腹壁与脐-2 + PDF

Vessels and Nerves of the Abdominal Wall 腹壁的血管和神经

Vascular Supply 血供

      The anterolateral abdominal wall receives its arterial supply from the last six intercostals and four lumbar arteries, superior and inferior epigastric arteries, and deep circumflex iliac arteries. The trunks of the intercostal and lumbar arteries, together with the intercostal, iliohypogastric, and ilioinguinal nerves, course between the transversus abdominis and internal oblique muscles. The distalmost extensions of these vessels pierce the lateral margins of the rectus sheath at various levels and communicate freely with branches of the superior and inferior epigastric arteries. The superior epigastric artery, one of the terminal branches of the internal mammary artery, reaches the posterior surface of the rectus abdominis muscle through the costoxiphoid space in the diaphragm. It descends within the rectus sheath to anastomose with branches of the inferior epigastric artery. The inferior epigastric artery, derived from the external iliac artery just proximal to the inguinal ligament, courses through the preperitoneal areolar tissue to enter the lateral rectus sheath at the semilunar line of Douglas. The deep circumflex iliac artery, arising from the lateral aspect of the external iliac artery near the origin of the inferior epigastric artery, gives rise to an ascending branch, which penetrates the abdominal wall musculature just above the iliac crest, near the anterior superior iliac spine.

      腹壁前外侧接受来自最后6个肋间和4个腰动脉、上腹部上下动脉和旋髂深动脉的动脉supply。肋间动脉和腰动脉的主干，连同肋间神经、髂腹神经和髂腹股沟神经，在腹横肌和内斜肌之间走行。这些扩张的血管在不同程度上穿透直肌鞘的外侧缘，与上腹部和下腹部动脉的分支自由沟通。上腹部动脉是内乳动脉的终末支之一，通过膈肌的肋血样间隙到达腹直肌的后表面。在直肌鞘内下降，与上腹部下动脉分支吻合。腹壁下动脉起源于髂外动脉，靠近腹股沟韧带，通过腹膜前乳晕组织进入道格拉斯半月线的外直肌鞘。旋髂深动脉起源于髂外动脉的外侧，靠近腹壁下动脉的起点，在髂嵴上方，靠近髂前上棘的腹壁肌肉组织中形成一个升支。

      The venous drainage of the anterior abdominal wall follows a relatively simple pattern in which the superficial veins above the umbilicus empty into the superior vena cava by way of the internal mammary, intercostal, and long thoracic veins. The veins inferior to the umbilicus—the superficial epigastric, circumflex iliac, and pudendal veins—converge toward the saphenous opening in the groin to enter the saphenous vein and become a tributary to the inferior vena cava. The numerous anastomoses between the infraumbilical and supraumbilical venous systems provide collateral pathways whereby venous return to the heart may bypass an obstruction of the superior or inferior vena cava. The paraumbilical vein, which passes from the left branch of the portal vein along the ligamentum teres to the umbilicus, provides important communication between the veins of the superficial abdominal wall and portal system in patients with portal venous obstruction. In this setting, portal blood flow is diverted away from the higher pressure portal system through the paraumbilical veins to thelower pressure veins of the anterior abdominal wall. The dilated superficial paraumbilical veins in this setting are termed caput medusae.

      腹壁前壁静脉引流遵循一个相对简单的模式，即脐上的浅静脉通过内乳、肋间和长胸静脉流入上腔静脉。脐下静脉上腹部浅静脉、旋髂静脉和阴部静脉向腹股沟的隐静脉口汇合，进入隐静脉，成为下腔静脉的一条支流。脐下静脉系统和脐上静脉系统之间的大量吻合supply 了侧支通路，静脉回流heart 可绕过上、下腔静脉阻塞。脐旁静脉是门静脉阻塞患者腹壁浅静脉与门静脉系统之间的重要通道，从门静脉左支沿圆韧带向脐静脉走行。在这种情况下，门静脉血流通过脐旁静脉从高压门静脉系统转移到腹前壁的低压静脉。扩张的脐旁浅静脉称为水母头。

