男性盆腔内脏神经的解剖学研究及其临床意义

男性盆腔内脏神经与盆筋膜及盆内脏器的毗邻关系复杂,且个体形态学差异大,临床上涉及肛肠外科、泌尿外科、男科等多个学科,应用甚广。近年来,对内脏神经的术中保护越来越受到重视。男性盆腔内脏神经主要包括上腹下丛、腹下神经、下腹下丛(即盆丛)、盆内脏神经、膀胱丛、前列腺丛、直肠丛及其分支等。现已证明盆腔内脏神经的损伤会给患者的排便、排尿及阴茎勃起等造成功能障碍。熟悉男性盆腔内脏神经及其分支的形态特点及其与周围结构的关系,能降低手术并发症,提高患者术后生活质量。     

男性盆丛神经的观察及其临床意义

目的：直肠癌扩大根治术是提高术后生存率，减少癌细胞转移的重要术式，但其术后排尿和性功能障碍并发症较多，其原因是术中损伤了盆丛神经。本文对盆丛的研究可为改进直肠癌扩大根治术，降低并发症，提高生存质量，提供解剖学资料。方法：用３０侧男性盆腔标本，通过冰醋酸松解剥离方法，对盆丛的起源、组成和分支分布进行了详细观测。结果：盆丛长径为４１．６±７．３ｍｍ，宽径２９．８±８．５ｍｍ。盆丛又继续形成直肠丛、膀胱丛和前列腺丛，三个次级丛参与管理排尿功能和性功能。结论：手术中如能对盆丛及其次级丛神经加以保护，免受或减少损伤，可防止或减少术后并发症的发生。     

上腹下丛的应用解剖及临床意义

目的了解上腹下丛(SHR)的走行,为临床提供解剖学参考。方法对36具动脉灌注红色乳胶的成人防腐固定标本进行解剖观测。观察SHP主干的位置,并测量主干右缘到前正中线的距离。结果SHP主干位于正中线左侧者占88.89%(32/36),其右侧缘距离前正中线(8.23±2.78)mm。结论上腹下丛主干位于髂间三角的右侧,临床处理时应引起注意,采取相应措施。     

男性盆腔神经丛的外科应用解剖

目的　探讨泌尿外科术中避免损伤盆腔神经丛 (盆丛 )的解剖标志。方法　对 42具盆腔器官作盆腔解剖或组织切片 ,观察盆丛与盆腔脏器的毗邻关系。结果　盆丛位于直肠的前外侧 ,距肛门口 ( 9.5± 1.6)cm ,精囊的后外侧 ,在前列腺基底部与前列腺血管形成神经血管束 ,于尿道膜部外侧和后外侧 ,穿尿生殖膈。结论　精囊和前列腺神经血管束可作为泌尿外科术中防止损伤盆丛的一个标志。     

人海绵体神经的应用解剖及临床意义

海绵体神经起源于盆神经丛的次级神经丛-前列腺丛,含有交感神经纤维和副交感神经纤维两种成分。该神经与尿道血管形成神经血管束,沿前列腺两侧向远端走形,穿尿生殖膈后,发出分支进入海绵体,或与阴茎背神经交通,最后管理阴茎勃起组织。在盆内手术如膀胱、前列腺的根治性手术和全直肠系膜切除术后因海绵体神经损伤而导致患者术后勃起功能障碍时有发生。熟悉海绵体神经及其分支的走行特点及其与周围结构的关系,能降低手术并发症。在海绵体神经损伤后的重建方面也取得了一定的成果。     

