精索显微结构解剖研究及三维重建

发布时间：2018-06-03 19:40

本文选题：精索 + 计算机辅助解剖　；参考：《南方医科大学》2014年硕士论文

【摘要】：背景和目的:精索是男性从腹股沟管深环至睾丸上端的一对柔软的圆索状结构,精索内走行的血管是睾丸重要的血供保障和回流通路,其内的神经对睾丸的功能维持、位置固定和保护有重要的意义。与精索相关的疾病如精索静脉曲张等是成年男性发病率较高的疾病,近年来随着显微外科技术在泌尿男科疾病中的广泛应用,精索的显微结构解剖成为了显微手术过程中重要的客观依据和基础。精索静脉曲张(Varicocele,VAC)是青壮年男性高发的泌尿生殖系统疾病之一,其在成年男性的发病率约为15%,在青少年男性的发病率约为13.7%～16.2%。精索静脉曲张与男性不育症关系密切,其在原发性男性不育症人群中发病率约为35%,在继发性男性不育人群中发病率约为80%以上。精索静脉曲张的治疗以手术治疗为主,显微镜下精索静脉结扎术(Microsurgical varicocelectomy,MV)在1985年首次被报道随后在1992年报道了一种基于初始MV的改良手术,此后由于MV较之高位结扎术及腹腔镜手术有更低的术后复发率(0%-1.5%)和手术并发症发生率(鞘膜积液发生率0%-0.44%,睾丸萎缩发生率1%)且能有效保护睾丸动脉并且能显著改善精液质量、提高受孕率,越来越多的学者将MV作为手术首选方案或者手术治疗"金标准"。目前大部分的研究均关注MV较开放式或腹腔镜手术的优势,很少有研究提及精索组织的临床解剖,特别是对手术过程有重要意义的显微结构解剖,同时由于目前研究均以临床和手术中观察为主,存在一定主观性,在一些手术程序问题上存在矛盾和争议,例如输精管位置与精索内筋膜的关系等,也使用了许多不精确的术语,这对手术的规范化普及造成很大影响。目前关于MV的手术路径报道以腹股沟管内(MHSV)及外环口下(MISV)为主。对于两种路径的优劣势,不同的学者对此有不同的报道,有研究发现外环口下水平比腹股沟管内水平有更多小静脉,有更大的概率发现复杂的精索内静脉蔓状静脉网紧紧包绕精索内动脉,这使得手术难度更大,因此认为采用腹股沟管路径能更有效地降低手术难度,减少损伤动脉的风险,节约手术时间。但是也有另外的研究结果表明两个路径的精索静脉以及动脉数量并没有显著性差异,外环口下路径并不会增加手术难度和手术时间,由于两组数据均来自国外,且可能存在种族差异,因此客观性的精索组织的显微结构解剖研究可以提供确切的中国男性人群中相应水平血管数量,血管与筋膜毗邻关系等,也为规范显微镜下精索静脉曲张结扎术提供显微解剖基础。顽固性睾丸疼痛是另一个与精索结构相关的疾病,因其间断或持续的睾丸疼痛不适严重影响患者的日常生活。顽固性睾丸痛潜在的病因包括感染、肿瘤、腹股沟疝、鞘膜积液、精液囊肿、精索静脉曲张、牵涉痛、外伤、手术史等。但大约25%的顽固性睾丸疼痛的患者不能发现明确的病因。显微镜下睾丸神经剔除术逐渐被广泛应用于治疗这一部分的顽固性睾丸痛患者。这一手术目的主要是剔除睾丸的神经来源,特别是精索内的神经。传统的解剖学方法以大体解剖及观察为主,对于显微镜下放大的细微解剖结构了解不够清晰,对相应的手术程序的指导意义不大。近年来,随着计算机硬件及软件的不断发展,计算机辅助下的三维重建技术在医学领域得到日益广泛的应用,目前在医学上应用较多的三维重建多是基于影像学手段获得二维图像,这些图像容易获得,采集时可自动定位及匹配,因此易于重建。但这些图像最多仅能达到毫米级水平,难以获得较精细的显微组织学信息。基于连续切片的计算机辅助解剖技术(computer-assisted anatomic dissection,CAAD)的三维重建是指针对某一组织器官进行定位下的连续组织切片,通过获取切片上的结构位置信息利用计算机图像处理及图像生成功能获得该组织的复杂的三维结构,以其获得更精确的解剖参数。这种方法突破了传统大体解剖方法的限制,获取的信息对显微镜下手术有重要的参考价值。本研究尝试在连续组织切片基础上对精索进行初步三维重建,以期获得更精确的显微结构解剖信息,为手术的指导或改进提供更加精确的客观依据。方法:1.从南方医科大学解剖教研室尸体库取得13例相对新鲜的成年男性尸体,所有尸体来源及用途均遵循相关法律及科研准则,准确的死因未知,我们对尸体标本进行了严格的检查,均未发现肾脏及肾血管明显的器质性病变,睾丸及精索均未发现明显手术干预迹象。精索取材范围从附睾头一直到内环口上1cm。取材后的精索切成标准小块,按序号进行固定、脱水、透明、定位、包埋、切片。制作好的石蜡切片分别进行HE染色、天狼星红-饱和苦味酸染色、银浸染色和免疫组化染色。2.分别对精索左、右侧,腹股沟管水平、外环口下水平的动、静脉,神经纤维束数量进行统计,采用SPSS 16.0统计软件进行试验数据的统计学处理,数据以均数±标准差(X±s)表示,计量资料用t检验,计数资料用卡方检验,以P0.05为差异有统计学意义。3.用体视显微镜采集二维图像,用Photoshop 7.0软件处理二维图像,将编辑好的二维图片按顺序导入mimics软件,完成三维重建。结果:我们的研究结果发现:在精索外筋膜和提睾肌内部存在两层较薄的结缔组织薄膜,两层膜在分别在外侧沿着提睾肌的轮廓紧贴提睾肌,内部两层膜紧贴在一起,分隔开输精管及其附属血管与精索内血管丛,我们认为包绕精索内血管丛的筋膜为精索内筋膜(ISF),包绕输精管及其附属血管的筋膜为输精管筋膜(VF),精索内筋膜和输精管筋膜分别环形完整包绕并分隔精索内血管丛与输精管以及其附属血管,两层筋膜共同位于精索外筋膜和提睾肌的内部且相互伴行,左侧外环口下水平静脉数量有8至15条,平均11.00±2.26条;左侧腹股沟管水平静脉数量有7至13条,平均9.60±2.22条;右侧外环口下水平静脉数量有7至13条,平均10.00±2.05条;右侧腹股沟管水平静脉数量有6至14条,平均9.90±2.76条。左侧外环口下动脉数量有3至5条,平均4.10±0.87条;右侧外环口下动脉数量有2至5条,平均4.10±0.81条;左侧腹股沟管水平动脉数量2至5条,平均3.40±0.84条;右侧腹股沟管水平动脉数量3至5条,平均4.00±0.88条。左右侧外环口下水平与腹股沟管水平动脉数量对比没有显著性差异,左右侧腹股沟管水平静脉数量对比没有显著性差异,左右侧外环口下静脉数量对比没有显著性差异。左右侧外环口下水平与腹股沟管水平静脉数量对比没有显著性差异,左右侧腹股沟管水平静脉数量对比没有显著性差异,左右侧外环口下静脉数量对比没有显著性差异。左右侧的腹股沟管路径与外环口下路径动脉数量并无统计学差异。左右侧精索神经纤维束数量没有显著差异,神经纤维束在精索中广泛分布,按我们划定的区域分布来讲,在精索外结构、输精管周围及精索内血管丛内均有数量不等的神经纤维束分布,总的来说神经纤维的分布主要集中在输精管、精索内动脉周围、提睾肌肌束间;输精管动脉周围、蔓状静脉丛周围结缔组织中可见少量分布,极少数情况可以在脂肪组织中发现神经纤维,神经纤维束的分布并不固定在一点上,而按上述规律随机的分布在区域里。这些显微结构解剖的呈现为显微男科或显微生殖手术的发展和改良提供了客观的基础。结论:1.精索结构中在提睾肌内部存在精索内筋膜和输精管筋膜,分别包绕精索内血管丛和输精管及其血管丛,输精管不被精索内筋膜包绕;2.显微镜下精索静脉曲张结扎术的腹股沟管路径及外环口下路径手术难度并无明显差异;左右侧精索的动、静脉数量无显著统计学差异,腹股沟管水平和外环口下水平总的动静脉数量无显著统计学差异;3.神经纤维的分布主要集中在输精管、精索内动脉周围、提睾肌肌束间;输精管动脉周围、蔓状静脉丛周围结缔组织中可见少量分布,极少数情况可以在脂肪组织中发现神经纤维,神经纤维束的分布并不固定在一点上,而随机的分布在区域里。
