本文選題：精索 + 計算機輔助解剖　； 參考：《南方醫(yī)科大學》2014年碩士論文

【摘要】：背景和目的:精索是男性從腹股溝管深環(huán)至睪丸上端的一對柔軟的圓索狀結構,精索內走行的血管是睪丸重要的血供保障和回流通路,其內的神經對睪丸的功能維持、位置固定和保護有重要的意義。與精索相關的疾病如精索靜脈曲張等是成年男性發(fā)病率較高的疾病,近年來隨著顯微外科技術在泌尿男科疾病中的廣泛應用,精索的顯微結構解剖成為了顯微手術過程中重要的客觀依據和基礎。精索靜脈曲張(Varicocele,VAC)是青壯年男性高發(fā)的泌尿生殖系統(tǒng)疾病之一,其在成年男性的發(fā)病率約為15%,在青少年男性的發(fā)病率約為13.7%～16.2%。精索靜脈曲張與男性不育癥關系密切,其在原發(fā)性男性不育癥人群中發(fā)病率約為35%,在繼發(fā)性男性不育人群中發(fā)病率約為80%以上。精索靜脈曲張的治療以手術治療為主,顯微鏡下精索靜脈結扎術(Microsurgical varicocelectomy,MV)在1985年首次被報道隨后在1992年報道了一種基于初始MV的改良手術,此后由于MV較之高位結扎術及腹腔鏡手術有更低的術后復發(fā)率(0%-1.5%)和手術并發(fā)癥發(fā)生率(鞘膜積液發(fā)生率0%-0.44%,睪丸萎縮發(fā)生率1%)且能有效保護睪丸動脈并且能顯著改善精液質量、提高受孕率,越來越多的學者將MV作為手術首選方案或者手術治療"金標準"。目前大部分的研究均關注MV較開放式或腹腔鏡手術的優(yōu)勢,很少有研究提及精索組織的臨床解剖,特別是對手術過程有重要意義的顯微結構解剖,同時由于目前研究均以臨床和手術中觀察為主,存在一定主觀性,在一些手術程序問題上存在矛盾和爭議,例如輸精管位置與精索內筋膜的關系等,也使用了許多不精確的術語,這對手術的規(guī)范化普及造成很大影響。目前關于MV的手術路徑報道以腹股溝管內(MHSV)及外環(huán)口下(MISV)為主。對于兩種路徑的優(yōu)劣勢,不同的學者對此有不同的報道,有研究發(fā)現外環(huán)口下水平比腹股溝管內水平有更多小靜脈,有更大的概率發(fā)現復雜的精索內靜脈蔓狀靜脈網緊緊包繞精索內動脈,這使得手術難度更大,因此認為采用腹股溝管路徑能更有效地降低手術難度,減少損傷動脈的風險,節(jié)約手術時間。但是也有另外的研究結果表明兩個路徑的精索靜脈以及動脈數量并沒有顯著性差異,外環(huán)口下路徑并不會增加手術難度和手術時間,由于兩組數據均來自國外,且可能存在種族差異,因此客觀性的精索組織的顯微結構解剖研究可以提供確切的中國男性人群中相應水平血管數量,血管與筋膜毗鄰關系等,也為規(guī)范顯微鏡下精索靜脈曲張結扎術提供顯微解剖基礎。頑固性睪丸疼痛是另一個與精索結構相關的疾病,因其間斷或持續(xù)的睪丸疼痛不適嚴重影響患者的日常生活。頑固性睪丸痛潛在的病因包括感染、腫瘤、腹股溝疝、鞘膜積液、精液囊腫、精索靜脈曲張、牽涉痛、外傷、手術史等。但大約25%的頑固性睪丸疼痛的患者不能發(fā)現明確的病因。顯微鏡下睪丸神經剔除術逐漸被廣泛應用于治療這一部分的頑固性睪丸痛患者。這一手術目的主要是剔除睪丸的神經來源,特別是精索內的神經。傳統(tǒng)的解剖學方法以大體解剖及觀察為主,對于顯微鏡下放大的細微解剖結構了解不夠清晰,對相應的手術程序的指導意義不大。近年來,隨著計算機硬件及軟件的不斷發(fā)展,計算機輔助下的三維重建技術在醫(yī)學領域得到日益廣泛的應用,目前在醫(yī)學上應用較多的三維重建多是基于影像學手段獲得二維圖像,這些圖像容易獲得,采集時可自動定位及匹配,因此易于重建。但這些圖像最多僅能達到毫米級水平,難以獲得較精細的顯微組織學信息。基于連續(xù)切片的計算機輔助解剖技術(computer-assisted anatomic dissection,CAAD)的三維重建是指針對某一組織器官進行定位下的連續(xù)組織切片,通過獲取切片上的結構位置信息利用計算機圖像處理及圖像生成功能獲得該組織的復雜的三維結構,以其獲得更精確的解剖參數。這種方法突破了傳統(tǒng)大體解剖方法的限制,獲取的信息對顯微鏡下手術有重要的參考價值。本研究嘗試在連續(xù)組織切片基礎上對精索進行初步三維重建,以期獲得更精確的顯微結構解剖信息,為手術的指導或改進提供更加精確的客觀依據。方法:1.從南方醫(yī)科大學解剖教研室尸體庫取得13例相對新鮮的成年男性尸體,所有尸體來源及用途均遵循相關法律及科研準則,準確的死因未知,我們對尸體標本進行了嚴格的檢查,均未發(fā)現腎臟及腎血管明顯的器質性病變,睪丸及精索均未發(fā)現明顯手術干預跡象。精索取材范圍從附睪頭一直到內環(huán)口上1cm。取材后的精索切成標準小塊,按序號進行固定、脫水、透明、定位、包埋、切片。制作好的石蠟切片分別進行HE染色、天狼星紅-飽和苦味酸染色、銀浸染色和免疫組化染色。2.分別對精索左、右側,腹股溝管水平、外環(huán)口下水平的動、靜脈,神經纖維束數量進行統(tǒng)計,采用SPSS 16.0統(tǒng)計軟件進行試驗數據的統(tǒng)計學處理,數據以均數±標準差(X±s)表示,計量資料用t檢驗,計數資料用卡方檢驗,以P0.05為差異有統(tǒng)計學意義。3.用體視顯微鏡采集二維圖像,用Photoshop 7.0軟件處理二維圖像,將編輯好的二維圖片按順序導入mimics軟件,完成三維重建。結果:我們的研究結果發(fā)現:在精索外筋膜和提睪肌內部存在兩層較薄的結締組織薄膜,兩層膜在分別在外側沿著提睪肌的輪廓緊貼提睪肌,內部兩層膜緊貼在一起,分隔開輸精管及其附屬血管與精索內血管叢,我們認為包繞精索內血管叢的筋膜為精索內筋膜(ISF),包繞輸精管及其附屬血管的筋膜為輸精管筋膜(VF),精索內筋膜和輸精管筋膜分別環(huán)形完整包繞并分隔精索內血管叢與輸精管以及其附屬血管,兩層筋膜共同位于精索外筋膜和提睪肌的內部且相互伴行,左側外環(huán)口下水平靜脈數量有8至15條,平均11.00±2.26條;左側腹股溝管水平靜脈數量有7至13條,平均9.60±2.22條;右側外環(huán)口下水平靜脈數量有7至13條,平均10.00±2.05條;右側腹股溝管水平靜脈數量有6至14條,平均9.90±2.76條。左側外環(huán)口下動脈數量有3至5條,平均4.10±0.87條;右側外環(huán)口下動脈數量有2至5條,平均4.10±0.81條;左側腹股溝管水平動脈數量2至5條,平均3.40±0.84條;右側腹股溝管水平動脈數量3至5條,平均4.00±0.88條。左右側外環(huán)口下水平與腹股溝管水平動脈數量對比沒有顯著性差異,左右側腹股溝管水平靜脈數量對比沒有顯著性差異,左右側外環(huán)口下靜脈數量對比沒有顯著性差異。左右側外環(huán)口下水平與腹股溝管水平靜脈數量對比沒有顯著性差異,左右側腹股溝管水平靜脈數量對比沒有顯著性差異,左右側外環(huán)口下靜脈數量對比沒有顯著性差異。左右側的腹股溝管路徑與外環(huán)口下路徑動脈數量并無統(tǒng)計學差異。左右側精索神經纖維束數量沒有顯著差異,神經纖維束在精索中廣泛分布,按我們劃定的區(qū)域分布來講,在精索外結構、輸精管周圍及精索內血管叢內均有數量不等的神經纖維束分布,總的來說神經纖維的分布主要集中在輸精管、精索內動脈周圍、提睪肌肌束間;輸精管動脈周圍、蔓狀靜脈叢周圍結締組織中可見少量分布,極少數情況可以在脂肪組織中發(fā)現神經纖維,神經纖維束的分布并不固定在一點上,而按上述規(guī)律隨機的分布在區(qū)域里。這些顯微結構解剖的呈現為顯微男科或顯微生殖手術的發(fā)展和改良提供了客觀的基礎。結論:1.精索結構中在提睪肌內部存在精索內筋膜和輸精管筋膜,分別包繞精索內血管叢和輸精管及其血管叢,輸精管不被精索內筋膜包繞;2.顯微鏡下精索靜脈曲張結扎術的腹股溝管路徑及外環(huán)口下路徑手術難度并無明顯差異;左右側精索的動、靜脈數量無顯著統(tǒng)計學差異,腹股溝管水平和外環(huán)口下水平總的動靜脈數量無顯著統(tǒng)計學差異;3.神經纖維的分布主要集中在輸精管、精索內動脈周圍、提睪肌肌束間;輸精管動脈周圍、蔓狀靜脈叢周圍結締組織中可見少量分布,極少數情況可以在脂肪組織中發(fā)現神經纖維,神經纖維束的分布并不固定在一點上,而隨機的分布在區(qū)域里。
