【作者】 张虹；

【导师】 李建民；

【作者基本信息】 山东大学 ， 外科学（骨外科）（专业学位）， 2023， 博士

【摘要】 目的:腹股沟区的重建修复一直是一个困扰临床医生的难题。已有的研究证实使用肌瓣重建修复腹股沟区可以有效降低术后并发症发病率,但是首选治疗方案并无共识。目前对长收肌肌瓣重建修复腹股沟区及长收肌的解剖学研究鲜有报道。本研究旨在探讨长收肌解剖学特点、其血供模型及长收肌肌瓣在重建修复腹股沟区的临床应用,为长收肌肌瓣重建修复腹股沟区提供解剖学基础及其在临床推广应用提供借鉴。方法:1.新鲜成人下肢尸体标本12侧,通过髂外动脉灌注红色乳浆后低温保存,解冻后对其解剖。显露长收肌血管门,解剖分离长收肌血供来源及分支走行,使用游标卡尺(精确度0.02mm)、直尺(精确度0.1cm)对血管的管径、神经血管位置等数据进行解剖学测量;使用量筒(精确度2ml)通过排水法对长收肌及缝匠肌肌瓣的体积进行测量。2.自2016年3月以来,对山东大学齐鲁医院骨肿瘤科16名患者进行了回顾性研究。研究对象为那些在腹股沟区接受肿物扩大切除和或腹股沟淋巴结清扫,并一期采用了带蒂长收肌肌瓣进行腹股沟区修复重建。对其进行了术后并发症随访,并评估了其临床治疗效果。结果:1.长收肌接受股动脉来源的穿支、股深动脉来源的高位支、穿支及副穿支提供的血液供应,主要血供来源于股深动脉来源的穿支及副穿支。2.12例标本中观测到股动脉来源穿支(100%),肌支管径为(0.58±0.32)mm,测量高度与腹股沟韧带垂直距离为(13.51±3.45)cm。11例标本中观测到股深动脉高位支(91.7%),肌支管径为(0.77±0.52)mm,距离腹股沟韧带垂直距离为(7.5±3.16)cm。12例标本中观测到股深动脉来源穿支(100%),肌支管径(0.92±0.58)mm,入肌点与腹股沟韧带垂直距离为(11.45±2.64)cm。7例标本观测到股深动脉来源的副穿支,肌支管径(1.09±0.73)mm,入肌点距离腹股沟韧带的垂直距离为(13.24±1.56)cm。3.闭孔神经前分支支配长收肌,穿入肌腹点距离闭孔的直线距离为(9.24±0.75)cm。4.缝匠肌与长收肌肌瓣体积比值平均为0.70,T检验标本总体均值与0.70并无明显统计学差异(P<0.05)。5.所有16名患者术后恢复良好,不需要再次任何手术干预治疗。4名患者自述腹股沟周围的轻度不适。5名患者的患侧股部内收力量与术前力量相比略有减退,上述并发症均在术后长期随访得到了缓解,对患者的日常生活没有造成任何影响。无一例肌瓣坏死或部分坏死,伤口在术后1个月内全部愈合。本病例系列中未见如感染、血清肿或伤口裂开等常见术后并发症。结论:长收肌接受股动脉来源的穿支、股深动脉来源的高位支、穿支及副穿支提供的血液供应,主要血供来源于股深动脉来源的穿支及副穿支。股深动脉来源穿支稳定存在,副穿支及高位支有较多变异。长收肌可以作为带蒂肌瓣或游离肌瓣使用。长收肌肌瓣较缝匠肌肌瓣体积更大。带蒂长收肌肌瓣重建修复腹股沟区是一种行之有效的新型治疗方法。更多还原

