腹股沟区解剖及腹股沟斜疝患者腹内压力的研究(可编辑)
腹股沟区解剖及腹股沟斜疝患者腹内压力的研究
中山大学
硕士学位
腹股沟区解剖及腹股沟斜疝患者腹内压力的研究 Study about groin anatomy and the intra?abdominal
pressure in indirect hernia patients
临床医学七年制硕士研究生:周太成
专业名称:外科学
指导导师:陈双主任医师
答辩委员会主席:
\、, l I,\
j彩k
下机弘
“幺’1乏L
《善?
中山文学硕,.学位论文
腹股沟区解俐及腹股沟科知您者腹内m力的研究 腹股沟区解剖及腹股沟斜疝患者腹内压力 的研究
学科专业:外科学专业
硕士研究生:周太成
‘
导
师:陈双主任医师
中山大学附属第二医院普通外科广州(510120)
摘要
腹股沟疝是人类特有的常见病和多发病。其中斜疝是最常见的腹外疝,发病
率占全部腹外疝的75%~90%;占腹股沟疝的85%~95%。虽然外科治疗腹股
沟疝有数百年的历史,疝外科治疗也由经典的张力修补发展到目前的无张力修补
技术,各种补片及腔镜技术也应用于临床,但疝外科治疗结果仍不十分满意。无
论何种技术、何种方法,仍有一定的术后复发率。究其原因,我们认为丰要是对
疝的本质尚未完全弄清,人们对疝的解剖、生理、病理等方面的基础研究不全面。
为此,本研究从解剖和牛理角度来观察腹股沟区域的变化,以期对今后临床
有所帮助。
本研究由两个部分组成:
l、解剖尸体研究腹股沟区域结构,内容包括内环位置、腹股沟管和髂前上
棘与耻骨结节连续的夹角等解剖结构,观察并对比两侧解剖有无差异。
2、测定腹股沟斜疝患者的腹内压力,并与非疝人群对照组进行比较,了解
观察两组病人腹内压有无差异及变化。
第一部分:腹股沟区解剖结构分析研究
研究目的
了解腹股沟区域与斜癌发生有关的重要结构结构
研究方法
1.研究对象:经福尔马林防腐处理尸体共11具,由中山大学中山医学院解
亏山文学硕1:节位论文
娌j拯沟区解剖及叛雌沟斜弛也者耀肉瓜力的研究
剖教研室提供。尸体为成年,估计年龄在20?60岁之间,其中男7
具、女4具。
2.解剖方法:大体按层解剖,由浅至深,先后依次切开皮肤、皮下,将腹
外斜肌踺膜从髂前上棘水平切至腹直肌外缘,然后沿腹直肌外缘切至耻骨
结节,再将腹外斜肌腱膜翻向外下方,向下观察腹横筋膜结构,游
标卡尺
和量角器分别测量内环位置、腹股沟管和髂前上棘与耻骨结节连线夹角。
3.观察指标
1)内环的位置:以腹股沟韧带中点(MIL)为标志点,分别测量内环中点与
MIL竖直(偏内用负数
示,偏外用正数表示)线及与水平线的距离。
2)腹股沟管倾斜度:测量腹股沟管和髂前上棘与耻骨结节连续的夹角。
II
?中山文学硕f.学位论文
腔股沟区解荆及腹股沟斜蛐患者腹内K力的研究
4.统计学处理
本实验各测量值采用Mean?SD表示,采用SPSS 13.0统计软件包处理,
两独立样本间比较用t检验,左右两侧比较采用配对比较检验,P
书,自愿参加木项研究。
1.斜疝组:为本科收治的腹股沟斜疝患者,男性(24岁~72岁,平均57.6
岁),共19入。
2.对照组:为本科收治的非疝病人。包括消化道肿瘤8例、胆道结石4例、
精索静脉曲张2例和肛瘘、痔及肛裂等疾病各l例。消化道肿瘤均为进
行可根治手术切除,其中直肠癌4例,胃癌2例,降结肠癌l例,直肠
腺瘤l例。均为男性(29岁~69岁,平均50.5岁),共20人。
3.排除
:
1)体重指数低于或超过正常(18.5~23.9Kg/mz);
2)患有神经源性膀胱、脊髓损伤等影响膀胱内压力的疾病:
3)有肠梗阻、胰腺炎等腹压升高或慢阻肺、肺心病等影响腹部压
力疾病。
二.腹内压测定方法:
采用间接法测定腹内压力,即留置尿管测定膀胱内压,压力值单位为cI【IH20。
取3次测量的平均值。
三.观察指标:
分别测量卧位膀胱内压(IVP)、卧位加压(Valsara动作)后膀胱内压力、
立位膀胱内压力、立位加压(Valsava动作)后膀胱内压力:
中山文学颂I学位论文
腹股淘K觯剖及腹唆沟斜他心者腹内?山的研究
I.卧位腹内压力=卧位IVP
2.立位腹内压力=立位IVP
3.卧位加压后腹内压力=卧位加压后IVP
4.立位加压后腹内压力=立位加压后IVP
再通过洲得值,计算出立卧位腹内压力差、卧位加压后腹内压力差、立位加
压后腹内压力差及立卧位加压后腹内压力差等各值进行统计分析。
5.立卧位腹内压力差=立位IVP一卧位IVP
6.卧位加压后腹内压力差=卧位加压后IVP一卧位加压前IVP
7.立位加压J舌腹内压力差=立位加压后IvP一立位加压前[VP
8.立卧位加压后腹内压力差=立位加压后IVP一卧位加压后IVP 四.统计学处理
两组各值均分别用Mean4-SD表示,采用SPSSl3.0处理,组问比较
采用t
检验,P
O.05)。