[Abstract]:Background and purpose: spermatic cord is a pair of soft circular cord structures from the deep ring of the inguinal canal to the upper testis of the male. The vessels in the spermatic cord are important blood supply and reflux pathways of the testicles. The nerves within the spermatic cord are important for the maintenance of the testicles, the location and protection of the testicles. The diseases related to spermatic cord, such as varicocele, are related to the spermatic cord. In recent years, with the widespread use of microsurgical techniques in urological diseases, the microstructural anatomy of spermatic cord has become an important objective basis and basis for microsurgery. Varicocele (VAC) is one of the high incidence of genitourinary diseases in young men. The incidence of adult male is about 15%. The incidence of 13.7% ~ 16.2%. varicocele in young men is closely related to male infertility. The incidence of the male infertility is about 35% in the primary male infertility. The incidence of the secondary male infertility is about 80%. The treatment of varicocele is mainly performed by surgical treatment. Microsurgical varicocelectomy (MV) was first reported in 1985 and a modified operation based on initial MV was reported in 1992. Since MV has a lower postoperative recurrence rate (0%-1.5%) and the incidence of surgical complications than the high ligation and laparoscopy (0%-0.44%), the incidence of hydrocele is 0%-0.44% The incidence of testicular atrophy is 1%) and it can effectively protect the testicular artery and improve the quality of the semen and increase the pregnancy rate. More and more scholars take MV as the first choice of operation or surgical treatment of "gold standard". Most of the studies are concerned about the advantages of MV than open or celioscope surgery. Few studies have mentioned the presence of spermatic cord tissue. The anatomy of the bed, especially the microstructural anatomy that has important significance to the process of operation, has a certain subjectivity, and there are contradictions and controversies in some surgical procedures, such as the relationship between the position of the vas deferens and the fascia in the spermatic cord, and the use of many inaccurate terms. There is a great impact on the standardized popularization of the operation. The current coverage of the surgical route for MV is mainly in the inguinal canal (MHSV) and under the outer ring mouth (MISV). For the advantages and disadvantages of the two paths, different scholars have different reports. It is found that the complicated spermatic vein network of the intricate spermatic vein is tightly wrapped around the internal spermatic artery, which makes the operation more difficult. Therefore, it is considered that the use of the inguinal canal can reduce the difficulty of the operation more effectively, reduce the risk of the injury of the arteries, and save the operation time. But there are also other results of the two pathways of the spermatic vein and the number of arteries. There is no significant difference in volume. The approach of the outer ring does not increase the difficulty and time of operation. As two groups of data are from abroad, and there may be racial differences, the objectivity of the microstructural anatomy of the spermatic cord tissue can provide the exact number of blood vessels in the Chinese male population, and the vessels and fascia adjacent to the vessel. It provides a microanatomical basis for the standard microscopical varicocele ligation. Intractable testicular pain is another disease associated with the spermatic cord structure, which seriously affects the daily life of the patient. The underlying causes of intractable testicular pain include infection, tumor, inguinal hernia, and vaginosis. Fluid, semen cysts, varicocele, involving pain, trauma, and the history of surgery. But about 25% of the patients with intractable testicular pain can not find a clear cause. Microscopically, testicular neurosurgery is widely used in the treatment of this part of the