【摘要】： 目的明確骶前區(qū)和骶棘韌帶周圍的血管神經(jīng)解剖,以尋找骶骨陰道固定術、骶棘韌帶固定術和髂尾肌筋膜懸吊術的安全區(qū)域;測定這些手術常用的骨盆筋膜與韌帶、陰道穹隆和坐骨棘筋膜的抗拉力;并驗證坐骨棘筋膜能否成為新的安全有力且便于縫合的陰道穹隆固定點。 方法解剖國人成年女性尸體10具(防腐固定的7具和新鮮的3具),觀察、測量骶前區(qū)及骶棘韌帶周圍的血管神經(jīng)解剖,并用拉力計測定骶骨前縱韌帶、骶棘韌帶、髂尾肌筋膜、坐骨棘筋膜及陰道左右側穹隆的最大抗拉力。 結果 1 9具(9/10)尸體的骶前血管分布有規(guī)律可循,基本每個椎體的盆面均有一支橫行的骶前橫靜脈支連接著兩側的骶外側靜脈(或髂內靜脈)與中線附近的骶正中靜脈,呈“樓梯”狀分布,位于骶前區(qū)中線上、距離骶骨岬3 cm、邊長也是3 cm的正方形的四個頂點附近為無血管區(qū)。 2骶棘韌帶的長度是52.3±4.2 mm,坐骨棘端的寬度為10.0±1.1 mm,距離坐骨棘2.5 cm處的寬度為12.0±2.1 mm。臀下血管出骨盆前經(jīng)過骶棘韌帶外側一半的后方或緊鄰上緣,大部分在陰部神經(jīng)、骶神經(jīng)的背側,在骶棘韌帶上緣有時可有一小段不被神經(jīng)遮蓋而外露。大部分臀下動脈(18/20)在近骶棘韌帶上緣處還發(fā)出尾動脈,它在骶棘韌帶上緣處距離坐骨棘15.7±5.6 mm。陰部神經(jīng)在坐骨棘內側從內上向外下斜行跨越骶棘韌帶后方進入坐骨小孔,位于陰部內血管的內側或內上方,在骶棘韌帶上、下緣其最內界與坐骨棘間的距離分別是23.4±3.6 mm和15.7±1.3mm。坐骨棘前下至內下1-2 cm扇形區(qū)域的髂尾肌背面走行陰部內血管、陰部神經(jīng)、肛神經(jīng)及肛血管,兩者幾乎緊鄰,髂尾肌厚度僅有2.54 mm(范圍1.60-3.80 mm)。75%(15/20)的半骨盆找到肛提肌神經(jīng),它跨越骶棘韌帶上緣處距離坐骨棘的平均距離是39.6 mm(標準差8.3 mm,范圍30-60mm)。 3在10具尸體上,骶骨前縱韌帶的最大抗拉力沿著骶骨向下逐漸減小,骶骨岬上緣的腰5骶1椎間盤水平、骶1水平和骶2水平前縱韌帶的抗拉力分別為99.2±29.5 N(69.4-157.0 N)、47.9±16.4 N(29.0-85.0 N)、22.8±10.1 N(8.5-43.0 N);骶棘韌帶、坐骨棘筋膜、髂尾肌筋膜和陰道穹隆的最大抗拉力分別是102.0±25.7 N(74.3-176.0 N)、64.4±14.7 N(38.0-85.0 N)、32.6±8.2 N(17.0-42.0 N)和31.6±5.6 N(26.0-46.7 N),它們的變化范圍都比較大。只有腰5骶1椎體處前縱韌帶的抗拉力在新鮮尸體上明顯大于在固定尸體上,分別是124.0 N和86.8 N,其他位點的抗拉力在新鮮尸體和固定尸體上相似。 4坐骨棘是尾骨肌、髂尾肌和骶棘韌帶的起點,也是肛提肌腱弓、盆筋膜腱弓和閉孔內肌筋膜的附著處,坐骨棘筋膜牢固有力;在坐骨棘表面無重要的血管神經(jīng)走行。 結論 1大部分尸體的骶前血管分布有規(guī)律可循,位于骶前區(qū)中線上、距離骶骨岬3 cm、邊長也是3 cm的正方形的四個頂點附近為無血管區(qū);第一骶前孔水平無血管區(qū)的前縱韌帶是骶骨陰道固定術的首選固定點,因第三、四骶椎表面的無血管區(qū)面積小且前縱韌帶的抗拉力太小不宜選擇該水平的前縱韌帶做固定點。 2骶棘韌帶固定術中,選擇縫合骶棘韌帶距離坐骨棘至少2.5 cm處、寬度為韌帶靠近下緣的一半、深度為韌帶全層厚度的淺層一半,即寬度約5mm,深度約1mm,能避免損傷其后方及上緣的血管神經(jīng),且能為陰道頂端提供足夠的支撐。 3因坐骨棘前下方至內下方1-2 cm處髂尾肌的背面走行陰部內血管、陰部神經(jīng)、肛神經(jīng)及肛血管,髂尾肌筋膜懸吊術中宜縫合肌肉的淺層及其表面的筋膜,而不宜垂直進針穿透全層縫合。 4坐骨棘筋膜牢固有力,表面無重要血管神經(jīng)走行,可以作為陰道穹隆新的懸吊點,安全可靠。
[Abstract]:Objective To determine the anatomy of the presacral region and the vessels and nerves around the sacrospinal ligament in order to find the safe areas for sacrovaginal fixation, sacrospinal ligament fixation and iliocutaneous myofascial suspension, to determine the tensile strength of pelvic fascia and ligament, vaginal fornix and sciatic fascia, and to verify whether sciocutaneous fascia can be a new safe area. Forceful and easily sutured vaginal fornix fixation point.
Methods Ten Chinese adult female cadavers (7 preserved and fixed and 3 fresh) were dissected. The vascular and nerve anatomy of the anterior sacral region and around the sacrospinal ligament were measured. The maximum tensile strength of the anterior longitudinal ligament, sacrospinal ligament, ilioconcoccygeal fascia, sciatic spine fascia and the left and right vaginal fornix were measured by tensiometer.
Result
In 19 (9/10) cadavers, there was a transverse presacral transverse vein branch on the pelvic surface of each vertebral body connecting the lateral sacral vein (or the internal iliac vein) and the median sacral vein near the median line. It was a "staircase" shape, located in the anterior line of the sacral region, 3 cm from the sacral promontory, and 3 cm in length. There is no vascular area near the four vertices of the square.
2. The length of the sacrospinal ligament is 52.3 (+ 4.2 mm), the width of the sciatic spine is 10.0 (+ 1.1 mm) and the width is 12.0 (+ 2.1 mm) from the 2.5 cm of the sciatic spine. Most of the inferior gluteal artery (18/20) also sends out the caudal artery near the margin of the sacrospinal ligament, which is 15.7 (+ 5.6 mm) away from the sciatic spine. The pudendal nerve obliquely crosses the medial superior inferior superior superior superior inferior superior superior superior inferior superior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior The distances between the innermost border of the ligament and the sciatic spine were 23.4 (+ 3.6 mm) and 15.7 (+ 1.3 mm), respectively. The dorsal surface of the iliocutaneous muscles running from the anterior inferior sciatic spine to the fan-shaped area of the medial inferior 1-2 cm ran through the pudendal vessels, the pudendal nerves, the anal nerves and the anal vessels, which were almost adjacent. The thickness of the iliocutaneous muscles was only 2.54 mm (range 1.60-3.80 mm). 