股前外侧部皮瓣的进一步解剖学研究--高位皮动脉与皮瓣血供的分型

目的：研究股前外侧皮瓣高位皮动脉及皮瓣的血供类型。方法：在50例灌注红色乳胶的成人防腐标本上对股前外侧部皮动脉进行解剖观察，记录高位皮动脉的出现率、来源动脉、位置及其走行，分析股前外侧部皮动脉的分布规律。结果：高位皮动脉出现率为58％（29侧，34支），其中发自旋股外侧动脉升支的占10％（5侧）、横支的占44％（22侧）和降支根部的占4％（2侧）。无高位皮动脉出现时，旋股外侧动脉降支发出皮动脉营养皮瓣，降支皮动脉浅出点在髂髌连线附近，可定为正常型（21侧，42％）。出现高位皮动脉时，降支发出的皮动脉位置偏低，管径较细，皮瓣的血供可分为降支皮动脉主要型（18侧，36％）、均匀分布型（6侧，12％）和高位皮动脉支主要型（5侧，10％）。结论：高位皮动脉出现率高，分布具有规律性，可作为股前外侧部皮瓣血管蒂的补充。     

股前外侧逆行岛状皮瓣供血动脉层次关系及其临床意义

目的：为股前外侧带感觉神经逆行岛皮瓣的设计提供动脉层次关系的解剖学基础。方法：在54例下肢标本上解剖观察了旋股外侧动脉降支末端与膝周围动脉吻合的层次主股外侧皮神经的血供来源。结果：（1）在浅筋膜层内，股外侧皮神经的血供来源是多源性，分节段的，这些营养血管互相吻合成网过皮下组织达皮肤。（2）旋股外侧动脉降支末端在膝关节上方的深筋膜层与膝周围动脉的吻合有三个类型。结论：以股外侧皮神经及其营养或旋股外侧动脉降支为蒂截取股前外侧带感觉神经逆行岛状皮瓣可用于膝周软组织缺损或膝下截肢创面的修复。     

欧洲人股前外侧皮瓣应用解剖和临床应用

目的：介绍欧洲人股前外侧皮瓣的应用解剖和临床应用。方法：１０具２０侧新鲜白种人标相股前外侧皮瓣解剖学观察。并临床应用１２例游离和带蒂肌前外侧皮瓣修复各种缺损。结果：皮瓣血供特点和走行与国人相比无较大差异,其血管蒂长,口径较粗大。第１穿支稳定及粗大,变异较少。皮瓣血管蒂以旋股外侧降支为主,少数病例为旋股外侧动脉横支,临床应用１２例修复四肢及躯体缺损,均成活,效果满意。结论：欧洲人股前外侧皮瓣应用解剖     

股前外侧单一高位穿支供血区域的形态学研究与皮瓣设计

目的：研究股前外侧各类型高位穿支的特点与供血区域。方法：（1）6侧动脉灌注明胶一氧化铅混悬液的新鲜整尸下肢标本，解剖观察股前外侧区高位皮动脉的数量和类型，取下被覆组织拍摄X线片，观察皮肤血管的走行及分布，选择不同类型高位皮动脉各1侧使用16排多层螺旋CT进行扫描，三维重建和穿支供血区域可视化研究。（2）在6侧灌注红色乳胶的成人防腐标本上对股前外侧区皮动脉进行解剖观察。结果：高位皮穿支来源于旋股外侧动脉升支和横支。高位皮穿支三维重建显示以髂髌连线为纵轴的皮瓣内主要血管高密度分布区，供血区为24cm×6．8cm，供血区域由纵轴向两侧区域扩展，高位皮穿支供血区域可达26cm×18cm，皮瓣高位穿支蒂长约5cm。结论：股前外侧皮瓣单一高位穿支供血面积可达30cm×22cm，高位穿支蒂长，可形成穿支蒂皮瓣。穿支三维重建的血管区域客观可靠。     

