耻骨肌孔的空间分离解剖在腹腔镜全腹膜外疝修补术中的应用及意义

目的　探讨应用腹腔镜技术对耻骨肌孔的空间分离解剖在腹腔镜全腹膜外疝修补术（totally extraperitoneal TEP）中的意义。  方法　我院自2005年至2013年开展TEP手术272例,术中将腹膜外耻骨肌孔区域分为初始空间、耻骨空间、髂窝空间和髂血管空间4个空间,依次解剖分离4个空间,在空间内安全操作。  结果　术中寻求相应解剖标志分别界定4个空间,最终融合为一个大范围空间。所有病例均应用耻骨肌孔的空间分离解剖技术指导完成手术,手术时间48 min（28~60 min）,术后住院时间5 d（3~8 d）。术后随访2~60个月,其中2例出现阴囊血肿经抽吸后治愈,无疝复发病例,无切口及补片感染,无慢性疼痛、睾丸萎缩、射精痛等并发症发生,无疝复发。  结论　耻骨肌孔的空间分离解剖技术可以缩短TEP手术的学习曲线,加深对其复杂的耻骨肌孔及其后方解剖结构的学习和理解,提高手术效率和手术质量,减少手术并发症。     

股薄肌的局部解剖学研究与临床

本文对25具50侧下肢的股薄肌进行了解剖观察。虽然股薄肌的动脉来源有多处,但主要血管是来自股深动脉的股薄肌支,该血管与股薄肌的支配神经构成血管神经束,血管神经束位于耻骨结节下90～160mm范围内,52％的位于130～140mm之间。所以,临床移植股薄肌对其游离在耻骨结节下方160mm以下进行,即不会损伤股薄肌的血管神经束。     

腹横筋膜与腹膜前疝修补术103例分析

目的重新认识腹横筋膜的解剖特点,从解剖学角度探讨腹膜前疝修补术的合理性。方法对术中腹横筋膜以及腹膜前间隙的解剖观察,回顾性分析腹膜前修补腹股沟疝103例的临床资料。结果耻骨肌孔由腹横筋膜的前层覆盖,腹横筋膜由两层构成,腹壁下血管位于两层之间。3种方法放置的补片在不同的腹膜前间隙覆盖耻骨肌孔。103例均成功,无切口感染、髂腹股沟神经痛病例。术后随访1～6年无复发。结论从解剖学特点看,覆盖耻骨肌孔的腹膜前疝修补具有合理性。前后入路腹膜前疝修补补片放置的间隙不同。     

腹腔镜腹股沟疝修补术肌耻骨孔的活体解剖学观察及临床意义

目的　探讨腹膜前间隙的解剖学特点,为腹腔镜腹股沟疝修补术的提供手术解剖依据。 方法　对我院30例腹股沟疝患者行LIHR时进行术中解剖观察及术后回顾分析手术视频,通过解剖学绘图描述LIHR手术入路、解剖层次及技术要点。 结果　腹膜前间隙由Retzius间隙和Bogros间隙组成,其间有间隔分开。腹横筋膜由深浅两层结构组成,腹膜与腹横筋膜的深层之间为无血管区域。 腹横筋膜在腹股沟韧带深面增厚形成髂耻束,参与构成股管的内侧壁及腹股沟管的下壁,生殖股神经股支及股外侧皮神经在髂耻束下方通过。 结论　熟悉腹膜前间隙肌耻骨孔区域解剖标志点,是LIHR手术的前提,具有重要临床意义。     

腹膜外间隙空间的建立与细分对耻骨肌孔后腹股沟疝修补术的意义

目的探讨将空间细分的方法运用于耻骨肌孔后方腹膜外间隙手术空间建立的意义。方法自2001年以来开展536例腹腔镜全腹膜外疝修补术(totally extraperitoneal,TEP),利用TEP电视腹腔镜的视觉效果以及CO2气压制造空间的作用在腹膜外间隙建立手术空间并将手术空间分成4部分,分别为第1、2、3、4空间。在"四空间"技术成熟之后将其应用于415例其它耻骨肌孔后方腹股沟疝修补手术中,如TAPP、IPOM、Kugel、开放TEP以及改良TAPP等手术。结果 "四空间"技术可使TEP手术操作连贯、易于掌握,手术时间缩短,手术并发症和疝复发减少。另外的收获是:"四空间"技术完全可以应用于其它耻骨肌孔后方腹股沟疝修补手术,使这些手术更加易于理解和进行。结论腹膜外间隙空间的建立与细分的方法可以:①缩短TEP手术的学习曲线;②加深对复杂的耻骨肌孔及其后方解剖结构的学习和理解;③促进TAPP、IPOM、Kugel、开放TEP以及改良TAPP等手术的开展;④有助于对疝复发部位和原因的研究;⑤帮助疝补片的材料和形态的改进与研究。     

