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浙江大学学报(医学版)  2018, Vol. 47 Issue (4): 329-337    DOI: 10.3785/j.issn.1008-9292.2018.08.01
指南与实践     
腹腔镜下间隙解剖观察阴道三水平理论的关键解剖结构
赵小峰1(),陈功立2(),雷玲3(),吴晓梅4(),刘世凯5(),汪俊涛6(),胡滨7(),吕卫国8()
1. 浙江省人民医院妇科, 浙江 杭州 310014
2. 陆军军医大学第一附属医院(重庆西南医院)妇产科, 重庆 400038
3. 安顺市人民医院妇科, 贵州 安顺 561000
4. 云南省第一人民医院妇科, 云南 昆明 650034
5. 沧州市中心医院妇一科, 河北 沧州 061000
6. 贵阳市第一人民医院龙洞堡分院妇产科, 贵州 贵阳 550005
7. 郑州大学第二附属医院妇科, 河南 郑州 450014
8. 浙江大学医学院附属妇产科医院肿瘤科 浙江省子宫恶性肿瘤诊治技术研究中心, 浙江 杭州 310016
Key anatomies of DeLancey's three levels of vaginal support theory: an observation in laparoscopic surgery
ZHAO Xiaofeng1(),CHEN Gongli2(),LEI Ling3(),WU Xiaomei4(),LIU Shikai5(),WANG Juntao6(),HU Bin7(),LYU Weiguo8()
1. Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou 310014, China
2. Department of Obstetrics & Gynecology, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
3. Department of Gynecology, People's Hospital of Anshun City, Anshun 561000, Guizhou Province, China
4. Department of Gynecology, the First People's Hospital of Yunnan Province, Kunming 650034, China
5. Department of Gynecology, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
6. Department of Obstetrics & Gynecology, Longdongbao Campus of the First People's Hospital of Guiyang, Guiyang 550005, China
7. Department of Gynecology, the Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450014, China
8. Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang Province, Department of Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
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摘要:

目的: 在宫颈癌腹腔镜手术中观察并验证阴道三水平理论的关键解剖结构,为盆腔器官脱垂患者手术提供依据。方法: 20例宫颈癌患者C型子宫切除及盆腔淋巴结清扫手术时在腹腔镜下基于自然间隙暴露阴道三水平理论相关解剖结构,观察分析其结构特征及承力方向。结果: Ⅰ水平主要的坚韧韧带样结构是子宫骶韧带,其作用力方向在骶骨方向,起主要的顶端固定作用,而主韧带区域主要是血管淋巴管及周围疏松结缔组织,缺乏坚韧结缔组织结构,其连接于髂内血管系统;Ⅱ水平阴道侧方未发现坚韧结缔组织连接于盆筋膜腱弓,盆筋膜腱弓是盆膈上筋膜的边缘,与闭孔内肌筋膜交界,表面光滑,紧贴肛提肌于近阴道中下三分之一交界处融合于阴道筋膜。游离输尿管隧道时可以发现输尿管子宫动脉交叉附近位置前后壁均有致密结缔组织结构,即膀胱宫颈韧带,固定膀胱三角的两个侧角,起自宫颈阴道而终止于膀胱肌层。结论: 肛提肌上方的盆底筋膜韧带支撑主要围绕阴道而成,而肛提肌以上的筋膜韧带结构呈两个平行面,可基于"阴道核心"和"双层吊床"解剖特征进行盆底重建手术设计。

关键词: 腹腔镜检查阴道/解剖学和组织学骨盆底/解剖学和组织学骨盆底/外科学子宫脱垂/病因    
Abstract:

Objective: To observe and verify the key anatomies of DeLancey's three levels of vaginal support theory through laparoscopic surgery by space dissection technique. Methods: The features and stress performance of related anatomies were observed and analyzed in laparoscopic type C hysterectomy and pelvic lymphadenectomy for cervical cancer by natural space exposures. Results: The main ligament-like structure at level Ⅰ was the uterosacral ligament, which acted as the main apical fixation in the sacral direction, while the cardinal ligament was mainly composed of vascular system, lymph-vessels and loose connective tissue around them, lacking the tough connective tissue structures, which was connected to the internal iliac vascular system. There were no strong ligaments connected to the tendinous arch of pelvic fascia (ATFP) at the lateral side of vaginal wall at level Ⅱ. ATFP was the edge of the superior fascia of pelvic diaphragm, which was bounded by the fascia of the obturator. Its surface was smooth and close to the levator ani muscle and fuses with the vaginal fascia in about one thirds of middle lower segments of the vagina. When the ureter tunnel is separated, dense connective structures can be found in both anterior and posterior walls near the intersection of the ureter across uterine artery, fixing the bilateral angle of the bladder triangle, starting from the cervix and vagina and ending in the tunica muscularis vesicae urinariae. Conclusion: Based on the laparoscopic anatomy, the pelvic floor fascia ligament support above the levator ani muscle can be considered mainly around the vagina, and fascial ligament above the levator ani muscle can be simply considered as two parallel planes forming a "double hammock" structure, which may provide more anatomic data for pelvic floor reconstruction.

Key words: Laparoscopy    Vagina/anatomy & histology    Pelvic floor/anatomy & histology    Pelvic floor/surgery    Uterine prolapse/etiology
收稿日期: 2018-01-20 出版日期: 2018-12-07
:  R711  
基金资助: 云南省创新团队(2017HC008);国家重点研发计划(2016YFC1302900)
作者简介: 赵小峰(1976-), 男, 博士, 主任医师, 主要从事妇科肿瘤、盆底疾病相关研究; E-mail:12908372@qq.com; https://orcid.org/0000-0002-8579-6997
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引用本文:

赵小峰,陈功立,雷玲,吴晓梅,刘世凯,汪俊涛,胡滨,吕卫国. 腹腔镜下间隙解剖观察阴道三水平理论的关键解剖结构[J]. 浙江大学学报(医学版), 2018, 47(4): 329-337.

ZHAO Xiaofeng,CHEN Gongli,LEI Ling,WU Xiaomei,LIU Shikai,WANG Juntao,HU Bin,LYU Weiguo. Key anatomies of DeLancey's three levels of vaginal support theory: an observation in laparoscopic surgery. J Zhejiang Univ (Med Sci), 2018, 47(4): 329-337.

链接本文:

http://www.zjujournals.com/med/CN/10.3785/j.issn.1008-9292.2018.08.01        http://www.zjujournals.com/med/CN/Y2018/V47/I4/329

图 1  宫颈癌手术几个主要间隙的示意图
图 2  闭孔内侧间隙腹腔镜下所见
图 3  不同形态的盆筋膜腱弓及其周围组织腹腔镜下所见
图 4  阴道筋膜及盆膈上筋膜腹腔镜下所见
图 5  子宫骶韧带及子宫血管周围组织腹腔镜下所见
图 6  膀胱宫颈韧带腹腔镜下所见
图 7  腹腔镜下盆底修复顶端固定“黄金三角”
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