腹壁解剖及操作课件

局部解剖学（十四）局部解剖学（十四）腹部的局部解剖与操作（腹部的局部解剖与操作（1）1主要内容主要内容 Main Content境境 界界 与与 分分 区区 The boundary and region表表 面面 解解 剖剖 The surface anatomy 腹腹 前前 外外 侧侧 壁壁 The Anterolateral Abdominal Wall 2一、一、境界与分区境界与分区Boundary and Region31.腹部的境界腹部的境界上界：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。42.(固有固有)腹腔的境界腹腔的境界上界：膈上界：膈下界：骨盆上口下界：骨盆上口53A.腹腹部部的的分分区区(九分法九分法)63B.腹腹部部的的分分区区(四分法四分法)7二、表二、表 面面 解解 剖剖The Surface Anatomy体表标志体表标志 Surface landmark表面投影表面投影 Surface projection8Xiphoid process剑剑 突突Costal arch肋肋 弓弓Iliac crest髂嵴髂嵴Anterior superior iliac spine髂前上棘髂前上棘Pubic tubercle耻骨结节耻骨结节Superior edge of pubic symphysis 耻骨联合上缘耻骨联合上缘Pubic crest 耻骨嵴耻骨嵴1.骨骨性性标标志志92.软软 组组 织织 标标 志志Location of inguinal ligament103.体体表表投投影影11三、三、腹腹 前前 外外 侧侧 壁壁The Anterolateral Abdominal Wall浅层结构浅层结构 Superficial structures 深层结构深层结构 Deep structures 12皮肤皮肤浅筋膜浅筋膜腹膜下筋膜腹膜下筋膜 深筋膜和肌肉深筋膜和肌肉 The layers of the anterolateral abdominal wall1.Skin2.Superficial fascia3.Deep fascia and muscles4.Transverse fascia5.Extraperitoneal fascia6.Parietal fascia腹横筋膜腹横筋膜 壁腹膜壁腹膜 13（一）（一）浅浅 层层 结结 构构The superficial structures皮肤皮肤 Skin浅筋膜浅筋膜 Superficial fascia141.Skin:thinner and more elastic 薄而富有弹性152.Superficial fascia：主要由脂肪和疏松结缔组织组成。：主要由脂肪和疏松结缔组织组成。Camper 筋膜v 在腹壁下部（约在脐平面以下），浅筋膜分为两层：浅层称为 Campers fascia,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；16v深层称为深层称为Scarpa fascia，是富有弹性纤维的膜性层，在中线附于白线，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（过耻骨联合向下至会阴，与会阴浅筋膜（Colles筋膜）相延续。筋膜）相延续。Scarpa 筋膜筋膜17浅浅 筋筋膜膜SkinSuperficial fasica Scarpas fasciaMuscles of anteriorabdominal Campers fasciaTransversalis fasciawall182.Superficial fasciavSuperficial fascia consists of a layer of connective tissue that contains a variable amount of fat.vAbove the level of umbilicus,it is a fatty layer.vIn the inferior part of the anterolateral wall,the subcutaneous tissue is composed of two layers,the fatty outer layer,known as Campers fascia,and the membranous inner layer,the Scarpa fascia.vThe Scarpa fascia:1)is attached to linea alba medially.2)continuse downwards cross the inguinal ligament to blend with the fascia lata of the thigh about 1.5cm below the inguinal ligament.3)is continuous with the superficial fascia of the perineum (Colles fascia).19浅浅动动脉脉、浅浅静静脉脉、皮皮神神经经20髂腹股沟区和下腹部的皮瓣髂腹股沟区和下腹部的皮瓣The ilioinguinal and the lower abdominal flaps21（二）（二）深层结构深层结构 The Deep Structures肌肉层次肌肉层次 Muscular layer血管、淋巴及神经血管、淋巴及神经 Vessels,lymph and nerve 腹横筋膜腹横筋膜 Transversalis fascia腹膜下筋膜腹膜下筋膜 Extraperitoneal fascia壁腹膜壁腹膜 Parietal peritoneum221.肌层肌层 The Muscular layerv前外侧群 The Anterolateral Group The three flat muscles are the:腹外斜肌 external oblique muscle腹内斜肌 internal oblique muscle腹横肌 transversus abdominis：腹直肌 rectus abdominis锥状肌 pyramidalis23（1）腹外斜肌腹外斜肌 external oblique muscle 腹股沟管皮下环腹股沟管皮下环 superficial inguinal ring:内侧脚内侧脚medial crus、外侧脚外侧脚lateral crus、脚间纤维、脚间纤维intercrural fibers.