盆底障碍性疾病的临床解剖学及生物力学研究
发布时间：2018-08-13 21:01
【摘要】： 目的明确骶前区和骶棘韧带周围的血管神经解剖,以寻找骶骨阴道固定术、骶棘韧带固定术和髂尾肌筋膜悬吊术的安全区域;测定这些手术常用的骨盆筋膜与韧带、阴道穹隆和坐骨棘筋膜的抗拉力;并验证坐骨棘筋膜能否成为新的安全有力且便于缝合的阴道穹隆固定点。 方法解剖国人成年女性尸体10具(防腐固定的7具和新鲜的3具),观察、测量骶前区及骶棘韧带周围的血管神经解剖,并用拉力计测定骶骨前纵韧带、骶棘韧带、髂尾肌筋膜、坐骨棘筋膜及阴道左右侧穹隆的最大抗拉力。 结果 1 9具(9/10)尸体的骶前血管分布有规律可循,基本每个椎体的盆面均有一支横行的骶前横静脉支连接着两侧的骶外侧静脉(或髂内静脉)与中线附近的骶正中静脉,呈“楼梯”状分布,位于骶前区中线上、距离骶骨岬3 cm、边长也是3 cm的正方形的四个顶点附近为无血管区。 2骶棘韧带的长度是52.3±4.2 mm,坐骨棘端的宽度为10.0±1.1 mm,距离坐骨棘2.5 cm处的宽度为12.0±2.1 mm。臀下血管出骨盆前经过骶棘韧带外侧一半的后方或紧邻上缘,大部分在阴部神经、骶神经的背侧,在骶棘韧带上缘有时可有一小段不被神经遮盖而外露。大部分臀下动脉(18/20)在近骶棘韧带上缘处还发出尾动脉,它在骶棘韧带上缘处距离坐骨棘15.7±5.6 mm。阴部神经在坐骨棘内侧从内上向外下斜行跨越骶棘韧带后方进入坐骨小孔,位于阴部内血管的内侧或内上方,在骶棘韧带上、下缘其最内界与坐骨棘间的距离分别是23.4±3.6 mm和15.7±1.3mm。坐骨棘前下至内下1-2 cm扇形区域的髂尾肌背面走行阴部内血管、阴部神经、肛神经及肛血管,两者几乎紧邻,髂尾肌厚度仅有2.54 mm(范围1.60-3.80 mm)。75%(15/20)的半骨盆找到肛提肌神经,它跨越骶棘韧带上缘处距离坐骨棘的平均距离是39.6 mm(标准差8.3 mm,范围30-60mm)。 3在10具尸体上,骶骨前纵韧带的最大抗拉力沿着骶骨向下逐渐减小,骶骨岬上缘的腰5骶1椎间盘水平、骶1水平和骶2水平前纵韧带的抗拉力分别为99.2±29.5 N(69.4-157.0 N)、47.9±16.4 N(29.0-85.0 N)、22.8±10.1 N(8.5-43.0 N);骶棘韧带、坐骨棘筋膜、髂尾肌筋膜和阴道穹隆的最大抗拉力分别是102.0±25.7 N(74.3-176.0 N)、64.4±14.7 N(38.0-85.0 N)、32.6±8.2 N(17.0-42.0 N)和31.6±5.6 N(26.0-46.7 N),它们的变化范围都比较大。只有腰5骶1椎体处前纵韧带的抗拉力在新鲜尸体上明显大于在固定尸体上,分别是124.0 N和86.8 N,其他位点的抗拉力在新鲜尸体和固定尸体上相似。 4坐骨棘是尾骨肌、髂尾肌和骶棘韧带的起点,也是肛提肌腱弓、盆筋膜腱弓和闭孔内肌筋膜的附着处,坐骨棘筋膜牢固有力;在坐骨棘表面无重要的血管神经走行。 结论 1大部分尸体的骶前血管分布有规律可循,位于骶前区中线上、距离骶骨岬3 cm、边长也是3 cm的正方形的四个顶点附近为无血管区;第一骶前孔水平无血管区的前纵韧带是骶骨阴道固定术的首选固定点,因第三、四骶椎表面的无血管区面积小且前纵韧带的抗拉力太小不宜选择该水平的前纵韧带做固定点。 2骶棘韧带固定术中,选择缝合骶棘韧带距离坐骨棘至少2.5 cm处、宽度为韧带靠近下缘的一半、深度为韧带全层厚度的浅层一半,即宽度约5mm,深度约1mm,能避免损伤其后方及上缘的血管神经,且能为阴道顶端提供足够的支撑。 3因坐骨棘前下方至内下方1-2 cm处髂尾肌的背面走行阴部内血管、阴部神经、肛神经及肛血管,髂尾肌筋膜悬吊术中宜缝合肌肉的浅层及其表面的筋膜,而不宜垂直进针穿透全层缝合。 4坐骨棘筋膜牢固有力,表面无重要血管神经走行,可以作为阴道穹隆新的悬吊点,安全可靠。
[Abstract]:Objective To determine the anatomy of the presacral region and the vessels and nerves around the sacrospinal ligament in order to find the safe areas for sacrovaginal fixation, sacrospinal ligament fixation and iliocutaneous myofascial suspension, to determine the tensile strength of pelvic fascia and ligament, vaginal fornix and sciatic fascia, and to verify whether sciocutaneous fascia can be a new safe area. Forceful and easily sutured vaginal fornix fixation point.
