右侧膈神经走行变异一例

笔者在解剖1具成年男性尸体时,发现其右侧膈神经走行变异,现报道如下. 右侧膈神经起于颈丛第3～5颈椎前支,经颈内静脉外侧,沿前斜角肌表面下行8.6cm至静脉角,经颈内静脉与颈外静脉之间夹角,跨越锁骨下静脉前方1.6cm,于静脉角外侧斜向内进入胸腔,伴心包膈动脉下行至膈肌,并支配膈肌,全长25.7 cm.     

膈神经变异1例

笔者在解剖一具老年女性标本时,发现其左侧膈神经罕见变异,现报道如下: 膈神经在左斜角肌间隙内,在前斜角肌后缘中点靠外0.7 cm处由臂丛上干发出(附图)。稍向外下方与前斜角肌后缘平行行走,经肩胛舌骨肌、锁骨下动静脉表面,于静脉角外侧进入胸腔,伴心包膈动脉走向膈     

带血管神经蒂股薄肌瓣重建尿道括约肌的应用解剖

目的为带血管神经蒂股薄肌瓣转位重建尿道括约肌术提供解剖学基础。方法在35例成人下肢标本上,对股薄肌的形态、主要血管、神经的来源,血管神经蒂的长度、入肌部位等进行解剖观测。结果股薄肌全长(42.0±0.6)cm,肌腹长(31.0±3.8)cm;肌腱长(10.9±0.9)cm;股薄肌的血供主要来源于股深动脉的股薄肌支,该分支起始处外径(2.1±0.6)mm,血管蒂长(9.2±0.9)cm,入肌部位在股薄肌中、上1/3交界处前缘的深面;股薄肌的神经支配,均恒定地来自闭孔神经前支,该神经在闭膜管处,横径为(1.7±0.4)mm;厚(0.5±0.2)mm,从闭膜管至入肌点处长(10.4±1.4)cm。结论带血管神经蒂股薄肌瓣转位重建尿道括约肌术,经尸体摹拟实验,证明具有可行性。     

逆行带锁髓内钉治疗股骨远端骨折的应用解剖

目的:为带锁髓内钉治疗股骨远端骨折提供形态学基础。方法:①选用30例成人干燥股骨测量股骨内外侧髁、内外上髁、髁间窝有关数据进行统计分析。②20侧下肢标本解剖观测膝降动脉及隐神经髌下支的分支、分支等及两者的关系。结果:髁间窝呈U型占35%,V型占65%,此窝最宽处横径:左侧(1.98±0.36)cm, 右侧(2.06±0.29) cm;内侧髁后关节面宽,左侧(2.21±0.23) cm,右侧(2.34±0.29) cm;内、外上髁的距离,左侧(7.30±0.60)cm,右侧(7.43±0.57)cm。膝降动脉髌下支和隐神经髌下支呈紧密的伴行关系。隐神经在缝匠肌中下1/3交界点穿出,有上、下两支分布到膝关节前外侧皮肤。结论:术中注意这些解剖位置特点,避免损伤神经和血管,减少手术出血,防止并发症。     

选择性腓肠肌肌支切断小腿减肥术应用解剖

目的:为临床选择性切断腓肠肌肌支进行小腿减肥术提供形态学依据。方法:常规解剖后,在23侧女性下肢标本上观察测量腓肠肌肌支等相关胫神经分支的起始、宽度、长度及相互关系等。结果:(1)腓肠肌内、外侧头肌支的起始形式与邻近神经的组合形式有7种;(2)腓肠肌内、外侧头肌支在胫神经上的起点较恒定,均落在窝中点上下不超过2.2cm的范围以内,平均值(3.8±6.9)mm,起始宽度分别为(2.1±0.5)mm和(2.3±0.4)mm,从起点到肌门的长度分别为(4.1±1.4)mm和(4.8±1.2)cm,各共干形式中的共干段长度为(1.2±0.5)cm;(3)腓肠内侧皮神经的起点几乎总是该段胫神经分支中的最高者,而腓肠肌内、外侧头肌支的相互位置关系也较恒定,前者有95%(19侧)起点高于后者,并多起自胫神经的内侧缘或后内侧。结论:腓肠肌内、外侧头肌支的起点位置恒定,但它们与邻近神经的组合形式复杂,宜在充分熟悉其各种组合形式及相互位置关系的基础上,按一定的顺序有计划地仔细寻找及分离神经及其共干段,宜在肌门处进行切断,以确保在切除腓肠肌内、外侧头肌支的同时,避免损伤比目鱼肌肌支和腓肠内侧皮神经。     

