腹外斜肌的神经入肌点定位与肌内神经分布研究

目的　对人腹外斜肌的神经入肌点定位和肌内神经染色观察，为其临床应用提供形态学资料。 方法　成尸11具定位神经入肌点和5具行Sihler’s 肌内神经染色。 结果　腹外斜肌受下8对肋间神经外侧肌支支配，各个肌齿的神经入肌点距离相应肌齿起端中点(1.54±0.33)cm，位于锁骨中线与第5肋下缘的交界处至腋后线与第11肋下缘交界处的连线上。Sihler’s染色显示支配腹外斜肌的肋间神经外侧肌支入肌后分出小分支分布到各肌齿的起端1/3，然后约在各肌齿的近、中1/3交界处分出2支二级神经分支，即上支与下支，它们分出小分支分布到各肌齿的中间1/3，相邻两个肌齿的上支与下支在各肌齿中远部形成“U”形吻合，从“U”形吻合弓上分出小分支分布到各肌齿的止端1/3。在腹外斜肌上半部，各肌齿的神经分支分布到相应的肌齿，但在腹外斜肌下半部，上一肌齿的远侧下份是由下一肌齿的神经分支(上支)分布。 结论　①为临床上腹壁局部麻醉和术后切口疼痛的神经阻滞提供指导意义；②腹外斜肌中远部从上至下形成“波浪形”的神经分支密集区；③腹部手术切口建议不要超过四个肌齿。     

男性单侧腹直肌罕见缺失变异1例

目的 报道1例罕见的右侧腹直肌完全缺失并不伴有其他器官系统变异尸体的腹部解剖过程,腹壁肌群及其供血情况。 方法 解剖并观察尸体腹壁肌、血供、神经支配,对比两侧腹直肌发育和形态差异。 结果 该尸体右侧腹直肌缺失,腹直肌鞘完好,腹壁上动脉和腹壁下动脉仍在腹直肌鞘内走行并相吻合,肋间神经及肋下神经（T7～T12）由鞘内穿出达皮下。左侧腹直肌发育正常并有代偿性增生。男尸腹壁未见疤痕和手术切痕,腹内器官无缺失,腹膜除肝区外无黏连。 结论 该尸体右侧腹直肌缺失可能是胚胎发育第6周之前出现异常所导致。目前腹直肌肌皮瓣常用于多项外科重建手术,全面了解腹直肌的相关变异,对于扩展重建手术的应用范围和作好术前准备,确保手术成功均具有指导意义。     

腹直肌形态与肌内神经分布研究及其临床意义

目的:通过对腹直肌形态学、神经入肌点和肌内神经分支分布的研究,为腹直肌的临床肌移植提供形态学资料.方法:大体解剖法和改良Sihler's肌内神经染色法.结果:(1)腹直肌肌重(47.80±12.89)g,肌长(33.18±3.38)cm,肌宽(4.55±1.87)cm,肌厚(0.55±0.24)cm,腱划长(1.06±0.32)cm.(2)腹白:肌神经入肌点在肌深面肌宽的中、外1/3交界处,自上而下呈线形排列.(3)腹直肌受第7～12胸神终前支和第1腰神经前支支配,呈节段性、重替性分布.神经主干和分支在肌内走行不受腱划分隔的影响.结论:腹直肌由多神经节段性重叠性支配,神经在肌内的行程不受腱划影响.腹直肌的神经入肌点在肌深面肌宽的中、外1/3交界处.     