Methods Ten Chinese adult female cadavers (7 preserved and fixed and 3 fresh) were dissected. The vascular and nerve anatomy of the anterior sacral region and around the sacrospinal ligament were measured. The maximum tensile strength of the anterior longitudinal ligament, sacrospinal ligament, ilioconcoccygeal fascia, sciatic spine fascia and the left and right vaginal fornix were measured by tensiometer.
Result
In 19 (9/10) cadavers, there was a transverse presacral transverse vein branch on the pelvic surface of each vertebral body connecting the lateral sacral vein (or the internal iliac vein) and the median sacral vein near the median line. It was a "staircase" shape, located in the anterior line of the sacral region, 3 cm from the sacral promontory, and 3 cm in length. There is no vascular area near the four vertices of the square.
2. The length of the sacrospinal ligament is 52.3 (+ 4.2 mm), the width of the sciatic spine is 10.0 (+ 1.1 mm) and the width is 12.0 (+ 2.1 mm) from the 2.5 cm of the sciatic spine. Most of the inferior gluteal artery (18/20) also sends out the caudal artery near the margin of the sacrospinal ligament, which is 15.7 (+ 5.6 mm) away from the sciatic spine. The pudendal nerve obliquely crosses the medial superior inferior superior superior superior inferior superior superior superior inferior superior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior The distances between the innermost border of the ligament and the sciatic spine were 23.4 (+ 3.6 mm) and 15.7 (+ 1.3 mm), respectively. The dorsal surface of the iliocutaneous muscles running from the anterior inferior sciatic spine to the fan-shaped area of the medial inferior 1-2 cm ran through the pudendal vessels, the pudendal nerves, the anal nerves and the anal vessels, which were almost adjacent. The thickness of the iliocutaneous muscles was only 2.54 mm (range 1.60-3.80 mm). 75% (15/20) of the semipelvis. The average distance from the levator ani nerve to the sciatic spine was 39.6 mm (standard deviation 8.3 mm, range 30-60 mm).
