结蛋白和抗肌营养不良蛋白在老年腹股沟疝患者腹内斜肌中的表达及意义

目的探索结蛋白和抗肌营养不良蛋白在腹内斜肌中的表达与老年腹股沟疝（inguinalhernia，IH）发病的关系。方法选择40例老年IH患者为研究组，20例无IH的老年阑尾炎患者为对照组，术中取同一解剖部位的腹内斜肌活组织，应用HE染色和免疫组织化学及显微镜图象分析的方法，观察HE染色下肌组织的形态及免疫组化下检测肌细胞内结蛋白和抗肌营养不良蛋白的含量。结果（1）HE染色图像分析表明：两组肌肉组织的形态学改变经分级后比较（P〈0．05），有统计学意义；（2）免疫组织化学和图像分析方法表明：老年IH患者中结蛋白的含量与对照组比较明显减少（P〈0．05）；老年IH患者中抗肌营养不良蛋白的含量与对照组比较明显减少（P〈0．05）。结论老年IH腹内斜肌的肌组织有明显的退行性改变，其肌细胞内结蛋白和抗肌营养不良蛋白表达减少，可能是老年IH发病的机理之一。     

Anatomic pecularities of the inguinal canal in West Indians. Influence on the management of inguinal hernia

Inguinal and umbilical hernias are much more frequent in the black and half-breed than in the white population. We have observed anatomical differences in the inguinal region between Whites and Blacks. The latter have a vertical, wide subcutaneous ring and a smaller conjoined tendon, and it is hardly possible to reconstruct the fascia of the obliquus externus abdominis anterior to the cord in them. For Black patients, we propose the suture of the conjoined tendon to the crural arch, like in the Bassini procedure, and the suture of the fascia of the obliquus externus to the arch, but in a retrofunicular position. This technique allows, so to speak, duplicating the caudal connection of the conjoined tendon to the arch by means of the extensive suture of 2 tissues of similar nature, ie. the fascia of the obliquus externus and the crural arch.     

Sensomotor function while wearing lumbar support ortheses

AIM: Flexible lumbar corsets should contribute to an improved active and passive stabilisation of the lumbar spine. In the present study, the effects of flexible corsets on sensory-motor abilities have been investigated. METHODS: 24 healthy subjects (m = 10, f = 14, 26.7 years) performed angle- and force-reproduction tasks with and without wearing a flexible corset. The subjects tried to reproduce trunk flexion angles of 20 degrees und 40 degrees as well as forces of 33% and 66% of the maximum strength of the back extensor muscles. Additionally, muscular reactions were measured during destabilizing stimuli. RESULTS: No significant differences were found for the reproduction tasks. When wearing the corset, the left erector spinae muscles showed a delayed onset (+15 ms, p < 0.05), and the obliquus abdominis reached maximal activity more rapidly (-18 ms, p < 0.05). In the preinnervation phase the obliquus abdominis (-33%, p < 0.01), in the eccentric phase the erector spinae (-27%, p < 0.05) and the right obliquus abdominis (-46%, p < 0.05) and in the concentric phase the right obliquus abdominis (-35%, p < 0.01) and the rectus abdominis (-32%, p < 0.05) showed lower activities. CONCLUSION: The reduced muscle activities with destabilizing stimuli can be interpreted as the result of an improved passive stabilisation of the lumbar region by wearing a flexible corset.     

Inguinal hernia: Measurement of the biomechanics of the lower abdominal wall and the inguinal canal

