下肢血管的三维重建及相关组织瓣设计改进的解剖学研究

发布时间：2018-06-28 21:36

本文选题：血管造影 + 三维重建　；参考：《南方医科大学》2009年博士论文

【摘要】： 研究背景和目的: 随着工业和现代化发展,各种交通事故和外伤导致的人体皮肤及其他组织缺损日趋增多;由于环境污染加剧,肿瘤患者增多,肿瘤切除后需要组织填充以恢复外形和覆盖创面;由于生活水平的提升,患者对于创伤修复的美学要求也越来越高。针对不同部位,不同程度的创伤,使用何种组织瓣进行修复,是临床医生和外科学工作者长期探索的问题。 1984年徐达传等首先报道了游离股前外侧皮瓣,罗力生等首先将该皮瓣应用于临床。股前外侧皮瓣具有解剖标志清楚、血管蒂长、口径粗、面积大、解剖变异少以及切取容易和供区较隐蔽的等优点,是股部较为理想的皮瓣供区。该皮瓣在首次报道后的短期内得以广泛应用,而且对其进一步的基础研究与临床应用术式探讨亦在不断深入,与之相应的解剖与临床应用的报道层出不穷,与其应用相关的手术方法或改进术式亦时有出现。 2005年,刘会仁报道了以旋股外侧动脉降支为蒂的分叶肌皮瓣的临床应用,认为以旋股外侧动脉降支为血管蒂,其皮支所带股前外侧皮肤及皮下组织形成皮瓣,而其肌支携带部分股外侧肌形成肌瓣,根据创面的大小和形态,利用不同的肌支间距调整肌瓣的位置与大小,以切取与创面相适应的分叶肌皮瓣,临床应用8例,获得满意效果。该术式设计新颖,操作简易,有很好的临床应用价值,值得推广,但其解剖学基础尚少见报道。小腿下1/3及足踝部软组织缺损伴有骨、钢板或肌腱外露是临床常见的问题,虽然处理方法较多,但每种方法均存在各自的不足,特别是有些方法由于操作较复杂或失败率较高,难以在基层医院推广应用。 2003年邓国三等报道了以腓骨短肌肌瓣修复小腿下1/3及足踝部软组织缺损,取得满意疗效。他认为因为腓骨短肌由腓动脉供血,一般软组织挫伤不容易损伤到腓骨短肌的营养血管,因此可在很多其他组织瓣不能使用的情况下仍能应用;同时手术操作简便,时间短,成功率高,对于供区几乎没有功能及外形上的影响。然而,腓骨短肌肌瓣修复小腿中下部创伤的不足之处也是显而易见的,因其不带皮肤与筋膜,只起到填补缺损的作用,而不能一次性完成创面的皮肤覆盖,需要在肌瓣的表面进行中厚皮片的游离移植。 1989年Hidalgo首次将游离腓骨瓣用于下颌骨缺损的修复,获得较好的效果,此后,用游离腓骨骨(皮)瓣重建与修复下颌骨缺损逐渐成为经典术式。该术式提示腓骨骨瓣,腓骨肌瓣与肌皮瓣可以联合使用,可以根据受区的特点与需要而进行灵活的设计与切取,形成复合组织瓣或嵌合组织瓣。经过多年的临床应用与解剖学基础研究,腓骨瓣的血供基础与临床应用均已清楚与明晰。而对于腓骨长肌、腓骨短肌各自的血供特点,及与之相关的皮动脉的分布与吻合情况却少有相关资料,尤其是逆行腓骨长肌肌皮瓣与腓骨短肌肌皮瓣的血供来源,其是否适应于小腿中下部及足背部缺损的修复,及手术中应该注意的问题等等,仍有进一步研究的必要。随着对人体形态学研究的深入和计算机技术在医学领域的运用与发展,人体解剖结构的三维可视化已经成为可能。在可视化模型上进行人体解剖结构的多方位展示,已在医学教学和临床实践中发挥了重要的作用。在人体可视化研究的基础上建立可供手术和术前制定方案的虚拟环境,在外科手术教学和仿真训练等方面,具有不可替代和令人鼓舞的应用前景。近年来,与三维虚拟有关的人体解剖学研究已有较多报道。对人体标本进行血管灌注与放射造影,从三维角度对局部区域的血管进行研究,是近年发展起来并且日臻成熟的血管研究方法。该方法通过血管造影,利用计算机软件对血管进行三维重建,然后从不同角度与层次对该区域的血管进行三维显示,并能与同一区域的骨、肌、皮等进行组合显示,能使用透明等方式明确该区域的血管走行与分布,对于该区域组织瓣的设计改进提供直观,实用性强的解剖学基础。