局部解剖腹部2腹膜與腹膜腔、結(jié)腸上區(qū)

1、局部解剖學(xué),腹部的局部解剖與操作（2）,主要內(nèi)容 Main Content,腹膜與腹膜腔 The Peritoneum and Peritoneal Cavity結(jié)腸上區(qū) The Supracolic Compartment,一、腹膜與腹膜腔The Peritoneum and Peritoneal Cavity,腹膜與腹膜腔的概念腹膜被覆臟器的情況腹膜形成的結(jié)構(gòu)膜膜腔的分區(qū),1．腹膜與腹膜腔的概念,,2.腹膜

2、被覆臟器的情況,腹膜內(nèi)位器官腹膜間位器官腹膜外位器官,網(wǎng)膜Omenta系膜Mesentery韌帶Ligament 皺襞Fold 陷凹Pouch 隱窩Recess,3.腹膜形成的結(jié)構(gòu),Lesser omentum,Greater omentum,Gastrocolic lig.,Hepatoduodenal lig.,Hepatogastric lig.,,,,,,,,大網(wǎng)膜,小網(wǎng)膜,,（1）網(wǎng)膜,,網(wǎng)膜囊是小網(wǎng)膜和胃后壁

3、與腹后壁的腹膜之間的一個(gè)扁窄間隙，又稱小腹膜腔，為腹膜腔的一部分。,網(wǎng)膜囊Omental Bursa,上壁是尾狀葉和膈下方的腹膜。上壁為大網(wǎng)膜前、后層的愈著處。,前壁是小網(wǎng)膜、胃后壁的腹膜和胃結(jié)腸韌帶。后壁為橫結(jié)腸及其系膜以及覆蓋在胰、左腎、左腎上腺等處的腹膜。,網(wǎng)膜囊后壁：為橫結(jié)腸及其系膜以及覆蓋在胰、左腎、左腎上腺等處的腹膜。,網(wǎng)膜囊的左側(cè)為脾、胃脾韌帶和脾腎韌帶。,網(wǎng)膜囊的右側(cè)為網(wǎng)膜孔，借網(wǎng)膜孔與腹膜腔的其余部分相通。,

4、,,,,,網(wǎng)膜孔o(hù)mental foramen(Winslow孔）：約在第12胸椎至第2腰椎體的前方，成人可容1~2指通過。網(wǎng)膜孔的境界：前界為肝十二指腸韌帶，后界為覆蓋在下腔靜脈表面的腹膜，上界為尾狀葉，下界為十二指腸上部。,臨床意義：手術(shù)時(shí)，遇有外傷性肝破裂或肝門附近動(dòng)脈出血，可將示指伸入網(wǎng)膜孔內(nèi)，拇指在小網(wǎng)膜游離緣前方加壓，進(jìn)行暫時(shí)止血。,,,（2）系 膜,Mesoappendix闌 尾,,Mesentery腸系膜,Tra

5、nsverse mesocolon橫結(jié)腸系膜,,,,,,Mesentery Transverse mesocolonMesoappendixSigmoid mesocolon,（2）系膜,,,,,（4）皺襞、隱窩和陷凹,Gastropancreatic fold Superior duodenal folds Inferior duodenal fold,,,,,,,（3）韌帶,Hepatoduodenal ligament

6、Hepatogasttric ligamentGastrophrenic ligament Gastrosplenic ligamentPhrenicocolic ligament,Gastropancreatic fold Superior duodenal folds Inferior duodenal fold,Superior duodenal recess Inferior duodenal recess S

7、uperior ileocecal recess Inferior ileocecal recess Retrocecal recess Intersigmoid recess,1）腹后壁的皺襞和隱窩,,,,,,,,,腹前壁內(nèi)面的皺襞及凹窩,2）腹前壁的皺襞和隱窩,,,,,,,,,,,,Rectovesical pouch直腸膀胱陷凹,Vesicouterine pouch 膀胱子宮陷凹,3）腹膜凹陷,,,,,Rectoute

8、rine pouch直腸子宮陷凹,4.膜膜腔的分區(qū)和間隙,The Supracolic Compartment 結(jié) 腸 上 區(qū)（subphrenic space 膈下間隙）The Infracolic Compartment 結(jié) 腸 下 區(qū),,,,,,,（1）膈下間隙,結(jié)腸旁溝 paracolic sulci腸系膜竇 mesenteric sinus,（2）結(jié)腸下區(qū)