[Abstract]:Background and purpose: spermatic cord is a pair of soft circular cord structures from the deep ring of the inguinal canal to the upper testis of the male. The vessels in the spermatic cord are important blood supply and reflux pathways of the testicles. The nerves within the spermatic cord are important for the maintenance of the testicles, the location and protection of the testicles. The diseases related to spermatic cord, such as varicocele, are related to the spermatic cord. In recent years, with the widespread use of microsurgical techniques in urological diseases, the microstructural anatomy of spermatic cord has become an important objective basis and basis for microsurgery. Varicocele (VAC) is one of the high incidence of genitourinary diseases in young men. The incidence of adult male is about 15%. The incidence of 13.7% ~ 16.2%. varicocele in young men is closely related to male infertility. The incidence of the male infertility is about 35% in the primary male infertility. The incidence of the secondary male infertility is about 80%. The treatment of varicocele is mainly performed by surgical treatment. Microsurgical varicocelectomy (MV) was first reported in 1985 and a modified operation based on initial MV was reported in 1992. Since MV has a lower postoperative recurrence rate (0%-1.5%) and the incidence of surgical complications than the high ligation and laparoscopy (0%-0.44%), the incidence of hydrocele is 0%-0.44% The incidence of testicular atrophy is 1%) and it can effectively protect the testicular artery and improve the quality of the semen and increase the pregnancy rate. More and more scholars take MV as the first choice of operation or surgical treatment of "gold standard". Most of the studies are concerned about the advantages of MV than open or celioscope surgery. Few studies have mentioned the presence of spermatic cord tissue. The anatomy of the bed, especially the microstructural anatomy that has important significance to the process of operation, has a certain subjectivity, and there are contradictions and controversies in some surgical procedures, such as the relationship between the position of the vas deferens and the fascia in the spermatic cord, and the use of many inaccurate terms. There is a great impact on the standardized popularization of the operation. The current coverage of the surgical route for MV is mainly in the inguinal canal (MHSV) and under the outer ring mouth (MISV). For the advantages and disadvantages of the two paths, different scholars have different reports. It is found that the complicated spermatic vein network of the intricate spermatic vein is tightly wrapped around the internal spermatic artery, which makes the operation more difficult. Therefore, it is considered that the use of the inguinal canal can reduce the difficulty of the operation more effectively, reduce the risk of the injury of the arteries, and save the operation time. But there are also other results of the two pathways of the spermatic vein and the number of arteries. There is no significant difference in volume. The approach of the outer ring does not increase the difficulty and time of operation. As two groups of data are from abroad, and there may be racial differences, the objectivity of the microstructural anatomy of the spermatic cord tissue can provide the exact number of blood vessels in the Chinese male population, and the vessels and fascia adjacent to the vessel. It provides a microanatomical basis for the standard microscopical varicocele ligation. Intractable testicular pain is another disease associated with the spermatic cord structure, which seriously affects the daily life of the patient. The underlying causes of intractable testicular pain include infection, tumor, inguinal hernia, and vaginosis. Fluid, semen cysts, varicocele, involving pain, trauma, and the history of surgery. But about 25% of the patients with intractable testicular pain can not find a clear cause. Microscopically, testicular neurosurgery is widely used in the treatment of this part of the intractable testicular pain. The aim of this operation is to eliminate the nerve sources of the testis. In particular, the nerve in the spermatic