Transcript 凌树才_Anterolateral Abdominal Wall

Regional anatomy
Anterolateral Abdominal Wall
The Anterolateral Abdominal Wall
• Superficial structures 浅层结构
• Deep structures 深层结构
1.Skin
2.Superficial fascia
3.Deep fascia and muscles
4.Transverse fascia
皮肤
5.Extraperitoneal fascia
浅筋膜
6.Parietal fascia
深筋膜和肌肉
腹横筋膜
腹膜下筋膜
壁腹膜
The layers of the anterolateral abdominal wall
Ⅰ.The superficial structures 浅层结构
• Surface Features of Skin
• Superficial fascia 浅筋膜
Surface Features of the Abdomen
Superficial fascia
Divisions below
umbilicus（脐以下）
• Superficial fatty
layer (Camper’s)
• Membranous layer
(Scarpa’s)
Superficial vessels and cutaneous nerves
• Arteries
– Superficial epigastric a.
– Superficial iliac
circumflex a.
• Veins
– Thoracoepigastric v.
– Superficial epigastric v.
• Cutaneous nerves
– Anterior and lateral
cutaneous n. of lower six
thoracic
– Iliohypogastric n. (first
lumb nerves)
• 浅动脉、浅静脉、皮神经
The ilioinguinal and the lower abdominal flaps
髂腹股沟区和下腹部的皮瓣
Ⅱ.The Deep Structures 深层结构
• Muscular layer 肌层
• Vessels, lymph and nerve 血管、淋巴及神经
• Transversalis fascia 腹横筋膜
• Extraperitoneal fascia 腹膜下筋膜
• Parietal peritoneum 壁腹膜
Muscles of abdomen
Anterolateral group
•
obliquus externus
abdominis 腹外斜肌
•
oblequus enternus
abdominis 腹内斜肌
•
transversus abdominis
腹横肌
•
rectus abdominis
腹直肌
Posterior group
• Quadiatus lumborum
腰方肌
• Psoas major
腰大肌
Obliquus externus absominis 腹外斜肌
General direction of fibers:
downward, forward and medially
(run down and inward)
Structures
• Inguinal ligament
腹股沟韧带
• Lacunar ligament
腔隙韧带
• pectineal ligament
耻骨梳韧带
• Superficial inguinal ring
腹股沟浅环 －triangular-shaped
defect in aponeurosis of obliquus
externus abdominis above pubic
tubercle
Inguinal
ligament
pectineal
ligament
Superficial inguinal ring
Lacunar
ligament
Superficial inguinal ring
Obliquus internus abdominis 腹内斜肌
•
Deep to obliquus
externus abdominis
•
General direction
of fibres: upwards,
forwards and
medially
Transversels abdominis 腹横肌
•
Deep to obliquus
internus
• inguinal ligament腹股沟韧带、lacunar ligament腔隙韧带、
pectineal ligament耻骨梳韧带
• Inguinal falx 腹股沟镰:
arch over spermatic
cord, inserted with
transverses
abdominis fiber into
medial part of
pecten of pubis
• Cremaster 提睾肌:
around the
spermatic cord and
testis
Inguinal falx
Rectus abdominis 腹直肌
• Position: lie on to either of
midline
• Origin: pubic crest and
symphysis
• Insertion: xiphoid and 5th7th costal cartilages
• Has 3-4 tendinous
intersections 腱划
• linea semiluaris 半月线
arcuate line Linea alba 白线
－tendinous raphe between right and left recti from xiphoid to pubic
symphysis.
Linea
alba
Deep vessels and nerves
Arteres
• Superior and inferior epigastric
arteris
• Lower posterior intercostal a.
• Subcostal a.
• Four lumbar a.
Nerves
• Intercostal n.(6-11)
• Subcostal n.
Nerves
• Iliohypogastric n.
髂腹下神经
• Ilioinguinal n.
髂腹股沟神经
• Genitofemoral n.