下肢常用皮瓣的应用解剖学要点

股前外侧皮瓣 一、血管蒂 旋股外侧动静脉降支及其分支(图1),属于肌皮血管穿支型血管(1)。 动脉:旋股外侧动脉降支发出4—9条肌皮动脉穿支(2)。第一肌皮动脉上方3cm处,降支的外径2.1(1.1～2.8)mm。 静脉:在旋股外侧动脉降支的两侧有同名伴行静脉,外径分别为2.3mm和1.8mm。 二、神经蒂 股外侧皮神经(图2),     

股前外侧皮瓣血管的临床分型及意义

作者通过30例股前外侧皮瓣移植手术,对皮血管的临床观察发现,皮动脉在降支干上的起始部位,在肌中穿行的长度和深度以及出肌后进入筋膜—皮肤的部位与其形式皆不尽相同,共见有6种。作者从临床实用出发,作出临床分型:Ⅰ型.肌皮动脉穿支型;Ⅱ型.高位肌皮动脉穿支型;Ⅲ型.肌间隙皮支型。并对各型皮动脉的术中处理体会作了介绍。     

旋股外侧血管蒂复(联)合组织瓣移植的解剖学基础

目的：为以旋股外侧血管蒂复(联)合组织瓣移植提供解剖学基础。方法：50侧成人下肢标本解剖观察旋股外侧动脉分支起始类型及其分布。结果：旋股外侧动脉分支起始主要有3型：Ⅰ型：旋股外侧动脉发升支、横支和降支占76％；Ⅱ型：升支、横支、降支由两干从股深动脉或股动脉发出占20％；Ⅲ型：升支、横支、降支单独从股深动脉或股动脉发m占4％。升支恒定分支分布于阔筋膜张肌和髂嵴前外侧部；横支分支分布于股外侧肌上部和大转子前外侧部；降支分支分布于股外侧肌和股前外侧部皮肤。结论：76％可以旋股外侧血管为蒂形成：①升支阔筋膜张肌皮瓣和／或髂骨瓣；②横支大转子骨瓣或骨膜瓣；③降支股前外侧皮瓣。20％则可以升支和横支或横支和降支共十形成相应两个组织瓣：     

股前外侧部皮瓣的解剖学一个新的游离皮瓣供区

在35侧下肢标本上,对股前外侧部的皮肤上供进行了应用解剖学研究。发现以旋股外侧动脉降支为轴,通过其股外侧肌皮动脉穿支或肌间隙皮支可以构成一个新的皮瓣供区,并于1983年用于临床。旋股外侧动脉降支在发出第一支肌皮动脉穿支上方3 cm处外径为2,1mm,肌皮动脉穿支的外径为0.6mm。     

同体两侧股前外侧皮瓣的解剖学对比

目的 探讨同体两侧股前外侧（ALT）皮瓣的解剖学差异,为术前进行供侧大腿选择的必要性提供解剖学依据。 方法 10具新鲜尸体标本（共20例）上行双侧ALT皮瓣制取,寻找皮瓣的营养穿支,记录穿支类型和数量,并逆向追溯到血管蒂;测量各穿支、血管蒂的长度和管径,统计学数据采用均值±标准差。 结果 10具标本中有3具两侧股前外侧皮瓣为肌间隔穿支和肌皮穿支双供血型;其余7具两侧穿支类型不同。7具标本两侧皮瓣的穿支数量不同,另外3具的穿支数量相同。肌间隔穿支走行于股直肌与股外侧肌之间的肌间隙内,肌皮穿支或垂直或斜形穿过股外侧肌,其穿支长度各异。皮瓣穿支全部发自旋股外侧动脉（LCFA）降支的有14例,另有6例（30%,源于5具标本）皮瓣既有降支又有斜支参与供血,其中1具标本两侧均由斜支与降支双重供血,其余4具标本均只有1侧为斜支与降支双重供血。10具标本共20例皮瓣的两侧主要穿支和血管蒂管径及长度差别不大(P>0.05)。 结论 同体两侧股前外侧皮瓣的营养穿支在类型、数量、走行、血管蒂来源上存在差异,穿支的种类及走行对于皮瓣制取的难易及操作时间有直接影响。术前进行供侧大腿的选择有助于股前外侧皮瓣精准、快捷的制取。     