胸廓内动脉上段至心包分支的解剖学特点

前言关于供应心包的血液来源,各书记载不一。一般认为最主要的是由胸廓内动脉和胸主动脉的分支供给,Щвецов,И.М.最近的研究进一步证实了这一点。关于胸廓内动脉至心包的分支状况,一般教科书的叙述既过于简单又不一致,有的只提到心包膈动脉,有的还提到胸廓内动脉的心包支,也有的文献提到了胸腺动脉或前纵隔动脉。Щвецов,И.М.提到了下列四支:(1)胸腺动脉至心包的分支,(2)心包膈动脉,     

坐骨神经桥接颈7神经根二期移位重建截瘫下肢功能的应用解剖

目的:为带血供的坐骨神经桥接颈7神经根二期移位重建截瘫下肢功能提供解剖学依据。方法:在动脉内灌注红色乳胶30侧成人下肢标本上,解剖观测坐骨神经营养血管的来源、分布和吻合;坐骨神经与自身躯干长度比例;选择性臀下动脉墨汁注射。结果:坐骨神经臀段营养血管来自臀下动脉,由前内侧进入,外径(1.5±0.7)mm(0.6～3.8mm);股后段来自股深动脉穿支,由前外侧进入;小腿段胫神经来自胫后动脉分支。上述节段血管在神经干表面分出升支和降支,彼此吻合,形成一个纵贯神经全长和供血丰富纵向的吻合血管链。自梨状肌下缘至内外踝连线,神经长(79.3±3.6)cm(70.0～86.0cm),梨状肌下缘至锁骨上缘中点距离为(60.6±3.1)cm(51.0～66.0cm)。选择性臀下动脉墨汁注射显示胫神经远端有墨染。结论:臀下动脉坐骨神经营养支是带血供坐骨神经移位桥接重要的供血途经。     

肱三头肌长头重建肩外展功能的应用解剖

目的研究肱三头肌长头血管神经蒂特点为以其重建肩外展功能提供解剖学基础。方法对44侧固定尸体的肱三头肌长头肌肉起点及血管神经蒂进行解剖与测量。结果肱三头肌长头起点背侧为肌性,腹侧为腱性,腱性起点长度(9.9±1.5)cm,宽度(2.4±0.4)cm。神经支配来自桡神经的分支,可分离长度(6.8±2.7)cm,直径(2.0±0.4)mm。血供来自①肱动脉肱三头肌支,长度(3.4±1.4)cm,外径(2.0±0.3)mm;②肱深动脉的分支,长度(2.5±0.9)cm,外径为(1.6±0.5)mm,分离至肱动脉长度为(3.9±1.3)cm。血管神经蒂以多级分支为主。结论依据肱三头肌长头及其血管神经蒂的特点,可作为肩外展功能重建术中的动力肌。     

左胸廓内动脉合并左肺分叶变异一例

女尸1具,40岁左右,身高约155cm。发育欠佳,死因不明。解剖过程中发现：左胸廓内动脉起源于左侧腋动脉,从距左腋动脉根部约6．3cm处发出,穿行于尺神经与正中神经之间抵达腋窝底,在窝底内穿出腋筛筋膜迂曲向前上行至腋前襞,横行向胸内侧走行于左乳房上缘的浅筋膜内（双侧乳房发育不良）,抵至胸骨角第2肋间隙处进入胸腔,在胸腔内行于胸骨左缘1．1cm处。此动脉从起始处至入胸腔处全长34．4cm,管径约0．45cm,迂曲呈正弦波形态。其中从起始处至左腋前襞约10．6cm,腋前襞至入胸腔处13．8cm。     

