局部解剖PBL (原题+翻译+答案).doc

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1、Lab Manual of Regional Anatomy (for Chinese Students)Department of Regional Anatomy & Operative Surgery The 1st Affiliated Hospital of China Medical UniversityNOTICEl Try to find the answers to the questions before practice class.l Preview the cases before practice class. Dont pay much attention on

2、disease. Try to find corresponding anatomical points in the cases and study on them. In the practice class, the cases will be discussed in English. Every student will get a score according to their appearance in discussion.Assignments:Complete the learning module entitled abdominal wall, inguinal re

3、gion and peritoneal cavity.Objectives:1. Recognize and define the abdominal cavity, peritoneal cavity. Describe the divisions of the anterolateral abdominal wall and abdominal cavity.answer：the division of the anterolateral abdominal wall (腹前外侧壁)(1)right hypochondriac epigastricleft hypochondriacreg

4、ion regionright lumbar regionumbilicalleft lumbar regionregionright inguinal regionhypogastricleft inguinal regionregion(2) Median planeRight upper abdomen area left upper abdomen areaRight lower abdomen a left lower abdomen area2. Describe the general layers of the anterolateral abdominal wall and

5、the relationships of the layers, partitions划分 and compartments分割 one encounters when dissecting from superficial to deep in any particular region. Answer:1-skin2-superficial fascia (Campers fascia fatty ,superficially浅层，脂肪较多) （Scarpas fascia-membranous，deep 深层，膜性）3-muscles rectus abdominis muscle腹直肌

6、 External oblique muscle 腹外斜肌 Internal oblique muscle 腹内斜肌 Transverse abdominis 腹横肌4-transversalis fascia 腹横筋膜5.extraperitoneal fascia 腹膜外筋膜6.parietal peritoneal壁腹膜3. Describe the blood supply and innervations of the anterolateral abdominal wall. Answer:(1) superfacial layerlateral wall: the branch

7、of posterior intercostals arteries , subcostal artery , lumbar arteries.nearby the median line: superior epigastric artery, inferior epigastric arterylower half: superficial epigastric artery, superficial iliac circumflex artery(2) deep layerposterior intercostal artery, subcostal artery, lumbar art

8、ery, superior epigastric artery, inferior epigastric artery, superficial iliac circumflex artery腹侧壁： 肋间后动脉、肋下动脉和腰动脉的分支 正中线附近： 腹壁上动脉、腹壁下动脉的分支下半部： 腹壁浅动脉 旋髂浅动脉下5对肋间后动脉、肋下动脉及4对腰动脉,腹壁上动脉（胸廓内动脉的终支之一 ）, 腹壁下动脉及旋髂深动脉 Nerve肋间神经，肋下神经，髂腹下神经，髂腹股沟神经，生殖股神经Intercostal nerves, subcostal nerve, iliohypogastric nerve,

9、 ilioinguinal nerve.4. Recognize the anatomical structures related to incisions on anterolateral abdominal wall.5. Recognize and define the inguinal region. Describe the general layers of the inguinal region and ligaments in this region. Trigone formed by the lateral borderof rectus abdominis, ingui

10、nal ligament and the horizontal line between anterior superior iliac spine and lateral border of rectus abdominis.Its a weak region of abdominal wallskinSuperficialfascia:camper layer and Scarpa layerMuscle layer: obliquus externus abdominis, inguinal ligament ,lacunar ligament, superficial inguinal

11、 ring. Ligaments: injuinal ligament, lacunar ligament.6. Recognize and define the inguinal canal and the 4 walls and 2 openings of it. Inguinal canal: it is an oblique passage,4-5cm long, through the abdominal wall. It passed downwards and medially from the deep to superficial inguinal rings and lin

12、es parallel to, and immediately above, the inguinal ligament. The inguinal canal is occupied in male by the cord and in female by the round ligament of uterus.It has 4 walls and 2 openings. That is:The anterior wall: aponeurosis of obliquus externus abdominis in the superficial layer, reinforced by