然而虚拟结构是否能完全代替实体,两者间是否有差异,两者的优越性和局限性分别是什么?这些问题都还有待进一步研究与认识。本文采用30例标本,结合巨微解剖与三维重建技术,拟对:(1)以旋股外侧动脉降支为蒂分叶肌皮瓣的解剖学基础进行研究;(2)利用同样的方法,研究逆行腓骨肌皮瓣的血供来源、取瓣面积,旋转点位置及临床注意事项等;(3)将三维重建的虚拟的下肢血管,与实体结构进行对比,以探讨虚拟结构是否能完全代替实体,两者间是否有差异,两者的优越性和局限性等等问题。方法: (1)新鲜下肢标本20侧,动脉灌注红色乳胶,在大腿部解剖观测旋股外侧动脉降支的起始、走行、分支、分布的情况,特别是其本干进入股外侧肌的部位,及其在股外侧肌内的分支、分布与吻合情况。在小腿部解剖与观测腓动脉在腓骨长肌、腓骨短肌及其表面皮肤与皮下组织中的起始、走行、分支、分布的情况,特别是肌皮穿支血管的走行与分布情况。 (2)另6侧新鲜下肢标本,股动脉灌注明胶-氧化铅混悬液,冷凝后行CT扫描,利用三维软件重建下肢动脉及其分支。观察旋股外侧动脉降支与股外侧肌、股前外侧部皮肤、股骨等结构的位置关系。为旋股外侧动脉降支为蒂分叶肌皮瓣的设计与切取提供直观的解剖学依据。观察小腿外侧部血管的走行与吻合情况及其与周围结构的位置关系,为逆行腓骨肌皮瓣的设计与临床应用提供直观的解剖学依据。 (3)另用新鲜人体下肢标本各2侧,分别从动脉与静脉灌注显影剂,CT扫描后利用三维软件进行分割与重建;解剖扫描后的标本,分别显示各自的血管系统。将三维图形与标本照片进行比较,以研究虚拟结构是否能完全代替实体,两者间是否有差异,两者的优越性和局限性等等问题。结果: 1、80.8%的降支发自旋股外侧动脉,平均外径3.7mm,于股直肌深面,沿股外侧肌前缘下降,在距其起始处9.0cm处分为内、外两侧支;外侧支营养股外侧肌,肌外血管蒂长8.1cm,在股外侧肌中段肌内行走的全程发出6.6支口径1.0mm的肌支或肌皮支,平均支间距18.6mm。相邻分支间在肌内有明显的吻合。旋股外侧动脉外侧支的终支与膝上外侧动脉升支在股外侧肌内吻合,下行达膝关节附近,参加膝关节动脉网的形成。除1例外,25侧标本共出现皮支63支,外径0.8mm,其中肌间隙穿支占23.8%,而肌皮穿支占76.2%。26侧中有15侧肢体出现直径0.8mm的高位皮动脉19支。 2、腓动脉起始外径3.7mm,沿途发出多条肌支,供给比目鱼肌、拇长屈肌、腓骨长、短肌及表面皮肤。腓动脉起始处至第一滋养动脉干长52.1mm,起始处平均管径3.0mm。在腓骨中部发出数支弓状动脉,最粗的1支外径平均为1.5mm,绕过腓骨至腓骨骨膜表面,而后沿腓骨下行,沿途发出2-4个肌支营养腓骨短肌。腓动脉发出皮支5.4支,从比目鱼肌与腓骨长肌间隙穿出,供血于小腿外侧皮肤,平均外径0.7mm,皮穿支常有1-2条伴行静脉。腓动脉穿支的血管蒂可游离长度为3.5cm。腓动脉末段在胫腓骨骨间膜中穿出,外径1.2mm,分为升支和降支。降支沿腓骨和外踝前缘下降并与外踝前动脉吻合形成外踝前动脉弓,外径1.3mm。腓骨短肌肌腹的上部有一支较粗的腓浅动脉发自胫前动脉,向前穿骨间膜行于腓骨长肌与小腿前群肌之间,血管管径1.8mm,行向下营养腓骨短肌、腓浅神经和小腿前外侧部皮肤。腓浅神经的营养血管平均每侧有5.4支,包括起始处的腓浅动脉、腓动脉穿支的升、降支及足背动脉的皮支。 3、利用三维软件可分割与重建出独立的骨、血管、皮肤、肌肉,所重建的图形可以分别单独显示,也可以组合显示。可以从不同层次,不同角度观察血管的走行、分布、吻合等情况。