后鞘前入路腹腔镜视野下腹股沟区脂肪归属的解剖要点及临床意义

The anatomic key points and clinical significance of fat attribution in the inguinal region under laparoscopic vision via anterior posterior sheath approach

目的观察腹腔镜视野下后鞘前入路脂肪形态及血管分布,探讨脂肪的归属及层面的解剖要点。方法回顾分析2022年1月至2023年5月青岛阜外心血管病医院和青岛大学附属医院所完成的后鞘前入路全腹膜外疝修补术(TEP)的视频资料,共30例,对TEP的手术路径、解剖标志,尤其脂肪的归属进行分析。结果30例患者均成功完成手术,在全程后鞘前入路下黄色脂肪的归属,具有层面导向,不论在后鞘前初建空间,还是在手术区域的腹膜前间隙,包括Retzius和Bogros间隙,重要的解剖标志:膀胱前筋膜、耻骨梳韧带、髂外血管、腹壁下血管、输精管(子宫圆韧带)、生殖血管、死亡冠、危险三角、股外侧皮神经、生殖股神经、闭孔神经和闭孔动脉等,均有黄色脂肪的层面,均涉及归属问题,通过脂肪的归属,有效安全完成精索去腹膜化,防止腹膜破裂,降低并发症,有效处理疝囊,安全、有效、高质量完成TEP手术。结论正确的脂肪归属,层面的清晰解剖,对腹腔镜视野下全腹膜外腹股沟疝的修补具有重要意义,熟练掌握脂肪的归属,有利于缩短TEP的学习曲线并更加有效地掌控该手术方式,术者和患者均受益。

Objective To observe fat morphology and blood vessel distribution by anterior posterior sheath approach under laparoscope,and to discuss the attribution of fat and the anatomical key points of the level.Methods Video data of 30 cases of totally extra-peritoneal hernia repair(TEP)performed by anterior posterior approach in Qingdao Fuwai Cardiovascular Hospital and the Affiliated Hospital of Qingdao University from January 2022 to May 2023 was retrospectively analyzed.Surgical paths,anatomical markers,especially fat attribution of TEP were analyzed.Results 30 cases were operated successfully,the attribution of yellow fat under the whole anterior posterior approach is stratifier-oriented,whether in the initial space in the anterior posterior sheath or in the preperitoneal space in the surgical area,including the Retzius and Bogros Spaces.Important anatomical markers:anterior bladder fascia,pectineal ligament,external iliac blood vessel,subabdominal blood vessel,vas deferens(round ligament of uterus),genital vessels,corona mortis,dangerous triangle,femoral lateral cutaneous nerve,genital femoral nerve,obturator nerve and obturator artery,etc.All of them have yellow fat levels,and involve attribution issues.By the attribution of the fat,we can complete spermatic cord deperitonealization effectively and safely,prevent peritoneal tears and reduce complications,manage the hernia sac effectively,and complete the TEP surgery safely,effectively and with high quality.Conclusion The correct attribution of fat and the clear anatomy of the layer have great significance for the laparoscopic TEP inguinal hernia repair.Knowing the attribution of fat is conducive to shorten the learning curve of TEP and control the operation method more effectively,which benefits both the surgeon and the patient.