Background. The stability of the lower abdominal wall may play a considerable role in the development of inguinal hernia. Therefore, the strength of the individual wall layers needs to be quantified. Despite numerous advances in hernia repair, comparatively few systematic biomechanic and morphometric analyses have been performed. Our aim was to establish and apply a standardised procedure for testing the abdominal wall layers stability. Methods. After dissecting the abdominal walls of 16 cadavers into separate layers, we used a spherical punch and a force transducer to investigate the forces necessary to foraminate the layer. In addition, maximum tensile-strength and suction tests and histologic morphometry were performed. Results. The transversalis fascia was torn up on an average of 10.5 N, the peritoneum including pre- and subperitoneal tissue on 46.6 N, the aponeurosis of obliquus internus abdominis muscle on 51.7 N, and the aponeurosis of obliquus externus abdominis muscle on 92.6 N. Tensile tests of tissue strips obtained from defined areas showed comparable results. In contrast, surgical mesh revealed values between 60 and 150 N in punching tests. Left-right comparisons, as well as comparisons of the individual areas, revealed considerable intra- and inter-individual differences. Conclusions. Biological hernia repair should focus on a reinforcement of the tissue layers with the highest biomechanic stability. Reinforcement of the transversal fascia must be questioned according to our results of poor mechanical resistance.     

胸腹壁随意皮瓣联合腹直肌肌瓣修复胸壁缺损

目的探讨胸腹壁随意皮瓣联合腹直肌肌瓣移位修复胸壁缺损的临床应用价值。方法2002年1月～2005年6月,对5例胸壁缺损患者行胸腹壁随意皮瓣联合腹直肌肌瓣移位修复术。其中胸骨骨髓炎术后、胸骨肿瘤刮除术后、胸骨结核病灶清除术后各1例,心脏手术术后2例;均因感染致胸骨及内置物外露,病程6个月～2年。先行病灶清除,视创面大小设计切取15cm×10cm的胸腹壁随意皮瓣,然后切取腹直肌肌瓣移位修复胸壁缺损。结果术后4例皮瓣期愈合,1例皮瓣延期愈合,无并发症。皮瓣外观良好,无臃肿及色素沉着,X线片显示胸骨死骨阴影消失。随访1～3年,平均1年6个月,无复发。腹部供区皮肤愈合良好,无腹壁疝发生。结论胸腹壁随意皮瓣联合腹直肌肌瓣移位修复术是治疗胸骨体周围胸壁缺损的一种简单、有效方法,值得推广应用。     

The possibility of nervus ilioinguinalis and nervus iliohypogastricus injury in lower abdominal incisions and effects on hernia formation

AIM: The aim of this study was to determine the distances of nervus ilioinguinalis and nervus iliohypogastricus to McBurney's and paramedian incisions. MATERIALS AND METHODS: This study was performed on 12 adult cadavers. Right and left inguinal regions of the cadavers were dissected by inguinal incision. The points where the nerves perforated the internal obliquus muscles were determined, and the distances of these points to the spina iliaca anterior superior (SIAS) and to the umbilicus were measured. These distances were marked over a diagram, and distances of the nerves to McBurney's and paramedian incisions were measured by illustrating these incisions on the same diagram. FINDINGS: While the distance of the iliohypogastric nerve from the SIAS was 1.5-8 cm on the right and 2.3-3.6 cm on the left, the distance of the ilioinguinal nerve from the SIAS was 3-6.4 cm on the right and 2-5 cm on the left. The distance of the ilioinguinal nerve from McBurney's incision was 0.2-6.1 cm on the right and 1.8-7.5 cm on the left, and that of the iliohypogastric nerve was 2.2-6.9 cm on the right and 2.9-6.2 cm on the left. The distances of the nerves from paramedian incision were found to be 4.6-10 cm on the right and 6.4-11.2 cm on the left for the ilioinguinal nerve and 5-11.2 cm on the right and 7.4-11.6 cm on the left for the iliohypogastric nerve. CONCLUSION: Both nerves perforate the musculus obliquus internus, scattered in a wide area. Considering the distances, the paramedian incision seems to be more reliable with respect to the risk of nerve injury. Incisions performed in the lower abdomen carry the risk of injury to the ilioinguinal and iliohypogastric nerves.     