【Abstract】 Objective:Reconstructive repairment of the inguinal region has always been a challenge for clinicians.Studies have demonstrated that the use of muscle flap reconstruction to repair the inguinal region can effectively reduce the incidence of postoperative complications,but there is no consensus on the preferred treatment option.Few anatomical studies have been reported on the use of adductor longus flaps for repairment of the inguinal region and the adductor longus muscle itself.This study aims to investigate the anatomical characteristics of the adductor longus muscle,its vascularized characteristics and the clinical application of the adductor longus flap in the reconstruction and repairment of the inguinal region,to provide an anatomical basis for the reconstruction and repairment of the inguinal region with the adductor longus flap and to provide a reference for the promotion of its application in the clinic.Methods:1.12 sides of fresh lower limb specimens from adult cadavers,through the external iliac artery infusion of red latex after cryopreservation,thawed and dissected.The vascular gates of the adductor longus muscle were exposed,the source of blood supply and branching course of the adductor longus muscle were dissected and separated,and anatomical measurements of the vessel diameter and neurovascular location were made using vernier calipers(accuracy:0.02 mm)and straightedge(accuracy:0.1 cm);the volume of the adductor longus muscle and the sartorius muscle was measured by a measuring cylinder(accuracy:2 ml).2.A retrospective study of 16 patients with localized inguinal region interventions and reconstructed by adductor longus flap since March 2016.All patients had unilateral inguinal region involvement—seven cases on the left and nine cases on the right.The patients’ clinical course,operative course,and postoperative follow-up data were evaluatedResults:1.The adductor longus muscle receives blood supply from a perforating branch from the femoral artery,along with a higher branch,a perforating branch,a secondary perforating branch which were all raised from the femoral profound artery.The main blood supply was originating from a perforating branch and a secondary perforating branch of the femoral profound artery.2.Perforators of femoral arterial origin were observed in 12 specimens(100%).with a muscular branch diameter of(0.58±0.32)mm,and a vertical distance from the inguinal ligament of(13.51±3.45)cm.Higher perforators from the femoral profound artery were observed in 11 specimens(91.7%),with a perforator diameter of(0.77±0.52)mm,and a vertical distance from the inguinal ligament of(7.5±3.16)cm.12 specimens were observed the main perforator from the femoral profound artery(100%),with a diameter of the perforator of(0.92±0.58)mm,and a vertical distance between the point of entry and the inguinal ligament of(11.45±2.64)cm.7 specimens were observed a secondary perforator from the femoral profound artery,with a diameter of the perforator of(1.09±0.73)mm,and a vertical distance between the point of entry and the inguinal ligament was(13.24±1.56)cm.3.The anterior branch of the obturator nerve innervates the adductor longus muscle,and the straight-line distance from the point of entry to the obturator foramen is(9.24±0.75)cm.4.The mean ratio of the volume of the sartorius to that of the adductor longus muscle flap was 0.70,and the overall mean value of the T-test specimen was not statistically significantly different from 0.70(P<0.05).5.All 16 patients recovered well post-operatively and did not require any re-intervention.Four patients experienced negligible discomfort around the groin area.Five patients experienced a minor strength deficit in thigh adduction compared with that of preoperative strength in the same or contralateral leg.The aforementioned complications resolved during the postoperative course and had no functional impact on their activity of daily living.All adductor longus flaps survived,completely filled the inguinal dead space,and wounds healed uneventfully within 3 weeks except for three patients who suffered delayed wound healing for more than 4 weeks.Other common complications such as infection,seroma,or wound dehiscence were not encountered in this series.Conclusion:The adductor longus muscle receives blood supply from a perforating branch from the femoral artery,along with a higher branch,a perforating branch,a secondary perforating branch which were all raised from the femoral profound artery.The main blood supply was originating from a perforating branch and a secondary perforating branch of the femoral profound artery.The femoral profound artery-derived main perforator branch exists stably,and the secondary perforator and the higher perforator have more variations.The adductor longus muscle can be used as a pedicled or free muscle flap.The adductor longus flap is larger than the sartorius flap.The pedicled adductor longus flap is a promising additional flap choice for inguinal region reconstruction,especially for patients suffering malignant tumor around this area.更多还原