前斜角肌变异一例报导

在解剖一成人男尸颈外侧区时发现：双侧前斜角肌出现对称性变异。具体是：该肌均起自第３—６颈椎横突前结节,向下合为一肌束,至锁骨下动脉穿经处分两束分别紧贴其前方和后方,然后共同止于第一肋前斜角肌结节。锁骨下静脉行经该肌前束浅面,臂丛行经后束与中斜角肌之间。测量结果是：前束肌宽０．９０ｃｍ,厚０．２５ｃｍ;后束肌宽０．７５ｃｍ,厚０．１３ｃｍ。在锁骨下动脉穿经此二肌束处无缩小现象。这种变异的出现易导致前斜角肌综合征的发生。临床上应引起注意。前斜角肌变异一例报导@冉茂成$川北医学院人解教研室!南充637007…     

大鼠结肠肌间神经丛Cajal间质细胞的形态

目的；观察大鼠结肠肌间丛Ｃａｊａｌ间质细胞的形态，为进一步研究其在胃肠动力调控中的作用提供形态学资料。方法：用碘化锌－锇酸组织化学法对成年大鼠结肠肌间丛铺片染色，观察Ｃａｊａｌ间质细胞形态。结果：分布于肌间丛的Ｃａｊａｌ间质细胞有两种不同的形态，一类胞体呈三角形或星形，胞核大而明显，胞体在神经纤维形成的网眼中，有２￣３个细长突起，突起与神经纤维关系密切；另一类胞体为卵圆形，有２￣３个长突起，二级分     

拇收肌后间隙内独立肌束的形态学研究

解剖观察成人手标本94侧（左52，右42），在拇收肌后间隙内独立肌束的存在率为72．34％，肌束远端肌腿终止于拇收肌腱近侧及拇指指背腱膜，依肌束近端附着位置和状态分为第一掌骨型（57．35％，第二掌骨型（7．35％），掌筋膜型（5．88％）及混合型（29．42％），肌束由尺神经支配，可视为拇内收肌的重要协同肌。     

腹直肌肌皮瓣在腹部中线切口疝修补术的解剖学基础及疗效分析

目的　探讨腹壁组织瓣在中、大型中线切口疝修补术的解剖学基础及效果。　方法　（1）中线中、大型切口疝48例,年龄介于23～65岁,中型切口疝28例,其中男性18例,女性10例,大型切口疝20例,其中男性13例,女性7例,采用腹直肌肌皮瓣修补;（2）与同期52例中、大型中线切口疝开放法肌后补片无张力修补术对照,年龄介于20～67岁,中型切口疝29例,其中男性17例,女性12例,大型切口疝23例,其中男性13例,女性10例。　结果　腹直肌肌皮瓣在腹部中线切口疝修补术与补片修补术相比：（1）在复发率上,其中在中型切口疝中,复发率分别为：7.1％和3.4％,P>0.05,在大型切口疝中分别为：15.0％和4.3％,P>0.05。（2）腹壁异物感及术后慢性疼痛,在中型切口疝观察组发生率分别为：0％和10.7％,对照组分别为：41.3％和95.7％,P分别<0.05;在大型切口疝中,对照组分别为：0％和30％,在对照组分别为：34.5％和47.8％,P分别<0.05。　结论　腹直肌肌皮瓣在中、大型中线切口疝修补效果与无张力修补术相当,但术后不适及并发症较补片法相比优势明显。     

