateral to medial approach to avoid inadvertently injuring them, as they are occasionally located along the presumed needle trajectory superficial to the fascia iliaca. Clin. Anat. 30:413–420, 2017. © 2017 Wiley Periodicals, Inc.     

Lateral femoral cutaneous neuralgia: an anatomical insight

A detailed anatomic study was carried out on the lateral femoral cutaneous nerve to better understand the etiology and treatment of lateral femoral cutaneous neuralgia. As it passed from the pelvis into the thigh, the lateral femoral cutaneous nerve ran through an "aponeuroticofascial tunnel," beginning at the iliopubic tract and ending at the inguinal ligament; as it passed through the tunnel, an enlargement in its side-to-side diameter was observed, suggesting that the fascial structures proximal to the inguinal ligament may be implicated in the genesis of lateral femoral cutaneous neuralgia. The finding of pseudoneuromas at this location, distant from the inguinal ligament, supports this hypothesis. The anterior superior iliac spine is located approximately 0.7 cm from the lateral femoral cutaneous nerve and serves as the bony landmark for nerve localization. Within the first 3 cm of leaving the pelvis, the lateral femoral cutaneous nerve was observed deep to the fascia lata; therefore, surgical dissection within the subcutaneous fascia may be conducted with relative impunity near the anterior superior iliac spine just inferior to the inguinal ligament. In 36% of cases there was no posterior branch of the nerve, which is correlated to lateral femoral cutaneous neuralgia symptoms often being limited to the anterior branch region. An accessory nerve was found in 30% of cases.     

Defining the position of deep inguinal ring in patients with indirect inguinal hernias

A preliminary survey of surgeons of all grades in our hospital revealed confusion about the position of the deep inguinal ring. Standard teaching is that the deep inguinal ring is lateral to the femoral artery. The aim of this study was to define the position of the deep ring in patients undergoing elective inguinal hernia repair. Thirty consecutive male patients undergoing indirect inguinal hernia repair under local anaesthesia were studied. The following landmarks were marked on the patient with a felt pen: anterior superior iliac spine (ASIS), femoral artery (FA), deep inguinal ring (DR), pubic tubercle (PT) and pubic symphysis (PS). The distance of each point from the ASIS was measured in centimetres. The relation of the femoral artery to the deep inguinal ring was confirmed by palpation through the deep ring during surgery. The femoral artery was consistently identified midway between the anterior superior iliac spine and pubic symphysis (mid-inguinal point). The deep inguinal ring was located medial (22/30) or above (8/30) the femoral artery, but never lateral. The mean distances from the anterior superior iliac spine to the deep ring and femoral artery were 8.8 and 7.7 cm, respectively. Contrary to standard teaching, this study demonstrates that the deep inguinal ring lies medial, not lateral, to the femoral artery. This may clarify some of the variations in textbook anatomy, and explain the difficulty in distinguishing direct and indirect inguinal hernias pre-operatively.Presented at the Association of Surgeons of Great Britain and Ireland (ASGBI, April 2004 Harrogate)     

股神经周围筋膜及其毗邻结构的解剖

目的 探讨股神经周围是否存在完整的筋膜鞘以及股神经与周围筋膜的解剖学关系,为下肢外周神经阻滞麻醉的选择提供形态学依据。方
法选择5具10%福尔马林固定的两侧第1腰椎至大腿中段保存完整的标本进行研究,共10侧;其中8侧由远端向近端逐步注射乳胶后局部解剖观察,
1具标本即2侧经-35℃冷冻1周后制成横断面连续断层切片,行断层解剖观察。结果 本实验未发现股神经周围存在完整筋膜鞘。股神经周围有筋膜
样结构包绕,从近端向远端主要包括腰丛筋膜、腰大肌肌间隔、髂筋膜及疏松的脂肪组织。结论 大体解剖学观察股神经周围并不存在完整筋膜
鞘。     

Anatomical mythology? A study of surface markings of the inguinal region

The surface markings used by authors for structures in the inguinal region were reviewed and differences noted. In this study of 40 cadaveric limbs the surface markings of both the deep inguinal ring and the femoral artery were found to lie closer to the midinguinal point than to the midpoint of the inguinal ligament, which lay lateral to both structures considered. Usually the femoral artery was located lateral to the medial margin of the deep inguinal ring, but occasionally lay medial. In some subjects poor definition of the bony features rendered precise localisation of the positions of the pubic tubercle and anterior superior iliac spine difficult. The origin of the inferior epigastric artery, often used to identify the medial margin of the deep inguinal ring, was subject to variation. A single surface marking, namely the midinguinal point, is suggested for both the femoral artery and the deep inguinal ring on grounds of accuracy, simplicity, and ease of identification.     