3 On 10 cadavers, the maximum tensile strength of the anterior longitudinal ligament decreased downward along the sacrum, at the level of lumbar 5-sacral 1 intervertebral disc, at the level of sacral 1 and at the level of sacral 2, at the level of 99.2 + 29.5 N (69.4-157.0 N), 47.9 + 16.4 N (29.0-85.0 N), 22.8 + 10.1 N (8.5-43.0 N), at the sacral spine ligament, sciatic fascia, and iliac coccygeal fascia, respectively. The maximum tensile forces of myofascial and vaginal fornix were 102.0 (+25.7 N) (74.3-176.0 N), 64.4 (+14.7 N) (38.0-85.0 N), 32.6 (+8.2 N) (17.0-42.0 N) and 31.6 (+5.6 N) (26.0-46.7 N), respectively. Only the tensile forces of anterior longitudinal ligament in lumbar 5-1 vertebral body were significantly greater than those in fresh cadavers, which were fixed at lumbar 5-1 vertebral body, respectively. .0 N and 86.8 N showed similar resistance to other sites in fresh cadavers and fixed cadavers.
4. The sciatic spine is the starting point of the coccygeal muscle, the iliocutaneous muscle and the sacrospinal ligament. It is also the attachment of the levator ani tendon arch, the pelvic fascia tendon arch and the myofascial fascia in the obturator. The sciatic spine fascia is firm and powerful, and there are no important vessels and nerves running on the surface of the sciatic spine.
conclusion
1. The presacral vessels of most cadavers are regularly distributed in the middle line of the presacral region, 3 cm from the sacral promontory and 3 cm from the four apex of the square. The anterior longitudinal ligament of the horizontal vessel-free area of the first presacral foramen is the preferred fixation point for sacrovaginal fixation, because the third and fourth sacral vertebral surface is the vascular-free area. The small anterior longitudinal ligament is too small to choose the anterior longitudinal ligament.
2 In sacrospinal ligament fixation, the sacrospinal ligament should be sutured at least 2.5 cm from the sciatic spine, half the width of the ligament near the inferior margin, half the thickness of the superficial layer of the ligament, that is, about 5 mm in width and 1 mm in depth. It can avoid injuring the posterior and superior vascular nerves and provide sufficient support for the vaginal apex.
3. Because the internal pudendal vessels, pudendal nerves, anal nerves and anal vessels run along the dorsal surface of iliocutaneous muscle from anterior inferior to inferior sciatic spine to 1-2 cm, it is better to suture the superficial layer of muscle and the fascia on the surface of iliocutaneous muscle during the operation of iliocutaneous fascial suspension, but not to penetrate the whole suture through the vertical needle.
4. The sciatic spine fascia is firm and powerful, and has no important vessels and nerves on its surface. It can be used as a new suspension point of vaginal fornix and is safe and reliable.
【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】：2008
【分类号】：R711;R322;R318.01
本文编号：2182175
[Abstract]:Objective To determine the anatomy of the presacral region and the vessels and nerves around the sacrospinal ligament in order to find the safe areas for sacrovaginal fixation, sacrospinal ligament fixation and iliocutaneous myofascial suspension, to determine the tensile strength of pelvic fascia and ligament, vaginal fornix and sciatic fascia, and to verify whether sciocutaneous fascia can be a new safe area. Forceful and easily sutured vaginal fornix fixation point.
Methods Ten Chinese adult female cadavers (7 preserved and fixed and 3 fresh) were dissected. The vascular and nerve anatomy of the anterior sacral region and around the sacrospinal ligament were measured. The maximum tensile strength of the anterior longitudinal ligament, sacrospinal ligament, ilioconcoccygeal fascia, sciatic spine fascia and the left and right vaginal fornix were measured by tensiometer.
Result
In 19 (9/10) cadavers, there was a transverse presacral transverse vein branch on the pelvic surface of each vertebral body connecting the lateral sacral vein (or the internal iliac vein) and the median sacral vein near the median line. It was a "staircase" shape, located in the anterior line of the sacral region, 3 cm from the sacral promontory, and 3 cm in length. There is no vascular area near the four vertices of the square.