眶上动脉蒂反流轴型耳颞皮瓣的应用解剖

目的:为临床各型额部皮瓣特别是跨血管系统反流轴型皮瓣的应用提供解剖学基础。方法:15具福尔马林保存的成人尸体头面部进行肉眼解剖,观察眶上动脉、滑车上动脉和颞浅动脉额支的位置、口径、走行和相互吻合状况及其与周围组织的关系;5具新鲜成人头部标本制作血管铸型。结果:眶上动脉、滑车上动脉和颞浅动脉额支走行基本恒定,且三者存在众多吻合,吻合支集中区域为上界距眶上缘(4.9±0.4)cm,下界为眶上缘水平,上界内侧距离前正中线(1.0±0.2)cm,外侧距离前正中线(4.5±0.4)cm;下界内侧距离前正中线(1.4±0.2)cm,外侧(2.3±0.5)cm。结论:额部有眶上动脉、滑车上动脉和颞浅动脉额支供血,吻合支丰富且吻合区域较恒定,故可制成多种类型的跨血管的反流式皮瓣,增大血管蒂旋转的角度和长度以及灵活性。     

An anatomical study of the full-length phrenic nerve and its blood supply: clinical implications for endoscopic dissection

For surgeries aimed at the dissection of full-length phrenic nerve, a full appreciation of its trajectory, blood supply and correlation with adjacent anatomical structures is necessary, especially for endoscopic manipulations. A fresh cadaver study was conducted with the purpose of avoiding surgical complications and ensuring further efficacy and efficiency of endoscopic manipulations. Ten fresh adult cadavers were dissected. Special attention was paid to the topography of the origin, the trajectory of the phrenic nerve, and its anatomic communication with the surrounding vessels and organs. In the second side of the cadavers, thoracic endoscopic manipulations and observations were also performed. The full length of the phrenic nerve was 24.6 ± 1.7 and 30.6 ± 1.8 cm on the right and left side, respectively; the blood supply of the phrenic nerve in the thoracic cavity came exclusively from the pericardiacophrenic artery; the distance between the origin of the pericardiacophrenic artery and that of the internal thoracic artery ranged from 0.5 to 5.2 cm on the right side, and from 1.4 to 5.6 cm on the left; most of the pericardiacophrenic veins intermingled with small vessels of pericardium and pleura, forming a venous network and joining the innominate vein. Endoscopic dissection of the thoracic phrenic nerve together with the accompanying pericardiacophrenic artery can be performed. Extreme attention should be paid during surgery to a section of about 6 cm in length of the artery originating from the internal thoracic artery, while the accompanying veins do not require to be spared.     

颈前区器官的应用解剖研究

目的观察颈前区器官与血管和神经的毗邻关系,为临床手术提供解剖学依据。方法在18例36侧成人头颈标本上解剖观测喉、气管颈部和甲状腺的血管和神经的走行及分布。结果甲状腺左、右叶平均长度为48．9±8．8mm和49．9±7．9mm．锥状叶者8例,占44．4％;1例出现甲状腺最下动脉（出现率5．6％）．2例出现甲状腺最下静脉（出现率11．1％）;喉上动脉人喉处在甲状软骨上角的前下方左侧为13．94±2．79mm,右侧为14．93±2．58mm,差异有统计学意义;喉上神经内支人喉处在甲状软骨上角前下方左侧为11．78±3．44mm,右侧为12．26±2．66mm;喉下神经在甲状软骨下角后下人喉,距离甲状软骨下角左侧5．34±1．61mm,右侧5．72±1．74mm,差异有统计学意义。结论手术时应注意这一区域血管神经走行情况,防止并发症的发生。     