腹前外侧群肌的肌内神经分布模式

目的 揭示腹前外侧群肌的肌内神经分布模式,探讨其临床意义。 方法 取经甲醛固定的12具24侧中国成年尸体的腹前外侧群肌,行改良的Sihler染色。 结果 腹前外侧群肌的神经绝大多数源于节段性分布的胸神经。腹外斜肌各肌齿有独立的神经支配,在髂前上棘和髂结节之间的髂嵴上方有一纵向神经密集带。腹内斜肌腹股沟韧带中点上方有一纵向神经密集带,髂嵴上方有一横向神经密集带。腹横肌髂前上棘与第8、9肋软骨连结处之间有一弧形的神经密集带。腹直肌各肌腹中部有一横向神经密集带,上3个肌腹有独立神经支配。 结论 腹外斜肌和腹直肌可分出神经肌肉亚部;各肌内的神经密集带应被考虑为肉毒毒素A注射和局部麻醉的最佳靶点部位,不宜设为腹壁手术的切口部位。     

第一骨间背侧肌肌内神经解剖学

目的:为临床带血供的第1骨间背侧肌远端肌支神经肌蒂转移修复拇对掌功能手术提供供区肌肉神经、血管相关解剖学依据,评估切取该肌远端肌支对供区的影响.方法:手部固定标本,采用显微解剖方法,观察第1骨间背侧肌形态和神经支配情况.通过再改良Sihler's染色法对第1骨间背侧肌进行肌内神经染色.结果:第1骨间背侧肌神经来源于尺神经深支,在进入第1骨间背侧肌前分成2支.其中近端分支主要分布于肌腹的上2/3,远端分支主要分布在肌腹的下1/3.结论:切取第1骨间背侧肌远端肌支神经肌蒂转位修复拇对掌肌的功能是可行的,其对供区功能的影响较小.     

多血管神经蒂腹内斜肌瓣修复面瘫的应用解剖

目的：为了探索晚期面瘫动力性修复中多神经支配的供区，提供多血管神经蒂腹内斜肌瓣的应用解剖学基础。方法：在２２侧红色乳胶灌注的成人尸体上，测量观察了腹内斜肌的神经支配及血供情况。结果：腹内斜肌主要接受第１１肋间神经和肋下神经支配的占９０．９％，接受第１０、１１肋间神经和肋下神经支配的占９．１％。第１１肋间神经入肌处至腋后线的平均长度为１２．７ｃｍ，肋下神经入肌处至腋后线的平均长度为１２．９ｃｍ，血供主要来源于第１１肋间动脉、肋下动脉和旋髂深动脉的腹壁肌支，在腹内斜肌和腹横肌筋膜之间有丰富的血管吻合。结论：可利用腹内斜肌多血管神经支配的特点，设计超长吻合多血管神经蒂的腹内斜肌瓣跨面移植治疗晚期面瘫的新术式。     

多血管神经蒂腹内斜肌瓣修复面瘫的解剖学基础

目的：为多血管神经蒂腹内斜肌瓣修复晚期面瘫提供解剖学基础。方法：在３６侧成尸标本上,对腹内斜肌的形态、血供及神经支配进行解剖观测。结果：腹内斜肌中部上１／２肌腹主要由第１１肋间神经支配,下１／２肌腹主要由肋下神经支配。上１／２肌腹的血供６６．７％来自第１１肋间后动脉,３３．３％来自旋髂深动脉的髂嵴支;下１／２肌腹的血供主要来自旋髂深动脉的腹壁肌支。第１１肋间神经、肋下神经在腋后线横径分别为２．２ｍｍ和２．４ｍｍ,入肌点距腋后线长分别为１３．３ｃｍ和１３．８ｃｍ。第１１肋间后动脉在腋后线外径为１．７ｍｍ,入肌点距腋后线长为１３．１ｃｍ;旋髂深动脉腹壁肌支和髂嵴支的起始外径分别为１．３ｍｍ和１．８ｍｍ,入肌点至起点长分别为５．１ｃｍ和８．６ｃｍ。结论：吻合多血管神经腹内斜肌瓣移植可全面修复晚期面瘫     