13、muscle fibers of obliquus internus abdominis in the deep layer at the outer 1/3 of the canalThe posterior wall: transverse fascia, reinforced by the conjoined tendon at the inner 1/3 of the canalThe superior wall: arched fibers formed by the and the transversus abdominisThe inferior wall: inguinal l

14、igamentThe inner opening: deep inguinal ring, which is about 1cm above the middle point of inguinal ligamentThe outer opening: superficial inguinal ring7. Recognize and define the inguinal triangle.Its surrounded by inferior epigastric artery , the inguinal ligament and the lateral border of rectus

15、Abdominis. This area is easy to have direct inguinal hernia.Questions:1. Try to describe the differences of the abdomen, abdominal cavity and peritoneal cavity. Answer:Abdomen: a part of body between thorax (胸部)and pelvis（盆部）Abdominal cavity:the cavity between diaphragm and superior pelvic aperture(

16、骨盆上口) Peritoneal cavity: the irregular cavity surrounded by parietal peritoneum(壁腹膜) and visceral peritoneum（脏腹膜）2. How to locate the pyloric level? What important structures at this level?3. Which layers will you meet when you choose a McBurneys incision? How about transrectal incision? Answer：(1)M

17、cburneys incision 皮肤-浅筋膜-腹外斜肌腱膜-腹内斜肌-腹横肌-腹横筋膜-腹膜外筋膜-壁腹膜Skin-superfacial fascia-aponeurosis of obliquus externus abdominis-internal oblique muscle of abdomen-transversus abdominis muscle-transverse fascia-extraperitoneal fascia-parietal (2) Transcrectal incision4. Try to describe the distribution of

18、superficial blood vessels, lymphatic vessels and cutaneous nerves of anterolateral abdominal wall.5. Try to describe the blood vessels and nerves in the deep layers of anterolateral abdominal wall.6. Why do hernias occur in inguinal region? Its a weak region of abdominal wall. the obliquus externus

19、abdominis change into aponeurosis of obliquus externus abdominis;there is no mucle over the region;male: spermatic cord, male: round ligament of uterus go through inguinal canal;when standing ,the pressure in inguinal region is 3 times higher than lie down wall7. Try to locate the inguinal canal and

20、 describe the four walls and two openings of it.8. Where to perform an abdominal puncture? Why? Answer：we can peform an abdominal puncture at rectovesical pouch for a man or at rectouterine pouch for women . The reason is that mans rectovesical pouch and womans rectouterine pouch is the lowest point

21、 of his or her body when he or she is stand or in semirecumbent.9. Which nerves go alongside the spermatic cord? Describe the passage of them. What will happen if they were damaged? Answer : the nerves that go alongside the spermatic cord are iliohypogastric nerve、 ilioinguinal nerve and genitofemor

22、al nerve. The iliohypogastric nerve start from twelfth thoracic nerve and the start of lumbar nerve I It go toward front lower and go through internal oblique at the point which 2.5cm above the anterior superior spine ,then go down to the inside aponeurosis of external oblique ，next go through the a

23、poneurosis of external oblique at the point which 2.5cm above superficial inguinal ring。The ilioinguinal nerve is 1.5cm under the iliohypogastric nerve and go parallel with it. It is in the outside of spermatic cord,It distribute in front skin of scrotum or greater lip of pudendum after it go out su

24、perficial inguinal ring .Its genital branch go down along spermatic cord ,it distribute in cremaster and dartos coat of scrotum.If they were damagrd in a operation the corresponding muscle will paralysis and will be easily to relapse. 10. How to distinguish the direct or indirect hernia? Indirect he

25、rnia: It is out of from deep inguinal ring, and it is from superior and lateral. The hernia sac neck is apparent.Direct hernia: It is out of from the inguinal triangle, and it is from anterior. The hernia sac neck is not apparent.11. You should pay attention on which blood vessels and nerves in hern

26、iorrhaphy. Try to tell their relationships. Answer:(1)Femoral artery and femoral vein.They locate in the mid point and deep inside surface of inferior wall of the inguinal canal(inguinal ligament)(2)Inferior epigastric artery. It locate in the medial of the deep inguinal canal(the lateral border of

