腹壁解剖及操作

局部解剖学（十四）腹部的局部解剖与操作（1）主要内容MainContent•境界与分区Theboundaryandregion•表面解剖Thesurfaceanatomy•腹前外侧壁TheAnterolateralAbdominalWall一、境界与分区BoundaryandRegion1.腹部的境界•上界：为胸廓下口，即剑突、肋弓、第11肋前端、第12肋下缘和第12胸椎围成；•下界：为耻骨联合上缘、耻骨嵴、耻骨结节、腹股沟韧带、髂嵴至第5腰椎下缘的连线。2.(固有)腹腔的境界•上界：膈•下界：骨盆上口3A.腹部的分区(九分法)3B.腹部的分区(四分法)二、表面解剖TheSurfaceAnatomy•体表标志Surfacelandmark•表面投影SurfaceprojectionXiphoidprocess剑突Costalarch肋弓Iliaccrest髂嵴Anteriorsuperioriliacspine髂前上棘Pubictubercle耻骨结节Superioredgeofpubicsymphysis耻骨联合上缘Pubiccrest耻骨嵴1.骨性标志2.软组织标志Locationofinguinalligament3.体表投影三、腹前外侧壁TheAnterolateralAbdominalWall•浅层结构Superficialstructures•深层结构Deepstructures皮肤浅筋膜腹膜下筋膜深筋膜和肌肉Thelayersoftheanterolateralabdominalwall1.Skin2.Superficialfascia3.Deepfasciaandmuscles4.Transversefascia5.Extraperitonealfascia6.Parietalfascia腹横筋膜壁腹膜（一）浅层结构Thesuperficialstructures•皮肤Skin•浅筋膜Superficialfascia1.Skin:thinnerandmoreelastic薄而富有弹性2.Superficialfascia：主要由脂肪和疏松结缔组织组成。Camper筋膜在腹壁下部（约在脐平面以下），浅筋膜分为两层：浅层称为Camper`sfascia,含有丰富的脂肪组织，又称脂肪层，向下与股部的浅筋膜相互延续；深层称为Scarpa`fascia，是富有弹性纤维的膜性层，在中线附于白线，向下在腹股沟下方约一横指处，紧附于股部的深筋膜，在耻骨结节之间，越过耻骨联合向下至会阴，与会阴浅筋膜（Colles筋膜）相延续。Scarpa筋膜浅筋膜SkinSuperficialfasicaScarpa’sfasciaMusclesofanteriorabdominalCamper’sfasciaTransversalisfasciawall2.SuperficialfasciaSuperficialfasciaconsistsofalayerofconnectivetissuethatcontainsavariableamountoffat.Abovethelevelofumbilicus,itisafattylayer.Intheinferiorpartoftheanterolateralwall,thesubcutaneoustissueiscomposedoftwolayers,thefattyouterlayer,knownasCamper`sfascia,andthemembranousinnerlayer,theScarpa`fascia.TheScarpa`fascia:1)isattachedtolineaalbamedially.2)continusedownwardscrosstheinguinalligamenttoblendwiththefascialataofthethighabout1.5cmbelowtheinguinalligament.3)iscontinuouswiththesuperficialfasciaoftheperineum(Colles’fascia).浅动脉、浅静脉、皮神经髂腹股沟区和下腹部的皮瓣Theilioinguinalandthelowerabdominalflaps（二）深层结构TheDeepStructures•肌肉层次Muscularlayer•血管、淋巴及神经Vessels,lymphandnerve•腹横筋膜Transversalisfascia•腹膜下筋膜Extraperitonealfascia•壁腹膜Parietalperitoneum1.肌层TheMuscularlayer前外侧群TheAnterolateralGroupThethreeflatmusclesarethe:–腹外斜肌externalobliquemuscle–腹内斜肌internalobliquemuscle–腹横肌transversusabdominis：–腹直肌rectusabdominis–锥状肌pyramidalis（1）腹外斜肌externalobliquemuscle•腹股沟管皮下环superficialinguinalring:内侧脚medialcrus、外侧脚lateralcrus、脚间纤维intercruralfibers.腹外斜肌Externaloblique腹外斜肌腱膜Externaloblique，aponeurosisIntercruralfibersMedialcrus腹股沟管皮下环superficialinguinalring:内侧脚medialcrus、外侧脚lateralcrus、脚间纤维intercruralfibers.