重建图像显示旋股外侧动脉降支发出一系列分支至股外侧肌,部分分支穿过股外侧肌至深浅筋膜和皮肤。在股外侧肌内的分支之间有明显的相互吻合,位于深浅筋膜中的皮动脉之间亦有明显的相互吻合,这些结果为旋股外侧动脉降支为蒂的肌瓣,皮瓣乃至于肌皮瓣提供了直观的解剖学基础。重建图像显示腓动脉有穿支和交通支分别与胫前动脉、胫后动脉相沟通,发现腓骨短肌肌支、皮穿支与周围主干血管之间有广泛而丰富的吻合。采集三维重建的股前外侧血管图形,利用Photoshop软件使之与标本照片复合,并进行一定的调整、定位与透明,可在同一张图片上观察到标本与三维重建的股前外侧血管的图形,使标本照片与三维图形有一个直观的对比。由复合图形可知,三维重建图形所能表达的信息量要多于标本照片,前者能同时显示不同层面,不同方向的所有血管分支,而标本照片只能显示所解剖的单层面的信息,而对于被覆盖的部份则无法显示。但三维图形的不足之处也是显而易见的,如重建的血管明显比实物更加粗大与粗糙,从三维软件中采集的平面图形,其立体感有所下降。而且有显示误差,不适合数据采集。剥制标本上可清晰地观察到血管系统,可观察任一支血管的来源、走行、分布与吻合等情况,可以进行数据测量,但不能同时显示多层结构。结论: 1、以旋股外侧动脉降支为蒂,利用肌支可以形成肌瓣,利用肌皮支可以形成皮瓣。根据创面的形态与位置,可以用不同部位的血管支的距离来调整肌瓣和肌皮瓣的叶间距离,使分叶肌皮瓣与所修复创面更加吻合。以旋股外侧动脉降支为蒂的分叶肌皮瓣是临床修复复杂创面的一种极佳选择。 2、以腓动脉中、下部穿支或终末支与其它血管的吻合为蒂,可以设计切取逆行腓骨长、短肌肌皮瓣,修复小腿下部及足背部缺损。 3、血管灌注结合三维重建的方法对于观察人体血管的三维状态、不同角度与不同层面的走行与分布具有相当的优势,但不能完全替代传统的剥制标本。主要创新点: 1、为以旋股外侧动脉降支为蒂的分叶肌皮瓣设计提供了详实的解剖学基础,可指导临床手术,为临床修复巨大软组织缺损,感染性创面,或女性乳房再造等复杂创面设计提供了新的和理想的选择。 2、提出和开发设计了逆行腓骨肌皮瓣,并从解剖学角度详细地论证了该肌皮瓣的可行性与实用性,为小腿中下部及足背软组织缺损的修复提供了可靠并实用的组织瓣供区。 3、首次对三维重建结构与实物标本进行比较,从血管解剖学角度研究了三维重建的血管与实物标本上血管的差异,为后期血管的三维重建及三维血管研究奠定了坚实的基础。
[Abstract]:Research background and purpose:
With the development of industry and modernization, human skin and other tissue defects caused by traffic accidents and injuries are increasing. As the environmental pollution is aggravating, the tumor patients are increasing. After the tumor excision, tissue filling is needed to restore the shape and cover the wound. The higher the number of wounds, the different tissues and wounds to be repaired. This is a problem that clinicians and surgeons have been exploring for a long time.