临床常用肌瓣肌内神经分布的研究

目的:研究临床常用肌瓣的肌内神经走行及分布,为临床提供解剖学基础。方法:在5具新鲜成人尸体标本上,完整取下展肌、背阔肌、股薄肌、腹直肌、胸小肌以及缝匠肌,观察测量肌外神经来源,并采用改良Sihler’s肌内神经染色法观察肌内神经的分支分布。结果:经Sihler’s染色后的肌肉标本,大体形态保持完整,呈透明或半透明、淡蓝色,肌内神经分支被染成蓝紫色,其在肌肉内的分布及走行清晰可见。结论:(1)根据染色结果可将肌肉分为不同的肌亚部;(2)结果对临床外科手术具有重要的指导意义。     

上后锯肌肌构筑及肌内神经分布的实验研究

目的研究上后锯肌的构筑学特征和肌内神经分布特点,为临床应用上后锯肌提供解剖学基础。方法大体解剖法、肌构筑法、改良Sihler’s肌内神经染色法。结果上后锯肌肌重(17.54±1.44)g,肌长(12.52±1.86)cm,肌纤维长(4.13±1.03)cm,生理横切面积(4.12±1.01)cm2。上后锯肌由2~4肋间神经支配,神经入肌后在肌腹中部发出树枝样分支。结论上后锯肌倾向于速度型设计;上后锯肌肌内神经密集区主要分布于肌腹中部。     

前臂伸肌内神经血管分布的解剖学研究及其临床意义

目的：观察前臂伸肌内神经血管解剖分布，探讨前臂肌是否可被分割为若干个功能单位，以提供新的功能性骨骼肌游离移植供区。方法：解剖10具10％甲醛固定的成人尸体共20侧前臂伸肌，观察其肌外神经血管的分布形式。5具新鲜成人尸体标本共10侧前臂伸肌，用Sihler＇s染色法观察肌内神经的分布。4具新鲜成人尸体标本共8侧前臂伸肌，经30％硫酸钡、乳胶混悬液血管灌注并行X线钼靶摄片，而后对照观察各肌的神经、血管在肌内分布关系。结果：按前臂肌肌内神经的分布及其形状分为3类：Ⅰ类肌肉为扁平形肌肉，主要肌内神经干垂直于肌纤维的走行方向。Ⅱ类肌肉为纺锤形肌肉，Ⅱa类肌肉，单羽肌为主，神经分支多为单干支配，神经多在其肌腹的上1／3入肌，神经入肌后多平行肌纤维纵向走行至肌远端。Ⅱb类肌肉，可分为两个部分，每个部分都有独立的神经支配，部分肌肉在其神经入肌门处还有一个返支配肌腹的上1／3。Ⅲ类肌肉，多个止点，神经在肌内呈横向穿越或纵向平行于肌纤维走行，在其肌肉起始部，有神经返支支配肌腹的上1／3。前臂伸肌血供是多源性的，以节段血管蒂型为主。结论：前臂伸肌内中Ⅱb类肌肉的第1，2种类型和Ⅲ类肌肉可将其分为不同的功能单位，供节段性游离肌肉移植。     

Anatomical study of innervated transverse rectus abdominis musculocutaneous and deep inferior epigastric perforator flaps