3.2斜疝患者组卧位加压前后腹内压力差值为:29.77?
16.36cmH20
对照组的卧位加压前后腹内压力差值为:22.45?11.36cmH20: 两者之间比较无显著性差异:p=O.788
3.3斜疝患者组立位加压前后腹内压力差值为:45.50?
11.96cmH20
对照组的立位加压前后腹内压力差值为:29.98-t-16.93cmll20:
两者之间比较有显著性差异:p=O.002
3.4斜疝患者组立卧位加压后腹内压力差值为:40.39?
13.02cmH20
对照组立卧位加压后腹内压力差值为:22.45?11.35c时120 两者之间比较有显著性差异:p=O.00
结论
1.在静息状态,斜疝组病人与对照组病人立、卧位的腹内压力并
无明显差别。
2.直立位做加压动作时,斜疝患者腹内压力明显大于对照组。
3.斜疝患者体位变化并做如压动作时,腹内压变化差值明显大于
对照组。
关键词:腹股沟斜疝;成因;腹股沟区解剖;腹内压
VI
《》中山上学硕I.学位论文
腹腔沟区解剖及腹雌沟斜癌忠者腹内m力的研究
Study about inguinal anatomy and the intra-?abdominal pressure in indirect hernia
patients
Postgraduate:Zhou Tai?cheng
Supervisor:Prof.Chen Shuang
Department
ofGeneral Surgery,The Second Affiliated Hospital of
Sun扬乒&,z
University,Guangzhou,P.R.China AB STRACT
Introduction
Inguinal hernia is
a
kind ofcommon and frequently occurring illness peculiarly
in
human being.Indirect inguinal hernia,which is the most common hernia in abdominal
external hernias,occupies 75%-090%in abdominal external hernias
and 85%--95%in
inguinal hernia.The history of surgical treatment for inguinal hernia is勰long
as
hundreds of years,the hernial surgery has developed into the
era
of tension free repair
from classic tension
repair,and
lots of kinds of patch and laparoscopic techniques
are
adopted in clinic,but the therapeutic result of inguinal hernia still remain
not very
satisfied.No
matter which technique
or
method,has its own recurrence
postoperative.
We
think the main
cause
is that we
haven’t
understood the nature of hernia completely,
and
and
the relative studies about hernia are scarcag,such
SOOIL
as
anatomy,physiology,pathology,
We studied
the changes in
anatomy and physiology ofgroin
area,and
we wish this
research will do some help to clinic. This study is
composed
ofthe following two parts:
1.We studied the inguinal anatomic structures ofcadavers,including location of
internal
inguinal
ring
and
the included
angle
between
inguinal calla[and the
line
acrossing anterior superior lilac spine and
pubic
tubercle.We
compared the structure
between two sides to determine whether there Was difference.