In 1984, the anterolateral thigh flap was first reported, and the flap was first applied to the clinic. The anterolateral thigh flap has the advantages of clear anatomical marks, long vascular pedicle, large diameter, large area, less anatomical variation, easy cutting and concealment of the donor area. It is the ideal flap donor area of the femoral head. The flap is in the first place. The flap is in the first place. The flap is in the first place. The second report has been widely used in the short term, and the further basic research and clinical application are also in depth, and the relevant reports of anatomical and clinical applications are emerging, and the related surgical methods or improvements are also present.
In 2005, Liu Huiren reported the clinical application of the lobular myocutaneous flap pedicled with the descending branch of the lateral femoral circumflex artery. It was considered that the descending branch of the lateral circumflex artery was a vascular pedicle. The cutaneous branch formed a flap with the anterolateral thigh skin and subcutaneous tissue, and the muscle branches carried some of the lateral femoris to form the muscle flap, using different muscles according to the size and shape of the wound. The position and size of the muscle flap of the branches were adjusted to cut the lobular myocutaneous flap adapted to the wound. It was used in 8 cases to obtain satisfactory results. The design was novel and easy to operate. It had good clinical value and was worth popularizing, but its anatomical basis was rarely reported.
The soft tissue defect of 1/3 and foot and ankle in the lower leg with bone, plate or tendon exposure is a common problem in clinical. Although there are many treatment methods, each method has its own shortcomings. Especially, some methods are difficult to be applied in grass-roots hospitals because of the complexity of operation or high failure rate.
In 2003, Deng Guo three reported the repair of the soft tissue defect of the lower leg and the ankle with the fibula muscle flap of the fibula. He believed that the peroneal short muscle was not easy to damage the nutrient vessels of the fibula short muscle because of the peroneal artery supply to the peroneal muscle, so it could be used in many cases where the 1/3 was not used. At the same time, the operation is simple, the time is short, and the success rate is high.
However, the deficiency of the fibula muscle flap to repair the lower and lower leg trauma is also obvious. Because it does not take the skin and fascia, it only plays the role of filling the defect, but can not complete the skin cover of the wound at once. It is necessary to carry out the free transplantation of the medium thick skin slices on the surface of the muscle flap.
In 1989, the free fibula flap was first used to repair the defect of the mandible for the first time. After that, the free fibula (skin) flap was used to reconstruct and repair the mandible defect. The fibula bone flap, the fibula muscle flap and the myocutaneous flap can be used together, which can be used according to the characteristics and needs of the area. A composite tissue flap or chimeric tissue flap can be formed by living design and cutting.
After years of clinical application and anatomical basis, the blood supply basis and clinical application of the fibula flap are clear and clear. There are few related data for the characteristics of the blood supply of the peroneal long muscles and the peroneal short muscles, and the related distribution and anastomosis of the cutaneous arteries, especially the retrograde peroneal myocutaneous flap and the peroneal muscle skin. The source of the blood supply of the valve, whether it adapts to the repair of the lower and lower leg and the defect of the foot and back, and the problems that should be paid attention to during the operation are still necessary for further research.
With the in-depth study of human morphology and the application and development of computer technology in the field of medicine, it is possible to visualize the three-dimensional structure of human body. It has played an important role in the medical teaching and clinical practice in the visual model of human anatomy, and it has been played in the medical teaching and clinical practice. On the basis of the establishment of a virtual environment for surgical and preoperative formulation, it has an irreplaceable and inspiring application prospect in the teaching of surgery and simulation training. In recent years, more reports have been made on the anatomy of human anatomy related to three-dimensional virtual. Research on vessels in local area is a new method of vascular research which has developed and matured in recent years.