intractable testicular pain. The aim of this operation is to eliminate the nerve sources of the testis. In particular, the nerve in the spermatic cord. The traditional anatomical method is based on general anatomy and observation. It is not clear about the microscopic anatomy structure enlarged under the microscope, and is not of great significance to the corresponding procedure. In recent years, with the continuous development of computer hardware and software, the computer aided 3D reconstruction technology is in medicine. The field has been widely used. At present, three-dimensional reconstruction is mostly used in medicine to obtain two-dimensional images based on imaging methods. These images are easy to obtain. They can be automatically located and matched in acquisition, so it is easy to reconstruct. However, these images can only reach the level of millimeter level, and it is difficult to obtain fine microscopic histology information. The three-dimensional reconstruction of computer-assisted anatomic dissection (CAAD) based on continuous slice is the continuous tissue section of an organ in which the pointer is positioned. By obtaining the information on the structure of the slice, the complex 3D of the organization is obtained by using the computer image processing and image generation function. This method breaks through the limitations of the traditional general anatomical methods. The information obtained is of great reference value for the operation under the microscope. This study attempts to reconstruct the spermatic cord on the basis of continuous tissue section, in order to obtain more accurate microstructural anatomy information for surgery. The guidance or improvement provided more accurate objective basis. Methods: 1. from the cadaver Department of Southern Medical University, 13 cases of relatively fresh adult male bodies were obtained. All the sources and uses of the corpses followed relevant laws and scientific research guidelines, and the exact cause of death was unknown. We have carried out strict examination of the cadaver specimens and did not find the kidneys. No obvious surgical intervention was found in the visceral and renal vessels. The spermatic cord was removed from the epididymal head from the epididymal head to the 1cm. of the inner ring. The spermatic cord was fixed, dehydrated, transparent, located, embedded and sliced. The paraffin sections were stained with HE, and Sirius red. Saturated picric acid staining, silver immersion and immunohistochemical staining.2. were used to calculate the left, right, groin level, the level of the lateral groin, the number of veins and nerve fibers at the outer ring mouth, and the statistical processing of the experimental data with SPSS 16 statistical software. The data were expressed with the mean number of standard deviation (X + s), and the measurement data were tested with t test. The data were checked with chi square, and the difference was statistically significant in P0.05..3. was collected by stereoscopic images for two-dimensional images, and two dimensional images were processed with Photoshop 7 software. The edited two-dimensional images were introduced into Mimics software in order to complete 3D reconstruction. Results: Our results found that there were two layers inside the outer spermatic fascia and the testosterone muscle. In the thinner connective tissue film, the two layers of the membrane closely stick the testosterone muscle along the outline of the testosterone muscle on the lateral side. The two layers of the inner membrane close together, separate the vas deferens and its accessory vessels and the endovascular plexus. We think the fascia wrapped around the inner vessel of the spermatic cord is the ISF, which is wrapped around the fascia of the vas deferens and its accessory vessels. The