VII
卞山文学硕}:学位论文
腹腔淘区解创及腹帔沟斜癌您青腹内堆力的研究
2.We measured
intra-abdominal pressure of patients with hernia,and
compared
the results with other patients tO
identify whether there were changes I
-25Part
and difference.
Study and analysis
on
inguinal anatomic structure Objective
To investigate the important groin anatomic structures
attributing tO the genesis of indirect inguinal hernia
Methods of study
1.Material
The groin
al'cas
of 1 1 human cadavers were studied,which、?ere kindly
supplied
by Anatomy of Sun-Yat Sen medical college and
fixed in
a
10%formaldehyde
solution.The specimens
age?
2.Methods
included
7 males and 4 females,aged from 25 to 60 years of The
skin and subcutaneous tissue of each specimen was cut open
in order.The
aponeurosis of obliquus externn.s abdominis was excised
from
anterior
superior iliac
spine to external border of rectus abdominis,and then to
pubic tubercle along the
border,and finally Was tumed OVer,The structure
oftransversalic faseia was
observed.
Intemal rings and inguinal canal were detected with vernier
caliper and conimeter.
3.Observation index
11.Location ofinternal ring
The labeling is the medial point of inguinal ligament(MIL),we measured
the
vertical distance between
medial
point ofdeep
ring(MDR)and
the erect/horizontal
lines crossing MIL respectively.
2、.Slope ofinguinal
canal
We measured
the
included angle between inguinal canal and the
line acrossing
anterior superior iliac spine and pubic tubercle.
VHI
中山文学颀1卞位论文
4.Statistical analysis
腹|蹬沟区解;=}?及腹股淘斜缅忠者腹IJjHi力的研究
The values in this study were expressed硝mean+SD(Standard Deviation)and
analyzed with software SPSS 1 3.0.t-test WaS adopted in the
analysis of
independent
samples,and
paired
test WaS taken in comparison between data of left and right
sides.
Significance
is
assigned
for p<0.05.
Results
1.Location ofinguinal deep ring
1.1 The vertical distance between MDR and
the erect line crossing MIL. Left side:一2.45士3.70mm
Right side:一3.64士4.46mm
The P value
ofpaired
test
between
two group data Was O.135.there Was
no
significant difference between two sides.
1.2 The vertical
distance
between MDR
and the
horizontal line crossing MIL.
Left side:11.55士5.03mm
Rjght side:13.45士5.94mm
The P value
ofpaired
test
between two group
data was O.017.the distance between MDR and the horizonlal line crossing MIL WaS
thall that in the left side. inguinal canal.
-82.Slope of
Left side:13.64士3.32 degree
Right side:15.28士3.1 0 degree
significantly
longer
TheP
valueofpairedtestbetweentwo groupdamWaSO.216,thereWaSno
significant
difference
between two sides.
Conclusion
1.The inguinal anatomic structures
ale
not exactly the sa/ne as the other side.
2.The opening of IDR in right is higher
and more
internally
deviated than
that in the
left side.The
slope ofinguinal
in right is slightly larger than that in the left side.
?
中山土学硕f:学位论文
Part
腹般淘区解剖及腹盼沟斜蛐忠者腹内压力的研究
II
Study about intra?abdominal pressure(IAP)in indirect
hernia patients
Objective
IAP and its changes in indirect hernia patients were
studied and
that ofother patients’.
enmp删with
1.Patients:
Methods
to
study
All the
1).Indirect
patients
inguinal
taking part in this study were voluntary and signed
permission.
hernia group:19 male patients with indirect inguinal hemia
admitting ha
our department
were smdicd in this re:辩arch,24~72years old.the average
age is 57.6 years old.
21.Control group:20 male patients with other diseases
which didn’t affect patients’
LAP were chose
as
contr01.These diseases
included
8 case of tumom of alimentary
tract(4
cases
of rectal cancer,2 cases of gastric carcinoma,1 case of
left colonic
carcinoma
and
1
case
of rectal adenoma,all the tumors can
be radically
resected),4
cases of biliary calculi,2 c舔cs of varicocele.1 case
respectively
of anal fistula,
hemorrhoid,anal fissure,etc.29~69 31.Standard for exclusion:
years old,the average age is 50.5 years old.