腹外斜肌腹外斜肌External oblique腹外斜肌腱膜腹外斜肌腱膜External oblique，aponeurosisIntercrural fibersMedial crus24v 腹股沟管皮下环腹股沟管皮下环 superficial inguinal ring:内侧脚内侧脚medial crus、外侧脚外侧脚lateral crus、脚间纤维、脚间纤维intercrural fibers.v返转韧带返转韧带reflected ligament、腹股沟韧带、腹股沟韧带inguinal ligament、腔隙韧带腔隙韧带lacunar ligament、耻骨梳韧带、耻骨梳韧带pectineal ligament25腹股沟韧带腹股沟韧带inguinal ligament、腔隙韧带、腔隙韧带lacunar ligament、耻骨梳韧带、耻骨梳韧带pectineal ligament26（2）腹内斜肌及其腱膜）腹内斜肌及其腱膜 internal oblique muscle&aponeurosis：参与构成腹直肌鞘前、后层，结合腱：参与构成腹直肌鞘前、后层，结合腱 和提睾肌。和提睾肌。Internal oblique muscleInternal oblique m.aponeurosis27Transversus abdominis,aponeurosisTransversus abdominis（3）腹横肌及其腱膜）腹横肌及其腱膜 transversus muscle&aponeurosis：参与构成腹直肌鞘前层（弓状线以下）、后层（弓状线以上）参与构成腹直肌鞘前层（弓状线以下）、后层（弓状线以上），结，结合腱合腱 和提睾肌。和提睾肌。28提睾肌提睾肌 Cremaster muscle腹股沟镰腹股沟镰Inquinal falx联合腱联合腱 Conjoined tendon腹横肌下缘腹横肌下缘 腹内斜肌及其腱膜和腹横肌及其腱膜形成的结构腹内斜肌及其腱膜和腹横肌及其腱膜形成的结构 29Rectus sheath,posterior layer腱腱 划划tendinous intersections Rectus abdominis弓状线弓状线Arcuate linePyramidal m.（4）腹直肌腹直肌 rectus abdominis（5）锥状肌锥状肌 pyramidal muscletendinous intersectionsRectus sheath,anterior layer30腹腹直直肌肌鞘鞘31腹直肌鞘腹直肌鞘 rectus sheath32 腹直肌鞘腹直肌鞘 Rectus sheath腹直肌鞘腹直肌鞘包绕腹直肌，由腹外侧壁三个扁肌的腱膜构成，分包绕腹直肌，由腹外侧壁三个扁肌的腱膜构成，分为前、后两层。为前、后两层。在弓状线以上：在弓状线以上：腹直肌鞘前层腹直肌鞘前层 anterior layer of the rectus sheath 由腹由腹外斜肌腱膜和腹内斜肌腱膜前层构成；外斜肌腱膜和腹内斜肌腱膜前层构成；腹直肌鞘后层腹直肌鞘后层 posterior layer of the rectus sheath 由腹由腹内斜肌腱膜的后层和腹横肌腱膜构成。内斜肌腱膜的后层和腹横肌腱膜构成。在弓状线以下：在弓状线以下：腹直肌鞘前层由三个扁肌的腱膜构成；腹直肌鞘前层由三个扁肌的腱膜构成；腹直肌鞘后层缺如。腹直肌鞘后层缺如。332.血管、淋巴及神经血管、淋巴及神经Vessels,Lymph and Nerve34(1(1)动动脉脉3536(2(2)静静脉脉37(3(3)神神经经383.腹腹横横筋筋膜膜Transversalis Fascia39腹横筋膜腹横筋膜 Transverse fascia 精索内筋膜精索内筋膜internal spermatic fascia40腹股沟深环deep inguinal ring窝间韧带 interfoveolar ligament腹横筋膜腹横筋膜 Transverse fascia41腹前壁内面的皱襞及凹窝腹前壁内面的皱襞及凹窝4.壁腹膜壁腹膜 Parietal peritoneum425.腹腹前前壁壁手手术术常常用用切切口口Thoracoabdominal incisionSuperior median incisionTransrectus incisionPararectus incisionParamedian incision43Subcostal incisionSuperior transverse incisionMcBurneysincisionInferiormedian incisionInferiortransverse incision44Above the arcuate lineBelow the arcuate line45四、腹四、腹 股股 沟沟 区区The Inguinal Region境界境界 The boundary层次与特点层次与特点 The layers and characteristics腹股沟管腹股沟管 The inguinal canal腹股沟三角腹股沟三角 The inguinal triangle 疝疝 hernias：腹股沟直疝：腹股沟直疝 Direct inguinal hernias、腹股沟斜疝、腹股沟斜疝 indirect inguinal hernias、股疝、股疝 femoralhernias46（一）境界 Boundary1.皮肤 skin2.浅筋膜 superficial fascia3.腹外斜肌 aponeurosis of external obliquus abdominis（二）腹股沟区层次结构（二）腹股沟区层次结构The Layers of the Inguinal Region474.髂腹下神经 Iliohypogastric n.和髂腹股沟神经 ilioinguinal n.5.腹内斜肌 Obliquus internus abdominis6.腹横肌 Transversus abdominis（二）腹股沟区层次结构腹股沟区层次结构The Layers of the Inguinal Region487.腹横筋膜腹横筋膜 Transverse fascia8.腹膜外筋膜腹膜外筋膜 Extraperitoneal fascia9.腹璧下动脉腹璧下动脉Inferior epigastric a.and 旋髂深动脉旋髂深动脉 deep circumflex iliac a.10.璧腹膜璧腹膜 Parietal peritoneum特点：特点：腹外斜肌在此区移行为腱膜，并在下部形成一裂口腹外斜肌在此区移行为腱膜，并在下部形成一裂口(浅环浅环)；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；肌层覆盖；有精索或子宫圆韧带通过，形成了一潜在性裂隙；有精索或子宫圆韧带通过，形成了一潜在性裂隙；在人体站立时，该区所承受的腹内压力比平卧时高在人体站立时，该区所承受的腹内压力比平卧时高3倍。