盆部内脏神经血管的解剖特点及临床应用

目的:探讨经腹腔镜行全直肠系膜切除术中盆部内脏神经和血管的保护.方法:解剖32具成人躯干标本(女15、男17)和31侧成人男性骨盆矢状标本,结合腹腔镜手术,观测有关的盆腔血管神经的形态及定位.结果:(1)骶中静脉大多1支,61%偏左,骶外侧静脉53%为两支,骶前静脉丛在骶曲处密集粗大,骶椎椎前穿通静脉在第4、5骶椎前方形成静脉窦,且与骨膜结合紧密.(2)盆从位于距直肠外侧约1.1cm和距直肠膀胱陷凹上外测约4.7cm处的骨盆侧壁.左右腹下神经分别于骶骨岬上下1.0～2.0 cm的范围内分出,其夹角约95.9°.上腹下丛位于腹主动脉分叉周围至骶骨岬下2 cm之间.(3)腹腔镜下骶前间隙主要由少量的疏松结缔组织填允容易分离,解剖层面清晰.结论:手术中应找准解剖层面,根据血管神经的定位以神经为导向进行分离,可避免损伤盆部的内脏神经及骶前静脉丛.     

腹腔镜全直肠系膜切除术中输尿管保护的临床解剖

目的:探讨与腹腔镜全直肠系膜切除术(LTME)有关的左输尿管解剖学特点和保护方法。方法:利用腹腔镜对2004年10月~2005年5月接受LTME的24例直肠癌患者进行解剖学观察。结果:左输尿管腹段偏向中线侧走行,与左半乙状结肠系膜关系密切;输尿管盆段靠外侧走行,与直肠系膜和直肠侧韧带距离较远;输尿管位于肾前筋膜/骶前筋膜后外侧,而乙状结肠直肠系膜位于肾前筋膜前面,两者处于不同的解剖间隙。结论:左输尿管腹段损伤的几率较大,盆段较安全。LTME中保护输尿管的方法是:保持正确的外科平面,紧贴结直肠系膜,避免突破肾前筋膜/骶前筋膜,与输尿管保持安全距离;充分暴露,直视下锐性解剖;避免在盆侧壁盲目电凝止血等。     

腰丛神经的数字化解剖及其临床意义

目的:对腰丛及其周围的组织结构进行可视化的研究,为微创手术提供更精确的数据和解剖学资料.方法:利用“虚拟中国人“Ⅰ号女性数据集,重建腰丛及其周围组织结构的三维可视化模型.结果:通过数字人数据集重建的三维图片显示腰丛神经及其主要分支与主要血管和椎体及肾脏之间的关系,又可清楚的显示腰丛神经与腰大肌之间的关系.结论:数字人数据集可提供腰丛和周围组织器官的断层图片,为腰丛的解剖学位置及腰椎前路手术提供了形态依据.     

下颌神经管的解剖结构

背景:在下颌后牙种植术中,由于下颌神经管走行于下颌骨体内,有时可损伤下齿槽神经,因而制约了牙种植术的应用。 因此,牙种植术的应用需详细了解下颌神经管的解剖结构。 目的：观察下颌神经管在下颌骨内的走行及管内的解剖结构。 方法：共纳入15具成人牙下颌骨标本与4具新鲜下颌骨动脉灌注标本。纳入对象均牙列完整,后牙无缺失,牙槽骨无吸收。测量15具成人牙下颌骨标本下颌管走行及其管腔各径长度,包括下颌管横径与纵径,下颌管至上下内外缘距离。观察4具新鲜下颌骨动脉灌注标本管内下颌神经管内神经、血管位置关系。 结果与结论：下颌管内缘至舌侧骨板的距离比下颌管外缘至颊侧骨板距离短(P < 0.01);下颌管上缘至牙槽嵴顶的距离较下颌管下缘至下颌骨下缘的距离大(P < 0.01)。表明下颌管在下颌骨体部走行中偏舌侧、偏下颌骨下缘。下颌神经管在下颌骨体部的部分横径小于纵径(P < 0.05),亦即下颌管截面形态为上下径略长的椭圆形。神经管横纵径于前后牙位区差异无显著性意义。实验还发现在暴露的下颌管腔中下牙槽神经及伴随血管有一层被膜包绕成神经血管束,血管位于神经上方,而且位置恒定,并发出小分支包绕神经。结果提示,下牙槽血管神经束在下颌管内走行中血管位于神经之上。     