cord. The traditional anatomical method is based on general anatomy and observation. It is not clear about the microscopic anatomy structure enlarged under the microscope, and is not of great significance to the corresponding procedure. In recent years, with the continuous development of computer hardware and software, the computer aided 3D reconstruction technology is in medicine. The field has been widely used. At present, three-dimensional reconstruction is mostly used in medicine to obtain two-dimensional images based on imaging methods. These images are easy to obtain. They can be automatically located and matched in acquisition, so it is easy to reconstruct. However, these images can only reach the level of millimeter level, and it is difficult to obtain fine microscopic histology information. The three-dimensional reconstruction of computer-assisted anatomic dissection (CAAD) based on continuous slice is the continuous tissue section of an organ in which the pointer is positioned. By obtaining the information on the structure of the slice, the complex 3D of the organization is obtained by using the computer image processing and image generation function. This method breaks through the limitations of the traditional general anatomical methods. The information obtained is of great reference value for the operation under the microscope. This study attempts to reconstruct the spermatic cord on the basis of continuous tissue section, in order to obtain more accurate microstructural anatomy information for surgery. The guidance or improvement provided more accurate objective basis. Methods: 1. from the cadaver Department of Southern Medical University, 13 cases of relatively fresh adult male bodies were obtained. All the sources and uses of the corpses followed relevant laws and scientific research guidelines, and the exact cause of death was unknown. We have carried out strict examination of the cadaver specimens and did not find the kidneys. No obvious surgical intervention was found in the visceral and renal vessels. The spermatic cord was removed from the epididymal head from the epididymal head to the 1cm. of the inner ring. The spermatic cord was fixed, dehydrated, transparent, located, embedded and sliced. The paraffin sections were stained with HE, and Sirius red. Saturated picric acid staining, silver immersion and immunohistochemical staining.2. were used to calculate the left, right, groin level, the level of the lateral groin, the number of veins and nerve fibers at the outer ring mouth, and the statistical processing of the experimental data with SPSS 16 statistical software. The data were expressed with the mean number of standard deviation (X + s), and the measurement data were tested with t test. The data were checked with chi square, and the difference was statistically significant in P0.05..3. was collected by stereoscopic images for two-dimensional images, and two dimensional images were processed with Photoshop 7 software. The edited two-dimensional images were introduced into Mimics software in order to complete 3D reconstruction. Results: Our results found that there were two layers inside the outer spermatic fascia and the testosterone muscle. In the thinner connective tissue film, the two layers of the membrane closely stick the testosterone muscle along the outline of the testosterone muscle on the lateral side. The two layers of the inner membrane close together, separate the vas deferens and its accessory vessels and the endovascular plexus. We think the fascia wrapped around the inner vessel of the spermatic cord is the ISF, which is wrapped around the fascia of the vas deferens and its accessory vessels. The vasorelal fascia (VF), the fascia of the spermatic cord and the