倍。因此，腹因此，腹股沟区为腹壁的薄弱区，是腹壁疝的多发部位。股沟区为腹壁的薄弱区，是腹壁疝的多发部位。49（三）腹股沟管（三）腹股沟管The inguinal canal位置位置 Position 通过的结构通过的结构 Structures passing through it两口、四璧两口、四璧 Two opening and four walls精索精索 Forming of the spermatic cord腹股沟斜疝腹股沟斜疝 Indirect inguinal hernia50（三）腹股沟管（三）腹股沟管 Inguinal Canal1.1.位置位置2.2.内容内容3.3.构成构成4.4.临床意义临床意义 51 The inguinal canal is an oblique,inferomedially passage(between the superficial and deep inguinial rings)through the inferior part of the anterior abdominal wall),35cm long.The inguinal canal lies parallel and just superior to the medial half of the inguinal ligament.The main occupant of the inguinal canal is the spermatic cord in males and the round ligament of the uterus in females.It also contains blood and lymphatic vessels and the ilioinguinal nerve in both sexes.5253vThe deep(internal)inguinal ring,entrance to inguinal canal,is an outpouching of the transversalis fascia approximately 1.25cm superior to the middle of the inguinal ligament and lateral to the inferior epigastric vessels.v The anterior wall of the inguinal canal is formed by the external oblique aponeurosis throughout the length of the canal,with the anterior wall of the lateral part of the canal being reinforced by fibers of internus oblique.vThe posterior wall of the inguinal canal is formed by the transversalis fascia with the posterior wall of the medial part of the canal being reinforced the conjoint tendon.vRoof(superior wall)is formed by the arching fibers of the internal oblique and transverse abdominal muscles.vFloor(inferior wall)is formed by the inguinal ligament.vThe superficial(external)inguinal ring-exit from inguinal canal-is a slitlike opening between the diagonal fibers of the aponeurosis fo the external oblique,superolateral to the pubic tubercle.54腹股沟三角腹股沟三角 Inguinal Triangle （海氏三角海氏三角 Hesselbachs triangle）构成：构成：腹壁下动脉、腹直肌外侧缘和腹股沟韧带内侧半所围成的三角形区域。腹壁下动脉、腹直肌外侧缘和腹股沟韧带内侧半所围成的三角形区域。临床意义：临床意义：由腹股沟三角突出的疝，称腹股沟直疝。由腹股沟三角突出的疝，称腹股沟直疝。55腹腹股股沟沟三三角角腹腹股股沟沟直直疝疝、腹腹股股沟沟斜斜疝疝、股股疝疝56Indirect HerniaDirect Hernia股疝股疝 femoral hernia57睾睾丸丸下下降降过过程程58卵卵巢巢下下降降过过程程59睾丸下降过程睾丸下降过程 descending process of the testis60 先天性腹股沟斜疝先天性腹股沟斜疝A congenital indirect inguinal hernia 后天性腹股沟斜疝后天性腹股沟斜疝 A acquired indirect inguinal hernia61 先天性腹股沟斜疝先天性腹股沟斜疝A congenital indirect inguinal hernia 后天性腹股沟斜疝后天性腹股沟斜疝 A acquired indirect inguinal hernia62精索精索的被的被膜与膜与腹前腹前外侧外侧壁层壁层次的次的关系关系63精索或睾丸被膜与腹前外侧壁层次的关系精索或睾丸被膜与腹前外侧壁层次的关系64解剖与观察Dissection and Observation浅层结构 superficial structures三层阔肌、血管和神经 Three flat muscles,vessels and nerves腹直肌 rectus abdominis腹直肌 rectus sheath腹股沟区 inguinal region腹股沟管 inguinal canal腹股沟三角 inguinal triangle 651.切口切口 Incision662.