Age‐related changes in inguinal region anatomy from 0 to 19 years of age

Knowledge of the age‐related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast‐enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794–802, 2019. © 2019 Wiley Periodicals, Inc.     

Descriptive anatomy of the femoral portion of the iliopsoas muscle. Anatomical basis of anterior snapping of the hip

Abstract: Anterior hip snapping is a rare clinical observation. The physiopathological hypothesis currently held is a sudden slip of the iliopsoas tendon over the iliopectineal eminence. For symptomatic cases, a surgical technique is proposed. The aim of this work is to describe the anatomy of the femoral portion of the iliopsoas, which is the target of surgery. We have studied, through dissection of embalmed cadavers, the different components of the musculotendinous complex forming the femoral portion of the muscle and the gliding apparatus associated with it. The psoas major tendon exhibited a characteristic rotation. The iliacus tendon, more lateral, received the most medial iliacus muscular fibers, then fused with the main tendon. The most lateral fibers, starting in particular from the ventral portion of the iliac crest, ended up without any tendon on the anterior surface of the lesser trochanter and in the infratrochanteric region. The most inferior muscular fibers of the iliacus, starting from the arcuate line, joined the principal tendon of the psoas major passing around it by its ventromedial surface. An ilio-infratrochanteric muscular bundle was observed, in a deeper position, under the iliopsoas tendon; it arose from the interspinous incisure and on the anterior inferior iliac spine, ran along the anterolateral edge of the iliacus and inserted without any tendon onto the anterior surface of the lesser trochanter of the femur and in the infratrochanteric area. The iliopectineal bursa was studied on horizontal cross sections of a frozen pelvis and on 5 of the non-frozen preparations after dividing the iliopsoas tendon. The iliopectineal bursa had the shape of a 5 to 6-cm high and 3-cm wide cavity; in its upper part, it was divided into 2 compartments a medial compartment for the main tendon and a lateral compartment for the accessory tendon.     

Descriptive anatomy of the femoral portion of the iliopsoas muscle. Anatomical basis of anterior snapping of the hip

Anterior hip snapping is a rare clinical observation. The physiopathological hypothesis currently held is a sudden slip of the iliopsoas tendon over the iliopectineal eminence. For symptomatic cases, a surgical technique is proposed. The aim of this work is to describe the anatomy of the femoral portion of the iliopsoas, which is the target of surgery. We have studied, through dissection of embalmed cadavers, the different components of the musculotendinous complex forming the femoral portion of the muscle and the gliding apparatus associated with it. The psoas major tendon exhibited a characteristic rotation. The iliacus tendon, more lateral, received the most medial iliacus muscular fibers, then fused with the main tendon. The most lateral fibers, starting in particular from the ventral portion of the iliac crest, ended up without any tendon on the anterior surface of the lesser trochanter and in the infratrochanteric region. The most inferior muscular fibers of the iliacus, starting from the arcuate line, joined the principal tendon of the psoas major passing around it by its ventromedial surface. An ilio-infratrochanteric muscular bundle was observed, in a deeper position, under the iliopsoas tendon; it arose from the interspinous incisure and on the anterior inferior iliac spine, ran along the anterolateral edge of the iliacus and inserted without any tendon onto the anterior surface of the lesser trochanter of the femur and in the infratrochanteric area. The iliopectineal bursa was studied on horizontal cross sections of a frozen pelvis and on 5 of the non-frozen preparations after dividing the iliopsoas tendon. The iliopectineal bursa had the shape of a 5 to 6-cm high and 3-cm wide cavity; in its upper part, it was divided into 2 compartments: a medial compartment for the main tendon and a lateral compartment for the accessory tendon.