75% (15/20) of the semipelvis. The average distance from the levator ani nerve to the sciatic spine was 39.6 mm (standard deviation 8.3 mm, range 30-60 mm).
3 On 10 cadavers, the maximum tensile strength of the anterior longitudinal ligament decreased downward along the sacrum, at the level of lumbar 5-sacral 1 intervertebral disc, at the level of sacral 1 and at the level of sacral 2, at the level of 99.2 + 29.5 N (69.4-157.0 N), 47.9 + 16.4 N (29.0-85.0 N), 22.8 + 10.1 N (8.5-43.0 N), at the sacral spine ligament, sciatic fascia, and iliac coccygeal fascia, respectively. The maximum tensile forces of myofascial and vaginal fornix were 102.0 (+25.7 N) (74.3-176.0 N), 64.4 (+14.7 N) (38.0-85.0 N), 32.6 (+8.2 N) (17.0-42.0 N) and 31.6 (+5.6 N) (26.0-46.7 N), respectively. Only the tensile forces of anterior longitudinal ligament in lumbar 5-1 vertebral body were significantly greater than those in fresh cadavers, which were fixed at lumbar 5-1 vertebral body, respectively. .0 N and 86.8 N showed similar resistance to other sites in fresh cadavers and fixed cadavers.
4. The sciatic spine is the starting point of the coccygeal muscle, the iliocutaneous muscle and the sacrospinal ligament. It is also the attachment of the levator ani tendon arch, the pelvic fascia tendon arch and the myofascial fascia in the obturator. The sciatic spine fascia is firm and powerful, and there are no important vessels and nerves running on the surface of the sciatic spine.
conclusion
1. The presacral vessels of most cadavers are regularly distributed in the middle line of the presacral region, 3 cm from the sacral promontory and 3 cm from the four apex of the square. The anterior longitudinal ligament of the horizontal vessel-free area of the first presacral foramen is the preferred fixation point for sacrovaginal fixation, because the third and fourth sacral vertebral surface is the vascular-free area. The small anterior longitudinal ligament is too small to choose the anterior longitudinal ligament.
2 In sacrospinal ligament fixation, the sacrospinal ligament should be sutured at least 2.5 cm from the sciatic spine, half the width of the ligament near the inferior margin, half the thickness of the superficial layer of the ligament, that is, about 5 mm in width and 1 mm in depth. It can avoid injuring the posterior and superior vascular nerves and provide sufficient support for the vaginal apex.
3. Because the internal pudendal vessels, pudendal nerves, anal nerves and anal vessels run along the dorsal surface of iliocutaneous muscle from anterior inferior to inferior sciatic spine to 1-2 cm, it is better to suture the superficial layer of muscle and the fascia on the surface of iliocutaneous muscle during the operation of iliocutaneous fascial suspension, but not to penetrate the whole suture through the vertical needle.
4. The sciatic spine fascia is firm and powerful, and has no important vessels and nerves on its surface. It can be used as a new suspension point of vaginal fornix and is safe and reliable.
【學位授予單位】：中國協(xié)和醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2008
【分類號】：R711;R322;R318.01

【引證文獻】

相關博士學位論文 前1條

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

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本文編號：2182175