This method can be used in three-dimensional reconstruction of blood vessels by computer software, and then three dimensional display of blood vessels in the region from different angles and levels, and can be combined with bone, muscle and skin in the same area to show the blood vessels in the region. It provides an intuitive and practical anatomical basis for improvement.
However, whether the virtual structure can completely replace the entity, whether there is difference between the two, what are the advantages and limitations of the two, these problems still need further research and understanding.
The anatomical basis of the pedicled myocutaneous flap pedicled with the descending branch of the lateral circumflex artery was studied with 30 specimens, combined with the technique of giant microanatomy and three-dimensional reconstruction. (2) the blood supply, the area of the flap, the position of the rotation point and the notice of clinical attention were studied by the same method, and (3) the deficiency of the three-dimensional reconstruction was made. The proposed lower extremities vessels are compared with the physical structure to explore whether the virtual structure can completely replace the entity, whether there is a difference between the two, the advantages and limitations of the two.
Method:
(1) 20 sides of fresh lower extremities, arterial infusion of red latex, and anatomic observation of the starting, walking, branching, distribution of the descending branch of the lateral femoral circumflex artery in the thigh, especially the part of its trunk entering the lateral femoral muscle, and its branches, distribution and anastomosis in the lateral femoral muscle. The peroneal artery was dissected and observed in the calf at the peroneal muscle and fibula. The origin, movement, distribution and distribution of the short bone and its surface and subcutaneous tissue, especially the distribution and distribution of the perforating branches of the musculocutaneous flap.
(2) on the other 6 sides of fresh lower limb specimens, the femoral artery was perfused with gelatin and lead oxide suspension, and the CT scan was performed after condensation. The three dimensional software was used to reconstruct the lower extremities arteries and their branches. The position of the descending branch of the lateral femoral artery and the lateral femoral muscle, the anterolateral femoral skin, the femur and other structures were observed. The design of the pedicle musculocutaneous flap for the descending branch of the lateral femoral artery and the pedicled lobular flap was designed. The anatomical basis of the lateral part of the leg and its relationship with the surrounding structure were observed, and the anatomical basis for the design and clinical application of the retrograde fibula myocutaneous flap was provided.
(3) in addition to the 2 sides of the fresh human lower extremities, the developer was perfused from the arteries and veins respectively. After CT scanning, the three-dimensional software was used for segmentation and reconstruction. The specimens after the scanning were dissected to show their respective vascular systems. The three-dimensional graphics were compared with the specimen photographs to investigate whether the virtual structure could completely replace the entity. There are differences, advantages and limitations of both.
Result:
1,80.8%'s descending branch of the lateral femoral artery, with an average external diameter of 3.7mm, fell in the deep surface of the rectus femoris and descended along the anterolateral femoral muscle. At the beginning of the lateral femoral muscle, the lateral branch was disposed of within the lateral branch of the lateral branch, and the lateral branch of the lateral branch of the nutrient femoral muscle and the external muscular vessel were long 8.1cm. 6.6 branches of the musculus or myocutaneous branches of the 6.6 caliber 1.0mm were issued in the middle of the lateral femur muscle. There was an obvious anastomosis between the adjacent branches of the 18.6mm. branches between the adjacent branches of the lateral branch of the lateral branch of the lateral circumflex femoral artery and the ascending branch of the lateral superior knee artery in the lateral femoral muscle, and the descending knee joint and the formation of the knee joint artery network. In addition to 1 exceptions, there were 63 cutaneous branches and a external diameter of 0.8mm, which accounted for 23.8% of the muscular space perforator. In the 76.2%.26 side of the musculocutaneous perforator, there were 15 lateral limbs with 19 0.8mm high cutaneous arteries.