The present study investigated anterior cutaneous branches of the 10th, 11th and 12th intercostal nerves. Innervated transverse rectus abdominis musculocutaneous (TRAM) flap and deep inferior epigastric perforator (DIEP) flap are often used in breast reconstruction. To innervate these flaps effectively, the appropriate anterior cutaneous branches of intercostal nerves must be selected. Dissection of 40 sides of 20 cadavers (5 male, 15 female) was performed. Nerves were classified into four groups according to vertical location from rectus abdominis (RA) entry points. Group 1 was situated from 0-19% of the umbilicus-to-pubic tubercle distance; Group 2, 20-39%; Group 3, 40-59%; and Group 4, 60-79%. Mean number of nerves per side was 1.4 in Group 1, 1.2 in Group 2, 1.1 in Group 3 and 0.2 in Group 4. The arcuate line was situated 32 +/- 9% below the umbilicus. Group 3 and 4 nerves tended to enter the RA more laterally than Group 1 nerves. Most nerves separated into 1-2 cutaneous branches while branching off several muscular branches. Several nerves in Groups 1 and 2 displayed no cutaneous branches. More muscular branches were present in Groups 1 and 2 than in Groups 3 and 4. Distance from lateral edge of the RA sheath to RA entry point was longer in Groups 1 and 2 than in Group 4. Cutaneous points, indicating entry points of a nerve into the dermis, were situated slightly more inferior than RA entry points. To innervate flaps effectively, a nerve entering the RA slightly superior to the expected sensory recovery area should be chosen. Clinically, Group 1 or 2 nerves seem to be selected in many TRAM or DIEP flap cases. If the cutaneous branch in Group 3 or 4 is easy to separate from RA, this can be included in the flap along with a main nerve, and might enable the flap to recover sensation in a wider area or reinforce the occasional lack of a sensory branch from Group 1 or 2. The present findings provide the basis for more precise dissection of TRAM and DIEP flaps, and should facilitate reliable preservation of sensation in flaps.     

保留外侧部分腹直肌的带蒂腹直肌皮瓣移植再造乳房

目的 探讨保留外侧部分腹直肌的带蒂腹直肌皮瓣移植再造乳房的临床疗效。方法 系列病例报告研究。纳入2021年8月—2022年2月湖南省肿瘤医院采用保留外侧部分腹直肌的带蒂腹直肌皮瓣移植再造乳房的11例乳腺癌女性患者,年龄32~57岁（平均45.1岁）。均为乳腺癌改良根治术后即刻乳房再造。切取皮瓣长22~30（24.5±0.8）cm,皮岛宽10~12（11.2±0.5）cm。具体制备肌皮瓣形式包括：类型Ⅰ,一侧传统带蒂腹直肌皮瓣联合对侧保留外侧部分腹直肌的带蒂腹直肌皮瓣移植;类型Ⅱ,双侧保留外侧部分腹直肌的带蒂腹直肌皮瓣移植;类型Ⅲ,一侧保留外侧部分腹直肌的带蒂腹直肌皮瓣联合对侧游离腹壁下动脉穿支皮瓣移植。观察皮瓣血运情况、并发症和随访情况。结果 11例患者的皮瓣制备类型Ⅰ4例、类型Ⅱ4例、类型Ⅲ3例。所有皮瓣顺利成活,未见明显并发症。11例患者均获随访,随访时间6~12个月,平均9.4个月。再造乳房外形可,质地满意,无皮瓣挛缩变形;皮瓣供区仅遗留线性瘢痕,腹壁功能无明显影响。结论 保留外侧部分腹直肌的带蒂腹直肌皮瓣制备手术难度不大,能有效减小供区损伤,获得满意的手术效果,可以作为乳腺癌术后乳房再造较好的手术方法选择。     

Microanatomy and number of nerve fibres of the lower intercostal nerves with respect to a nerve anastomosis. Donor nerve analysis. I. (IV).

A human intercostal nerve has about 10,000 myelinated nerve fibres, of which about 1000 to 2000 are motor. At about the axillary line the nervus intercostalis splits into the ramus cutaneous lateralis and a deep branch to the musculus rectus abdominis and other muscles. The ramus cutaneous lateralis consists of 2 skin branches of about 3000 nerve fibres and a muscle branch to the musculus obliquus externus of about 400 to 1100 nerve fibres. The deep branch to the musculus obliquus internus, the musculus transversus and the musculus rectus abdominis and the anterior skin consists of about 2500 to 7000 fibres of which 400 to 1700 are skin fibres. There is indication that the muscle branch to the musculus obliquus externus has about 50% motor fibres. The intercostal nerve is, as it splits after about 20 cm into 4 branches, a suitable donor of at least 2 different muscle functions and a skin sensible function for a direct nerve anastomosis. A crude model for calculating matching probabilities of motor and sensory fibres between donor and acceptor nerves is introduced. Besides the importance of having enough donor nerve fibres, it is calculated that the small amount of motor nerve fibres can be best used if muscle branches of the donor nerves are connected to muscle branches of the acceptor nerves. Because of the separation between normal laboratory animals and humans on the phylogenetic scale, differences in regeneration and plasticity are discussed.     