      The lymphatic supply of the abdominal wall follows a pattern similar to the venous drainage. Those lymphatic vessels arising from the supraumbilical region drain into the axillary lymph nodes, whereas those arising from the infraumbilical region drain toward the superficial inguinal lymph nodes. The lymphatic vessels from the liver course along the ligamentum teres to the umbilicus to communicate with the lymphatics of the anterior abdominal wall. It is from this pathway that carcinoma in the liver may spread to involve the anterior abdominal wall at the umbilicus (Sister Mary Joseph node [or nodule]).

      腹壁的淋巴supply遵循与静脉引流相似的模式。那些淋巴管起源于脐上区引流到腋窝淋巴结，而起源于脐下区区域引流到腹股沟浅淋巴结。从肝经经经圆韧带到脐的淋巴管与腹前壁的淋巴管相连。正是通过这个途径，liver 中的癌细胞可能扩散到脐部的前腹壁（姐妹玛丽·约瑟夫结[或结节]）。

Innervation 神经分布

      The anterior rami of the thoracic nerves follow a curvilinear course forward in the intercostal spaces toward the midline of the body. The upper six thoracic nerves end near the sternum as anterior cutaneous sensory branches. Thoracic nerves 7 to 12 pass behind the costal cartilages and lower ribs to enter a plane between the internal oblique muscle and the transversus abdominis. The seventh and eighth nerves course slightly upward or horizontally to reach the epigastrium, whereas the lower nerves have an increasingly caudal trajectory. As thesenerves course medially, they provide motor branches to the abdominal wall musculature. Medially, they perforate the rectus sheath to provide sensory innervation to the anterior abdominal wall. The anterior ramus of the 10th thoracic nerve reaches the skin at the level of the umbilicus and the 12th thoracic nerve innervates the skin of the hypogastrium.

      胸神经前支在肋间空间向身体中线呈曲线前进。上6条胸神经在胸骨附近末端为前皮感觉支。胸神经7～12穿过肋软骨和下肋骨进入内斜肌和腹横肌之间的平面。第七和第八神经稍微向上或水平走向到达上腹部，而下神经有一个越来越尾端的轨迹。当这些神经在内侧走行时，它们向腹壁肌肉组织supply 运动分支。在内侧，它们穿过直肌鞘，为腹前壁supply 感觉神经支配。第10胸神经前支到达脐平面皮肤，第12胸神经支配下腹皮肤。

      The ilioinguinal and iliohypogastric nerves often arise in common from the anterior rami of the 12th thoracic and first lumbar nerves to provide sensory innervation to the hypogastrium and lower abdominal wall. The iliohypogastric nerve runs parallel to the 12th thoracic nerve to pierce the transversus abdominis muscle near the iliac crest. After coursing between the transversus abdominis muscle and internal oblique for a short distance, the nerve pierces the latter to travel under the external oblique fascia toward the external inguinal ring. It emerges through the superior crus of the external inguinal ring to provide sensory innervation to the anterior abdominal wall in the hypogastrium. The ilioinguinal nerve courses parallel to the iliohypogastric nerve, but closer to the inguinal ligament. Unlike the iliohypogastric nerve, the ilioinguinal nerve courses with the spermatic cord to emerge from the external inguinal ring, with its terminal branches providing sensory innervation to the skin of the inguinal region and scrotum or labium. The ilioinguinal nerve, iliohypogastric nerve, and genital branch of the genitofemoral nerve are commonly encountered during the performance of inguinal herniorrhaphy.

