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Regional anatomy Anterolateral Abdominal Wall The Anterolateral Abdominal Wall • Superficial structures 浅层结构 • Deep structures 深层结构 1.Skin 2.Superficial fascia 3.Deep fascia and muscles 4.Transverse fascia 皮肤 5.Extraperitoneal fascia 浅筋膜 6.Parietal fascia 深筋膜和肌肉 腹横筋膜 腹膜下筋膜 壁腹膜 The layers of the anterolateral abdominal wall Ⅰ.The superficial structures 浅层结构 • Surface Features of Skin • Superficial fascia 浅筋膜 Surface Features of the Abdomen Superficial fascia Divisions below umbilicus(脐以下) • Superficial fatty layer (Camper’s) • Membranous layer (Scarpa’s) Superficial vessels and cutaneous nerves • Arteries – Superficial epigastric a. – Superficial iliac circumflex a. • Veins – Thoracoepigastric v. – Superficial epigastric v. • Cutaneous nerves – Anterior and lateral cutaneous n. of lower six thoracic – Iliohypogastric n. (first lumb nerves) • 浅动脉、浅静脉、皮神经 The ilioinguinal and the lower abdominal flaps 髂腹股沟区和下腹部的皮瓣 Ⅱ.The Deep Structures 深层结构 • Muscular layer 肌层 • Vessels, lymph and nerve 血管、淋巴及神经 • Transversalis fascia 腹横筋膜 • Extraperitoneal fascia 腹膜下筋膜 • Parietal peritoneum 壁腹膜 Muscles of abdomen Anterolateral group • obliquus externus abdominis 腹外斜肌 • oblequus enternus abdominis 腹内斜肌 • transversus abdominis 腹横肌 • rectus abdominis 腹直肌 Posterior group • Quadiatus lumborum 腰方肌 • Psoas major 腰大肌 Obliquus externus absominis 腹外斜肌 General direction of fibers: downward, forward and medially (run down and inward) Structures • Inguinal ligament 腹股沟韧带 • Lacunar ligament 腔隙韧带 • pectineal ligament 耻骨梳韧带 • Superficial inguinal ring 腹股沟浅环 -triangular-shaped defect in aponeurosis of obliquus externus abdominis above pubic tubercle Inguinal ligament pectineal ligament Superficial inguinal ring Lacunar ligament Superficial inguinal ring Obliquus internus abdominis 腹内斜肌 • Deep to obliquus externus abdominis • General direction of fibres: upwards, forwards and medially Transversels abdominis 腹横肌 • Deep to obliquus internus • inguinal ligament腹股沟韧带、lacunar ligament腔隙韧带、 pectineal ligament耻骨梳韧带 • Inguinal falx 腹股沟镰: arch over spermatic cord, inserted with transverses abdominis fiber into medial part of pecten of pubis • Cremaster 提睾肌: around the spermatic cord and testis Inguinal falx Rectus abdominis 腹直肌 • Position: lie on to either of midline • Origin: pubic crest and symphysis • Insertion: xiphoid and 5th7th costal cartilages • Has 3-4 tendinous intersections 腱划 • linea semiluaris 半月线 arcuate line Linea alba 白线 -tendinous raphe between right and left recti from xiphoid to pubic symphysis. Linea alba Deep vessels and nerves Arteres • Superior and inferior epigastric arteris • Lower posterior intercostal a. • Subcostal a. • Four lumbar a. Nerves • Intercostal n.(6-11) • Subcostal n. Nerves • Iliohypogastric n. 髂腹下神经 • Ilioinguinal n. 髂腹股沟神经 • Genitofemoral n. 生殖股神经 Regional anatomy Sheath of rectus abdominis 腹直肌鞘 Ant layer-formed by fusion of aponeurosis of obliquus externus abdominis and anterior leaf of aponeurosis of obliquus internus abdominis Post layer • Formed by fusion of posterion leaf of aponeurosis of obliquus internus abdominis and aponeurosis of transverses abdominis • Absent in about 4-5cm below the umbilicus, where aponeuroses of all three muscles form anterior layer the lower free border named arcuate line • Below this line rectus abdominis in contact with transverse fascia arcuate line The Inguinal