掌长肌内神经血管的解剖学观察及其临床意义

目的：观察掌长肌肌内神经血管解剖分布,探讨该肌肉能否被分割为若干个功能单位,以提供新的功能性骨骼肌游离移植供区.方法：解剖10具10%福尔马林固定的成人尸体共20侧掌长肌,观察其肌外神经血管的分布形式.10具新鲜成人尸体标本共20侧掌长肌,一侧的掌长肌完整剥离后用Sihler＇s染色法行肌内神经的染色,另一侧掌长肌用30%硫酸钡、乳胶混悬液血管灌注并行X线钼靶摄片.而后对照观察神经、血管在肌内分布及其关系.结果：掌长肌血供多为尺侧返动脉和尺动脉肌支,4侧出现肱动脉肌支.其神经支配来自正中神经发出的神经支.该支在进入肌肉前多为1支,有动脉伴行,构成神经血管束.尺侧返动脉肌支和正中神经分支在肌内的分布区域大致吻合.结论：根据掌长肌肌内神经血管在肌内分布的不同情况,可将其分为一个近端和两个远端的3个功能单位,供节段性游离肌肉移植.     

Architectural and morphological assessment of rat abdominal wall muscles: comparison for use as a human model

The abdominal wall is a composite of muscles that are important for the mechanical stability of the spine and pelvis. Tremendous clinical attention is given to these muscles, yet little is known about how they function in isolation or how they interact with one another. Given the morphological, vascular, and innervation complexities associated with these muscles and their proximity to the internal organs, an appropriate animal model is important for understanding their physiological and mechanical significance during function. To determine the extent to which the rat abdominal wall resembles that of human, 10 adult male Sprague‐Dawley rats were killed and formalin‐fixed for architectural and morphological analyses of the four abdominal wall muscles (rectus abdominis, external oblique, internal oblique, and transversus abdominis). Physiological cross‐sectional areas and optimal fascicle lengths demonstrated a pattern that was similar to human abdominal wall muscles. In addition, sarcomere lengths measured in the neutral spine posture were similar to human in their relation to optimal sarcomere length. These data indicate that the force‐generating and length change capabilities of these muscles, relative to one another, are similar in rat and human. Finally, the fiber lines of action of each abdominal muscle were similar to human over most of the abdominal wall. The main exception was in the lower abdominal region (inferior to the pelvic crest), where the external oblique becomes aponeurotic in human but continues as muscle fibers into its pelvic insertion in the rat. We conclude that, based on the morphology and architecture of the abdominal wall muscles, the adult male Sprague‐Dawley rat is a good candidate for a model representation of human, particularly in the middle and upper abdominal wall regions.     

General features of electrical and mechanical properties of smooth muscle cells in the guinea-pig abdominal aorta

The membrane potential in smooth muscle cells of the guinea-pig's abdominal aorta has a mean value of –57.2 mV. These cells are electrically connected and the space and time constant are 0.66 mm and 180 ms respectively. An increased K-concentration elicited a contraction at 20 mM and the maximum was reached at 77mM. The maximum depolarization produced by a tenfold increase of [K]₀ was 45 mV. Tetraethylammonium at concentrations exceeding 2 mM, depolarized the membrane, increased the membrane resistance and reduced the rectifying properties of the membrane. Only at 20 mM a small active response could be induced by outward current pulses. Low concentrations of noradrenaline (<10^–8 M) hyperpolarized the membrane, while higher concentrations (10^–7 M) depolarized. Isoprenaline at concentrations below 10^–7 M also hyperpolarized, but it depolarized from 10^–5 M onward. Acetylcholine at concentrations over 10^–8 M hyperpolarized the cells without exerting an effect on the resting tension, but it reduced a noradrenaline induced contraction. Low concentrations of caffeine (2 mM) hyperpolarize the membrane, while higher concentration (5 mM) depolarize. Caffeine is found to be a more efficient releaser of cellular Ca than noradrenaline. This might be due to the weak -agonist action of noradrenaline appearing at high noradrenaline concentrations. The hypothesis is supported by the finding that a -stimulation increases the Ca-uptake in the intracellular store. The study of the electrophysiological effects of different stimuli do not suggest an important role for electromechanical coupling in this tissue.     