肌间隔血管源游离皮瓣的解剖学

本文根据皮肤的血供规律,在传统的直接皮肤血管皮瓣、肌皮血管皮瓣和动脉干网状血管皮瓣三种类型基础上,提出一种新类型的肌间隔血管皮瓣。肌间隔皮肤动脉走行于肌间隔深面,容易分离,有较长的血管蒂,所供应的皮区均有部位适宜、质地优良的特点。本文在70例成人肢体和9个铸型标本上,研究了臂部和股部肌间隔的动脉,它们是:尺侧上副动脉、桡侧副动脉、第一穿动脉肌间隔枝、膝降动脉隐枝及其所供应皮区的应用解剖学。讨论了可供吻合血管游离皮瓣移植用的臂内侧皮瓣、臂外侧皮瓣、股后外侧皮瓣和小腿内侧皮瓣。     

犬肋骨肌瓣的应用解剖与气管成型及气管再造的实验研究

目的：对犬肋骨肌瓣与肌瓣环进行解剖学观察,并以此组织瓣进行气管成型与气管再造动物实验。方法：将犬的第３肋间血管灌注后观察其分布情况。将第３肋骨民上下肋间肌修整成带肌瓣蒂的肋骨瓣、骨肌瓣环,分别行胸内气管成型与环形替代术。结果：犬的肋骨肌瓣、瓣环血供均良好。第３肋间动脉、静有多个分支在胸腊民骨膜之间上行分布玩具闰肋间肌。实验获得满意效果,气管成型手术的犬与非手术犬一样正常活动。气管再造的１８条犬中１     

延迟术通过加强血管扩张的方式促进跨区皮瓣存活

目的：在小鼠耳上建立耳瓣延迟模型,探究延迟术促进组织存活的原因。方法 ICR小鼠30只,等分入延迟组、非延迟组及分叉以下组。延迟组小鼠先在中间血管体分叉即上水平做一切口,1周后再切开尾侧血管体;非延迟组小鼠在中间血管体分叉即上水平剪断尾侧与中间血管体;分叉以下组在中间血管体分叉即下水平剪断中间与尾侧血管体。术后对3组耳瓣的坏死率进行测量,对延迟组与非延迟组耳瓣内不同位置出现显著管径变化的choke血管的数量及管径进行计数与测量。结果延迟组、非延迟组及分叉以下组最终坏死率分别为（7.7±4.8）%、(31.0±12.4)%及(15.4±7.4)%,有显著性统计学差异(P=0.003)。延迟组小鼠平均每耳瓣出现(8.8±2.0)根有显著形态学变化的choke血管;非延迟组小鼠平均每耳瓣出现(6.5±1.2)根,显著少于延迟组（t=3.083,P=0.006）。延迟组小鼠耳瓣内choke静脉的扩张幅度显著大于非延迟组,延迟组小鼠耳瓣内平均血管内阻力显著小于非延迟组。结论延迟术通过加强choke血管扩张的方式促进皮瓣的存活。中间血管的类型及处理方式可能对跨区皮瓣的存活起重要作用。     

18例腹部皮瓣修复手部重度热压伤临床分析

目的探讨腹部皮瓣修复手部重度热压伤的方法和疗效。方法 18例手部重度热压伤采用各种腹部带蒂皮瓣进行创面修复术。术后皮瓣覆盖多指者行分指整形术,皮瓣臃肿者行皮瓣去脂术,术后早期进行康复治疗。结果 18例术后皮瓣全部成活,6例行分指整形术,5例行皮瓣去脂术。经6~12个月随访,皮瓣颜色质地佳,手外形和功能恢复满意。结论腹部皮瓣修复早期手部热压伤创面具有简便、可靠的特点。     