Region 腹股沟区 • Boundary 境界 • Layers and characteristics 层次与特点 • Inguinal canal 腹股沟管 • Inguinal triangle 腹股沟三角 • Hernias 疝 : Direct inguinal hernias 腹股沟直疝 Indirect inguinal hernias 腹股沟斜疝 Femoralhernias 股疝 Inguinal region 腹股沟区 Boundaries • Inguinal ligament • Lateral margin of rectus abdominis • A horizontal line stretching from anterior iliac spine to laeral margin of rectus abdominis Inguinal canal 腹股沟管 Position: oblique passage, 4cm long, located 1.5cm above medial half of inguinal lig. • • Boundaries Ant wall – – Aponeurosis of obliquus externus abdominis Obliquus internus abdominis (lateral third of wall) • Posterior wall – Transverse fascia – Inguinal flax medially • Roof-arched lower fibers of obliquus internus and transversua abdominis • Floor-inguinal lig. • Two openings – Superficial inguinal ring 腹股沟浅环 – Deep inguinal ring 腹股沟深环 -defect in transverse fascia 1.5cm above midpoint of inguinal ligament • Structures passing through the inguinal canal – Spermatic cord 精索 and ilioinguinal nerve髂腹股沟神经 in males – Round ligament of uterus 子宫圆韧带and ilioinguinal nerve 髂腹股沟神经 in females Descent of testes Seven-week embryo showing the testis before its descent from the dorsal abdominal wall Fetus at 28 week the testis passing through the inguinal canal Newborn Inguinal Triangle (of Hesselbach) 腹股沟三角 Boundaries • Inguinal ligament inferiorly • Lateral border of rectus abdominis medially • Inferior epigastric artery laterally Inguinal Triangle 腹股沟三角 (Hesselbach’s triangle 海氏三角 ) ①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。 ②临床意义:由腹股沟三角突出的疝,称腹股沟直疝。 腹 股 沟 腹 直 疝、 股 腹 沟 股 沟 三 斜 角 疝、 股 疝 Indirect inguinal heinia and direcet inguinal heinia 直疝 Direcet heinia 斜疝 Indirect inguinal ehinia Hernias Hernias Hernias Layer ? Subcostal incision Muscle-splitting incision Median or midline incision Left paramedian incision Transverse incision Suprapubic incision Regional anatomy The peritoneum Ling Shucai Ⅰ.General features • The peritoneum is a thin serous membrane that line the walls of the abdominal and pelvic cavities and cover the organs within these cavities • Parietal peritoneum 壁腹膜 -lines the walls of the abdominal and pelvic cavities • Visceral peritoneum 脏腹膜 -covers the organs • Peritoneal cavity 腹膜腔-the potential space between the parietal and visceral layer of peritoneum, in the mail, is a closed sac, but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina Function • Secretes a lubricating serous fluid that continuously moistens the associated organs • Absorb • Support viscera Ⅱ.The relationship between viscera and peritoneum • Intraperitoneal viscera 腹膜内位器官 • Interperitoneal viscera 腹膜间位器官 • Retroperitoneal viscera 腹膜外位器官 Intraperitoneal viscera Interperitoneal viscera Retroperitoneal viscera Interperitoneal viscera 腹膜间位器官 Ⅲ. Formative formation by peritoneum The omentum 网膜 The mesenteries and mesocolons 系膜 The ligaments 韧带 The peritoneal recesses, pouches, fossae and folds 隐窝和陷凹 Omentum 网膜 -two-layered fold of peritoneum that extends from stomach to adjacent organs Lessor omentum 小网膜 Greater omentum 大网膜 Lessor omentum 小网膜 • Hepatogastric ligament 肝胃韧带-extends from porta hepatis to lesser curvature of stomach • Hepatoduodenal ligament 肝十二指肠韧带 – Extends from porta hepatis to superior part of duodenum – Contains common bile duct, proper hepatic a. and hepatic portal v. Omental foramen 网膜孔 • Behind the right border of hepatoduodenal ligament • Superior-caudate