9、,肝周間隙 脾周間隙,左腸系膜竇 Left mesenteric sinus右腸系膜竇Right mesenteric sinus,左結(jié)腸旁溝Left paracolic sulcus右結(jié)腸旁溝 Right paracolic sulcus,二、結(jié)腸上區(qū)的器官和結(jié)構(gòu),食管腹段 abdominal part of esophagus胃 stomach十二指腸 duodenum肝 liver肝外膽道脾 spleen

10、胰 pancreas,（一）胃 Stomach,位置和毗鄰網(wǎng)膜與韌帶（見腹膜）血管與淋巴神經(jīng),1A.胃的位置,胃在中等程度充盈時(shí)，大部分位于左季肋區(qū)、小部分位于腹上區(qū)，賁門位于第11胸椎體左側(cè)，幽門約在第1腰椎體右側(cè)。,1B.胃的毗鄰,胃前壁：其右側(cè)份鄰接左半肝，左側(cè)份上部緊鄰膈，下部接觸腹前壁（稱胃前壁的游離區(qū)）。,1B.胃的毗鄰,胃后壁隔網(wǎng)膜囊與胰、左腎上腺、左腎、脾、橫結(jié)腸及其系膜相毗鄰，這些器官共同形成胃床“stoma

11、ch bed”。,2. 胃的韌帶,Gastrocolic ligament,Hepatogastric ligament,,,,,Gastropancreatic ligament,Gastropancreatic fold,3A. 胃的血管,The arteries of the stomach are derived from the celiac trunk or the branches of the celiac trunk.

12、 The veins of stomach accompany the arteries.,3A. 胃的淋巴管和淋巴結(jié),4. The Innervation of Stomach,The sympathetic nerve comes from the celiac ganglia which gives rise to postganglion fribers that accompany the arteries to the s

13、tomach. The parasympathetic nerve is derived from branches of the anterior and posterior vagal trunk.The visceral sensory nerve,胃的交感神經(jīng)和副交感神經(jīng),,高選擇性迷走神經(jīng)切斷術(shù),（二）十二指腸 Duodenum,位置分部及毗鄰十二指腸懸韌帶血管,1.位置,十二指腸介于胃與空腸之間，位于腹后壁

14、第１～３腰椎的右前方，呈“C”形包繞胰頭，除始、末兩端外，均在腹膜后隙。可分為上部、降部、水平部和升部4部。,,（1）上部superior part:在第1腰椎右側(cè)起自胃的幽門，水平行向右后方，至十二指腸上曲。,（3）水平部horizontal part:起自十二指腸下曲，跨過第3腰椎至其左側(cè)的一段腸管。,（2）降部descending part:介于十二指腸上曲與下曲之間，行于第1～3腰椎體和胰頭的右側(cè)。,（4）升部ascending

15、 part:從第3腰椎左側(cè)上升至第2腰椎左側(cè)十二指腸空腸曲的一段腸管。,２A.分部及其主要結(jié)構(gòu),1）十二指腸球duodenal bulb:十二指腸上部近側(cè)與幽門相連接的一段腸管，長(zhǎng)約2.5cm,其腸壁薄、管徑大、粘膜光滑平坦無環(huán)狀皺襞，為十二指腸潰瘍的好發(fā)部位。。,形態(tài)結(jié)構(gòu),2）十二指腸大乳頭Major duodenal papilla:十二指腸降部中份后內(nèi)側(cè)上十二指腸縱襞下端的圓形隆起，距上頜中切牙75cm，為肝胰壺腹的開口處。其上方

16、可見十二指腸小乳頭，為副胰管的開口處。,,2 B.十二指腸各部的毗鄰,,,3.十二指腸懸韌帶Suspensory ligament of duodenum：由十二指腸懸肌和十二指腸空腸襞共同構(gòu)成，又稱Treitz韌帶，是確定空腸起始的重要標(biāo)志。,,十二指腸空腸襞,腸系膜上動(dòng)脈壓迫綜合征,,,,4A.十二指腸的動(dòng)脈,4B.十二指腸的靜脈,（三）肝 Liver,位置、毗鄰與體表投影 韌帶和膈下間隙肝門與肝蒂分葉與分段淋巴,1A.肝

17、的位置,肝大部分位于右季肋區(qū)和腹上區(qū)，小部分位于左季肋區(qū)。肝的前面大部分被肋所掩蓋，在腹上區(qū)的左右肋弓之間、劍突之下與腹前壁相接觸。,,1B.肝的毗鄰,,1C.肝的體表投影,（1）肝的上界與膈一致，在右鎖骨中線與第5肋相交；在前正中線與劍胸結(jié)合線相交；在左鎖骨中線與第5肋間隙相交。,（2）肝下界與肝前緣一致，右側(cè)與右肋弓一致；中部在劍突下約3cm;左側(cè)被肋弓掩蓋。,2A.肝的韌帶,2A. 肝的韌帶,2B. 膈下間隙：分為肝上間隙和肝下間