      髂腹股沟神经和髂腹胃神经常共同起源于第12胸段和第一胸段的前支腰神经为下腹和下腹壁supply 感觉神经支配。髂腹胃神经平行于第12胸神经穿入髂嵴附近的腹横肌。在腹横肌和内斜肌之间走一小段距离后，神经穿入内斜肌，在外斜肌筋膜下向腹股沟外环走去。它通过腹股沟外环的上脚出现，为腹下段的前腹壁supply 感觉神经支配。髂腹股沟神经走行与髂腹胃神经平行，但更接近腹股沟韧带。与髂腹神经不同，髂腹股沟神经与精索走行，从腹股沟外环显露出来，其末端分支为腹股沟区皮肤和阴囊或阴唇supply 感觉神经支配。腹股沟疝修补术中常见髂腹股沟神经、髂腹胃神经和生殖股神经的分支。

Abnormalities of the Abdominal Wall 腹壁异常

These can be congenital or acquired. 这些可能是先天的，也可能是后天的。

Congenital Abnormalities 先天畸形

Umbilical Hernias 脐疝

      Umbilical hernias may be classified into three distinct forms: 脐疝可分为三种不同的形式:

1. Omphalocele and gastroschisis 脐膨出和腹裂

2. Infantile umbilical hernia 婴幼儿脐疝

3. Acquired umbilical hernia 后天性脐疝

Omphalocele 脐疝

      An omphalocele is a funnel-shaped defect in the central abdomen through which the viscera protrude into the base of the umbilical cord. It is caused by failure of the abdominal wall musculature to unite in the midline during fetal development. The umbilical vessels may be splayed over the viscera or pushed to one side. In larger defects, the liver and spleen may lie within the cord, along with a major portion of the bowel. There is no skin covering these defects, only peritoneum and, more superficially, amnion. Of infants who are born with an omphalocele, 50% to 60% will have concomitant congenital anomalies of the skeleton, gastrointestinal (GI) tract, and nervous, genitourinary, and cardiopulmonary systems.

      脐膨出是腹部中央的漏斗状缺损，内脏通过它伸入脐带底部。这是由于胎儿发育过程中腹壁肌肉组织未能在中线处结合所致。脐带血管可以在内脏上张开或推到一侧。在较大的缺陷中，liver 和spleen可能位于脐带内，以及肠道的主要部分。没有皮肤覆盖这些缺陷，只有腹膜和更浅的羊膜。出生时有脐膨出的婴儿中，50%至60%会伴有骨骼、胃肠道、神经、泌尿生殖系统和心肺系统的先天性异常。

Gastroschisis 腹裂

      Gastroschisis is another congenital defect of the abdominal wall in which the umbilical membrane has ruptured in utero, allowing the intestine to herniate outside the abdominal cavity. The defect is almost always to the right of the umbilical cord and the intestine is not covered with skin or amnion. Typically, the intestine has not undergone complete mesenteric rotation and fixation; hence, the infant is at risk for mesenteric volvulus, with resultant intestinal ischemia and necrosis. Concomitant congenital anomalies occur in about 10% of these patients.

      腹裂是另一种先天性腹壁缺损，其中脐膜破裂在子宫内，使肠在腹腔外突出。缺损几乎总是在脐带的右侧，肠没有皮肤或羊膜覆盖。通常情况下，小肠没有经历完整的肠系膜旋转和固定；因此，婴儿有肠系膜扭转的风险，从而导致肠缺血和坏死。约10%的患者伴有先天性畸形。

Infantile Umbilical Hernia 婴幼儿脐疝

      Infantile umbilical hernias appear within a few days or weeks after the stump of the umbilical cord has sloughed. It is caused by a weakness in the adhesion between the scarred remnants of the umbilical cord and umbilical ring. In contrast to omphalocele, the infantile umbilical hernia is covered by skin. Generally, these small hernias occur in the superior margin of the umbilical ring. They are easily reducible and become prominent when the infant cries. Most of these hernias resolve within the first 24 months of life, and complications such as strangulation are rare. Operative repair is indicated for those children in whom the hernia persists beyond the age of 3 or 4 years.