生殖股神经
Regional anatomy
Sheath of rectus abdominis 腹直肌鞘
Ant layer－formed by fusion of
aponeurosis of obliquus
externus abdominis and
anterior leaf of aponeurosis of
obliquus internus abdominis
Post layer
•
Formed by fusion of posterion
leaf of aponeurosis of obliquus
internus abdominis and
aponeurosis of transverses
abdominis
•
Absent in about 4-5cm below
the umbilicus, where
aponeuroses of all three
muscles form anterior layer
the lower free border named
arcuate line
•
Below this line rectus
abdominis in contact with
transverse fascia
arcuate line
The Inguinal Region 腹股沟区
• Boundary 境界
• Layers and characteristics 层次与特点
• Inguinal canal 腹股沟管
• Inguinal triangle 腹股沟三角
• Hernias 疝 ：
Direct inguinal hernias 腹股沟直疝
Indirect inguinal hernias 腹股沟斜疝
Femoralhernias 股疝
Inguinal region 腹股沟区
Boundaries
• Inguinal ligament
• Lateral margin of
rectus abdominis
• A horizontal line
stretching from
anterior iliac spine to
laeral margin of
rectus abdominis
Inguinal canal 腹股沟管
Position: oblique passage, 4cm long, located 1.5cm
above medial half of inguinal lig.
•
•
Boundaries
Ant wall
–
–
Aponeurosis of
obliquus externus
abdominis
Obliquus internus
abdominis (lateral
third of wall)
• Posterior wall
– Transverse fascia
– Inguinal flax
medially
• Roof－arched lower
fibers of obliquus
internus and
transversua
abdominis
• Floor－inguinal lig．
• Two openings
– Superficial inguinal ring
腹股沟浅环
– Deep inguinal ring
腹股沟深环 －defect in
transverse fascia 1.5cm
above midpoint of inguinal
ligament
• Structures passing through the inguinal canal
– Spermatic cord 精索 and ilioinguinal nerve髂腹股沟神经 in
males
– Round ligament of uterus 子宫圆韧带and ilioinguinal nerve
髂腹股沟神经 in females
Descent of testes
Seven-week embryo showing the
testis before its descent from the
dorsal abdominal wall
Fetus at 28 week the testis passing
through the inguinal canal
Newborn
Inguinal Triangle (of Hesselbach) 腹股沟三角
Boundaries
• Inguinal ligament
inferiorly
• Lateral border of
rectus abdominis
medially
• Inferior epigastric
artery laterally
Inguinal Triangle 腹股沟三角
（Hesselbach’s triangle 海氏三角 ）
①构成：腹壁下动脉、腹直肌外侧缘和腹股沟韧带内侧半所围成的三角形区域。
②临床意义：由腹股沟三角突出的疝，称腹股沟直疝。
腹
股
沟
腹
直
疝、
股
腹
沟
股
沟
三
斜
角
疝、
股
疝
Indirect inguinal heinia and direcet inguinal heinia
直疝
Direcet heinia
斜疝
Indirect
inguinal ehinia
Hernias
Hernias
Hernias
Layer ?
Subcostal incision
Muscle-splitting incision
Median or midline incision
Left paramedian incision
Transverse incision
Suprapubic incision
Regional anatomy
The peritoneum
Ling Shucai
Ⅰ.General features
• The peritoneum is a thin serous
membrane that line the walls of the
abdominal and pelvic cavities and cover
the organs within these cavities
• Parietal peritoneum 壁腹膜
－lines the walls of the abdominal and
pelvic cavities
• Visceral peritoneum 脏腹膜
－covers the organs
• Peritoneal cavity 腹膜腔－the potential
space between the parietal and visceral
layer of peritoneum, in the mail, is a
closed sac, but in the female, there is a
communication with the exterior
through the uterine tubes, the uterus,
and the vagina
Function
• Secretes a lubricating
serous fluid that
continuously moistens
the associated organs
• Absorb
• Support viscera
Ⅱ.The relationship between viscera and peritoneum
• Intraperitoneal viscera 腹膜内位器官
• Interperitoneal viscera 腹膜间位器官
• Retroperitoneal viscera 腹膜外位器官
Intraperitoneal viscera
Interperitoneal viscera
Retroperitoneal viscera
Interperitoneal viscera 腹膜间位器官
Ⅲ. Formative formation by peritoneum

The omentum 网膜

The mesenteries and mesocolons 系膜

The ligaments 韧带

The peritoneal recesses, pouches, fossae
and folds 隐窝和陷凹
Omentum 网膜
－two-layered fold of
peritoneum that extends
from stomach to adjacent
organs
 Lessor omentum 小网膜
 Greater omentum 大网膜
Lessor omentum 小网膜
•
Hepatogastric ligament
肝胃韧带－extends from
porta hepatis to lesser
curvature of stomach
•
Hepatoduodenal ligament
肝十二指肠韧带
–
Extends from porta
hepatis to superior part
of duodenum
–
Contains common bile duct,
proper hepatic a. and
hepatic portal v.
