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1、局部解剖学（十六）,腹部的局部解剖与操作（3）,主要内容 Main Content,The infracolic compartment 结肠下区The retroperitoneal space 腹膜后隙,一、结肠下区Infracolic Compartment,概述空肠 jejunum 回肠 ileum盲肠cecum阑尾 vermiform appendix结肠colon,结肠下区位于横结肠及其系膜与小骨盆上口之间，主要有空肠、回肠、盲肠、阑尾、结肠及其的血管、淋巴和神经等。,Appendix,（一）空肠与回肠Jejunum and Ileum,位置与形态结构 肠系膜 mesentery血
2、管 blood vessels淋巴lymph神经 nerves,（1）空肠占空回肠全长的近侧2/5；回肠占远侧3/5。（2）空肠位于左腰区和脐区；回肠位于脐区、右腹股沟区和盆腔内。,1.位 置,空肠 回肠,（2）回肠管径较细，管壁较薄，血管弓级数较多，呈粉灰色，粘膜皱襞疏而低，有集合淋巴滤泡。,（1）空肠管径较粗，管壁较厚，血管弓级数较少，呈粉红色，粘膜皱襞高而密。,2.形态结构,小肠的X线像（前后位）,jejunumileum,（3）空肠血管弓级数为12级；（4）回肠血管弓级数为3 4级。,空、回肠的区别,2.肠系膜,Mesentery,肠系膜窦 mesenteric sinus左肠系膜窦
3、Left mesenteric sinus右肠系膜窦Right mesenteric sinus,肠系膜根radix of mesentery,3.空、回肠的动脉和静脉,Antimesenteric border对 系 膜 缘,Mesenteric border系 膜 缘,Mesenteric triangle,空、回肠的血管分布特点及临床应用,肠切除吻合术时肠系膜应作扇形切除，且对系膜缘侧的肠壁应稍多切除一些，以保证吻合口对系膜缘侧有充足的血供，避免术后缺血坏死或愈合不良。,4.空、回肠的淋巴,5.空、回肠的神经,（二）盲肠 Cecum,位置毗邻形态结构,盲肠的位置、毗邻和动脉,盲肠的形态结
4、构,网膜带,独立带,结肠带,系膜带,盲肠的形态结构,回盲瓣回盲口阑尾开口,（三）阑尾 appendix,位 置体表投影形态结构血 管国人阑尾常见位置及其炎症时的临床表现,阑尾的位置、形态结构和血管,阑尾根部的体表投影：McBurneys point is a point at the lateral third of the line joining umbilicus and right anterior superior iliac spines（在脐与右髂前上棘连线的中、外1/3交界处）,indicating the base of the descending appendix。,临床
5、意义：诊断阑尾炎时，确切的体表投影位置并不十分重要，有临床价值的症状是转移性右下腹疼痛，并在右下腹有一个局限性固定压痛点则更具有诊断意义(问号上的一点)。,内1/3段,中1/3段,外1/3段,Lanzs point is a point at the right third of the line joining the anterior superior iliac spines,indicating the tip of the descending appendix.,McBurneys point,左1/3段,中1/3段,右1/3段,国 人 阑 尾 常 见 位 置,（28%）,（26%
6、）,（24%）,（6%）,（8%）,阑尾常见位置及其炎症时的临床表现,（四）结肠 colon,分部位置及毗邻 血管,结肠的分部及形态特征,Features of colon,结肠带 colic bands(mesocolic band,omental band,free band)结肠袋 haustra肠脂垂 epiploic,Division,Ascending colon,Descending colon,Right colic flexure,left colic flexure,Transverse colon,Sigmoid colon,结肠的动脉,结肠的淋巴管和淋巴结,（五）肝门静
7、脉Hepatic Portal Vein,组成类型行径毗邻属支收集范围,肝门静脉的组成,肝门静脉的行径和毗邻,肝门静脉的属支和收集范围,Cystic vein,肠系膜下静脉汇入部位的类型,1,1,1,2,2,2,3,3,3,型52.0%,型13.3%,型34.7%,肠系膜上静脉Superior mesenteric vein,2.脾静脉Splenic vein,3.肠系膜下静脉Inferior mesenteric vein,3）肝门静脉系与上、下腔静脉系之间的交通途径:食管静脉丛；直肠静脉丛；脐周静脉网；椎静脉丛。,门-腔吻合的临床意义：正常情况下，门-腔间的吻合支细小、血流量少。当肝门静脉