下腰椎侧方血管神经及毗邻结构的应用解剖

目的:为下腰椎微创极外侧椎体间融合术(XLIF)提供解剖学依据。方法:解剖30具成人尸体,观测下腰椎侧方血管神经及毗邻结构的走行、分布及毗邻关系。结果:腰L1、L2、L3节段血管走行、分布比较恒定,走行于相应椎体的中央偏下水平,但L4动、静脉走行变异较大,其中36.7%(11例)走行于L4/L5间隙表面;L3～L5椎间孔外口处脊神经的直径及脊神经前支距下位椎间盘的距离均逐渐增大;脊神经前支与椎体正中矢状面的夹角L3～L4增大,而L5却减少到L3的水平;L3～L5左右侧手术窗均逐渐增大,且同一节段水平左侧手术窗大于右侧。结论:由于两侧髂嵴的遮挡,XLIF在L5/S1间隙难于进行,在L3/L4、L4/L5间隙可以顺利进行。     

The surgical anatomy of the fasciae and the fascial spaces related to the rectum

The perirectal fasciae and their vascular and neural relationships were studied based on the dissection of 46 fresh cadavers. The rectal fascia is a tubular sleeve, areolar in nature, which houses the superior rectal vessels and lymphatics. The nerves which supply fibres to the pelvic plexus run close to the rectum, contained in the urogenital and presacral fasciae. The rectum is attached to these two fasciae by the rectal stalks, which take a spiral course round the rectum, being posterolateral in the upper rectum, lateral in the mid-rectum and anterolateral in the lower rectum. During rectal resection the pelvic nn. may be preserved if the rectal dissection proceeds close to the rectal fascia. After cutting the rectal insertion of the presacral fascia, the lower rectal stalks (paraproctium) come into direct view and can be divided close to the rectal wall with no risk of damage to the pelvic plexus.     

The surgical anatomy of the fasciae and the fascial spaces related to the rectum

Summary The perirectal fasciae and their vascular and neural relationships were studied based on the dissection of 46 fresh cadavers. The rectal fascia is a tubular sleeve, areolar in nature, which houses the superior rectal vessels and lymphatics. The nerves which supply fibres to the pelvic plexus run close to the rectum, contained in the urogenital and presacral fasciae. The rectum is attached to these two fasciae by the rectal stalks, which take a spiral course round the rectum, being posterolateral in the upper rectum, lateral in the mid-rectum and anterolateral in the lower rectum. During rectal resection the pelvic nn. may be preserved if the rectal dissection proceeds close to the rectal fascia. After cutting the rectal insertion of the presacral fascia, the lower rectal stalks (paraproctium) come into direct view and can be divided close to the rectal wall with no risk of damage to the pelvic plexus.

---

Anatomie chirurgicale des fascias et espaces en rapport avec le rectum

Résumé Les fascias péri-rectaux et leurs rapports vasculo-nerveux ont été étudiés par dissection de 46 cadavres frais. Le fascia rectal est un manchon tubulaire, de nature aréolaire, qui enveloppe les vaisseaux rectaux supérieurs et les lymphatiques. Les nerfs qui alimentent le plexus pelvien courent près du rectum, contenus par les fascias uro-génital et pré-sacré. Le rectum est relié à ces deux fascias par les ailerons du rectum, dont le trajet en spirale est postéro-latéral à la partie haute du rectum, latéral à sa partie moyenne, antéro-latéral à sa partie inférieure. Au cours des résections rectales, il est possible de respecter les nerfs pelviens si la dissection du rectum est menée au ras du fascia rectal. Après avoir coupé l'insertion rectale du fascia présacré, les ailerons rectaux inférieurs (paraproctium) sont directement visibles et peuvent être sectionnés au ras de la paroi rectale sans risque de lésion du plexus pelvien.