lobe of liver • Inferior-superior part of duodenum • Anterior-hepatodudenal ligament • Posterior-peritoneum covering the inferior vena cava Greater omentum 大网膜 -four-layered fold of peritoneum, the anterior two layers descend from the greater curvature of stomach and superior part of duodenum and hangs down like an apron in front of coils of small intestine, and then turns upward and attaches to the transverse colon. If an infection occurs in the intestine, plasma cells formed in the lymph nodes combat the infection and help prevent it from spreading to the peritoneum. Lessor omentum Greater omentum Omental bursa 网膜囊 Position-situated behind the lesser omentum and stomach Walls • Superior-peritoneum which covers the caudate lobe of liver and diaphragm • Anterior-formed by lesser omentum, peritoneum of posterior wall of stomach, and anterior two layers of greater omentum • Inferior-conjunctive area of anterior and posterior two layers of greater omentum • Posterior-formed by posterior two layers of greater omentum, transverse colon and transverse mesocolon, peritoneum covering pancreas, left kidney and suprarenal gland • Left-formed by the spleen, gastrosplenic ligament胃脾韧带 and splenorenal ligament 脾肾韧带 • Right-formed by omental foramen The Omental bursa (lesser sac) communicates with the greater sac through the omental foramen. Mesenteries or mesocolons -two-layered fold of peritoneum that attach part of the intestines to the posterior abdominal wall The mesenteries and mesocolons 系膜 Mesentery 肠系膜 -suspends the small intestine from the posterior abdominal wall • Broad and a fan-shaped • Consists of two peritoneal layers • Intestinal border-folded, 7 m long • Radix of mesentery – 15 cm long – Directed obliquely from left side of L2 to in front of right sacroiliac joint Mesoappendix 阑尾系膜 • Triangular mesentery- extends from terminal part of ileum to appendix • Appendicular artery runs in free margin of the mesoappendix Transverse mesocolon 横结肠系膜 -a double fold of peritoneum which connects the transverse colon to the posterior abdominal wall Sigmoid mesocolon 乙状结肠系膜 -inverted V-shaped, with apex located in front of left ureter and division of common iliac artery Ligaments 韧带 - two-layered folds of peritoneum that attached the lesser mobile solid visera to the abdominal wall Ligaments of liver • Falciform ligament of liver 镰状韧带 • Coronary ligament 冠状韧带 • Left and right triangular ligaments 左、右三角韧带 • Hepatogastric ligament 肝胃韧带 • Hepatoduodenal ligament 肝十二指肠韧带 • Ligamentum teres hepatis 肝圆韧带 Ligaments of spleen • Gastrosplenic ligament 胃脾韧带 • Splenorenal ligament 脾肾韧带 • Phrenicosplenic ligament 膈脾韧带 • Splenocolic ligament 脾结肠韧带 Ligaments of stomach • Hepatogastric ligament 肝胃韧带 • Gastrosplenic ligament 胃脾韧带 • Gastrophrenic ligament 胃膈韧带 • Gastrocolic ligament 胃结肠韧带 • Gastropancrestic ligament 胃胰韧带 The peritoneal recesses, pouches, fossae and folds • Superior duodenal fold and recess 十二指肠上襞和上隐窝 • Inferior duodenal fold and recess 十二指肠下襞和下隐窝 • Intersigmoid recess 乙状结肠 间隐窝-formed by the inverted V attachment of sigmoid mesocolon The peritoneal recesses, pouches, fossae and folds • Superior duodenal fold and recess 十二指肠上襞和上隐窝 • Inferior duodenal fold and recess 十二指肠下襞和下隐窝 • Intersigmoid recess 乙状结肠 间隐窝-formed by the inverted V attachment of sigmoid mesocolon • Retrocecal recess 盲肠后隐窝 -in which the appendix frequenty lies • Hepatorenal recess 肝肾隐窝 -lies between the right lobe of liver, right kidney, and right colic flexure, and is the lowest parts of the peritoneal cavity when the subject is supine ★ Folds and fossas of anterior abdominal wall • Median umbilical fold 脐正中襞-contain the remnant of urachus (median umbilical ligaments) • Medial umbilical fold 脐内侧襞-contains remnants of the umbilical arteries (medial umbilical ligaments) • Lateral umbilical fold 脐外侧襞-contains the inferior epigastric vessels • Supravesical fossa 膀胱上窝 • Medial inguinal fossa 腹股沟内侧窝 • Lateral inguinal fossa 腹股沟外侧窝 Pouches • In male - rectovesical pouch 直肠膀胱陷窝 • In female – Rectouterine pouch 直肠子宫陷窝-between rectum and uterus – Vesicouterine pouch 膀胱子宫陷窝-between bladder and uterus Ⅳ.Peritoneal subdivisions The transverse colon and transverse mesocolon divides the greater sac into supracolic and infracolic compartments. Supracolic compartments 结肠上区(subphrenic space)-lies between diaphragm and transverse colon and transverse mesocolon Infracolic compartments. 结肠下区-lies below the transverse colon and transverse mesocolon Subphrenic Space 结肠上区 Suprahepatic recess 肝上间隙 Left suprahepatic recesses 左肝上间隙 left anterior suprahepatic spaces 左肝上前间隙 left posterior suprahepatic spaces 左肝上后间隙 Right suprahepatic recesses 右肝上间隙 right anterior suprahepatic spaces 右肝上前间隙 right posterior suprahepatic spaces 右肝上后间隙 bare area of live (extraperitoneal space) 肝裸区 Infrahepatic recess 肝下间隙 Right infrahepatic recesses 右肝下间隙 (hepatorenal recess) Left infrahepatic recesses 左肝下间隙 left anterior infrahepatic space 左肝下前间隙 left posterior infrahepatic space 左肝下后间隙(网膜囊) Suprahepatic recess 肝上间隙 lies between the diaphragm and live- the falciform ligament divides it into right and left suprahepatic recesses • Left suprahepatic recesses 左肝上间隙 – left anterior suprahepatic spaces – left posterior suprahepatic spaces • Right suprahepatic recesses 右肝上间隙 – right anterior suprahepatic spaces – right posterior suprahepatic spaces – bare area of live (extraperitoneal space) Infrahepatic recess 肝下间隙 lies between the live and transverse colon and transverse mesocolon-the ligamentum teres hepatic divides it into right and left infrahepatic recesses • Right infrahepatic recesses 右肝下间隙 (hepatorenal recess 肝肾隐窝) • Left infrahepatic recesses 左肝下间隙 – left anterior infrahepatic space 左肝下前间隙 – left posterior infrahepatic space 左肝下后间隙(网膜囊) Infracolic compartments 结肠下区 -lies below the transverse colon and transverse mesocolon • Right paracolic sulcus 右结肠旁沟 -lies lateral to the ascending colon. It communicates with the hepatorenal recess and the pelvic cavity. It provides a route for the spread of infection between the pelvic and the upper abdominal region. • Left paracolic sulcus 左结肠旁沟 -lies lateral to the descending colon. It is separated from the area around the spleen by the phrenicocolic ligament, a fold of peritoneum that passes from the colic flexure to the diaphragm. • Right mesenteric sinus 右肠系膜窦 -triangular space, lies between root of mesentery, ascending colon, right 2/3 of transverse colon and transverse mesocolon • Left mesenteric sinus 左肠系膜窦 -lies between root of mesentery, descending colon, right 1/3 of transverse colon and transverse mesocolon, its widens below where it is continuous with the cavity of the pelvis 上下流通,左沟不畅,右窦封闭,左窦入盆。 思考题 • • • • • 分别叙述腹前壁各种纵、斜切口经过哪几层? 试述腹股沟斜疝、直疝及股疝的解剖学基础。 打开腹膜腔可以看到哪些器官,如何进行腹膜腔探查? 什么是膈下间隙?试述其分区。 为什么阑尾炎穿孔可引起膈下脓肿?从形态学的特点来看,应 采取什么措施予以防止?