Functional analysis of the muscles of the anterolateral wall of the abdomen using electromyocartography]

The purpose of this study was to analyze the function of the superficial muscles of the anterolateral wall of the abdomen in dorsal decubitus by an original technique: electromyocartography. This technique attempts to monitor the individual or inter-subjective variations that complicate quantitative analysis of the overall electromyogram with integration of action potentials. It is shown that relative quantification of the areas explored with respect to the most active area considerably improves the consistency of the results. The most dependable electrode locations for the analysis of the abdominal muscles are determined. From a functional point of view: The rectus abdominis is active in flexion of the cranial portion of the trunk, either alone or in combination with right or left rotation of the trunk. Its activity is less, and predominates in the distal portion of the muscle, in flexion of the caudal portion of the trunk in combination with a 15 degree flexion of the hips. The obliquus internus abdominis, which can be explored only in a single area, is especially active in rotation. The obliquus externus abdominis plays a major role in stabilizing the pelvis when the lower limbs are involved in the movement of the trunk.     

Co-activation of the abdominal and pelvic floor muscles during voluntary exercises

The response of the abdominal muscles to voluntary contraction of the pelvic floor (PF) muscles was investigated in women with no history of symptoms of stress urinary incontinence to determine whether there is co-activation of the muscles surrounding the abdominal cavity during exercises for the PF muscles. Electromyographic (EMG) activity of each of the abdominal muscles was recorded with fine-wire electrodes in seven parous females. Subjects contracted the PF muscles maximally in three lumbar spine positions while lying supine. In all subjects, the EMG activity of the abdominal muscles was increased above the baseline level during contractions of the PF muscles in at least one of the spinal positions. The amplitude of the increase in EMG activity of obliquus externus abdominis was greatest when the spine was positioned in flexion and the increase in activity of transversus abdominis was greater than that of rectus abdominis and obliquus externus abdominis when the spine was positioned in extension. In an additional pilot experiment, EMG recordings were made from the pubococcygeus and the abdominal muscles with fine-wire electrodes in two subjects during the performance of three different sub-maximal isometric abdominal muscle maneuvers. Both subjects showed an increase in EMG activity of the pubococcygeus with each abdominal muscle contraction. The results of these experiments indicate that abdominal muscle activity is a normal response to PF exercise in subjects with no symptoms of PF muscle dysfunction and provide preliminary evidence that specific abdominal exercises activate the PF muscles.     

经腹直肌入路改良Kugel疝修补术治疗腹股沟疝

目的探讨经腹直肌入路改良Kugel疝修补术治疗腹股沟疝的应用价值。方法采用经腹直肌入路改良Kugel疝修补术治疗腹股沟疝18例,其中腹股沟斜疝12例,腹股沟直疝5例,股疝1例。结果全部治愈,手术时间20～60 min,平均40 min;住院时间3～8 d,平均4 d。未见皮下血肿、阴囊积液、异物感等并发症。随防6个月无病例复发。结论经腹直肌入路改良Kugel疝修补术操作简便,安全,效果确切,术后恢复快,副反应少,值得临床偿试。     

利用腹外斜肌腱膜翻转修补下部腹壁肌性缺损

目的 探讨腹外斜肌腱膜在下腹部腹壁肌性缺损修补中的应用。方法 用腹外斜肌及其腱膜翻转修补先天性腹壁肌肉缺损综合征6例,巨大腹壁切口疝5例。结果 全组11例术后近期效果满意,随访7月～10年,腹壁完整无膨出,发育正常,功能良好。结论 用腹外斜肌腱膜修补下部腹壁肌性缺损有其可行性和优越性,临床效果满意。     

