1、局部解剖学,腹部的局部解剖与操作（2）,主要内容 Main Content,腹膜与腹膜腔 The Peritoneum and Peritoneal Cavity结肠上区 The Supracolic Compartment,一、腹膜与腹膜腔The Peritoneum and Peritoneal Cavity,腹膜与腹膜腔的概念腹膜被覆脏器的情况腹膜形成的结构膜膜腔的分区,1腹膜与腹膜腔的概念,2.腹膜被覆脏器的情况,腹膜内位器官腹膜间位器官腹膜外位器官,网膜Omenta系膜Mesentery韧带Ligament 皱襞Fold 陷凹Pouch 隐窝Recess,3.腹膜形成的结构,Less
2、er omentum,Greater omentum,Gastrocolic lig.,Hepatoduodenal lig.,Hepatogastric lig.,大网膜,小网膜,（1）网膜,网膜囊是小网膜和胃后壁与腹后壁的腹膜之间的一个扁窄间隙，又称小腹膜腔，为腹膜腔的一部分。,网膜囊Omental Bursa,上壁是尾状叶和膈下方的腹膜。上壁为大网膜前、后层的愈着处。,前壁是小网膜、胃后壁的腹膜和胃结肠韧带。后壁为横结肠及其系膜以及覆盖在胰、左肾、左肾上腺等处的腹膜。,网膜囊后壁：为横结肠及其系膜以及覆盖在胰、左肾、左肾上腺等处的腹膜。,网膜囊的左侧为脾、胃脾韧带和脾肾韧带。,网膜囊的右
3、侧为网膜孔，借网膜孔与腹膜腔的其余部分相通。,网膜孔omental foramen(Winslow孔）：约在第12胸椎至第2腰椎体的前方，成人可容12指通过。网膜孔的境界：前界为肝十二指肠韧带，后界为覆盖在下腔静脉表面的腹膜，上界为尾状叶，下界为十二指肠上部。,临床意义：手术时，遇有外伤性肝破裂或肝门附近动脉出血，可将示指伸入网膜孔内，拇指在小网膜游离缘前方加压，进行暂时止血。,（2）系 膜,Mesoappendix阑 尾,Mesentery肠系膜,Transverse mesocolon横结肠系膜,Mesentery Transverse mesocolonMesoappendixSigmo
4、id mesocolon,（2）系膜,（4）皱襞、隐窝和陷凹,Gastropancreatic fold Superior duodenal folds Inferior duodenal fold,（3）韧带,Hepatoduodenal ligamentHepatogasttric ligamentGastrophrenic ligament Gastrosplenic ligamentPhrenicocolic ligament,Gastropancreatic fold Superior duodenal folds Inferior duodenal fold,Superior du
5、odenal recess Inferior duodenal recess Superior ileocecal recess Inferior ileocecal recess Retrocecal recess Intersigmoid recess,1）腹后壁的皱襞和隐窝,腹前壁内面的皱襞及凹窝,2）腹前壁的皱襞和隐窝,Rectovesical pouch直肠膀胱陷凹,Vesicouterine pouch 膀胱子宫陷凹,3）腹膜凹陷,Rectouterine pouch直肠子宫陷凹,4.膜膜腔的分区和间隙,The Supracolic Compartment 结 肠 上 区（subp
6、hrenic space 膈下间隙）The Infracolic Compartment 结 肠 下 区,（1）膈下间隙,结肠旁沟 paracolic sulci肠系膜窦 mesenteric sinus,（2）结肠下区,肝周间隙 脾周间隙,左肠系膜窦 Left mesenteric sinus右肠系膜窦Right mesenteric sinus,左结肠旁沟Left paracolic sulcus右结肠旁沟 Right paracolic sulcus,二、结肠上区的器官和结构,食管腹段 abdominal part of esophagus胃 stomach十二指肠 duodenum肝
7、liver肝外胆道脾 spleen胰 pancreas,（一）胃 Stomach,位置和毗邻网膜与韧带（见腹膜）血管与淋巴神经,1A.胃的位置,胃在中等程度充盈时，大部分位于左季肋区、小部分位于腹上区，贲门位于第11胸椎体左侧，幽门约在第1腰椎体右侧。,1B.胃的毗邻,胃前壁：其右侧份邻接左半肝，左侧份上部紧邻膈，下部接触腹前壁（称胃前壁的游离区）。,1B.胃的毗邻,胃后壁隔网膜囊与胰、左肾上腺、左肾、脾、横结肠及其系膜相毗邻，这些器官共同形成胃床“stomach bed”。,2. 胃的韧带,Gastrocolic ligament,Hepatogastric ligament,Gastrop
8、ancreatic 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. The veins of stomach accompany the arteries.,3A. 胃的淋巴管和淋巴结,4. The Innervation of Stomach,The sympathetic nerve comes from the celiac ganglia which give
9、s rise to postganglion fribers that accompany the arteries to the stomach. The parasympathetic nerve is derived from branches of the anterior and posterior vagal trunk.The visceral sensory nerve,胃的交感神经和副交感神经,高选择性迷走神经切断术,（二）十二指肠 Duodenum,位置分部及毗邻十二指肠悬韧带血管,1.位置,十二指肠介于胃与空肠之间，位于腹后壁第腰椎的右前方，呈“C”形包绕胰头，除始、末两