8、及其分支受压迫，导致血液回流受阻时，肝门静脉内的血液将逆流，经门-腔吻合回流至腔静脉。由于门-腔吻合支血流量增多、血管增粗，致食管静脉丛曲张、直肠静脉丛曲张和脐周静脉网扩张，出现呕血、便血和海蛇头样外观。失代偿时，收集区的器官淤血，出现脾肿大和腹水等门脉高压综合征的表现。,二、腹膜后隙 Retroperitoneal Space,基本概念肾 kidney输尿管腹部 abdominal part of ureters肾上腺 suprarenal gland腹主动脉 abdominal aorta下腔静脉 inferior vena cava腰交感干 lumbar sympathetic trun
9、k,腹膜后隙retroperitoneal space：位于后腹壁的壁腹膜与腹内筋膜之间，上起自膈，下至骶骨岬，两侧向外连于腹膜下筋膜。,（一）基本概念,腹膜后间隙内有肾上腺、肾、输尿管、腹部大血管、神经和淋巴结等器官结构以及大量疏松结缔组织。,（二）肾 Kidney,位置与毗邻 position&relations肾门、肾窦和肾蒂 renal hilum,renal sinus and renal pedicle肾血管与肾段 blood vessels of kidney and renal segment肾被膜 covering membrane of kidney,1A.位置:肾位于脊柱
10、两侧，腹膜后间隙内，属腹膜外位器官；左肾在第11胸椎体至第2腰椎体之间，右肾在第12胸椎体上缘至第3腰椎体之间。,或肾角,肾门在腹后壁的体表投影点：在竖脊肌外缘与第12肋的夹角处，称肾区renal region、脊肋角或肾角renal angle。肾病患者触压和扣击该处可引起疼痛。,2.5cm,7.58.5cm,肾的体表投影,1B.肾的毗邻 relations of kidney,The right kidney is related to the right lobe of liver,descending part of duodenum,and right colic flexure.T
11、he left kidney is related to the stomach,spleen,tail of pancreas,coils of jejunum and left colic flexure.,Anteriorly,Superiorly-the suprarenal gland,Medially-the pedicle of kidney,inferior vena cava,abdominal aorta,Posteriorly,The costodiaphragmatic recess The 12th rib，psoas major,quadratus lumborum
12、,transversus abdominis,Posteriorly,The diaphragm The lumbocostal triangleThe subcostal vesselsThe iliohypogastric nerveThe ilioinguinal nerveThe genitofemoralnerveThe psoas majorThe quadratus lumborumThe transversus abdominis,（1）肾门renal hilum：为肾内侧缘中部的凹陷处，是肾血管、肾盂、神经和淋巴管出入的部位。,2.肾的结构,（2）肾窦renal sinus：
13、为肾门向肾内延伸，由肾实质围成的腔隙，内有肾小盏minor renal calices、肾大盏major renal calices、肾盂renal pelvis、肾动脉分支和肾静脉属支及淋巴、神经和脂肪等。,（3）肾蒂renal pedicle：由出入肾门的肾血管、肾盂、神经和淋巴管等所组成。其主要结构的排列，自前向后为肾静脉、肾动脉和肾盂，由上向下为肾动脉、肾静脉、肾盂。,3A.肾的动脉和静脉,Posterior segmental a.,Anterior trunk,Posterior trunk,Superior segmental a.,Superior anterior segme
14、ntal a.,Inferior anterior segmental a.,Inferior segmental a.,Renal a.,3B.肾段动脉与肾段,右肾的前面观,右肾的后面观,4B.肾的淋巴,4B.肾的神经,（1）肾被膜由外向内依次为肾筋膜、脂肪囊、纤维囊。,5.肾被膜,（2）肾筋膜前、后两层向下互相分离，并分别与腹膜下组织和髂筋膜移行，其间有输尿管通过。,（3）肾易向下方游走，称肾下垂。肾周脓液可沿肾筋膜向下蔓延至髂窝或大腿根部。,（三）输尿管腹部abdominal part of Ureter,行程 course分部 division 生理性狭窄 physiological
15、stricture毗邻relations体表投影 surface rejection,左、右输尿管腹部的毗邻,ileum,Duodenojejunal flexure,Testicular vessels,Descending part of duodenum,肠系膜根部root of mesentery,乙状结肠系膜部root of sigmoid mesocolon,输尿管腹部的体表投影,在腹前壁与半月线相当；在腰部约在腰椎横突尖端的连线上。,输尿管的动脉,（三）肾上腺 suprarenal gland,位置 position形态 shape毗邻 relation动脉 artery静脉 v