Characteristic behavior of the respiratory muscles, esophagus, and external anal and urethral sphincters during straining, retching, and vomiting in the decerebrate dog

To ascertain differences in the brainstem pattern generators for straining and retching, discharges of 230 respiratory single motor units from the intercostal nerves and discharges of the nerves to accessory respiratory muscles, the esophagus, and external anal and urethral sphincters were observed during straining, retching, and vomiting (fictive expulsion) in decerebrate and paralyzed dogs. Straining and retching were identified with coactivation of the phrenic nerve and the nerve to the rectus abdominis, which was elicited by distension of the rectum and stomach, respectively. Synchronous discharges with each retch and straining were always exhibited by the phrenic nerve, the nerves innervating the abdominal part of the rectus abdominis and the external anal and urethral sphincters. In contrast, different behaviours were constantly observed in four nerves. 1) The nerves to the serratus dorsalis cranialis was inhibited during straining, but activated synchronously with each retch and vomiting. 2) Vagal pharyngeal branches innervating the upper esophagus and branches of the recurrent nerve innervating the lower part of the cervical esophagus fired synchronously with straining. The esophageal nerves, on the other hand, did not fire with each retch, but did fire strongly between retches. 3) The nerve to the sacrocaudalis dorsalis lateralis discharged concomitantly with straining but did not with retches. Straining and retching behaviors exhibited by the nerves innervating other thoracic accessory inspiratory muscles (the intercartilagineus, rectus thoracis, scalenus) varied from dog to dog. The nerves innervating the thoracic parts of the rectus abdominis and obliquus externus abdominis always discharged synchronously with straining, and discharged with retches in the majority of dogs, but did not in a minority of dogs. The expiratory units from the internal intercostal nerves showed intense discharges synchronously with coactivation in straining (96%), retching (65%), and vomiting (100%). In contrast, none of the inspiratory units from the external intercostal nerves exhibited such intense discharges with straining and retching. These results suggest that the functional difference in straining and retching mainly depends on the differences in the behavior of the serratus dorsalis cranialis and esophagus. The forms of this dependence were discussed.     

Morphometrical study of the arterial perforators of the deep inferior epigastric perforator flap

Although abdominal perforator flaps based on a cutaneous branch of the deep inferior epigastric artery (DIEP flaps) have many advantages, preparing these flaps is technically difficult and requires great skill, especially as the portion of the artery running under the anterior rectus abdominis sheath must be operated upon "blind". To allow easier preparation and elevation of a DIEP flap pedicle, we propose that the arterial perforator should: 1) be more than 1.0 mm large; 2) run a straight intramuscular course, parallel to the rectus abdominis m. fibers, with no large muscular branches; and 3) have only a short portion running immediately under the anterior rectus abdominis sheath. We examined 329 perforators (more than 0.5 mm in diameter at the anterior sheath) in 66 rectus abdominis mm. from 33 cadavers among them: 1) 52 "large" perforators were over 1.0 mm in diameter; 2) 107 "suitable" perforators ran parallel to the muscle fibers without giving off large muscular branches; and 3) 35 "ideal" perforators combined these characteristics. The ideal perforators were usually located in the mid-abdominal region, 10-30 mm lateral to the umbilicus. The suitable perforators were usually present, often in combination with the ideal perforator(s), in a restricted area 20 mm cranial and 40-50 mm lateral to the umbilicus. We classified the course and ramification pattern of the deep inferior epigastric a. into six patterns, depending on whether the anastomosis was sited in the medial or lateral branch and the level at which the branches originated.     