将皮瓣翻向外侧将皮瓣翻向外侧 reflect skin flaps laterally.673.Identify the fatty layer of the superificial fascia.684.Identify the superficial epigastric vessels.695.Remove the superficial fascia.706.Identify the membranous layer of the superficial fascia.717.Identify several anterior cutaneous branches of the lowest five intercostal nerves(T7T11)and the subcostal nerve(T12).728.Identify the terminal branches of the iliohypogastric nerve(L1)and the ilioinguinal nerve(L1).739.Remove deep investing covering the external abdominal oblique muscle.10.Identify the direction of the fibers and the aponeurosis of the external abdominal oblique muscle.7411.Identify the inguinal ligament,the superficial inguinal ring,11.Identify the inguinal ligament,the superficial inguinal ring,the medial crus,the lateral crus and the intercrural fibers.the medial crus,the lateral crus and the intercrural fibers.7512.Reflect the external abdominal oblique and expose the internal 12.Reflect the external abdominal oblique and expose the internal abdominal oblique.Reflect the internal abdominal oblique and expose abdominal oblique.Reflect the internal abdominal oblique and expose the transversalis muscle.the transversalis muscle.13.Identify the vessels and nerves.13.Identify the vessels and nerves.7614.Cut through the anterior layer of the rectus abdominis.14.Cut through the anterior layer of the rectus abdominis.15.Identify the muscular part and tendinous part of the rectus abdominis,15.Identify the muscular part and tendinous part of the rectus abdominis,and the pyramidal muscle.and the pyramidal muscle.7716.Free the lateral edge of rectus abdominis,and make a horizontal incision 16.Free the lateral edge of rectus abdominis,and make a horizontal incision through the entire width of the rectus abdominis muscle at the level of the through the entire width of the rectus abdominis muscle at the level of the umbilicus.Reflect the segments of transected muscle superiorly and inferiorly.umbilicus.Reflect the segments of transected muscle superiorly and inferiorly.7817.Identify 17.Identify the superior and inferior epigastric vesselsthe superior and inferior epigastric vessels,the intercostal the intercostal and subcostal nerves,the posterior layer of the rectus sheath and the and subcostal nerves,the posterior layer of the rectus sheath and the arcuate line.arcuate line.7918.Dissect the inguinal region.Identify the iliohygogastric nerve,the 18.Dissect the inguinal region.Identify the iliohygogastric nerve,the ilioinguinal nerve,the transverse fascia and the inferior epigastric ilioinguinal nerve,the transverse fascia and the inferior epigastric artery.artery.8019.Identify the two openings and four walls of the inguinial canal.19.Identify the two openings and four walls of the inguinial canal.8120.Dissect the 20.Dissect the spermatic cord and identify its components.8221.Identify five folds of the peritoneum and fossae located on 21.Identify five folds of the peritoneum and fossae located on the inner surface of the anterior abdominal wall.the inner surface of the anterior abdominal wall.83The End84