18、隙,肝上間隙：被鐮狀韌帶分為右肝上間隙、左肝上間隙（被左冠狀韌帶和左三角韌帶分為左肝上前間隙和左肝上后間隙）和腹膜外間隙。,肝下間隙,右肝下間隙左肝下前間隙左肝下后間隙,,膈下間隙矢狀面示意圖,,,,,,膈下間隙矢狀面示意圖,,,,,（左肝下后間隙）,3A. 第一肝門與肝蒂 First porta hepatis and hepatic pedicle,P

19、ortal vein,Cystic artery,Cystic duct,Common bile duct,Proper hepatic artery,,,,,,Right hepatic artery,,,Left hepatic artery,Left and right hepatic ducts,,,3B.第二肝門與第三肝門,4.肝的分葉和分段,按外形分葉：肝的膈面被鐮狀韌帶分為左葉、右葉，肝的臟面被H形溝分為左葉、右葉、方葉和

20、尾狀葉。按肝內(nèi)管道系統(tǒng)分為兩個(gè)半肝（左、右半肝）、5個(gè)葉（右前葉、右后葉、左內(nèi)葉、左外葉和尾狀葉）和6個(gè)段（右后葉上、下段，左外葉上、下段和尾狀葉左、右段,肝內(nèi)管道系統(tǒng),Glisson系統(tǒng)肝靜脈系統(tǒng),國(guó)人肝段的劃分,右后葉上段,右后葉下段,右前葉,左內(nèi)葉,左外葉上段,左外葉下段,左外葉上段,左外葉下段,左內(nèi)葉,右前葉,右前葉上段,右前葉下段,尾狀葉,左段,右段,國(guó)外肝段的劃分,5.肝的淋巴,,（四）肝外膽道 Extrahepati

21、c Biliary Apparatus,膽囊 gallbladder肝管 hepatic duct肝總管 common hepatic duct膽總管 common bile duct,肝外膽道,膽總管的分段和毗鄰,,（五）胰 Pancreas,位置、分部與毗鄰胰管與副胰管血管和淋巴,1. 胰的位置,1.胰的分部與毗鄰,,2.胰管與副胰管,,3A. 胰的動(dòng)脈,,3B.胰的靜脈,,3C.胰的淋巴,,（六）脾 spleen

22、,位置與毗鄰韌帶血管副脾,,1A.脾的位置,1B.脾的毗鄰,,2.脾的韌帶,,,胃脾韌帶gastrosplenic ligament、脾腎韌帶splenorenal ligament、膈脾韌帶phrenicosplenic ligament和脾結(jié)腸韌帶splenocolic ligament,3A.脾的動(dòng)脈,,3B.脾的靜脈,,解 剖 與 觀 察Dissection and Observation,,Identify the

23、parietal and visceral layers of the peritoneum.,,Identify the greater omentum.,,Identify the gastrocolic ligament.,,Identify the lesser omentum.,,Identify the epiploic foramen（of Winslow) which lies posterior to the fre

24、e edge the lesser omentum.,,Examine the extent of the lesser peritoneal sac through the incision in the gastrocolic ligament.,確認(rèn)網(wǎng)膜孔、胃胰襞和胃胰韌帶,,,Identify the gastrolienal and splenorenal ligament.,,Identify the falciform

25、and round ligament of liver.,Examine the lobes of liver, the left and right triangular ligament, the coronary ligament, and subphrenic space.,,Identify the mesentery.,,Identify the mesoappendix.,,Identify the transverse

26、and sigmoid mesentery.,,Identify the left and right paracolic gutters.,,Identify the left and right mesenteric sinuses.,,Remove the left lobe of the liver.,解剖腹腔干及其分支,,Reflect the stomach superioly. Remove the parietal pe

27、ritoneum.Identify the structures of the stomach bed.,Dissect the celiac trunk and its branches.,Clean and identify the structures(common bile duct, proper hepatic artery and portal vein) that lie in the hepatoduodenal li

28、gament.,,Identify the cystic duct and cystic triangle(of Calot). The cystic artery is found in the triangle.,,Identify the 1st~4th part of the duodenum and the duodenojejunal flexure.,,Open the anterior wall of the duode

29、num along its entire length.,observe the greater and lesser duodenal papillas.,Identify the head, neck, body , tail of the pancreas and uncinate process.,,Observe the location, shape, ligament, artery, vein and relations