肾蒂的解剖学观测

目的观测肾蒂的解剖结构,为肾手术的临床应用提供形态学依据,丰富体质与形态学数据。方法解剖甲醛固定的成人尸体标本66例,分离解剖肾蒂内结构,对相关结构进行观测,对数据进行统计分析。结果肾蒂长度左侧（4.70±1.31）cm,右侧（3.15±1.17）cm;肾动脉长度左侧（4.70±1.31）cm,右侧（6.22±1.44）cm;肾动脉管径左侧（0.77±0.48）cm,右侧（0.74±0.18）cm;肾静脉长度左侧（6.88±1.34）cm,右侧（3.15±1.17）cm;47侧出现副肾动脉,占35.6%;肾静脉管径左侧（1.76±0.38）cm,右侧（1.34±0.31）cm;肾静脉汇入下腔静脉角度左侧（77.9°±16.3°）,右侧（66.8°±22.9°）;肾蒂内结构的位置关系,由前向后为静脉、动脉、肾盂者占59.8%,肾动脉位于最前面占40.2%。结论肾蒂内动脉分支、静脉属支、各结构位置关系类型复杂,变异多样,临床手术中应予以充分注意。     

Topographic anatomy of the tibial nerve in the medial malleolus: application to the effect of nerve block anesthesia

To better understand the anatomical variations and pathogeny of tarsal tunnel syndrome, the tibial nerve were dissected in 20 ankles of fresh black African cadavers. The tibial nerve located to 1.75 cm on average from the posterior side of the malleolus and to 2 cm from medial side of the calcaneus tendon. The nerve always ended according to dichotomic method. 90% cases of bifurcation were noted under the flexor retinaculum at 1 cm from the malléolo_calcaneus line; in 10% of dissections, we found proximal bifurcation at 5 cm from this line. The medal calcaneus branch which is a collateral branch of tibial nerve was constant, unique in 80% of cases and double in 20% of cases. The anatomical constatations allow a more precise anesthesia of tibial nerve block. We use constant anatomical marks formed by calcaneus tendon and internal malleolus tip. Olso we more understand the possibility of lesion of tibial nerve at the ankle during the synovites, or ossifications of flexor rétinaculum.     

带尺侧上副动脉尺神经转位的解剖及临床意义

目的为临床上带血管蒂的尺神经移植在健侧颈7移位治疗臂丛根性撕脱伤中的应用提供解剖学依据。方法取新鲜经动脉灌注红色乳胶的成人上肢标本22侧进行显微解剖,观察尺神经外部营养动脉的来源。另取患骨肿瘤而截肢新鲜成人上肢6侧作仅保留尺侧上副动脉的尺神经游离,采用动脉灌注墨汁和尺神经组织切片的方法,观察尺侧上副动脉对尺神经内部血供营养的范围。结果尺神经在腋部由胸外侧或腋动脉的分支供应,在内侧肌间隔后方由尺侧上副动脉供应,在尺神经沟由尺侧上副动脉与尺侧返动脉后支的吻合支供应,在前臂由尺侧返动脉和尺动脉的分支供应。尺侧上副动脉灌注墨汁后,尺神经腕部、手背支及腋部的神经束内微血管被墨汁充填。结论以尺侧上副动脉的起始处为血管蒂部旋转点,尺神经可提供平均为(46.5±2.6)cm的有血供的移植长度,可经胸前皮下隧道逆向转位与对侧颈7神经根吻合。以尺侧上副动脉为血供的尺神经移植的设计是合理的。     

"Pes anserinus" of the right phrenic nerve innervating the serous membrane of the liver: a case report (anatomical study)

During the preparations of cadavers for educational purposes we followed the course of the right phrenic nerve. On one of them and especially a female cadaver aged 72-year-old we found a branch arising from the thoracic portion of the right phrenic and passing through the two layers of the falciform ligament distributed to the upper surface of the serous layer of the liver in the form of "pes anserinus". As it is known, pain referred from the diaphragmatic peritoneum is classically felt in the shoulder tip but pain from thoracic surfaces supplied by the phrenic nerve is usually located there albeit vaguely. We believe that the above anatomical finding is the explanation of distinct radiating pain from the hepatic region to the right shoulder in some patients. The stimulations is carried through the phrenic nerve to the fourth cervical neurotome from were arise the supraclavicular nerves which are distributed to the shoulder region.     

