脊柱胸腰段左侧胸膜外腹膜后手术入路的解剖观察及临床意义

目的：研究脊柱胸腰段（T11-L2）左侧胸膜外腹膜后的手术入路解剖，为该部位手术提供层次解剖学基础。方法：用15例10％甲醛固定的成人尸体标本（男10例，女5例），按脊柱胸腰段椎体病灶的左侧胸膜外腹膜后手术入路逐层解剖，观察T11～L2椎体前外侧面的器官、血管和神经等结构的位置及毗邻关系，重点观察肋膈窦、腹膜腔和膈肌之间解剖关系。结果：（1）经左侧胸膜外腹膜后入路显露胸腰段脊柱，经过皮肤、浅筋膜，背部浅、深层肌及腹壁肌层，肋、肋间隙，在膈上、下推开壁胸膜和壁腹膜，剪开部分膈肌避开椎前的血管、神经、食管和胸导管即可显露T11-L2椎体。（2）左肋膈窦底由后向前，先后与12肋、11肋间神经血管和11肋平齐，在T11～T12左椎间孔处第11肋间神经与左肋膈窦底的上下距离为（34．3±1．0）mm，在左竖脊肌外缘为（21．4±0．8）mm，在左腋前线至胸前外侧壁二者平齐，向前内行渐低于左肋膈窦底部。结论：左侧胸膜外腹膜后入路经膈肌与壁腹膜和膈胸膜之间隙可显露T11～L2椎体，第11肋间动静脉和肋间神经的走行可作为肋膈窦底的参考标志。

Anatomical Study on Operative Approaches to Thoracolumbar Vertebral Column through Left Pleural and Retroperitoneal Lateral

Objective：To study the anatomy of operative approaches to thoracolumbar vertebral column （T11 -L2 ） through left pleural and retroperitoneal lateral. Methods ：The operations were performed on 15 adult cadavers（ 10 males and 5 females）. Following the left lateral pleura and retroperitoneal operative approaches, to dissect the specimens step by step and observe the organs, blood vessels, nerves and other structures, which located at anterolateral spaces of T11 -L2, and their adjacent relationships, especially to observed the anatomic relationship of costophrenic sinus, peritoneal cavity and diaphragma. Results： The operative approach went straight through skin, superficial fascia, superficial and deep muscles on back, muscular layer of abdominal wall, ribs and intercostals, after bursting through pleura and peritoneum on the superior and inferior surface of midriff and scissoring the part of diaphragm and keeping away from of blood vessels, nerves, esophagus and thoracic duct, and got to centrums of T11 -L2. The bottom of costodaphragmaticus recessus flushed with the 12th rib, 11 th rib and intercostal nerve and blood vessels from the back toward front. The vertical distance between the 11 th intereostals nerves and the bottom of costodaphragmaticus recessus was （34.25 ± 1.00） mm at left intervertebral foramina, （ 21.42 ± 0.82 ） mm at the outer edge of erector spinae, and was/lush each other from anterior axillary line to colpns lateral paries and then the intercostals nerves went forwards and inward and lower than the bottom of left costodaphragmaticus recessus gradually. Conclusions： The T11 -L2 centrums were revealed via the operative approaches passing through the interspaces of diapbragma, parietal peritoneum and diaphragmatic pleura. The 11 th intercostal nerves and arteries and veins could be used as a reference mark of the bottom of costodiaphragmatic recessus.