Differential activity of regions of transversus abdominis during trunk rotation

The role of the abdominal muscles in trunk rotation is not comprehensively understood. This study investigated the electromyographic (EMG) activity of anatomically distinct regions of the abdominal muscles during trunk rotation in six subjects with no history of spinal pain. Fine-wire electrodes were inserted into the right abdominal wall; upper region of transversus abdominis (TrA), middle region of TrA, obliquus internus abdominis (OI) and obliquus externus abdominis (OE), and lower region of TrA and OI. Surface electrodes were placed over right rectus abdominis (RA). Subjects performed trunk rotation to the left and right in sitting by rotating their pelvis relative to a fixed thorax. EMG activity was recorded in relaxed supine and sitting, and during an isometric hold at end range. TrA was consistently active during trunk rotation, with the recruitment patterns of the upper fascicles opposite to that of the middle and lower fascicles. During left rotation, there was greater activity of the lower and middle regions of contralateral TrA and the lower region of contralateral OI. The upper region of ipsilateral TrA and OE were predominately active during right rotation. In contrast, there was no difference in activity of RA and middle OI between directions (although middle OI was different between directions for all but one subject). This study indicates that TrA is active during trunk rotation, but this activity varies between muscle regions. These normative data will assist in understanding the role of TrA in lumbopelvic control and movement, and the effect of spinal pain on abdominal muscle recruitment.     

Use of transversus abdominis in repair of indirect inguinal hernia

Four points in the anatomy of the inguinal region are brought out; first, the close relationship between the internal ring and the free edge of the transversus abdominis above and with Poupart's ligament below; second, the fact that the transversus abdominis is aponeurotic at this point; third, that the transversus abdominis aponeurosis and the transversalis fascia are almost on planes of identical depth in the makeup of the abdominal wall; fourth, the dangerous position of the deep epigastric vessels medial to the inner margin of the internal abdominal ring.Considering these anatomical facts, a technic has been devised in which the aponeurosis of the transversus abdominis is sewed down to the shelving margin of Poupart's ligament, the ring margins being included in the sutures for the closure of the dilated internal ring found in association with indirect inguinal hernias. The intimate reinforcement given by this technic, and the lack of “dead space” following its use is emphasized.     

横行腹直肌肌皮瓣感觉神经的应用解剖

目的 观察Ｔ１１,Ｔ１２神经在腹直肌内及穿出前鞘后分布于下腹部皮肤的规律,分析横形腹直肌肌皮瓣（ｔｒａｎｓｖｅｒｓｅ ｒｅｃｔｕｓ ａｄｂｏｍｉｎｉｓ ｍｕｓｃｕｌｏｃｕｔａｎｅｏｕｓ ｆｌａｐ,ＴＲＡＭ）形成了与Ｔ１１,Ｔ１２神经相关的应用解剖学基础及手术要点。方法 在１１具２２侧常规防腐固定的成人尸体上,解剖并观察腹前外侧壁局部结构。结果 ＴＲＡＭ的皮神经来自Ｔ１１,Ｔ１２神经前支。其主干在腹     

腹横肌后平片腹股沟疝修补法的初步研究

目的初步评估腹横肌后平片腹股沟疝修补术的安全性和有效性。 方法筛选绍兴市人民医院2018年1至6月,30例原发性单侧腹股沟疝患者进行预试验。手术中完成疝囊高位游离并回纳至腹膜前间隙,缩小内环口,分离腹横筋膜和腹横肌之间间隙,将原Lichtenstein腹股沟疝修补术中放置于腹外斜肌腱膜后的补片向后移位,放置于腹横肌后,固定。观察手术时间、术中出血、术后疼痛、住院时间及复发率。 结果30例全部顺利完成手术,平均手术（46.6±7.1）min,术中出血量（12.5±5.0）mL,术后疼痛视觉模拟评分（2.8±0.9）分,术后无其他并发症发生,平均住院时间（3.4±1.0）d。术后随访平均（2.5±1.2）个月,未见复发。 结论初步的预试验证明全腹横肌后平片腹股沟疝修补术是安全有效的,但由于观察人群特殊、样本数小,随访时间短,还有待于进一步研究。     

Surgical treatment of cryptorchidism in children with deep inguinal ring translocation]

Results of surgical treatment of 83 boys with cryptorchidism were analyzed. Three-stage approach of simultaneous descendence of testicle was proposed: performance of m. cremaster plasty, using muscular flap, excised from m. obliquus internus abdominis, transposition of anulus inguinalis profundus in medial direction and to tuberculum pubicum, securing necessary elongation of elements of funiculus spermaticus for the testicle descendence in 98% of observations.     