27、the inguinal triangle)(3)Iliohypogastric nerve,They locate in one finger width beyond the inguinal canal,and are parrellel with the inguinal canal.(4)Ilioinguinal nerve. They locate in the inguinal canal through anterior of the cord.12. Try to describe the divisions of abdominal cavity.The abdominal

28、 cavity is divided into 9 parts by 2 horizontal lines (the inferior end of costal arch, the anterior superior iliac spine) and 2 vertical lines (the midpoint of right/left inguinal ligament), that is, right hypochondriac region, epigastric region, left hypochondriac region, right lumber region, umbi

29、lical region, left lumber region, right inguinal region, hypogastric region, left inguinal region.Case 1（94K）A twenty-five year-old female presented to the emergency room with a complaint of “colicky” periumbilical pain which had intensified over the last 6-8 hours and started to migrate to the righ

30、t lower quadrant. The patient reported some initial nausea, and as the pain had increased, she had an increasing emesis and anorexia. Physical exam demonstrated that the patient had no distension, auscultation revealed hyperactive bowel sounds, and palpation on the McBurneys Point demonstrated abdom

31、inal guarding, rebound tenderness, and the muscles of the anterior wall in the right lower quadrant were rigid. In addition, the patient had a low-grade fever, and laboratory tested reveal a rising white blood cell count. The attending determined that the patient had acute appendicitis and then the

32、patient had been taken to the O.R. for an appendectomy.The surgeons chose the McBurneys incision in the right lower quadrant and then opened and explored the abdominal cavity. After finding the vermiform appendix, surgeons ligated the mesoappendix, and then cut the appendix successfully. Finally, th

33、e abdomen was closed layer by layer.2 days after the operation, the patient got a high fever suddenly, with the tenderness at the right upper quadrant. The patient had been diagnosed as “liver abscess” according to the report of the ultrasound examination.25岁，女生以“脐周疼痛加剧6-8小时，现转移至右下腹”为主诉来急诊就诊。患者最初恶心，

34、随疼痛增加出现呕吐、食欲减退。经过查体后：腹部无膨隆，听诊时发现肠鸣音活跃，在麦氏点处有压痛，反跳痛，右下腹肌紧张。患者低热，实验室检查血白细胞增高。主治医诊断为急性阑尾炎，之后病人被带到手术室实行阑尾切除术。外科医生选择右下腹的麦氏切口，打开并且探查腹腔。找到阑尾后，医生结扎了阑尾系膜，然后成功切除阑尾。最后，一层一层的缝合了腹腔。手术2天后，病人突然发高烧并有右上腹的疼痛。根据超声检查报告，病人被诊断为肝脓肿。Case 2Jone, a 25-year-old man, was carrying furniture out to a moving van in preparation fo

35、r his familys move. When Jone strained to pick up a particularly heavy coffee table, he suddenly felt a sharp pain in his right inguinal region. Later, he noticed that a painful bulge had developed in his inguinal region which disappeared when he laid on his back. He did not like going to the doctor

36、, so he ignored the condition. After several months, the pain and the bulge in his groin increased and he finally consented to see a physician. On examination, the physician observed a swelling which began about midway between the anterior superior iliac spine and the midline, progressed medially fo

37、r about 4 cm, and then turned toward the scrotum. The doctor asked Jone to lie down and saw the swelling disappeared gradually. Then he marked a point which was about 1.5 cm above the midpoint of the inguinal ligament on the skin, and pressed it hardly. At the same time, he told Jone to stand up and

38、 hold breath. The swelling couldnt be seen. Taking the history and physical findings into account, the physician made a diagnosis of indirect inguinal hernia. Then the doctor ligated the hernial sac at high lever, and then repaired the hernia. 7 days later, the patient left the hospital with the syn

39、drome never happened again.Jone，男，25岁，因要搬家而在将家具抬入面包车中。在他用力的抬起一张咖啡桌时，他忽然感到右腹股沟区锐痛。之后，他注意到在他的腹股沟区出现一疼痛包块，该包块在他平躺时消失。他不想去看医生，所以他忽略了这一情况。几个月之后，他腹股沟区的包块疼痛加剧，最终不得不同意去看内科医生。在检查过程中，内科医生观察到腹部隆起出现在髂前上棘和正中线的连线的中点，均匀的向前延伸了约4厘米，之后向下进入阴囊。医生叫他平躺后看见隆起逐渐消失。之后，医生在他的髂前上棘中点上1.5cm处标记一点，并用力按压。隆起因而消失不再出现。结合病史和合体格检查，内科医生确诊