Lasers in infertility

Lasers have been used in fertility surgery for the past twodecades. This article reviews the development of different wavelengthlasers, the different tissue effects and their applicationsin infertility surgery. The CO₂ laser remains the most preciselaser, especially in the ultrapulse mode, for the division ofadhesions and the accurate and safe vaporization of depositsof endometriosis. The neodymium: YAG laser, because of its greaterdepth of penetration, is more suited to hysteroscopic surgery,and attempts to focus the energy by sapphire tips and sculptedquartz fibres merely enable tissue to be incised by a thermaleffect. Carbon dioxide laser energy is strongly absorbed bythe water molecule and is rendered ineffective in the presenceof blood so the visible light lasers, argon and potassium titanylphosphate (KTP/532) lasers, are more suitable for the treatmentof ovarian endometriomas and ectopic pregnancies. Techniquesand results of laser surgery in endometriosis, tubal surgery,ectopic pregnancy and polycystic ovarian syndrome are reviewed.The main advantage of the various lasers is that they allowfertility surgeons to perform operative surgery by the minimallyinvasive approach of laparoscopy rather than laparotomy.     

Conservative treatment in epithelial ovarian cancer: results of a multicentre study of the GCCLCC (Groupe des Chirurgiens de Centre de Lutte Contre le Cancer) and SFOG (Société Francaise d'Oncologie Gynécologique)

BACKGROUND: Results of conservative management of epithelial ovarian cancer (EOC) remain controversial in the literature. The aim of this study was to assess the clinical outcomes and fertility following fertility-sparing surgical management of EOC in a retrospective multicentre study. METHODS: A multicentre retrospective study was performed by members of two French groups. Six inclusion criteria were defined: (i) Histological review by the same pathologist; (ii) age < or =40 years; (iii) conservative management; (iv) complete peritoneal staging; (v) delivery of a platinum-based chemotherapy in stage > or = IC; and (vi) follow-up >1 year. RESULTS: Thirty-four patients fulfilled the inclusion criteria: 30 had stage IA disease; three had stage IC and one had stage IIA. Eleven patients had recurrence: 10 patients had invasive disease and one had borderline recurrence. Among 10 patients with invasive recurrence, initial stage and grade were: stage IA G1, n = 1; stage IA G2, n = 4; stage IA G3, n = 1; and stage> or = IC, n = 4. All patients with stage > IA had recurrence. Ten pregnancies were observed in nine patients. CONCLUSION: Conservative surgery for patients with EOC could be considered in young patients with stage IA G1 disease. This procedure should not be performed in patients with FIGO stage > IA.     

Gynaecoradiological uterine resection

We assessed the feasibility of performing uterine surgery underfluoroscopic control in an ambulatory setting that does notrequire operating room time and general anaesthesia. Four uterineseptae were resected and two cases of Asherman's syndrome weretreated using fluoroscopically guided scissors. All six surgicalprocedures were successfully completed. Gynaecoradiologicaluterine resection (GUR) procedures, utilizing fluoroscopy guidedscissors, are promising new techniques, which may allow thesuccessful performance of uterine surgery in a cost effectiveambulatory setting with no requirement of general anaesthesia.     

Surgery: Fertility after conservative surgery for adenomyomas

Reproductive performance was evaluated after conservative surgeryfor uterine adenomyoma in a prospective, observational study.Twenty-eight women with histologically proven adenomyomas hadconservative surgery in the period 1985–1990. Eighteenpatients wanting children were regularly followed for a mean± SD period of 53.2 ± 23.5 months. Crude and cumulativepregnancy rates were calculated after the operation. Thirteen(72.2%) women conceived, for a total of 18 pregnancies: nine(50%) ended in term deliveries, seven (38.8%) in spontaneousabortions, one (5.6%) in ectopic pregnancy and one (5.6%) ina pre-term delivery with neonatal death. The cumulative pregnancyrate at 36 months of follow-up was 74.7%. This analysis of asmall series indicates that conservative surgery for adenomyomasis associated with a good reproductive prognosis.     

Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory

BACKGROUND: If the menstrual reflux or implantation theory of endometriosis is true, refluxed endometrial cells could reach the right hypochondrium transported by the clockwise peritoneal fluid current and would implant more easily on the right diaphragmatic leaf as they are stuck there by the falciform ligament. METHODS: To investigate if a lateral asymmetry exists in diaphragmatic endometriotic lesion distribution, all articles on diaphragmatic endometriosis identified by MEDLINE, EMBASE and PUBMED database searches were retrieved, and additional reports were collected by systematically reviewing all references. The number of women and the side of the lesion with respect to the falciform ligament of the liver were obtained from individual studies, and the combined frequency of right- and left-side diaphragmatic endometriosis was computed. In addition, seven personal cases were described. RESULTS: There were 16 reports including 47 subjects selected. Diaphragmatic endometriosis was on the right side in 31 (66%) patients, on the left in 3 (6%) and bilateral in 13 (27%). In the personal series, lesions were on the right side in five cases, on the left in one and bilateral in one. Considering only unilateral lesions, the observed proportion of right-sided endometriotic implants (36/40) was 90% (95% CI 76-97%; chi(2)(1) 32.6, P < 0.0001). CONCLUSIONS: The observed major asymmetry in diaphragmatic endometriotic lesion distribution in favour of the right leaf supports the menstrual reflux theory.     

The ovarian endometrioma: why is it so poorly managed? Laparoscopic treatment of large ovarian endometrioma: why such a long learning curve?

The laparoscopic management of ovarian endometrioma was reported more than 15 years ago. An anonymous survey conducted among gynaecologists in the UK showed that 50% of ovarian endometrioma are still managed by laparotomy. This surprising result is discussed emphasizing the difficulties of the learning curve, pitfalls in surgical training and mistakes of the pioneers. Endoscopic surgery will become the standard technique when all practising gynaecologic surgeons have been trained during their residency. The goal of the endoscopic surgeon should be to achieve adequate surgical treatment. Endoscopic surgery is not a technical gimmick used to avoid laparotomy and to attract patients.     

Prevention of postoperative adhesion formation in rat uterine horn model by nimesulide: a selective COX-2 inhibitor

BACKGROUND: Pelvic surgery is one of the main causes of intraperitoneal (i.p.) adhesions that create various medical problems including pelvic pain, bowel obstructions and female infertility. A rat model was used to investigate the efficacy of nimesulide, a selective cyclooxygenase-2 inhibitor, in the prevention of adhesion formation. METHODS: Fifty Wistar-Albino rats underwent bilateral uterine horn injury with a unipolar cautery. Study groups were as follows: (i) control group, no adjuvant therapy; (ii) i.p. Ringer's lactate group, 2 ml Ringer's lactate solution was instilled i.p.; (iii) i.p. Ringer's lactate plus nimesulide group, 1 ml Ringer's lactate plus 1 ml nimesulide (0.5 mg/ml) were given i.p.; (iv) intramuscular (i.m.) nimesulide group, 1 ml i.m. nimesulide (0.5 mg/ml) was given preoperatively for 5 days; and (v) i.p. nimesulide group, 1 ml nimesulide (0.5 mg/ml) was instilled i.p. At the end of the study all animals were killed, and a standard adhesion scoring system was applied by a blinded examiner. RESULTS: The mean adhesion extent in study groups was as follows: 1.33 +/- 0.76 in control group, 1.40 +/- 0.90 in i.p. Ringer's lactate group, 0.75 +/- 0.70 in i.p. Ringer's lactate plus nimesulide group, 0.25 +/- 0.44 in i.m. nimesulide group and 0.31 +/- 0.70 in i.p. nimesulide group. The mean +/- SD adhesion severities of control, i.p. Ringer's lactate, i.p. Ringer's lactate plus nimesulide, i.m. nimesulide, and i.p. nimesulide groups were 0.58 +/- 0.35, 0.30 +/- 0.41, 0.27 +/- 0.3, 0.12 +/- 0.28 and 0.15 +/- 0.35 respectively. The lowest adhesions were found in the groups treated with nimesulide i.m. and nimesulide i.p. ( P < 0.05). CONCLUSIONS: This study showed that preoperative i.m. or postoperative i.p. administration of nimesulide to the site of injury reduced the formation of postoperative adhesions in a rat uterine horn model.