      婴儿脐疝在脐带残端脱落后几天或几周内出现。这是由于脐带疤痕残余物和脐带环之间的粘附力减弱引起的。与脐膨出不同，婴儿脐疝被皮肤覆盖。一般来说，这些小疝发生在脐环的上缘。它们很容易被还原，当婴儿哭泣时变得突出。其中大部分疝气在出生后的前24个月内就会消失，而且像勒死这样的并发症也很少见。对于疝气持续超过3或4岁的儿童，建议手术修补。

Acquired Umbilical Hernia  后天性脐疝

      In this condition, an umbilical hernia develops at a time remote from closure of the umbilical ring. This hernia occurs most commonly at the upper margin of the umbilicus and results from weakening of the cicatricial tissue that normally closes the umbilical ring. This may be caused by excessive stretching of the abdominal wall, which may occur with pregnancy, vigorous labor, or ascites. In contrast to infantile umbilical hernias, acquired umbilical hernias do not spontaneously resolve but gradually increase in size. The dense fibrous ring at the neck of this hernia makes strangulation of herniated intestine or omentum an important complication.

      在这种情况下，脐疝是在远离脐带闭合的时间发生的。这种疝最常见于脐上缘，是由于通常闭合脐环的瘢痕组织减弱所致。这可能是由于过度拉伸腹壁，这可能发生在怀孕，分娩旺盛，或腹水。与婴儿脐疝相比，后天性脐疝不是自发消退，而是逐渐增大。疝的颈部有密集的纤维环，使疝出的肠或大网膜的绞窄成为一个重要的并发症。

Abnormalities Resulting from Persistence of the Omphalomesenteric Duct 因脐肠管持续存在而引起的异常

      During fetal development, the midgut communicates widely with the yolk sac through the vitelline or omphalomesenteric duct. As the abdominal wall components approximate one another, the omphalomesenteric duct narrows and comes to lie within the umbilical cord. Over time, communication between the yolk sac and intestine becomes obliterated and the intestine resides free within the peritoneal cavity. Persistence of part or all of the omphalomesenteric duct results in a variety of abnormalities related to the intestine and abdominal wall.

      在胎儿发育过程中，中肠通过卵黄管或脐静脉与卵黄囊广泛沟通。当腹壁成分彼此接近时，脐肠系膜管变窄并位于脐带内。随着时间的推移，卵黄囊和肠道之间的通讯变得闭塞，肠道在腹腔内保持自由。部分或全部脐肠系膜管的持续存在导致与肠和腹壁有关的各种异常联系。

      Persistence of the intestinal end of the omphalomesenteric duct results in Meckel’s diverticulum. These true diverticula arise from the antimesenteric border of the small intestine, most often the ileum. A Rule of 2s is often applied to these lesions in thatthey are found in approximately 2% of the population, are within 2 feet of the ileocecal valve, are often 2 inches in length, and contain two types of ectopic mucosa (gastric and pancreatic). Meckel’s diverticula may be complicated by inflammation, perforation, hemorrhage, or obstruction. GI bleeding is caused by peptic ulceration of adjacent intestinal mucosa from hydrochloric acid secreted by ectopic parietal cells within the diverticulum. Intestinal obstruction associated with Meckel’s diverticulum is usually caused by intussusception or volvulus around an abnormal fibrous connection between the diverticulum and posterior aspect of the umbilicus..