40、为腹股沟斜疝。之后医生在高位结扎的疝囊，并修补了疝气。七天后，病人离开医院，症状再未复发。Assignments:1. Complete the learning module entitled stomach.2. Complete the learning module entitled duodenum. 3. Complete the learning module entitled jejunum and ileum. 4. Complete the learning module entitled cecum and appendix.5. Complete the learnin

41、g module entitled colon.Objectives:1. Describe the position and relationship of the stomach, duodenum, jejunum, ileum, cecum, appendix and colon. 2. Master the features of the stomach, duodenum, jejunum, ileum, cecum, appendix and colon.3. Master the blood supply, lymphatic drainage and innervations

42、 of these organs. Questions:1. Which structures are adjacent with the posterior wall of stomach? 胃后壁与哪些结构相毗邻（即胃床）？The posterior wall of stomach is adjacent with pancreas, left suprarenal gland, left kidney, spleen, transverse colon and transverse mesocolon.(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。)2.

43、Which arteries supply the stomach? Which ligament are they in? Arteries: left gastric artery胃左动脉 right gastric artery 胃右动脉right gastroepiploic artery胃网膜右动脉 left gastroepiploic artery 胃网膜左动脉 short gastric artery胃短动脉 posterior gastric artery 胃后动脉 ligament: hepatogastric ligament 肝胃韧带 gastrocolic ligam

44、ent 胃结肠韧带 gastrosplenic ligament 胃脾韧带 gastropancreatic ligament 胃胰韧带 gastrophrenic ligament 胃膈韧带3. Why the patients with perforation of gastroduodenal ulcer suffer pain in the right lower quadrant, which is confused with acute appendicitis? 为什么胃十二指肠穿孔患者感觉右下腹疼痛？区分一下阑尾炎the patient with perforation of

45、gastroduodenal ulcer sometimes those of gastrointestinal contents into the abdominal cavity less ascending colon next to the ditch along the stream to the right lower abdomen, causing right lower abdominal pain and tenderness, as when the metastatic resembles acute appendicitis right lower abdominal

46、 pain Erzhi misdiagnosed. 胃十二指肠溃疡有时空腹穿孔或穿孔小者，流入腹腔的胃肠内容物较少，可沿升结肠旁沟流至右下腹，引起右下腹疼痛和压痛，因酷似急性阑尾炎时的转移性右下腹痛而致误诊。4. How to recognize the boundary between the stomach and the duodenum in an operation?5. Please describe the blood supply, venous and lymphatic drainage of the stomach. (1)胃左动脉 left gastric artery

47、 (2)胃右动脉right gastric artery (3)胃网膜右动脉right gastroepiploic artery (4)胃网膜左动脉left gastroepiploic artery(5)胃短动脉short gastric arteries(6)胃后动脉posterior gastric arteryVenous:胃的静脉多与同名动脉伴行，均汇入肝门静脉hepatic portal vein系统。胃右静脉right gastric vein沿胃小弯右行，注入肝门静脉，途中收纳幽门前静脉，后者在幽门与十二指肠交界处前面上行，是辨认幽门的标志。胃左静脉left gastric

48、vein又称胃冠状静脉，沿胃小弯左行，至贲门处转向右下，汇入肝门静脉或脾静脉。胃网膜右静脉right gastroepiploic vein沿胃大弯右行，注入肠系膜上静脉superior mesenteric vein。胃网膜左静脉left gastroepiploic vein沿胃大弯左行，注入脾静脉splenic vein。胃短静脉来自胃底，经胃脾韧带注入脾静脉。此外，多数人还有胃后静脉posterior gastric vein，由胃底后壁和网膜囊后壁腹膜后方，注入脾静脉。6. In theory, why the high selective vagotomy is the ideal method to treat the duod