A study on the communication between the pectoral nerve and the extramural nerve branches of the intercostal nerves]

Kumaki et al. (1979) defined the extramural nerve as the rudimentary sensory nerve which appeared on the upper thoracic wall; it branched off the root of the lateral cutaneous nerve of the second, third or fourth intercostal nerve, ran inferomedially adhering to the fascia of the intercostalis externus muscle and ended supplying the membrane covering the adjacent rib. They also stated that the extramural nerve (Rxm) occasionally became a cutaneous nerve which pierced the pectoralis muscles and supplied the skin covering the thoracic wall similar to the lateral cutaneous nerve (Rcl) or the anterior cutaneous nerve (Rca). Further, they proposed that the muscular nerves to the obliquus externus abdominis muscle which are usually situated below the fifth rib might be considered a part of this Rxm series. Although the definition of Rxm is still not widely accepted, Rxm is thought to be a key morphological factor influencing the variations of peripheral nerve arrangement on the thoracic wall. In the student course of gross anatomy dissection at Iwate Medical University School of Medicine during the years 1987-1991, three cases of Rxm communicating with the pectoral nerve and supplying the pectoralis major muscle were observed. Some cases have been reported in which Rcl innervates part of the pectoral muscles. However, the communication between the pectoral nerve and Rxm has not yet been discussed. Therefore, to clarify the morphological significance of the communication between Rxm and the pectoral nerve, the branching pattern and the distribution of the pectoral nerves were extensively investigated and the intramuscular nerve supply of some pectoral nerves, especially the pectoral nerves which communicated with Rxm, was examined in detail under a stereomicroscope. The results are summarized as follows: 1. In the first case, Rxm of the second intercostal nerve originated from Rcl, ran inferomedially adhering to the fascia of the intercostalis externus muscle and pierced the origin of the pectoralis minor muscle at the third intercostal space. Then Rxm turned superolaterally to communicate with a pectoral nerve which originated from the loop composed of the lateral and medial pectoral nerves and passed inferior to the pectoralis minor muscle. After communication, the pectoral nerve with Rxm supplied the caudalmost part of the sternocostal portion of the pectoralis major muscle. In the second case, a similar branch of Rxm of the second intercostal nerve passed inferior to the pectoralis minor muscle.(ABSTRACT TRUNCATED AT 400 WORDS)     

Architectural design, fiber-type composition, and innervation of the rat rectus abdominis muscle.

The rectus abdominis muscle is architecturally compartmentalized by tendinous intersections and is supplied by multiple thoracic nerves. In this study, the rectus abdominis of the rat has been qualitatively and quantitatively examined with regard to muscle dimensions, fiber organization, fiber-type composition, and innervation. The muscle exhibits architectural heterogeneity and different patterns of innervation among its thoracic, epigastric, and hypogastric parts. The epigastric part, adherent to the rectus sheath via tendinous intersections, represents relatively simple design. It is formed by serially arranged compartments with shorter fibers, compared with the other parts. These compartments are segmentally supplied by thoracic nerves. The hypogastric part is more complex, forms an interdigitation of muscular slips, and has segmental distribution of thoracic nerves in mediolateral direction. The thoracic part much differs from the other parts. It has smaller cross-sectional areas, compartments composed of abundant nonspanning fibers with intrafascicular termination, and non-segmental distribution of thoracic nerves. In addition to these craniocaudal specializations among the three parts, the muscle exhibits mediolateral differences in fiber-type composition. Slow-twitch oxidative fibers are more densely distributed in the medial half region than the lateral, whereas fast-twitch glycolytic fibers follow an inverse pattern. The mediolateral differences in fiber-type composition as well as the craniocaudal specializations in architectural design and innervation imply regionally differentiated recruitments of the muscle in various behaviors.