Fibre types in human abdominal muscles

Histochemical muscle fibre composition was studied in biopsies from the four different muscles of the abdominal wall (rectus abdominis, RA, obliquus externus, OE, obliquus internus, OI, and transversus abdominis, Tr) in 13 normal human subjects (9 females and 4 males, age 24–55 years) undergoing gall-bladder surgery. Muscle fibres were classified as Type I, II A, II B or II C on the basis of their myofibrillar ATPases' pH lability. There were large inter-individual variations in fibre composition, whereas, in general, the differences between the different muscles were minor or non-existent. Mean fibre distribution ranges were 55–58% I, 15–23% II A, 21–28% II B, and 0–1% II C fibres. The least fibre diameters were similar for all types and muscles (range of means 50–54 μm) except for Tr in which the Type II fibres were smaller (mean 45 μm). There was a high correlation in the size of Type I vs. II fibres and Type II A vs. II B fibres in all layers. The oxidative potential (NADH-diaphorase staining intensity) appeared high in Type I fibres and low in Type II fibres, irrespective of subgroups. Thus, based on histochemical fibre composition, the different abdominal muscles appear to have a similar functional capacity. However, functional differences between individuals were indicated by the large inter-individual variation in muscle fibre distribution.     

从生物力学角度探讨腹直肌分离

腹直肌分离(diastasis recti abdominis,DRA)是产后并发症之一,常采用腹肌训练的方法促进其康复,但至今没有普遍可接受的训练模式及其相应理论支撑。 本文从腹壁生物力学角度对 DRA 机制和康复效果进行综述,同时也分析了其争议的原因。 主要原因包括腹直肌间距(inter-rectus distance,IRD)和腹肌厚度测量方法和测量部位 的不统一,以及未能用生物力学方法探讨 DRA 发生机制等。 因此,今后应规范 DRA 训练方法,研究 DRA 状态下的腹肌及其腱膜力学特征,为腹肌训练模式提供依据。     

基于OpenSim的腰部肌骨系统在体前屈状态下生物力学分析

目的基于OpenSim软件建立完善的腰部肌骨系统模型,深入了解体前屈状态下腰部肌群的受力情况。方法在软件现有腰部肌骨模型基础上,通过修改椎间约束,将腰椎还原为六自由度模型。同时,根据Thelen模型对肌肉参数进行修改,建立30岁成年人和70岁老年人肌肉模型,并添加椎间刚度矩阵和等效集中力表征的腹压模型。针对体前屈状态,探究手臂摆动、运动快慢、腹压改变、肌肉老化等因素对腰部九大肌群受力的影响。结果建立了包含九大腰部肌群的多刚体肌骨系统模型。基于前屈0°～70°的计算发现,手臂的摆动会明显减少腰大肌和腹外斜肌的受力,在完成前屈70°并恢复直立时,运动时间从5 s减小至2.5 s会明显增加腰大肌、腹外斜肌、腹直肌和竖脊肌的受力;其中,在5 s运动情况下,增加腹压能减少腰大肌的受力,而相应的腹外斜肌、腹内斜肌和腹横肌受力则有所增加。在2.5 s运动情况下对比不同状态下30、70岁两种肌肉模型的计算结果,没有发现明显区别。结论所建模型有效地分析了腰部肌群的受力情况,随着基本理论的更加完善,其在运动力学和康复医疗的应用前景十分广阔。     

Morphological study of external oblique motor nerves and nuclei in cats

In order to clarify the morphological features of peripheral motor nerves and motoneurons that innervate trunk muscles, the size distribution of external oblique (EO) peripheral motor fibers and motoneurons of the thoracic and the lumbar segments were examined. Histograms of the size distribution of EO motor fibers in peripheral nerves after ganglionectomy clearly had a bimodal distribution of small fiber groups and large fiber groups. It is very likely that small fiber groups correspond to gamma motor fibers and large fiber groups to alpha motor fibers. Gamma and alpha motor fiber groups were separated at 8-14 microm. The average diameter of the gamma and alpha motor fibers were different in each segment. The ratio of gamma and alpha motor fibers was approximately 1:2.0 in the thoracic segments and from 1:1.8 to 1:0.9 in the lumbar segments. Horseradish peroxidase was applied to the central stump of EO nerves, and the size distribution of EO motoneuron cell bodies in the thoracic and the lumbar spinal cords was examined. The size distribution of motoneuron cell bodies was bimodal in one cat (small and large motoneurons) and unimodal in three cats. When the ratio of small motor fibers to large motor fibers in peripheral nerves was applied to that of small motoneurons to large motoneurons, the separation of small and large motoneurons was approximately 40 microm. These results suggest that the morphological characteristics in peripheral nerves of trunk muscles are not reflected in motoneurons.     

