腹腔镜下间隙解剖观察阴道三水平理论的关键解剖结构

目的: 在宫颈癌腹腔镜手术中观察并验证阴道三水平理论的关键解剖结构，为盆腔器官脱垂患者手术提供依据。方法: 20例宫颈癌患者C型子宫切除及盆腔淋巴结清扫手术时在腹腔镜下基于自然间隙暴露阴道三水平理论相关解剖结构，观察分析其结构特征及承力方向。结果: Ⅰ水平主要的坚韧韧带样结构是子宫骶韧带，其作用力方向在骶骨方向，起主要的顶端固定作用，而主韧带区域主要是血管淋巴管及周围疏松结缔组织，缺乏坚韧结缔组织结构，其连接于髂内血管系统；Ⅱ水平阴道侧方未发现坚韧结缔组织连接于盆筋膜腱弓，盆筋膜腱弓是盆膈上筋膜的边缘，与闭孔内肌筋膜交界，表面光滑，紧贴肛提肌于近阴道中下三分之一交界处融合于阴道筋膜。游离输尿管隧道时可以发现输尿管子宫动脉交叉附近位置前后壁均有致密结缔组织结构，即膀胱宫颈韧带，固定膀胱三角的两个侧角，起自宫颈阴道而终止于膀胱肌层。结论: 肛提肌上方的盆底筋膜韧带支撑主要围绕阴道而成，而肛提肌以上的筋膜韧带结构呈两个平行面，可基于"阴道核心"和"双层吊床"解剖特征进行盆底重建手术设计。

Key anatomies of DeLancey's three levels of vaginal support theory: an observation in laparoscopic surgery

Objective: To observe and verify the key anatomies of DeLancey's three levels of vaginal support theory through laparoscopic surgery by space dissection technique. Methods: The features and stress performance of related anatomies were observed and analyzed in laparoscopic type C hysterectomy and pelvic lymphadenectomy for cervical cancer by natural space exposures. Results: The main ligament-like structure at level Ⅰ was the uterosacral ligament, which acted as the main apical fixation in the sacral direction, while the cardinal ligament was mainly composed of vascular system, lymph-vessels and loose connective tissue around them, lacking the tough connective tissue structures, which was connected to the internal iliac vascular system. There were no strong ligaments connected to the tendinous arch of pelvic fascia (ATFP) at the lateral side of vaginal wall at level Ⅱ. ATFP was the edge of the superior fascia of pelvic diaphragm, which was bounded by the fascia of the obturator. Its surface was smooth and close to the levator ani muscle and fuses with the vaginal fascia in about one thirds of middle lower segments of the vagina. When the ureter tunnel is separated, dense connective structures can be found in both anterior and posterior walls near the intersection of the ureter across uterine artery, fixing the bilateral angle of the bladder triangle, starting from the cervix and vagina and ending in the tunica muscularis vesicae urinariae. Conclusion: Based on the laparoscopic anatomy, the pelvic floor fascia ligament support above the levator ani muscle can be considered mainly around the vagina, and fascial ligament above the levator ani muscle can be simply considered as two parallel planes forming a "double hammock" structure, which may provide more anatomic data for pelvic floor reconstruction.