vasorelal fascia (VF), the fascia of the spermatic cord and the vasorelal fascia wrapped around and separated the spermatic vascular plexus and the vas deferens and its accessory vessels. The two layers of fascia were located in the external fascia of the spermatic cord and the muscles of the testosterone. The number of horizontal veins under the left outer rim of the outer ring was 8 to 15, with an average of 11 + 2.26; the left groin was in the left groin. The number of horizontal veins in the tube was 7 to 13, with an average of 9.60 + 2.22; the number of horizontal veins under the right lateral outer rim was 7 to 13, with an average of 10 + 2.05, and the horizontal vein in the right inguinal canal was 6 to 14, average 9.90, 2.76. The average number of horizontal arteries in the left inguinal canal was 2 to 5, with an average of 3.40 + 0.84, the number of horizontal arteries in the right inguinal canal was 3 to 5, with an average of 4 + 0.88. There was no significant difference between the lateral and the lateral inguinal horizontal arteries in the right and left lateral rim, and there was no significant comparison between the horizontal and the left and right lateral inguinal veins in the left and right lateral inguinal vessels. There was no significant difference in the number of inferior vena cava in the left and right lateral rim. There was no significant difference between the level of the left and right lateral and the horizontal veins of the inguinal canal. There was no significant difference in the number of horizontal veins in the left and right inguinal tubes. There was no significant difference between the left and right lateral inguinal veins. There was no significant difference between the route of the groin tube and the number of the arteries in the outer ring. There was no significant difference in the number of the left and right nerve fibers in the spermatic cord, and the nerve fiber bundles were widely distributed in the spermatic cord. In general, the distribution of nerve fibers is mainly concentrated in the vas deferens, the peripheral arteries of the spermatic cord, the muscular bundle of the testosterone, and a small amount of distribution around the artery of the vas deferens and the connective tissue around the vine shaped vein plexus, and a few cases can be found in the adipose tissue. The distribution of the fascicle of the God's Classics is not fixed at a point, but the above is the same. These microstructural anatomy provide an objective basis for the development and improvement of microsurgical or microreproductive surgery. Conclusion: the internal spermatic fascia and fascia of the spermatic cord in the 1. spermatic cord are wrapped around the spermatic cord and the VASO plexus and the vasa plexus, and the vas deferens are not. There was no significant difference in the difficulty of the inguinal canal path and the external ring path of the varicocele under 2. microscopes. There was no significant difference in the movement of the left and right spermatic cord and the number of veins in the lateral spermatic cord. There was no significant difference in the total number of arteriovenous veins between the level of the inguinal canal and the level of the outer ring mouth; and 3. nerve fibers. The distribution is mainly concentrated in the vas deferens, the peripheral arteries of the spermatic cord, the muscular bundle of the testosterone, and a small amount of distribution around the vas deferens artery and the connective tissue around the vine like plexus, and a few cases can be found in the adipose tissue. The distribution of the nerve fiber bundle is not fixed at one point, but it is randomly distributed in the region.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R322.6;R699

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