Surgical and experimental-biological aspects of inguinal hernia]

In experiment on 57 animals the method of plasty of anterior wall of inguinal channel by forming of the aponeurosis of m. abdominis obliqus ext. and suturing together the aponeurotic edges was simulated. The results of surgical correction of inguinal hernia in 257 patients were analysed. The correlational connection of immunological changes in organism with the degree of destructive changes of hematotesticular barrier (HTB) and spermatogenic epithelium was established. Considering the testicle autoimmunity the application of protective operative methods of pharmacological defense of HTB and spermatogenic epithelium are proposed.     

Choice of technique in covering an excision of neoplastic tissue in the inguinal area]

Cancer surgery of the groin may lead to large skin resection with exposure of the femoral vessels. A reliable coverage technique must be chosen to enable this kind of surgery. Six patients were operated on, and ten flaps were used (3 omentum - 3 rectus abdominis - 1 fascia lata - 1 gracilis - 2 latissimus dorsi free flaps). In the light of our results, omentum must be used when laparotomy is associated with inguinal resection and omentum is available. In the other cases, resection size could prohibit the use of local flaps and a contralateral rectus abdominis flap is chosen which allows coverage of the inguinal area down to the middle third of the thigh.     

超大面积前背阔肌皮瓣联合腹直肌皮瓣移植术

目的 探讨超大面积的前背阔肌皮瓣联合腹直肌皮瓣移植术的应用价值和手术技巧.方法 对2005年5月至2007年1月实施手术的3例患者进行随访,随访时间为10～40个月,平均24.7个月.其中男性2例,女性1例,3例患者均有皮肤缺损伴骨裸露.创面创伤性皮肤缺损1例,肿瘤切除导致皮肤缺损2例,皮瓣面积分别是:60cm×32 cm,55 cm×30 cm和50 cm×25 cm,皮瓣应用形式:带双血管蒂游离移植1例,一端带蒂一端游离移植1例,两端均带蒂移植1例.结果 皮瓣完全成活2例,皮瓣边缘小部分坏死1例,经换药后愈合.创面感染均得到有效控制,为功能恢复创造了条件.1例创伤患者骨折愈合,完全负重行走,恢复原有工作.结论 前背阔肌皮瓣联合腹直肌皮瓣移植术能够一次性修复体表较大面积皮肤缺损,而且效果满意.     

The "yo-yo" operation for inguinal hernia.

This article presents a new principle in the repair of difficult inguinal herniae. The testis is mobilized from the scrotum, returned to the abdominal cavity, brought down again through a new canal constructed through the rectus abdominis muscle, and then restored to the scrotum. The original inguinal canal can then be completely obliterated.     

内侧腹横肌平面阻滞在腹股沟疝修补术中的镇痛研究

目的探讨单侧腹股沟疝修补术的患者中，超声引导下的内侧腹横肌平面阻滞的镇痛效果。 方法对2017年1月至2018年4月在新疆维吾尔自治区人民医院治疗的年龄≥18岁、ASA麻醉分级为Ⅰ~Ⅱ级的100例男性患者进行前瞻性随机对照双盲试验。患者前瞻性随机分为2组，分别接受切口前同侧髂腹股沟-髂腹下神经阻滞50例（对照组）、内侧腹横肌平面阻滞50例（试验组）。观察2组术后24 h镇痛剂的消耗量、疼痛评分、术后副作用等。 结果试验组患者第1次要求镇痛剂的时间、术后24 h镇痛剂用量、麻醉满意度方面与对照组比较，差异无统计学意义（P>0.05）；试验组在时间节点8、12 h的术后疼痛数字评分低于对照组，差异有统计学意义（P<0.05）；术后其他时间点1、4、18、24 h与对照组比较，差异无统计学意义（P>0.05）。 结论内侧腹横肌平面阻滞是一种简单易行的麻醉方法，可用作腹股沟-髂腹下神经阻滞的替代方案，用于腹股沟疝修补术后患者的术后疼痛缓解。