     

Lymphangiomyomatosis arising in the pelvic cavity: a case report

Lymphangioleiomyomatosis (LAM) is a rare disease usually occurring in young women of child-bearing age. It is characterized by a distinctive proliferation of lymphatic smooth muscle cells, especially occurring in the pulmonary parenchyme. The majority of primary LAM occurs in the lung, but there are a few reports of extrapulmonary cases. We report a case of a 21-yr-old female who first complained of low abdominal pain and was referred from a local clinic with the impression of an ovarian cyst. Gynecologic ultrasonography revealed a large posterior pelvic mass with an irregular echogenicity measuring 9.7 x 4.2 cm in size. Pelviscopy showed a large, thin walled, partly cystic, pelvic mass. The mass was partly removed. Microscopically, the mass was characterized by a haphazard proliferation of smooth muscle cells arranged in fascicular, trabecular, and papillary patterns around a ramifying network of endothelium-lined spaces. The cells were plump or epithelioid with abundant eosinophilic cytoplasm and showed a positive reaction for both alpha-smooth muscle actin and HMB-45 antigen. Surgical and pathological findings were consistent with pelvic retroperitoneal LAM. Despite the numerous treatment attempts, the patient suffered from intractable chylous ascites and developed pulmonary LAM and died due to severe respiratory distress.     

Detailed anatomy of the capsulopalpebral fascia

This study was designed to elucidate the detailed anatomy of the capsulopalpebral fascia (CPF) and capsulopalpebral head (CPH), and their relationships to the inferior rectus muscle (IRM). In this cohort study, 40 eyes from 20 cadavers were observed macroscopically. Dissection was carried out from the CPF origin to its insertion, and the CPF origin pattern was photographed in each specimen. The width, length, and tensile strength of the CPF were measured. The CPF originated 25.07 ± 1.07 mm laterally and 24.86 ± 1.10 mm medially from the origin of the IRM and extended to the lower border of the inferior oblique muscle, and it firmly adhered to the IRM surface and formed into the CPH. The CPH was 4.31 ± 0.86 mm laterally and 6.18 ± 1.94 mm medially in length and 7.47 ± 0.81 mm in width. The CPF originated from the total width or 3/4 temporal part of the IRM in 32 (80%) of 40 faces. There was asymmetry in the pattern of the CPF origin between the left and right eyes in 4 of 20 paired specimens (20%). The tensile strength of the posterior layer was 19.12 ± 11.22 N, which was significantly higher than that of the anterior layer (8.59 ± 3.88 N) (P = 0.001). This study provided a good understanding of the CPF structures conducive to performing IRM surgery.     

骨盆的形态特点与不稳定型骨折内固定治疗评价

目的　探讨根据骨盆的形态特点选择不同的内固定手术治疗不稳定型骨盆骨折的临床应用价值。 方法　65例不稳定型骨盆骨折,31例Tile B型骨折经前入路,将耻骨联合或耻骨支复位用重建钢板固定,其中8例合并髂骨骨折经髂窝入路将之复位用重建钢板固定;34例Tile C型骨折的前环损伤均采用与Tile B型骨盆骨折相同的方法处理,后环损伤的固定方法：17例骶骨骨折或骶髂关节脱位之中,复位后在透视引导下从后方经皮骶髂螺钉固定11例,经髂骨的螺栓固定4例,经后路在双侧髂骨后嵴之间用张力带钢板固定2例;9例骶髂关节骨折-脱位之中,经皮骶髂螺钉固定6例,钢板固定3例;8例合并髋臼骨折行重建钢板内固定。 结果　通过对术后骨盆X线测量骨折分离移位的最大距离,根据Matta评分标准：小于4 mm为优,占86.1%（56例）;4~10 mm为良,占7.7%（5例）;10~20 mm为可,占6.2%（4例）;大于20 mm为差（0例）。本组骨盆X线测量结果总优良率为93.8%。 结论 不稳定型骨盆骨折应在血流动力学稳定时尽早根据骨折的类型及骨盆的解剖形态特点选择合理的内固定手术方案。     

内固定与外固定材料修复骨盆骨折损伤：合理选择与生物相容性

BACKGROUND: Pelvic fractures are mostly caused by high energy trauma. With the development of imaging techniques and in-depth study of the anatomical structure of the pelvis and biomechanics, internal fixation and external fixation materials are gradually being used in the repair of pelvic fracture.     