(重)Body
mass
index(BMI)exceeded
or
infra-normal
standard(18.5~23.9Kg/m2). ?Complicated
with diseases which can
affect intravesical pressure(IVP),including Neurogenic bladder,spinal injury,etc.
?Complicated
with
diseases
which
can
affect
intraabdominal
prcssure(IAP).
including intestinal obstruction,acute
pancreatic,COPD,etc. 2.Measurement
of lAP
We adopted indirect method,by which we measared IVP through Foley’s urinary tube,and we
took the average value ofthree measlll.ements as research
data.
3.Detect index
X
_r山土学硕I:学位论文
腹股沟区解荆及脾股沟斜I山忠者腹山m力的研究
We measured IVP in supine position(SIVP),and let patients
use
Valsava
maneuver to take increased IVP(svivP).Then
we
asked
patients to turn
to
upright
and measured IVP in
orthostatism(OIVP),finally got increased IVP in upright
potion(ovIvp).
1.S【AP=SIVP
2.0IAP=oIVP
3.SV乳~P=SV?P
4.OVIAP=OVIVP
According this measurement results,we calculated the
differences
between
different positions and/or whether using Valsava
maneuver
or
not.These differences included
the
difference
of lAP between orthostatism
and
supine
position(0SIAPD), the
differences of lAP
between before
and
after using the Valsava
maneuver
in supine
position(SVIAPD),the difference of队P between before and after using the Valsava
maneuver
in orthostatism(0VIAPD),the difference of lAP
between
orthostatism
and
supine position after using Valsava maneuver?SVIAPD).
5.OSlAF?D=OIVP.SIVP
6.SVLAPD=SVIVP?SIVP
7.oVlAPD--OVIVP-OIVP
8.OSV【APD=OVIVP。SVIVP
4.Statistical analysis
The values in this study were expressed as mean+SD(Standard
Deviation)and
analyzed
with software SPSS 13.0.t test Was adopted
in the analysis of two different group.Significance is assigned for p<0.05.
Results
1.There was
no
significant difference
in age,BMI and sickness
rate
of
benign
hypefplasia ofprostate between 2.Measured Pressure
experimental group and control group. 2.1
Experimental group:SIAP=5.65?1.81cmH20
Con仃ol
group:SnP=4.88_--_3.73cmH20 Xl
|P山大学硕l:学位论文
腹股沟区解俐及腹股沟斜蛐心者腹内,fi力的研究
There was
no
significant difference between two groups
in SlAP,P=0.42.
2.2 Experimental group:OIAP=29.394-4.60cmH20
Control group:OIAP=28.154-6.18cmH20 There was
no
significant difference
between two groups
in OIAP,P=0.482.
2.3 Experimental group:SVIAP=35.53 4-L6.30cmH20
Control group:SVIAP=36.08 4-16.95cmH20 There was
no
significant difference
between two groups
in SVIAP,P=O.919.
2.4
Expefimenml
group:OVIAP----76.00+1 1.21cmH20
Control
group:OVIAP=58.t3?18.90cmH20
The difference
between two
groups in OVIAP was significant,P=o,001. 3.Difference between IAP
3.1 Experimemal group:OSIAPD=23.74+_4.72cmH20 Control group:OSIAPD=23.274-4.54emH20 There was
no
significant difference between two groups in OSIAPD, P=-0.752.
3,2 Experimental group:SVIAPD=-29.774-16.36cmH20 Control group:SVIAPD 222.45-t-1 i.36cmH20 There was
no
significant
difference
between two groups
in SVIAPD,
P--0.788.
3.3 Experimental group:OVIAPD=45.504-1 1.96cmH20
Control
group:OVIAPD=29.984-16.93cmH20 The
difference
between two groups in OVIAPD was significant,P=0.002.
3.4
Experimental
group:OSVIAPD=40.39--+13.02cmH20 Control
group:OSVIAPD=22.45+1
1.35cmH20
The
difference between
two groups in
OSVIAPD wag significant,P=0.00. Conclusion
1。There is
no
significant
difference
in
lAP between patients with
IIH and
control group in
quiescent condition.
