女性盆底功能障碍性疾病及微创重建手术的临床解剖学研究
发布时间：2018-08-25 19:43
【摘要】：女性盆底功能障碍性疾病主要包括压力性尿失禁和盆腔器官膨出，其发生机制及手术治疗的理论依据有Delancey的“阴道三个水平支持”理论、“吊床假说”以及最重要的Petros的“整体理论”，其核心即支持盆底之结缔组织损伤所致的解剖结构改变导致这类疾病的发生，手术应通过修复受损的韧带完成解剖重建，恢复盆底功能。 目前，女性盆底解剖结构虽然已经很清晰，但肌肉、筋膜、韧带、器官之间如何协同作用并发挥功能仍不明确。因此对盆底解剖的研究已经不能局限于传统解剖学，功能性解剖和手术解剖研究受到了更多关注。 我们的研究在一具防腐的女性尸体上进行了盆底支持系统及括约肌系统的解剖。明确了肛提肌和盆腔结缔组织的微细结构，证实二者之间存在广泛的纤维连结，肛提肌通过与结缔组织的连接发挥其支持作用。明确了盆底支持系统和脏器括约肌系统之间存在纤维交叉，提示二者通过协同作用完成盆底排尿、排便、分娩、性交等功能。在国人尸体标本中明确了既往解剖研究很少涉及的结缔组织支持结构，包括盆腔筋膜腱弓、肛提肌腱弓、耻骨宫颈筋膜、直肠阴道筋膜、耻骨尿道韧带和尿道外韧带等，为盆底障碍性疾病相关理论的理解、应用和完善奠定了基础。 目前临床上治疗盆底障碍性疾病的微创吊带手术包括治疗SUI的经耻骨后途径阴道无张力吊带(tension-flee vaginal tape，TVT)手术、经闭孔途径TVT手术(TVT-obturator，TVT-O)和治疗阴道穹窿膨出的经阴道后路悬吊带(posterior intravaginal sling，P-IVS)手术。由于这些手术方法均为盲针穿刺技术，穿刺针通过体内的一段不能在直视下完成，所以有术中损伤重要血管、神经及脏器而发生严重并发症的可能。 本实验在5具新鲜尸体上进行TVT、TVT-O和P-IVS手术穿刺，然后采用10％福尔马林溶液防腐，并结合橡胶乳浆加球磨颜料血管灌注的方法，进行手术通路解剖及安全性测量工作。本实验结果显示，TVT穿刺针至膀胱壁的平均最近距离是0.6cm，距髂外血管4.2cm，，距闭孔血管4.3cm。TVT穿刺针在耻骨后隙有失控导致穿刺过深、轴向旋转或穿刺方向侧偏而损伤膀胱、髂外静脉、闭孔血管神经和腹壁下血管的风险。证实了TVT-O由内向外穿刺的术式手术通
[Abstract]:Female pelvic floor dysfunction mainly includes stress urinary incontinence and pelvic organ exudation. The mechanism and surgical treatment of pelvic floor dysfunction are based on Delancey's "three levels of vaginal support" theory. The "hammock hypothesis" and, most importantly, Petros's "holistic theory," the core of which supports the anatomical changes that result from connective tissue injury in the pelvic floor, should be performed by repairing the damaged ligaments. Restoration of pelvic floor function. At present, although the anatomical structure of female pelvic floor is very clear, it is still unclear how to coordinate and function among muscles, fascia, ligaments and organs. Therefore, the study of pelvic floor anatomy can not be confined to traditional anatomy, functional anatomy and surgical anatomy have received more attention. Our study dissected the pelvic floor support system and sphincter system on an embalmed female cadaver. The microstructures of the levator ani muscle and the pelvic connective tissue were clarified, and the extensive fiber connection between them was confirmed. The levator ani muscle played its supporting role through the connection with the connective tissue. The fiber crossing between the pelvic floor support system and the visceral sphincter system was identified, indicating that the two systems could perform the functions of pelvic floor urination, defecation, delivery and sexual intercourse by synergistic action. Connective tissue supporting structures, including the pelvic fascia tendon arch, the levator ani tendon arch, the pubic cervical fascia, the rectovaginal fascia, the pubic urethral ligament and the external urethral ligament, were identified in Chinese cadavers. It lays a foundation for the understanding, application and perfection of the theory of pelvic floor disorders. At present, minimally invasive sling surgery for pelvic floor disorders includes the treatment of SUI via the postpubic approach to vaginal tension free sling (tension-flee vaginal tape,TVT) surgery. TVT's operation (TVT-obturator,TVT-O) and transvaginal posterior suspension band (posterior intravaginal sling,P-IVS) for vaginal fornix bulge. Because these surgical methods are all blind needle puncture technique, the puncture needle can not be completed under the direct vision through a section of the body, so there is the possibility of serious complications caused by the injury of important blood vessels, nerves and organs during the operation. In this experiment, TVT,TVT-O and P-IVS were performed on 5 fresh cadavers. Then 10% formalin solution was used for anticorrosion, combined with the method of rubber emulsion and ball milling pigment blood vessel perfusion, the operation path anatomy and safety measurement were carried out. The results showed that the average distance from the needle to the bladder wall was 0.6 cm, and 4.2 cm from the external iliac artery. The 4.3cm.TVT puncture needle from the obturator vessel caused the puncture to be out of control in the posterior space of the pubis, and the axial rotation or the side of the puncture direction damaged the bladder and the external iliac vein. The risk of obturator vessels, nerves, and subabdominal vessels. It is proved that the operative procedure of TVT-O from internal to external puncture.
