下腹部腹直肌肌皮瓣血供的应用解剖

PRELIMINARY DISSECTION OF THE BLOOD SUPPLY ON MYOCUTANEOUS FLAP OF RECTUS ABDOMINIS ON HYPOGASTRIC ZONE

目的了解与下腹部腹直肌肌皮瓣相关的血管分布情况,促进乳腺癌根治术后下腹部肌皮瓣移位乳房再造手术的推广。方法采用福尔马林浸泡未超过6个月的成人尸体15具30侧。上起锁骨下、下至腹股沟韧带,两侧至腋中线的胸腹壁完整切下。腹壁下动静脉自髂外动静脉起始处离断。分别用红、蓝乳胶墨水经腹壁下和胸廓内动静脉灌注,使其分支、属支显影。结果腹壁上、下动脉起始处外径分别为1.87±0.28mm及2.25±0.32mm。腹壁下动脉的皮下穿支分布有向脐水平逐渐密集的趋势,弓状线以下穿支明显减少,Rand各个区均可见穿支出腹直肌前鞘,排列上外侧穿支距腹直肌前鞘外侧缘、、区分别平均为1.22、1.46、1.57cm;内侧穿支在距正中线、、区平均1.54、1.62、1.66cm。近脐的穿支管径较其他部位粗和密集。腹壁上动脉在与肋弓下缘交界附近发出一肋缘动脉,距肋弓1.25±0.37cm。发出肋缘动脉后67%的肋缘动脉比腹壁下动脉本干粗。肋缘动脉分支分布于腹直肌中、外侧2/3,且与肋间前动脉及营养膈肌的血管间有广泛吻合。胸廓内动脉在发出腹壁上动脉前后还分出一分支营养剑突水平的腹直肌。结论以腹壁上动脉为蒂的横形下腹部肌皮瓣切取过程中,脐以下、弓状线以上保留腹直肌前鞘内、外侧各1cm在腹壁上和区的全部前鞘在皮瓣上,能较好保护腹壁下动脉肌皮动脉不受损伤。将肋弓下2cm以上的腹直肌前鞘和腹直肌完全保留在皮瓣上可有效保护肋缘动脉。肋缘动脉不受损是肌皮瓣成活的重要保证。

Objective To investigate the location of the artery correlated with rectus abdominis musculocutaneous flap in order to promote the reconstruction of the breast after radical mastectocy for breast cancer. Methods An anatomic study was carried out on 15 cadavers of 30 sides,which were immersed in paraformaldehyde less than six months. Whole thora-epigastrica wall was cutted, which scale was from subclavian as upper limit to inguinal ligament, the lower limit across left and right of middle axillary. Veins or arteries of inferior epigastrica and internal thorax in hang were injected with red or blue ink to show all of vessel branches. Results The external diameters of both the superior epigastric arteries and inferior vessels were 1.87±0. 28 mm and 2.25±0. 32 mm respectively. The myocutaneous arteries from inferior abdomen vessels had an intensive horizontal distribution on hylum. The perforators significantly decreased but could be found to pass through anterior rectus sheath in Rand. The distances between lateral perforators and Ⅰ , Ⅱand Ⅲ parts in external edge of anterior rectus sheath were 1.22, 1.46 and 1.57 cm, respectively; and the distances between medial perforators and Ⅰ , Ⅱ , and Ⅲ parts at median line were 1.54, 1.62, 1.66 cm. Perforators were more thick and intensive near hylum than in other part. The subcostal arteries derived from inferior abdomen artery and 1.25±0. 37 cm away from costal arch. After dividing into subcostal artery, the outer diameter of 67 percent of subcostal artery was bigger than that of inferior abdomen arteries. The branches of subcostal arteries were distributed at the 2/3 lateral rectus abdominis, forming an extensive choke anastomosis system with intercostal anterior artery and vessels supplied diaphragmatic muscle. The rectus abdominis at the level of xyphoid was supplied by a branch came from inferoir thorax artery, which diverged epigastric vessels at the same time. Conclusion During the process of making the inferior transverse rectus abdominis musculocutaneous flap base on superior epigastric vessels and superoir rectus abdobminis, reservation of pro theca edge 1 cm of rectus abdominis can protect inferior abdomen artery from injury. Reservation of more than 2 cm pro-theca and rectus abdominis below costal arch at the flag will protect effectively subcostal artery from injury. No damage of subcostal arteries can influence the survival of musculocutaneous flap.