【摘要】：女性盆底功能障礙性疾病主要包括壓力性尿失禁和盆腔器官膨出，其發(fā)生機制及手術(shù)治療的理論依據(jù)有Delancey的“陰道三個水平支持”理論、“吊床假說”以及最重要的Petros的“整體理論”，其核心即支持盆底之結(jié)締組織損傷所致的解剖結(jié)構(gòu)改變導(dǎo)致這類疾病的發(fā)生，手術(shù)應(yīng)通過修復(fù)受損的韌帶完成解剖重建，恢復(fù)盆底功能。 目前，女性盆底解剖結(jié)構(gòu)雖然已經(jīng)很清晰，但肌肉、筋膜、韌帶、器官之間如何協(xié)同作用并發(fā)揮功能仍不明確。因此對盆底解剖的研究已經(jīng)不能局限于傳統(tǒng)解剖學(xué)，功能性解剖和手術(shù)解剖研究受到了更多關(guān)注。 我們的研究在一具防腐的女性尸體上進行了盆底支持系統(tǒng)及括約肌系統(tǒng)的解剖。明確了肛提肌和盆腔結(jié)締組織的微細結(jié)構(gòu)，證實二者之間存在廣泛的纖維連結(jié)，肛提肌通過與結(jié)締組織的連接發(fā)揮其支持作用。明確了盆底支持系統(tǒng)和臟器括約肌系統(tǒng)之間存在纖維交叉，提示二者通過協(xié)同作用完成盆底排尿、排便、分娩、性交等功能。在國人尸體標(biāo)本中明確了既往解剖研究很少涉及的結(jié)締組織支持結(jié)構(gòu)，包括盆腔筋膜腱弓、肛提肌腱弓、恥骨宮頸筋膜、直腸陰道筋膜、恥骨尿道韌帶和尿道外韌帶等，為盆底障礙性疾病相關(guān)理論的理解、應(yīng)用和完善奠定了基礎(chǔ)。 目前臨床上治療盆底障礙性疾病的微創(chuàng)吊帶手術(shù)包括治療SUI的經(jīng)恥骨后途徑陰道無張力吊帶(tension-flee vaginal tape，TVT)手術(shù)、經(jīng)閉孔途徑TVT手術(shù)(TVT-obturator，TVT-O)和治療陰道穹窿膨出的經(jīng)陰道后路懸吊帶(posterior intravaginal sling，P-IVS)手術(shù)。由于這些手術(shù)方法均為盲針穿刺技術(shù)，穿刺針通過體內(nèi)的一段不能在直視下完成，所以有術(shù)中損傷重要血管、神經(jīng)及臟器而發(fā)生嚴重并發(fā)癥的可能。 本實驗在5具新鮮尸體上進行TVT、TVT-O和P-IVS手術(shù)穿刺，然后采用10％福爾馬林溶液防腐，并結(jié)合橡膠乳漿加球磨顏料血管灌注的方法，進行手術(shù)通路解剖及安全性測量工作。本實驗結(jié)果顯示，TVT穿刺針至膀胱壁的平均最近距離是0.6cm，距髂外血管4.2cm，，距閉孔血管4.3cm。TVT穿刺針在恥骨后隙有失控導(dǎo)致穿刺過深、軸向旋轉(zhuǎn)或穿刺方向側(cè)偏而損傷膀胱、髂外靜脈、閉孔血管神經(jīng)和腹壁下血管的風(fēng)險。證實了TVT-O由內(nèi)向外穿刺的術(shù)式手術(shù)通
[Abstract]:Female pelvic floor dysfunction mainly includes stress urinary incontinence and pelvic organ exudation. The mechanism and surgical treatment of pelvic floor dysfunction are based on Delancey's "three levels of vaginal support" theory. The "hammock hypothesis" and, most importantly, Petros's "holistic theory," the core of which supports the anatomical changes that result from connective tissue injury in the pelvic floor, should be performed by repairing the damaged ligaments. Restoration of pelvic floor function. At present, although the anatomical structure of female pelvic floor is very clear, it is still unclear how to coordinate and function among muscles, fascia, ligaments and organs. Therefore, the study of pelvic floor anatomy can not be confined to traditional anatomy, functional anatomy and surgical anatomy have received more attention. Our study dissected the pelvic floor support system and sphincter system on an embalmed female cadaver. The microstructures of the levator ani muscle and the pelvic connective tissue were clarified, and the extensive fiber connection between them was confirmed. The levator ani muscle played its supporting role through the connection with the connective tissue. The fiber crossing between the pelvic floor support system and the visceral sphincter system was identified, indicating that the two systems could perform the functions of pelvic floor urination, defecation, delivery and sexual intercourse by synergistic action. Connective tissue supporting structures, including the pelvic fascia tendon arch, the levator ani tendon arch, the pubic cervical fascia, the rectovaginal fascia, the pubic urethral ligament and the external urethral ligament, were identified in Chinese cadavers. It lays a foundation for the understanding, application and perfection of the theory of pelvic floor disorders. At present, minimally invasive sling surgery for pelvic floor disorders includes the treatment of SUI via the postpubic approach to vaginal tension free sling (tension-flee vaginal tape,TVT) surgery. TVT's operation (TVT-obturator,TVT-O) and transvaginal posterior suspension band (posterior intravaginal sling,P-IVS) for vaginal fornix bulge. Because these surgical methods are all blind needle puncture technique, the puncture needle can not be completed under the direct vision through a section of the body, so there is the possibility of serious complications caused by the injury of important blood vessels, nerves and organs during the operation. In this experiment, TVT,TVT-O and P-IVS were performed on 5 fresh cadavers. Then 10% formalin solution was used for anticorrosion, combined with the method of rubber emulsion and ball milling pigment blood vessel perfusion, the operation path anatomy and safety measurement were carried out. The results showed that the average distance from the needle to the bladder wall was 0.6 cm, and 4.2 cm from the external iliac artery. The 4.3cm.TVT puncture needle from the obturator vessel caused the puncture to be out of control in the posterior space of the pubis, and the axial rotation or the side of the puncture direction damaged the bladder and the external iliac vein. The risk of obturator vessels, nerves, and subabdominal vessels. It is proved that the operative procedure of TVT-O from internal to external puncture.
【學(xué)位授予單位】：中國協(xié)和醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2006
【分類號】：R713;R322

【引證文獻】

相關(guān)博士學(xué)位論文 前1條

1 商曉;女性盆底在體生物力學(xué)研究[D];北京協(xié)和醫(yī)學(xué)院;2011年

本文編號：2203906