Omental foramen 网膜孔
• Behind the right border of
hepatoduodenal ligament
• Superior－caudate lobe of
liver
• Inferior－superior part of
duodenum
• Anterior－hepatodudenal
ligament
• Posterior－peritoneum
covering the inferior vena
cava
Greater omentum 大网膜
－four-layered fold of
peritoneum, the anterior two
layers descend from the
greater curvature of stomach
and superior part of duodenum
and hangs down like an apron in
front of coils of small intestine,
and then turns upward and
attaches to the transverse
colon. If an infection occurs in
the intestine, plasma cells
formed in the lymph nodes
combat the infection and help
prevent it from spreading to
the peritoneum.
Lessor omentum
Greater omentum
Omental bursa 网膜囊
Position－situated behind the lesser
omentum and stomach
Walls
•
Superior－peritoneum which covers
the caudate lobe of liver and
diaphragm
•
Anterior－formed by lesser omentum,
peritoneum of posterior wall of
stomach, and anterior two layers of
greater omentum
•
Inferior－conjunctive area of anterior
and posterior two layers of greater
omentum
•
Posterior－formed by posterior two
layers of greater omentum, transverse
colon and transverse mesocolon,
peritoneum covering pancreas, left
kidney and suprarenal gland
•
Left－formed by the
spleen, gastrosplenic
ligament胃脾韧带 and
splenorenal ligament
脾肾韧带
•
Right－formed by
omental foramen
The Omental bursa
(lesser sac)
communicates with
the greater sac
through the omental
foramen.
Mesenteries or mesocolons
－two-layered fold of
peritoneum that attach
part of the intestines to
the posterior abdominal
wall
The mesenteries and mesocolons 系膜
Mesentery 肠系膜
－suspends the small
intestine from the posterior
abdominal wall
• Broad and a fan-shaped
• Consists of two peritoneal
layers
• Intestinal border－folded, 7
m long
• Radix of mesentery
– 15 cm long
– Directed obliquely from
left side of L2 to in front
of right sacroiliac joint
Mesoappendix 阑尾系膜
• Triangular mesentery－
extends from terminal
part of ileum to appendix
• Appendicular artery runs
in free margin of the
mesoappendix
Transverse mesocolon 横结肠系膜
－a double fold of peritoneum
which connects the transverse
colon to the posterior abdominal
wall
Sigmoid mesocolon 乙状结肠系膜
－inverted V-shaped, with apex
located in front of left ureter
and division of common iliac
artery
Ligaments 韧带
－ two-layered folds of peritoneum
that attached the lesser mobile
solid visera to the abdominal
wall
Ligaments of liver
• Falciform ligament of liver
镰状韧带
• Coronary ligament
冠状韧带
• Left and right triangular
ligaments
左、右三角韧带
• Hepatogastric ligament
肝胃韧带
• Hepatoduodenal ligament
肝十二指肠韧带
• Ligamentum teres hepatis
肝圆韧带
Ligaments of spleen
• Gastrosplenic ligament 胃脾韧带
• Splenorenal ligament 脾肾韧带
• Phrenicosplenic ligament 膈脾韧带
• Splenocolic ligament 脾结肠韧带
Ligaments of stomach
• Hepatogastric ligament 肝胃韧带
• Gastrosplenic ligament 胃脾韧带
• Gastrophrenic ligament 胃膈韧带
• Gastrocolic ligament 胃结肠韧带
• Gastropancrestic ligament 胃胰韧带
The peritoneal recesses, pouches, fossae and folds
• Superior duodenal fold and
recess 十二指肠上襞和上隐窝
• Inferior duodenal fold and
recess 十二指肠下襞和下隐窝
• Intersigmoid recess 乙状结肠
间隐窝－formed by the
inverted V attachment of
sigmoid mesocolon
The peritoneal recesses, pouches, fossae and folds
• Superior duodenal fold and
recess 十二指肠上襞和上隐窝
• Inferior duodenal fold and
recess 十二指肠下襞和下隐窝
• Intersigmoid recess 乙状结肠
间隐窝－formed by the
inverted V attachment of
sigmoid mesocolon
• Retrocecal recess 盲肠后隐窝
－in which the appendix
frequenty lies
• Hepatorenal recess
肝肾隐窝
－lies between the right lobe
of liver, right kidney, and right
colic flexure, and is the lowest
parts of the peritoneal cavity
when the subject is supine
★ Folds and fossas of anterior abdominal wall
• Median umbilical fold
脐正中襞－contain the remnant
of urachus (median umbilical
ligaments)
• Medial umbilical fold
脐内侧襞－contains remnants
of the umbilical arteries
(medial umbilical ligaments)
• Lateral umbilical fold
脐外侧襞－contains the inferior
epigastric vessels
• Supravesical fossa
膀胱上窝
• Medial inguinal fossa
腹股沟内侧窝
• Lateral inguinal fossa
腹股沟外侧窝
Pouches
• In male
- rectovesical pouch
直肠膀胱陷窝
• In female
– Rectouterine pouch
直肠子宫陷窝－between
rectum and uterus
– Vesicouterine pouch
膀胱子宫陷窝－between
bladder and uterus
Ⅳ.Peritoneal subdivisions
The transverse colon and transverse
mesocolon divides the greater sac
into supracolic and infracolic
compartments.
