后腹腔镜下肾脏手术解剖标志的应用研究

A new understanding of the anatomic structure of posterior abdominal wall in retroperitoneal laparo- scopic renal surgery

目的复习和再认识后腹腔镜下后腹壁解剖结构的形态和位置关系，建立和确认后腹腔镜下肾脏手术的解剖标志，提高后腹腔镜手术操作水平。方法2010年1—8月，对35例后腹腔镜下肾脏手术进入后腹腔和控制。肾动脉之前的操作过程进行分步解剖技术研究，记录后腹壁解剖标志的形态和位置毗邻关系，分析验证各解剖标志与。肾、肾门和肾动脉的关系。结果后腹腔镜下可见后腹壁由膈肌的腰部、腰方肌和腰大肌以及外侧弓状韧带、内侧弓状韧带和膈肌脚构成，这些肌肉和韧带在肾门背侧附近交界移行。内侧弓状韧带横行向脊柱方向指向肾门附近，膈肌脚的弧形部分与肾动脉走行成镜像状态。35例术中均可以观察到这些解剖结构，按此标志定位肾和肾门，35例均可直接到达肾门解剖分离肾动脉和静脉。结论后腹壁肌肉和韧带的位置和形态相对固定，在腹腔镜下清晰可见，可以作为后腹腔镜下肾脏手术的解剖标志。参考后腹壁的肌肉和韧带解剖标志定位肾脏，解剖分离。肾门和肾动脉是有效的实用操作技术。

Objective To provide reliable technical method by identifying referential anatomic land- marks for retroperitoneal laparoscopic renal surgery, with respect to the renal hilum and renal artery. Methods The regional anatomy of the posterior abdominal wall was studied in 35 cases of retroperitoneal laparoseopic renal surgery from January to August 2010. These included 27 cases of renal cancer, 6 cases of renal pelvis cancer and 2 cases of renal tuberculosis. Distended the retroperitoneal space using balloon dila- tion along with sharp and dull dissection. We recorded the forms and positions of the posterior abdominal cavity＇s anatomical landmarks and evaluated the relationship between each anatomical landmark with respect to the renal hilum and renal artery. Results The perirenal fascia posterior layer and perinephric fat on the renal side were observed, and several anatomical landmarks gradually appeared on the posterior abdominal wall. The diaphragm extended across the upper retroperitoneal space near the superior pole of the kidney, and the psoas major and the quadratus lumborum muscles were located at the lower retroperitoneal space, near the inferior part of the kidney. The intersection of the upper diaphragm muscle with the lower psoas ma- jor and quadratus lumborum muscles were bordered by the lateral and medial arcuate ligaments. The lateral arcuate ligament arched across the upper part of quadratus lumborum, while the medial areuate ligament arched across the upper part of psoas major. The medial arcuate ligament points extended towards the upper border of the renal hilum. These landmarks enable us to locate the position of the kidney, reach the renal hi- lum and identify the renal vessels in all 35 cases. Conclusions The relative position of the muscles and ligaments of the posterior abdominal wall are consistent and can be clearly seen under retroperitoneoscopy. Based on the position of the diaphragm and psoas major, the kidney can be located. In addition, based on the position of the medial arcuate ligament, the renal hilum and renal artery can be located. Assistance from these anatomical landmarks will simplify the retroperitoneal laparoscopie renal surgery.