16、ein,1位置:位于腹膜后隙，脊柱的两侧，平第11胸椎高度，两肾的上端属腹膜外器官，为成对的内分泌器官。,2形态:左肾上腺呈半月形，右肾上腺呈三角形。,3.毗邻,（1）后面：为膈。（2）两肾上腺之间：为腹腔丛。（3）前面：左肾上腺前面的上部邻网膜囊与胃后壁;下部邻胰尾、脾血管;内侧缘邻腹主动脉。右肾上腺前面为肝,内侧缘邻下腔静脉。,经肾上腺横断层面,经肾上腺横断层面(T12L1椎间盘),13.胆囊,24.右肾30.右肾上腺5.尾状叶23.下腔静脉7.肝门静脉9.肝固有动脉17.左肾19.左肾上腺4.脾静脉16.脾20.腹主动脉,肾上腺的动脉和静脉,（四）腹主动脉 abdominal aorta
17、,The celiac trunk(T12)The superior mesenteric a.(L1)The inferior mesenteric a.(L3),The middle suprarenal a.The renal a.(L2)The testicular(ovarian)a.,The inferior phrenic a.The lumbar a.The median sacral a.,The unpaired visceral braches:,Paired visceral branches：,Parietal branches：,（五）下腔静脉 Inferior V
18、ena Cava,Its main tributaries are The Hepatic veinThe right suprarenal veinThe renal veinThe right testicular(ovarian)veinThe inferior phrenic veinThe lumbar vein,（七）腰丛 lumbar plexus,（六）腰交感干 lumbar sympathetic trunk,Formation,location,The iliohypogastric n.The ilioinguinal n.The lateral femoral cuta
19、neous n.The femoral n.The genitofemoral n.The obturator n.The lumbosacral trunk,解剖与观察Dissection and Observation,Trace and clean the superior mesenteric artery and its branches.Trace and clean the superior mesenteric vein and its tributaries.,Trace and clean the inferior pancreatico-duodenal aa.,解剖阑尾
20、动脉,观察回盲口/瓣、阑尾口,Trace and clean the inferior mesenteric artery and its branches.Trace and clean the inferior mesenteric vein and its tributaries.,Trace and Clean the hepatic portal vein and its tributaries.,Remove the retroperitoneal(pararenal)fat on both sides of the vertebral column between the lev
21、el of the T12 to L3 vertebra to expose the anterior layer of the fasica.,Make a vertical incision through the renal fascia and adipose capsule of kidney to expose the fibrous capsule and kidney.,Identify the left and right suprarenal glands.,Trace and clean the superior,middle and inferior suprarena
22、l arteries.,Trace and clean the left and right suprarenal veins.,Open the anterior layer of renal fascia,and examine the renal adipose capsule.Open the fibrous capsule.Dissect the pedicle of kidney and examine the relationship of the contents.Clean the abdominal part of the ureters.Trace and clean the visceral and parietal branches of the abdominal aorta.Clean their accompanying vein.,Clean the lumbar sympathetic trunk.Dissect the branches of the lumbar plexus.,The End,谢谢,