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。     

肺叶切除术中行膈神经压扎对肺功能的影响

目的探讨肺叶切除术中膈神经压扎对肺功能的影响。方法40例行肺叶切除的患者,其中20例在行肺叶切除后加行膈神经压扎,另外20例未行膈神经压扎,分别测定其膈肌活动度、肺功能及术后发生并发症情况。结果两组患者比较,膈神经压扎组患者的膈肌活动度及肺功能均较未压扎组差,膈肌活动度分别为（1.17±0.41）cm和（2.11±0.42）cm（P〈0.05）;肺功能方面,压扎组患者肺活量、最大分钟通气量及第1秒用力呼气量分别为（70.25±5.25）%、（71.42±7.15）%和（65.50±4.51）%,未压扎组分别为（81.24±4.78）%、（80.87±8.65）%和（76.97±6.26）%,两组比较差异均有统计学意义（P〈0.05）。但术后并发症的发生率,两组之间并无差别。结论肺叶切除时行膈神经压扎将进一步降低患者的肺功能,膈神经压扎在肺叶切除术中并非绝对必要。     

The superior group of vessels in the falciform ligament: anatomical and radiological correlation

AIM: The purpose of this study was to clarify the anatomical detail of the superior group of vessels in the falciform ligament in terms of the relationship with the internal thoracic vessels, inferior phrenic vessels, and the intrahepatic portal vein. MATERIALS AND METHODS: (1) Anatomical study: we dissected eight adult human cadavers (seven normal and one cirrhotic liver) to determine the relationship between the superior group of vessels in the falciform ligament, the internal thoracic vessels, and the inferior phrenic vessels. (2) Clinical study: we determined the origin and destination of the superior group of veins demonstrated in 8 of 4,006 patients with chronic liver disease who underwent the contrast enhanced CT scans. RESULTS: (1) Anatomical study: the superior group of vessels anastomosed the right (n = 4), left (n = 2), and both (n = 2) internal thoracic vessels. They also anastomosed the left (n = 4), right (n = 1), and both (n = 2) inferior phrenic vessels. (2) Clinical study: the origin of the veins was identified as the left medial branch (n = 4), left lateral branch (n = 1), both the lateral and medial branches (n = 1), and the vein from the umbilical portion (n = 2) of the left portal vein. The drainage vein was identified as the left (n = 3), right (n = 2), and the both (n = 1) internal thoracic veins. CONCLUSION: We demonstrated the anastomoses between the superior group of vessels of the falciform ligament, the internal thoracic vessels, the inferior phrenic vessels, and the intrahepatic portal vein. These pre-existing anastomoses would develop as porto-systemic shunt in patients with portal hypertension.     

Partial removal of the pulmonary artery in video-assisted thoracic surgery for non-small cell lung cancer

Lobectomy with partial removal of the pulmonary artery in video-assisted thoracic surgery (VATS) currently remains a challenge for thoracic surgeons. We were interested in introducing pulmonary vessel blocking techniques in open thoracic surgery into video-assisted thoracic surgery (VATS) procedures. In this study, we reported a surgical technique simultaneously blocking the pulmonary artery and the pulmonary vein for partial removal of the pulmonary artery under VATS. Seven patients with non-small-cell lung cancer (NSCLC) received lobectomy with partial removal of the pulmonary artery using the technique between December 2007 and March 2012. Briefly, rather than using a small clamp on the distal pulmonary artery to the area of invading cancer, we replaced a vascular clamp with a ribbon and Hem-o-lock clip to block the preserved pulmonary veins so as to prevent back bleeding and yield a better view for surgeons. The mean occlusion time of the pulmonary artery and pulmonary veins were 44.0±10.0 and 41.3±9.7 minutes, respectively. The mean repair time of the pulmonary artery was 25.3±13.7 minutes. No complications occurred. No patients showed abnormal blood flow through the reconstructed vessel. There were no local recurrences on the pulmonary artery. In conclusion, the technique for blocking the pulmonary artery and veins is feasible and safe in VATS and reduces the risk of abrupt intraoperative bleeding and the chance of converting to open thoracotomy, and extends the indications of VATS lobectomy.