Mechanics of crural fascia: from anatomy to constitutive modelling

Ten dissections of inferior limbs and histological studies were performed to describe the structural conformation of the muscular fascia of the leg (crural fascia) and to propose a constitutive model to be adopted for the analysis of its biomechanical behaviour. The crural fascia had a mean thickness of 924 μm and was composed of three layers (mean thickness 277.6 μm) of parallel, collagen fibre bundles separated by a thin layer of loose connective tissue (mean thickness 43 μm). Only a few elastic fibres were highlighted. The disposition of the collagen fibres gives the crural fascia anisotropic characteristics. In addition, their crimped conformation is the cause of the non-linear elastic behaviour of the tissue. Both these aspects are included in the constitutive model. The constitutive modelling of the crural fascia represents a useful tool to rationally interpret the correlation between functional behaviour and structural conformation.     

Modelling the passive and nerve activated response of the rectus femoris muscle to a flexion loading: a finite element framework

A muscle modelling framework is presented which relates the mechanical response of the rectus femoris muscle (at the organ level) to tissue level properties, with the capability of linking to the cellular level as part of the IUPS Physiome Project. This paper will outline our current approach to muscle modelling incorporating micro-structural passive and active properties including fibre orientations and nerve innervation. The technique is based on finite deformation (using FE analysis) coupled to electrical nerve initiated muscle activation, and we present the influence of active tension through an eccentric contraction at specific flexion angles. Finally we discuss the future goals of incorporating cell mechanics and validating at the organ level to provide a complete diagnostic tool with the ability to relate mechanisms of failure across spatial scales.     

Fascial bundles of the infraspinatus fascia: anatomy,function, and clinical considerations

The infraspinatus fascia is a tough sheet of connective tissue that covers the infraspinatus fossa of the scapula and the muscle within. Muscle fibers originate from the fossa and fascia and then travel laterally to insert on the greater tubercle of the humerus. Frequently the infraspinatus fascia is quickly removed to appreciate the underlying muscle, but the fascia is an interesting and complex structure in its own right. Despite having a characteristic set of fascial bundles, no contemporary anatomy texts or atlases describe the fascia in detail. The infraspinatus fascia was dissected in detail in 11 shoulders, to characterize the fascial bundles and connections that contribute to it. Thereafter, 70 shoulders were dissected to tabulate the variability of the fascial bundles and connections. Six characteristic features of the infraspinatus fascia were noted: a medial band, an inferior‐lateral band, and superior‐lateral band of fascia, insertion of the posterior deltoid into the infraspinatus fascia, a transverse connection from the posterior deltoid muscle to the infraspinatus fascia, and a retinacular sheet deep to the deltoid and superficial to the infraspinatus and teres minor muscles. Although other structures of the shoulder are more frequently injured, the infraspinatus fascia is involved in compartment syndromes and the fascial bundles of this structure are certain to impact the biomechanical function of the muscles of the posterior shoulder.     

胆道高压对内脏大神经的影响及其意义

为了探讨胆道高压对内脏大神经的影响及其在重症急性胆管炎(ACST)发病机理中的意义。本实验采用自制“盲囊”加压装置制成家兔急性胆道加压模型,同步动态记录内脏大神经放电频率和血压变化,结果表明:在150mmHg(20kPa)加压条件下,内脏大神经放电频率于1分钟内即明显增加(P<0.01),且右侧远较左侧明显(P<0.01),同时血压也明显下降(P<0.01)。如迅速减压,则放电频率和血压均在短期内恢复至加压前水平。阻断右侧内脏大神经,则血压下降不明显(P>0.05)。实验结果提示,内脏大神经活动与重症急性胆管炎早期的血压下降有关,值得深入探讨。