vasorelal fascia wrapped around and separated the spermatic vascular plexus and the vas deferens and its accessory vessels. The two layers of fascia were located in the external fascia of the spermatic cord and the muscles of the testosterone. The number of horizontal veins under the left outer rim of the outer ring was 8 to 15, with an average of 11 + 2.26; the left groin was in the left groin. The number of horizontal veins in the tube was 7 to 13, with an average of 9.60 + 2.22; the number of horizontal veins under the right lateral outer rim was 7 to 13, with an average of 10 + 2.05, and the horizontal vein in the right inguinal canal was 6 to 14, average 9.90, 2.76. The average number of horizontal arteries in the left inguinal canal was 2 to 5, with an average of 3.40 + 0.84, the number of horizontal arteries in the right inguinal canal was 3 to 5, with an average of 4 + 0.88. There was no significant difference between the lateral and the lateral inguinal horizontal arteries in the right and left lateral rim, and there was no significant comparison between the horizontal and the left and right lateral inguinal veins in the left and right lateral inguinal vessels. There was no significant difference in the number of inferior vena cava in the left and right lateral rim. There was no significant difference between the level of the left and right lateral and the horizontal veins of the inguinal canal. There was no significant difference in the number of horizontal veins in the left and right inguinal tubes. There was no significant difference between the left and right lateral inguinal veins. There was no significant difference between the route of the groin tube and the number of the arteries in the outer ring. There was no significant difference in the number of the left and right nerve fibers in the spermatic cord, and the nerve fiber bundles were widely distributed in the spermatic cord. In general, the distribution of nerve fibers is mainly concentrated in the vas deferens, the peripheral arteries of the spermatic cord, the muscular bundle of the testosterone, and a small amount of distribution around the artery of the vas deferens and the connective tissue around the vine shaped vein plexus, and a few cases can be found in the adipose tissue. The distribution of the fascicle of the God's Classics is not fixed at a point, but the above is the same. These microstructural anatomy provide an objective basis for the development and improvement of microsurgical or microreproductive surgery. Conclusion: the internal spermatic fascia and fascia of the spermatic cord in the 1. spermatic cord are wrapped around the spermatic cord and the VASO plexus and the vasa plexus, and the vas deferens are not. There was no significant difference in the difficulty of the inguinal canal path and the external ring path of the varicocele under 2. microscopes. There was no significant difference in the movement of the left and right spermatic cord and the number of veins in the lateral spermatic cord. There was no significant difference in the total number of arteriovenous veins between the level of the inguinal canal and the level of the outer ring mouth; and 3. nerve fibers. The distribution is mainly concentrated in the vas deferens, the peripheral arteries of the spermatic cord, the muscular bundle of the testosterone, and a small amount of distribution around the vas deferens artery and the connective tissue around the vine like plexus, and a few cases can be found in the adipose tissue. The distribution of the nerve fiber bundle is not fixed at one point, but it is randomly distributed in the region.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R322.6;R699

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