10、端外，均在腹膜后隙。可分为上部、降部、水平部和升部4部。,（1）上部superior part:在第1腰椎右侧起自胃的幽门，水平行向右后方，至十二指肠上曲。,（3）水平部horizontal part:起自十二指肠下曲，跨过第3腰椎至其左侧的一段肠管。,（2）降部descending part:介于十二指肠上曲与下曲之间，行于第13腰椎体和胰头的右侧。,（4）升部ascending part:从第3腰椎左侧上升至第2腰椎左侧十二指肠空肠曲的一段肠管。,A.分部及其主要结构,1）十二指肠球duodenal bulb:十二指肠上部近侧与幽门相连接的一段肠管，长约2.5cm,其肠壁薄、管径大、粘膜光
11、滑平坦无环状皱襞，为十二指肠溃疡的好发部位。,形态结构,2）十二指肠大乳头Major duodenal papilla:十二指肠降部中份后内侧上十二指肠纵襞下端的圆形隆起，距上颌中切牙75cm，为肝胰壶腹的开口处。其上方可见十二指肠小乳头，为副胰管的开口处。,2 B.十二指肠各部的毗邻,3.十二指肠悬韧带Suspensory ligament of duodenum：由十二指肠悬肌和十二指肠空肠襞共同构成，又称Treitz韧带，是确定空肠起始的重要标志。,十二指肠空肠襞,肠系膜上动脉压迫综合征,4A.十二指肠的动脉,4B.十二指肠的静脉,（三）肝 Liver,位置、毗邻与体表投影 韧带和膈下间
12、隙肝门与肝蒂分叶与分段淋巴,1A.肝的位置,肝大部分位于右季肋区和腹上区，小部分位于左季肋区。肝的前面大部分被肋所掩盖，在腹上区的左右肋弓之间、剑突之下与腹前壁相接触。,1B.肝的毗邻,1C.肝的体表投影,（1）肝的上界与膈一致，在右锁骨中线与第5肋相交；在前正中线与剑胸结合线相交；在左锁骨中线与第5肋间隙相交。,（2）肝下界与肝前缘一致，右侧与右肋弓一致；中部在剑突下约3cm;左侧被肋弓掩盖。,2A.肝的韧带,2A. 肝的韧带,2B. 膈下间隙：分为肝上间隙和肝下间隙,肝上间隙：被镰状韧带分为右肝上间隙、左肝上间隙（被左冠状韧带和左三角韧带分为左肝上前间隙和左肝上后间隙）和腹膜外间隙。,肝下
13、间隙,右肝下间隙左肝下前间隙左肝下后间隙,膈下间隙矢状面示意图,膈下间隙矢状面示意图,（左肝下后间隙）,3A. 第一肝门与肝蒂 First porta hepatis and hepatic pedicle,Portal vein,Cystic artery,Cystic duct,Common bile duct,Proper hepatic artery,Right hepatic artery,Left hepatic artery,Left and right hepatic ducts,3B.第二肝门与第三肝门,4.肝的分叶和分段,按外形分叶：肝的膈面被镰状韧带分为左叶、右叶，肝的脏
14、面被H形沟分为左叶、右叶、方叶和尾状叶。按肝内管道系统分为两个半肝（左、右半肝）、5个叶（右前叶、右后叶、左内叶、左外叶和尾状叶）和6个段（右后叶上、下段，左外叶上、下段和尾状叶左、右段,肝内管道系统,Glisson系统肝静脉系统,国人肝段的划分,右后叶上段,右后叶下段,右前叶,左内叶,左外叶上段,左外叶下段,左外叶上段,左外叶下段,左内叶,右前叶,右前叶上段,右前叶下段,尾状叶,左段,右段,国外肝段的划分,5.肝的淋巴,（四）肝外胆道 Extrahepatic Biliary Apparatus,胆囊 gallbladder肝管 hepatic duct肝总管 common hepatic
15、duct胆总管 common bile duct,肝外胆道,胆总管的分段和毗邻,（五）胰 Pancreas,位置、分部与毗邻胰管与副胰管血管和淋巴,1. 胰的位置,1.胰的分部与毗邻,2.胰管与副胰管,3A. 胰的动脉,3B.胰的静脉,3C.胰的淋巴,（六）脾 spleen,位置与毗邻韧带血管副脾,1A.脾的位置,1B.脾的毗邻,2.脾的韧带,胃脾韧带gastrosplenic ligament、脾肾韧带splenorenal ligament、膈脾韧带phrenicosplenic ligament和脾结肠韧带splenocolic ligament,3A.脾的动脉,3B.脾的静脉,解 剖
16、与 观 察Dissection and Observation,Identify the 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 free edge the lesser omentum.,Examine the e
17、xtent of the lesser peritoneal sac through the incision in the gastrocolic ligament.,确认网膜孔、胃胰襞和胃胰韧带,Identify the gastrolienal and splenorenal ligament.,Identify the falciform and round ligament of liver.,Examine the lobes of liver, the left and right triangular ligament, the coronary ligament, and s
18、ubphrenic space.,Identify the mesentery.,Identify the mesoappendix.,Identify the transverse 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 par
19、ietal peritoneum.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 ligament.,Identify the cystic duct and cystic triangle(of Calot). The cyst
20、ic artery is found in the triangle.,Identify the 1st4th part of the duodenum and the duodenojejunal flexure.,Open the anterior wall of the duodenum 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.,The End,谢谢,