2. The length of the sacrospinal ligament is 52.3 (+ 4.2 mm), the width of the sciatic spine is 10.0 (+ 1.1 mm) and the width is 12.0 (+ 2.1 mm) from the 2.5 cm of the sciatic spine. Most of the inferior gluteal artery (18/20) also sends out the caudal artery near the margin of the sacrospinal ligament, which is 15.7 (+ 5.6 mm) away from the sciatic spine. The pudendal nerve obliquely crosses the medial superior inferior superior superior superior inferior superior superior superior inferior superior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior superior inferior superior The distances between the innermost border of the ligament and the sciatic spine were 23.4 (+ 3.6 mm) and 15.7 (+ 1.3 mm), respectively. The dorsal surface of the iliocutaneous muscles running from the anterior inferior sciatic spine to the fan-shaped area of the medial inferior 1-2 cm ran through the pudendal vessels, the pudendal nerves, the anal nerves and the anal vessels, which were almost adjacent. The thickness of the iliocutaneous muscles was only 2.54 mm (range 1.60-3.80 mm). 75% (15/20) of the semipelvis. The average distance from the levator ani nerve to the sciatic spine was 39.6 mm (standard deviation 8.3 mm, range 30-60 mm).
3 On 10 cadavers, the maximum tensile strength of the anterior longitudinal ligament decreased downward along the sacrum, at the level of lumbar 5-sacral 1 intervertebral disc, at the level of sacral 1 and at the level of sacral 2, at the level of 99.2 + 29.5 N (69.4-157.0 N), 47.9 + 16.4 N (29.0-85.0 N), 22.8 + 10.1 N (8.5-43.0 N), at the sacral spine ligament, sciatic fascia, and iliac coccygeal fascia, respectively. The maximum tensile forces of myofascial and vaginal fornix were 102.0 (+25.7 N) (74.3-176.0 N), 64.4 (+14.7 N) (38.0-85.0 N), 32.6 (+8.2 N) (17.0-42.0 N) and 31.6 (+5.6 N) (26.0-46.7 N), respectively. Only the tensile forces of anterior longitudinal ligament in lumbar 5-1 vertebral body were significantly greater than those in fresh cadavers, which were fixed at lumbar 5-1 vertebral body, respectively. .0 N and 86.8 N showed similar resistance to other sites in fresh cadavers and fixed cadavers.
4. The sciatic spine is the starting point of the coccygeal muscle, the iliocutaneous muscle and the sacrospinal ligament. It is also the attachment of the levator ani tendon arch, the pelvic fascia tendon arch and the myofascial fascia in the obturator. The sciatic spine fascia is firm and powerful, and there are no important vessels and nerves running on the surface of the sciatic spine.
conclusion
1. The presacral vessels of most cadavers are regularly distributed in the middle line of the presacral region, 3 cm from the sacral promontory and 3 cm from the four apex of the square. The anterior longitudinal ligament of the horizontal vessel-free area of the first presacral foramen is the preferred fixation point for sacrovaginal fixation, because the third and fourth sacral vertebral surface is the vascular-free area. The small anterior longitudinal ligament is too small to choose the anterior longitudinal ligament.
2 In sacrospinal ligament fixation, the sacrospinal ligament should be sutured at least 2.5 cm from the sciatic spine, half the width of the ligament near the inferior margin, half the thickness of the superficial layer of the ligament, that is, about 5 mm in width and 1 mm in depth. It can avoid injuring the posterior and superior vascular nerves and provide sufficient support for the vaginal apex.
3. Because the internal pudendal vessels, pudendal nerves, anal nerves and anal vessels run along the dorsal surface of iliocutaneous muscle from anterior inferior to inferior sciatic spine to 1-2 cm, it is better to suture the superficial layer of muscle and the fascia on the surface of iliocutaneous muscle during the operation of iliocutaneous fascial suspension, but not to penetrate the whole suture through the vertical needle.
4. The sciatic spine fascia is firm and powerful, and has no important vessels and nerves on its surface. It can be used as a new suspension point of vaginal fornix and is safe and reliable.
【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】：2008
【分类号】：R711;R322;R318.01
【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：2182175
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