髂腹股沟下入路中间窗解剖及改良

Anatomy and modification of the middle window in the subilioinguinal approach

目的为髋臼骨折髂腹股沟下入路血管损伤、术后血栓及淋巴漏的预防提供解剖学依据。方法 20具(男女各10具,40侧)国人尸体标本,参照临床手术步骤解剖,观察和测量与髂腹股沟下入路中间窗显露相关结构的特点及关系。结果腹壁下动脉23侧(57.5%)起自髂外动脉,7侧(17.5%)起自股动脉,起点距耻骨联合中点(41.35±2.33)mm,与髂外动脉夹角约(40.23±5.23)°,左右侧差异无统计学意义(P>0.05),且与骨盆纵径及半骨盆横径不相关(P>0.05)。髂血管周围无明确筋膜鞘样结构,血管和淋巴易受到牵拉损伤;股血管有明显鞘样结构,但与周围结构连接疏松易分离。髂耻弓起始处与腹股沟韧带内侧半呈(15.20±6.79)°锐性夹角,有少量菲薄膜样结构,易分离。髂筋膜内下部较厚,且厚度与骨盆纵径及半骨盆横径不相关(P>0.05)。结论髂腹股沟入路和髂腹股沟下入路中间窗显露时均易伤及血管和淋巴管,髂筋膜下部和髂耻弓结构致密,可从髂筋膜下分离与内侧窗贯通。

Objective To provide the anatomical evidence to prevent vascular damage and lyphatical leakage during the subilioinguinal approach for acetabulum fracture. Methods Twenty human adult cadavers were dissected in the Anatomy Department of Xinxiang Medical University. The structures associated with the middle window of the subilioinguinal approach were observed. Results Inferior epigastrie artery was derived from external iliac artery （57.5%） or femoral artery（ 17.5% ） , was （41.35 ± 2.33 ） mm from pubic symphysis, and had a （ 40.23± 5.23 ） ° angle with external iliac artery. There was no difference between left and right sides, and no correlation with the width and length of pelvis. There was no fascia-like structure around the iliac blood vesses. The fascia-like structure was observed around the femoral blood vessels but it was easy to be separated from the surrounding structures. The angle between the origin of iliopectineal arch and the medial end of the inguinal ligament was sharp and at （ 15.20± 6.79） ° and filled by a thin membrane-like structure. The medial and inferior part of the iliac fascia was thick and had no correlation with the width and length of pelvis. Conclusion Blood vessel and lymphatic vessel are prone to injury in the subinguinal and inguinal approaches. Inferior part of iliac fascia and iliopectineal arch are compact, and thus the lateral window may pass through medially under the fascia iliaea.