      持续的肠末端的脐肠系膜管导致梅克尔憩室。这些真正的憩室起源于小肠的反肠系膜边界，通常是回肠。2s法则通常适用于这些病变，在大约2%的人群中发现，位于回盲瓣2英尺内，通常2英寸长，并含有两种类型的异位粘膜（胃和pancreas）。梅克尔憩室可能并发炎症、穿孔、出血或梗阻。胃肠道出血是由潜伏期异位壁细胞分泌的水氯酸引起的邻近肠粘膜消化性溃疡引起的。与梅克尔憩室相关的肠梗阻通常是由肠套叠或肠扭转引起的，肠套叠或肠套叠位于憩室和脐后部之间的异常纤维连接处。。

      The omphalomesenteric duct may remain patent throughout its course, thus producing an enterocutaneous fistula between the distal small intestine and umbilicus. This condition presents with the passage of meconium and mucus from the umbilicus in the first few days of life. Because of the risk for mesenteric volvulus around a persistent omphalomesenteric duct, these lesions are promptly treated with laparotomy and excision of the fistulous tract. Persistence of the distal end of the omphalomesenteric duct results in an umbilical polyp, which is a small excrescence of omphalomesenteric ductal mucosa at the umbilicus. Such polyps resemble umbilical granulomas except that they do not disappear after silver nitrate cauterization. Their presence suggests that a persistent omphalomesenteric duct or umbilical sinus may be present, and hence they are most appropriately treated by excision of the mucosal remnant and underlying omphalomesenteric duct or umbilical sinus, if present. Umbilical sinuses result from the persistence of the distal omphalomesenteric duct. The morphology of the sinus tract can be delineated by a sinogram. Treatment involves excision of the sinus. Finally, the accumulation of mucus in a portion of a persistent omphalomesenteric duct may result in the formation of a cyst, which may be associated with the intestine or umbilicus by a fibrous band. Treatment consists of excision of the cyst and associated persistent omphalomesenteric duct.

      脐肠系膜管在整个过程中可能保持通畅，从而在小肠远端和脐之间产生肠皮瘘。这种情况表现为在生命的最初几天胎粪和黏液从脐部排出。由于持续性脐肠系膜管周围有肠系膜扭转的危险，这些病变可以通过开腹和瘘管切除术迅速治疗。脐部息肉是脐部脐部肠系膜管粘膜的一种小的赘生物。这些息肉与脐带肉芽肿相似，只是硝酸银烧灼后不消失。他们的存在表明持续的脐肠系膜管或可能存在脐静脉窦，因此，如果存在，可通过切除粘膜残端和下伏的脐肠系膜管或脐静脉窦来治疗。脐静脉窦是由远端脐肠系膜管持续存在引起的。窦道的形态可以用脑电图来描述。治疗包括切除鼻窦。最后，黏液在持续性脐肠系膜管的一部分积聚可能导致囊肿的形成，囊肿可能通过纤维带与肠或伞形肌相连。治疗包括囊肿切除和相关的持续性脐肠系膜管。

Abnormalities Resulting from Persistence of the Allantois 因尿囊持续存在而引起的异常

      The allantois is the cranialmost component of the embryologic ventral cloaca. The intra-abdominal portion is termed the urachus and connects the urinary bladder with the umbilicus, whereas theextra-abdominal allantois is contained within the umbilical cord. At the end of gestation, the urachus is converted into a fibrous cord that courses between the extraperitoneal urinary bladder and umbilicus as the median umbilical ligament. Persistence of part or all of the urachus may result in the formation of a vesicocutaneous fistula, with the appearance of urine at the umbilicus, an extraperitoneal urachal cyst presenting as a lower abdominal mass, or an urachal sinus with the drainage of a small amount of mucus. Treatment is excision of the urachal remnant with closure of the bladder, if necessary.

      尿囊是胚胎性腹泄殖腔最重要的组成部分。腹内部分称为脐尿管，连接膀胱和脐，而腹外尿囊则包含在脐带内。妊娠末期，脐尿管转变成纤维索，在腹膜外膀胱和脐之间作为正中脐韧带。部分或全部脐尿管破裂可导致膀胱皮肤瘘，表现为脐部尿液，腹膜外脐尿管囊肿表现为下腹部肿块，或脐尿管窦有少量黏液引流。治疗方法是切除脐尿管残端，必要时关闭膀胱。