2.1AP in patients with[IH is significantly larger than that
in control group
XII
中山土学硕I。学位论文
腹股沟区解j=}ll及腹股沟斜蛐忠者愎山}矗力的研究
when doing Valsava maneuver and taking upright position. 3.The change of lAP is more obvious than that in control
group only when
doing Valsava maneuver and thanging dorsal position to
uptight
position
Key
Words:indirect
inguinal
hernia;cause;groin
area
anatomy;
intra-abdominal pressure.
《》中山土学颂I.学位论文
腹IJ5}沟区解!!!塑脞沟斜仙!!!里悝坐力的研究
腹股沟区解剖及腹股沟斜疝患者腹内压力的研究
Study about groin anatomy and the intra-abdominal pressure
in
indirect hernia patients
专
业:外科学
硕士研究生:周太成
导
师:陈双主任医师
刖舌
人类对疝的认识最早可追溯至遥远的上古时代,疝的发展凝结了整个外科发
展各时期重要事件的精义,如外科解剖、无菌术、麻醉止痛、止血、牛物材料和
微创技术等。腹股沟疝是外科领域常见及多发疾病,全世界每年所进行的腹股沟
疝修补手术超过2000万例。腹股沟疝可发生于任何年龄,罹患腹股沟疝的终身
机率,男性可为27%,女性为3%。斜疝是最多见的腹外疝,发病率占全部腹外
疝的75%~90%;占腹股沟疝的85%~95%Ill‘2?“。腹壁和疝外科领域现今
的研究热点集中在疝成因、疝修补方法和复发性腹股沟疝的手术治疗等方面。
近年来,人们对斜痛成因研究也越来越多,且现代技术手段的应用一定程度
上使人们对其有了新的了解。腹股沟直疝的成因现己基本达成共识,即认为直疝
是腹股沟区先天的缺陷或是后天的损害,在持续增高的腹内压力作用下发生。但
迄今为止,占腹股沟疝大部分的斜疝,其确切原因、发病机制仍未得到阐明。
综合现代各观点,腹股沟斜疝主要有以下几个成因‘4儿朝‘“:
l-先天囊学说:以鞘状突未闭(PPV)形成先天存在的疝囊为理论基础,而
在婴幼儿腹股沟疝的发生中,这个学说已被大多人接受。但在许多四肢动物、部
分成年人中(10%~20%),他们的鞘状途保持终生开放,但他们终生不患斜疝。
专山文学硕1?学位论文
腹般沟区群荆及腹殷沟斜癌卷者驻内j鬟力的研究
所以该学说在腹股沟斜疝的发牛中的作用一直没有得到确定。
2.内环嵌闭机制削弱:在内环口内侧缘,腹横筋膜变厚形成u形的
Hesselbach韧带。当腹横筋膜收缩,该韧带将深环向外上牵拉,增加腹股沟管
的斜度,发挥嵌闭作用。如果这种机制减弱或消失,在PPV的患者中,斜疝就发
牛了。但现今对于该韧带的研究很少,甚至没有真正发现这个结构及其运动事实。
3.腹膜后脂肪下移学说:该学说认为因腹腔内几乎所有脏器都是固定在后腹
膜的,所以直立引起的腹腔脏器向下垂、牵拉,使得腹壁各部位的受力不均,后
腹膜的脂肪可逐渐向下移动。这种变化可能会改变内环口在腹腔内开口的角度和
结构,使得内环或直疝三角直接暴露在压力下,因此改变了机体原有的保护机制,
从而导致疝的发生。该理论为新近提出的疝成因假说,尚需通过研究加以检验。
4.遗传学说:依据建立在存在高发腹股沟斜疝的家族这个现象上,但这种家
族毕竟较少,且并不是每个斜疝患者都有家族史。加上遗传学说赖以牛存的相关
的基因一直没有找到,临床上也没有相关的证据证实该家族是否存在PPV,所以