2, the external diameter of the peroneal artery was 3.7mm, and a number of muscle branches were issued along the way, supplying the soleus muscle, the flexor pollicis long flexor, the long fibula, the short muscle and the surface skin. The beginning of the peroneal artery to the first nourishing artery was 52.1mm, and the average diameter of the initial diameter 3.0mm. emitted a number of arcuate arteries in the middle of the fibula, and the coarseest 1 external diameters averaged 1.5mm, bypassing the fibula to the periosteum of the fibula. The surface, then down along the fibula, sends out 2-4 branches of the fibula short muscle along the way. The peroneal artery sends out 5.4 cutaneous branches, from the soleus muscle and the long fibular gap, and the blood supply to the lateral leg skin, the average outer diameter is 0.7mm, and the skin perforator often has 1-2 veins. The free length of the peroneal perforator is 3.5cm. the distal fibular segment in tibia. The interosseous membrane was worn out in the interosseous membrane, and the outer diameter was 1.2mm, divided into the ascending and descending branches. The descending branch was descended along the anterior margin of the fibula and the lateral malleolus and anastomosed with the anterior lateral malleolus to form the anterior arch of the lateral malleolus. The outer diameter of the superficial peroneal artery of the 1.3mm. fibula had a superficial peroneal artery from the anterior tibial artery and the anterior interosseous membrane was between the peroneal and anterior group of the calf muscle. The diameter of the peroneal short peroneal muscle, superficial peroneal nerve and the anterolateral skin of the calf. The superficial peroneal nerve has 5.4 branches on each side of the peroneal nerve, including the superficial peroneal artery, the ascending of the peroneal perforator, the descending branch and the cutaneous branch of the dorsum artery of the peroneal artery, 1.8mm.
3, the three-dimensional software can be used to separate and reconstruct the independent bone, blood vessel, skin, muscle, and the reconstructed images can be displayed separately, and can also be combined. It can be observed from different levels and different angles.
The reconstruction images show that the descending branch of the lateral femoral circumflex artery sends out a series of branches to the lateral femoral muscle, and some branches pass through the lateral femoris to the deep fascia and skin. The branches in the lateral femoris have obvious mutual anastomosis, and there is a clear interphase between the cutaneous arteries in the deep fascia. These results are the descending branches of the lateral femoral circumflex artery. The pedicle muscle flap provides a direct anatomical basis for the flap and even the musculocutaneous flap.
The reconstructed images showed that the perforator and the traffic branch of the peroneal artery were communicated with the anterior tibial artery and the posterior tibial artery, and the muscle branch of the peroneal brevis muscle was found, and the cutaneous perforator was in a wide and rich anastomosis with the peripheral blood vessels.
Three-dimensional reconstruction of the anterolateral femoral vascular graphics, using Photoshop software to combine with the specimen photos, and make certain adjustments, positioning and transparency, can be observed on the same picture of the specimen and three-dimensional reconstruction of the anterolateral thigh blood vessels, so that the specimen photos and three-dimensional graphics have a visual comparison. The amount of information that the 3D reconstruction can express is more than the specimen photograph. The former can simultaneously display all vascular branches of different layers and different directions, while the specimen photos can only show the dissected information of the single plane, but can not be displayed for the covered parts. However, the defects of the 3D graphics are also obvious, such as the reconstruction. The blood vessels are obviously larger and rough than the objects, and the plane graphics collected from the three-dimensional software have decreased. Moreover, there is a display error and is not suitable for data acquisition. The vascular system can be clearly observed on the specimen, and the source, line, distribution and anastomosis of any vessel can be observed, but the data can be measured, but it can not be measured. The multi-layer structure can be displayed at the same time.
Conclusion:
1, pedicled with the descending branch of the lateral femoral circumflex artery, the muscle flap can be used to form the muscle flap and the skin flap can be used to form the flap. According to the shape and position of the wound, the distance of the vascular branches of different parts can be used to adjust the distance between the myocutaneous flap and the musculocutaneous flap, so that the lobular myocutaneous flap is more anastomosed with the repaired wound. The pedicle of the lateral circumflex artery is the pedicle. The lobular myocutaneous flap is a face to face.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2009
【分类号】：R658.3;R322

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