The muscles of the abdominal wall: a new functional approach with anatomoclinical deductions

Summary the basic functional anatomy of muscle can be investigated by histochemical analysis of the muscle fibers and kinesiologic electromyography. The results of these techniques lead to anatomoclinical deductions based on the structure of muscle.Histochemical analysis of the striated fibers of a given muscle shows the existence of three functionally different populations of fibers. The relative abundance of each category of muscle fibers (expressed as a percentage) demonstrates the basic function of the muscle.The investigation of muscle function by kinesiologic electromyography shows that there are three categories of motor activity in the course of movement. These different types of motor activity are dependent upon the muscle fibers which display different physiological features, especially with respect to their contraction time.These two investigative techniques, the overall results of which are concordant, were applied to the study of the function of the muscles of the abdominal wall and led to the following anatomoclinical deduction: tonico-postural motor activity is predominant in the rectus abdominis and flat abdominal muscles. Kinesiologic electromyography also allowed to demonstrate the functional development of these muscles according to the age, sex, corpulence and physical activity of the subjects studied.

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Les muscles de la paroi de l'abdomen. Nouvelle approche fonctionelle et déductions anatomo-cliniques

Résumé L'anatomie fonctionnelle fondamentale des muscles peut être explorée par l'analyse histochimique des fibres musculaires et l'électromyographie cinésiologique, aboutissant à des déductions anatomo-cliniques basées sur la structure musculaire.L'analyse histochimique des fibres striées d'un muscle donné révèle qu'il contient trois populations de fibres fonctionnellement différentes. L'importance réciproque de chacune des catégories de fibres, exprimée en pourcentage met en évidence les fonctions fondamentales du muscle.L'exploration de la fonction des muscles par l'électromyographie cinésiologique montre qu'il existe au cours du mouvement, trois catégories d'activités motrices, soutenues par des fibres, dont les caractères physiologiques sont différents et spécialement leur temps de contraction.Les deux méthodes dont les résultats généraux sont concordants ont été appliquées à l'étude de la fonction des muscles de la paroi abdominale et ont permis les déductions anatomo-cliniques suivantes: l'activité motrice tonico-posturale est prédominante au niveau du muscle rectus abdominis et des muscles larges. L'électromyographie cinésiologique permet en outre de révéler l'évolution fonctionnelle de ces muscles on fonction de l'âge, du sexe, de la corpulence et de l'activité physique des sujets étudiés.

     

Anatomical significance of the nerve to the pyramidalis muscle: A morphological study

Characteristics of the nerve to the pyramidalis muscle (NPy), including its origin, course and distribution, were observed (macroscopically) in detail in the present study. The spinal segments that give rise to the nerve vary considerably and involve Th12-L2. The course and distribution of the nerve also vary widely. The NPy is given off from one of the following: (i) the anterior cutaneus branch (Rca) of the intercostals nerve; (ii) the ilioinguinal (li) nerve; or (iii) the genital branch (Rg) of the genitofemoral nerve. The NPy can be classified into nine types according to features of the course and branching pattern of the Rca and li. In three of 67 cases, the pyramidalis muscle had two nerves. Double-innervated pyramidalis muscles received one nerve from a transitional-type Rca (Rcat) and a second nerve derived from one of the superficial Rca (Rcas), li or Rg. The NPy derived from the deep Rca (Rcap; Type 1), Rcat (Type 2) and containing their features as well as the Type 9 (Rcat + li + Rg) reach the muscle from behind. Types 3-8 (not containing features of the Rcap and Rcat) enter the muscle from its surface. The branch that gives off the NPy is determined by the level of segmental origin, with the segmental origin of branches from the Rca (Types 1-4), li (Types 5-6) and Rg (Types 7-9) getting lower in that order. The level of segmental origin of the NPy derived from different Rca becomes lower in the following order: Rcap (Type 1), Rcat (Type 2), Rcas (Type 3), Rcas' (Rcas entering the inguinal canal; Type 4). When the origin of the NPy is from a lower segment, the origin of the boundary nerve (Rcap/Rcas) is also deviated downward. The changes in the NPy are related to the deviation of the entire lumbar plexus.