该学说一直没有为辛流所接受。
5,胶原退变学说:目前,人们已经证实胶原纤维的退行性变化于年龄相关,
而且在成人疝患者中,腹膜、腹直肌鞘、腱膜等胶原纤维含量下降,且在疝修补
术后晚期复发的老年患者,几乎都有胶原的退行性变‘7卜m3。提示腹股沟疝是
一种年龄相关的全身性病变。但该学说在腹股沟斜疝的发生发展中的地位经过研
究并不明显。
另外,人们也一直推测腹腔内压力的变化可能在斜疝的发生过程中起着作
用。但国内外对其的作用一直未予详细的研究,我们也找不到确切的证据。腹腔
内压力增高究竟有没有对斜疝的发生发展起作用、怎样起作用?我们一直不得而
知。
1997年以来,无张力修补术在疝及腹壁外科领域不断得到推广和普及,由于
具有对局部解剖破坏小、复发率低、恢复快、操作简单及经济效
益好的特点,现
今无张力疝修补术己基本替代了传统修补术。且随着微刨时代的来临,腔镜手术
在疝领域的应用也日趋普遍。但无论何种技术、何种方法,仍有一定的术后复发
率。据统计[1l J国外的总体复发率为l%;而国内5年复发率仍为1%~3%,
有的地方甚至高达6.1%。究其原因,我们认为丰要是对疝的本质尚未完全弄清,
2
?中山文学硕L学位论文
愎腔沟呸竺型墨璺悭塑翌兰竺兰坚生!!:竺竺竺兰
人们对疝的解剖、牛理、病理等方面的基础研究不全面。尚需通过相关的研究,
提出更合理的治疗方法。
综上所述,本课题拟从以下两个角度进行研究:
l、解剖方面:解剖尸体了解腹股沟区解剖,包括内环位置、腹股沟管和髂
前上棘与耻骨结节连线的夹角等解剖结构。了解正常人腹股沟区与腹内压力作用
最重要的解剖结构:内环、腹股沟管的解剖特点,为进一步研究斜疝发牛后该各
个解剖结构发乍的变化提供对照、参考。
2、牛理方面:测定正常人与腹股沟斜疝患者不同体位、加压动作下的腹内
压力,并进行对比,以了解腹内压力变化在腹股沟斜瘸发辞三中的作用、地位。
我们希望通过这两方面及后续的一系列相关研究。能使斜疝的发病特点通过
腹内压力分布与腹股沟区解剖特点的关系来进行阐述;了解腹内压力在斜疝形成
中的地位;根据研究成果,应用于临床,能对现今斜疝修补术略加以改进,即通
过改变内环口在腹内开13角度,新的受力结构,使得内环处重新形成正常的
受力角度,组织腹腔内容物的继续突出,以维持腹股沟管的正常嵌闭机制:并积
极鼓励进一步相关临床研究,以减少腹股沟斜疝的复发率。
章山大李硕‘{:学位论文
壤股沟区解剂及龌Jl!}沟斜疝怨青腹内}f:力的研究
第1部分:腹股沟区解剖结构分析研究
1.1研究目的
了解腹股沟区域与斜疝发牛有关的重要结构结构
1.2研究方法
1.2.1研究对象:经福尔马林防腐处理尸体共ll具,由中山大学中山医学院解
剖教研室提供。尸体为成年,估计年龄在20?60岁之间,其中男7具、
女4具。
1.2.2解剖方法?1[133:按层解剖,由浅至深,依次切开皮肤、皮下,将腹外
斜肌腱膜从髂前上棘水平切至腹直肌外缘,然后沿腹直肌外缘切至耻骨
结节,再将腹外斜肌腱膜翻向外下方,向下观察腹横筋膜结构,游标卡尺
和量角器分别测量内环位置、腹股沟管和髂前上棘与耻骨结节连线夹角。
1.2.3观察指标
1)内环的位置:以腹股沟韧带中点(MIL)为标志点,分别测量内环中点与
MIL竖直(偏内用负数表示,偏外用正数表示)线及与水平线的距离。
尸体解剖内环定位意图
4
?中山太学顾I:乍位论文
腹股沟恒群荆及腹股淘斜知心青腹山压力的研究
2)腹股沟管倾斜度:测量腹股沟管和髂前上棘与耻骨结节连续的夹角。
图1-3
腹股沟管倾斜度的测量
1.2.4统计学处理:本实验各测量值采用Mean_+SD表示,采用SPSS 13.0统
计软件包处理,两独立样本间比较用t检验,左右两侧比较采用配对比
较检验,P
举报
浙公网安备 33021202002483