【学位授予单位】：中国协和医科大学
【学位级别】：博士
【学位授予年份】：2006
【分类号】：R713;R322
本文编号：2203906
[Abstract]:Female pelvic floor dysfunction mainly includes stress urinary incontinence and pelvic organ exudation. The mechanism and surgical treatment of pelvic floor dysfunction are based on Delancey's "three levels of vaginal support" theory. The "hammock hypothesis" and, most importantly, Petros's "holistic theory," the core of which supports the anatomical changes that result from connective tissue injury in the pelvic floor, should be performed by repairing the damaged ligaments. Restoration of pelvic floor function. At present, although the anatomical structure of female pelvic floor is very clear, it is still unclear how to coordinate and function among muscles, fascia, ligaments and organs. Therefore, the study of pelvic floor anatomy can not be confined to traditional anatomy, functional anatomy and surgical anatomy have received more attention. Our study dissected the pelvic floor support system and sphincter system on an embalmed female cadaver. The microstructures of the levator ani muscle and the pelvic connective tissue were clarified, and the extensive fiber connection between them was confirmed. The levator ani muscle played its supporting role through the connection with the connective tissue. The fiber crossing between the pelvic floor support system and the visceral sphincter system was identified, indicating that the two systems could perform the functions of pelvic floor urination, defecation, delivery and sexual intercourse by synergistic action. Connective tissue supporting structures, including the pelvic fascia tendon arch, the levator ani tendon arch, the pubic cervical fascia, the rectovaginal fascia, the pubic urethral ligament and the external urethral ligament, were identified in Chinese cadavers. It lays a foundation for the understanding, application and perfection of the theory of pelvic floor disorders. At present, minimally invasive sling surgery for pelvic floor disorders includes the treatment of SUI via the postpubic approach to vaginal tension free sling (tension-flee vaginal tape,TVT) surgery. TVT's operation (TVT-obturator,TVT-O) and transvaginal posterior suspension band (posterior intravaginal sling,P-IVS) for vaginal fornix bulge. Because these surgical methods are all blind needle puncture technique, the puncture needle can not be completed under the direct vision through a section of the body, so there is the possibility of serious complications caused by the injury of important blood vessels, nerves and organs during the operation. In this experiment, TVT,TVT-O and P-IVS were performed on 5 fresh cadavers. Then 10% formalin solution was used for anticorrosion, combined with the method of rubber emulsion and ball milling pigment blood vessel perfusion, the operation path anatomy and safety measurement were carried out. The results showed that the average distance from the needle to the bladder wall was 0.6 cm, and 4.2 cm from the external iliac artery. The 4.3cm.TVT puncture needle from the obturator vessel caused the puncture to be out of control in the posterior space of the pubis, and the axial rotation or the side of the puncture direction damaged the bladder and the external iliac vein. The risk of obturator vessels, nerves, and subabdominal vessels. It is proved that the operative procedure of TVT-O from internal to external puncture.
【学位授予单位】：中国协和医科大学
【学位级别】：博士
【学位授予年份】：2006
【分类号】：R713;R322
【引证文献】
相关博士学位论文 前1条
1 商晓;女性盆底在体生物力学研究[D];北京协和医学院;2011年
本文编号：2203906
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