返转韧带reflectedligament、腹股沟韧带inguinalligament、腔隙韧带lacunarligament、耻骨梳韧带pectinealligament•腹股沟韧带inguinalligament、腔隙韧带lacunarligament、耻骨梳韧带pectinealligament（2）腹内斜肌及其腱膜internalobliquemuscle&aponeurosis：参与构成腹直肌鞘前、后层，结合腱和提睾肌。InternalobliquemuscleInternalobliquem.aponeurosisTransversusabdominis,aponeurosisTransversusabdominis（3）腹横肌及其腱膜transversusmuscle&aponeurosis：参与构成腹直肌鞘前层（弓状线以下）、后层（弓状线以上），结合腱和提睾肌。☆提睾肌Cremastermuscle☆腹股沟镰Inquinalfalx联合腱Conjoinedtendon☆腹横肌下缘腹内斜肌及其腱膜和腹横肌及其腱膜形成的结构Rectussheath,posteriorlayer腱划tendinousintersectionsRectusabdominis弓状线ArcuatelinePyramidalm.（4）腹直肌rectusabdominis（5）锥状肌pyramidalmuscletendinousintersectionsRectussheath,anteriorlayer腹直肌鞘☆腹直肌鞘rectussheath☆腹直肌鞘Rectussheath•腹直肌鞘包绕腹直肌，由腹外侧壁三个扁肌的腱膜构成，分为前、后两层。•在弓状线以上：–腹直肌鞘前层anteriorlayeroftherectussheath由腹外斜肌腱膜和腹内斜肌腱膜前层构成；–腹直肌鞘后层posteriorlayeroftherectussheath由腹内斜肌腱膜的后层和腹横肌腱膜构成。•在弓状线以下：–腹直肌鞘前层由三个扁肌的腱膜构成；–腹直肌鞘后层缺如。2.血管、淋巴及神经Vessels,LymphandNerve(1)动脉(2)静脉(3)神经3.腹横筋膜TransversalisFascia腹横筋膜Transversefascia•精索内筋膜internalspermaticfascia•腹股沟深环deepinguinalring•窝间韧带interfoveolarligament腹横筋膜Transversefascia腹前壁内面的皱襞及凹窝4.壁腹膜Parietalperitoneum5.腹前壁手术常用切口ThoracoabdominalincisionSuperiormedianincisionTransrectusincisionPararectusincisionParamedianincisionSubcostalincisionSuperiortransverseincisionMcBurney’sincisionInferiormedianincisionInferiortransverseincisionAbovethearcuatelineBelowthearcuateline四、腹股沟区TheInguinalRegion•境界Theboundary•层次与特点Thelayersandcharacteristics•腹股沟管Theinguinalcanal•腹股沟三角Theinguinaltriangle•疝hernias：腹股沟直疝Directinguinalhernias、腹股沟斜疝indirectinguinalhernias、股疝femoralhernias（一）境界Boundary1.皮肤skin2.浅筋膜superficialfascia3.腹外斜肌aponeurosisofexternalobliquusabdominis（二）腹股沟区层次结构TheLayersoftheInguinalRegion4.髂腹下神经Iliohypogastricn.和髂腹股沟神经ilioinguinaln.5.腹内斜肌Obliquusinternusabdominis6.腹横肌Transversusabdominis（二）腹股沟区层次结构TheLayersoftheInguinalRegion7.腹横筋膜Transversefascia8.腹膜外筋膜Extraperitonealfascia9.腹璧下动脉Inferiorepigastrica.and旋髂深动脉deepcircumflexiliaca.10.璧腹膜Parietalperitoneum特点：①腹外斜肌在此区移行为腱膜，并在下部形成一裂口(浅环)；②腹内斜肌与腹横肌的下缘未达腹股沟韧带的内侧部，两者间无肌层覆盖；③有精索或子宫圆韧带通过，形成了一潜在性裂隙；④在人体站立时，该区所承受的腹内压力比平卧时高3倍。因此，腹股沟区为腹壁的薄弱区，是腹壁疝的多发部位。（三）腹股沟管Theinguinalcanal•位置Position•通过的结构Structurespassingthroughit•两口、四璧Twoopeningandfourwalls•精索Formingofthespermaticcord•腹股沟斜疝Indirectinguinalhernia（三）腹股沟管InguinalCanal1.位置2.内容3.构成4.临床意义•Theinguinalcanalisanoblique,inferomediallypassage(betweenthesuperficialanddeepinguinialrings)throughtheinferiorpartoftheanteriorabdominalwall),3~5cmlong.•Theinguinalcanalliesparallelandjustsuperiortothemedialhalfoftheinguinalligament.•Themainoccupantoftheinguinalcanalisthespermaticcordinmalesandtheroundligam