Supracolic compartments
结肠上区(subphrenic space)－lies
between diaphragm and transverse
colon and transverse mesocolon
Infracolic compartments.
结肠下区－lies below the transverse
colon and transverse mesocolon
Subphrenic Space 结肠上区
 Suprahepatic recess 肝上间隙
Left suprahepatic recesses 左肝上间隙
left anterior suprahepatic spaces 左肝上前间隙
left posterior suprahepatic spaces 左肝上后间隙
Right suprahepatic recesses 右肝上间隙
right anterior suprahepatic spaces 右肝上前间隙
right posterior suprahepatic spaces 右肝上后间隙
bare area of live (extraperitoneal space) 肝裸区
 Infrahepatic recess 肝下间隙
Right infrahepatic recesses 右肝下间隙 (hepatorenal recess)
Left infrahepatic recesses 左肝下间隙
left anterior infrahepatic space 左肝下前间隙
left posterior infrahepatic space 左肝下后间隙(网膜囊）
Suprahepatic recess 肝上间隙
lies between the diaphragm and live－
the falciform ligament divides it into
right and left suprahepatic recesses
• Left suprahepatic recesses 左肝上间隙
– left anterior suprahepatic spaces
– left posterior suprahepatic spaces
• Right suprahepatic recesses 右肝上间隙
– right anterior suprahepatic spaces
– right posterior suprahepatic spaces
– bare area of live (extraperitoneal
space)
Infrahepatic recess 肝下间隙
lies between the live and transverse colon
and transverse mesocolon－the
ligamentum teres hepatic divides it into
right and left infrahepatic recesses
• Right infrahepatic recesses 右肝下间隙
(hepatorenal recess 肝肾隐窝)
• Left infrahepatic recesses
左肝下间隙
– left anterior infrahepatic space
左肝下前间隙
– left posterior infrahepatic space
左肝下后间隙（网膜囊）
Infracolic compartments
结肠下区 －lies below the transverse
colon and transverse mesocolon
• Right paracolic sulcus 右结肠旁沟
－lies lateral to the ascending colon.
It communicates with the hepatorenal
recess and the pelvic cavity. It
provides a route for the spread of
infection between the pelvic and the
upper abdominal region.
• Left paracolic sulcus 左结肠旁沟
－lies lateral to the descending colon.
It is separated from the area around
the spleen by the phrenicocolic
ligament, a fold of peritoneum that
passes from the colic flexure to the
diaphragm.
• Right mesenteric sinus 右肠系膜窦
－triangular space, lies between root of
mesentery, ascending colon, right 2/3 of
transverse colon and transverse mesocolon
• Left mesenteric sinus 左肠系膜窦
－lies between root of mesentery,
descending colon, right 1/3 of transverse
colon and transverse mesocolon, its widens
below where it is continuous with the
cavity of the pelvis
 上下流通，左沟不畅，右窦封闭，左窦入盆。
思考题
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分别叙述腹前壁各种纵、斜切口经过哪几层?
试述腹股沟斜疝、直疝及股疝的解剖学基础。
打开腹膜腔可以看到哪些器官，如何进行腹膜腔探查?
什么是膈下间隙？试述其分区。
为什么阑尾炎穿孔可引起膈下脓肿?从形态学的特点来看，应
采取什么措施予以防止？