摘要
目的:探索髋臼骨折前路腹膜外解剖学靶向手术路径,逐步实现创伤骨科手术机器人精准微创技术需求。方法:新鲜中国成年人遗体标本,给予动脉血管灌注。仰卧位状态下,选择髋臼前柱、前壁、臼顶、内侧四边体、坐骨大切迹5个最常见骨折部位,测量上述区域直径≧2.0 mm血管的分布位置和密集度。拟定血管与骨骼最短直线距离0~5.0 mm为Ⅰ级极度危险,5.0~10.0 mm为Ⅱ级高度危险,10.0~20.0 mm为Ⅲ级一般危险。在半径30.0 mm范围内动、静脉血管分布数量≧10,8,6条,分别拟定为A级极度危险区/B级高度危险区/C级一般危险区。根据上述测量结果,拟定5个区域的血管保护级别。总结避让重要血管的腹膜外靶向微创手术路径通道。结果:Ⅰ级极度危险血管为死亡冠,闭孔动、静脉,股动、静脉,臀上动、静脉,需Ⅰ级保护。Ⅱ级高度危险血管为髂腰动、静脉,髂内动、静脉及其分支,髂外动、静脉,臀下动、静脉,需Ⅱ级保护。Ⅲ级一般危险血管为腹壁下动、静脉,脐动、静脉,睾丸动、静脉,需Ⅲ级保护。A级极度危险区位于坐骨大切迹。B级高度危险区位于耻骨上支闭孔区、臼顶、内侧四边体。C级一般危险区位于前壁。直径≧5.0 mm血管损伤后大出血,可致快速死亡,包括髂总动、静脉,髂外动、静脉,髂内动、静脉。5个区域的血管保护级别依次为ⅠA有臀上动、静脉,闭孔动、静脉,死亡冠血管;ⅠB有股动、静脉。ⅡA有髂内动、静脉,髂外动、静脉;ⅡB有臀下动、静脉。ⅢB有睾丸动、静脉,子宫圆韧带动、静脉,脐动、静脉。耻骨上支、前壁(2处)、臼顶部、弓状线坐骨大切迹区域为腹膜外靶向髋臼骨折微创路径。新发现3处以往解剖学著作和文献均未描述的动脉血管,直径1.0~1.5 mm,分别命名为死亡冠血管的耻骨后营养支、臀上动脉腰大肌支和腹膜支、髂肌血管髋臼顶营养支。结论:本研究为创伤骨科手术机器人完成髋臼骨折精准微创手术提供了5种靶向路径通道,可快速到达髋臼5个靶向骨折部位,减少对非骨折区域正常组织的医源性损伤。新发现的3处血管丰富了髋臼血管解剖学,对避免术中血管损伤出血有重要意义。
Objective:To explore the anterior extraperitoneal anatomical targeted surgical approach for acetabular fractures and to meet the requirements for precise minimally invasive robotic-assisted orthopedic surgery.Methods:Fresh adult Chinese cadavers were used with arterial perfusion.Based on the clinical needs of internal fixation of acetabular fractures,five most common fracture sites of acetabulum were selected,including anterior column,anterior wall,acetabular roof,medial quadrilateral surface and greater ischial notch.The distribution and density of blood vessels with diameter≧2.0 mm were measured in the above areas.The shortest linear distance between blood vessels and bone was categorized as follows:GradeⅠ(extremely hazardous,0–5.0 mm),GradeⅡ(highly hazardous,5.0–10.0 mm),or GradeⅢ(moderately hazardous,10.0–20.0 mm).Venous and arterial distribution density≥10,8,6 vessels within a 30.0 mm radius was classified as Grade A(extremely hazardous),Grade B(highly hazardous),or Grade C(moderately hazardous).According to the above measurements,the vascular protection levels for 5 regions were drawn up.The extraperitoneal targeted minimally invasive surgical pathways were summarized to avoid important blood vessels.Results:Grade I vessels included the corona mortis,obturator artery and vein,femoral artery and vein,superior gluteal artery and vein,which required levelⅠprotection.GradeⅡvessels comprised iliolumbar artery and vein,internal iliac artery and vein and their branches,external iliac artery and vein,inferior gluteal artery and vein,which needed levelⅡprotection.GradeⅢvessels consisted of deep inferior epigastric artery and vein,umbilical artery and vein,testicular artery and vein,which called for levelⅢprotection.Grade A area was located at the greater sciatic notch.Grade B area was located at the obturator area of the superior pubic ramus,the acetabular roof and the medial quadrangle.Grade C area was located on the anterior wall.Blood vessels with a diameter≥5.0mm could cause rapid fatal hemorrhage after injury,including common iliac artery and vein,external iliac artery and vein,and internal iliac artery and vein.The vascular protection levels for the five regions were as follows:levelⅠA(superior gluteal artery and vein,obturator artery and vein,and coronary artery of death),level IB(Femoral artery and vein),levelⅡA(internal iliac artery and vein,external iliac artery and vein),levelⅡB(inferior gluteal artery and vein),levelⅢB(testicular artery and vein,uterine round ligament artery and vein,umbilical artery and vein).Five extraperitoneal targeted minimally invasive pathways for acetabular fractures were identified in superior pubic ramus,anterior wall(2 sites),acetabulum roof,and the greater sciatic notch area of arcuate line.Three newly discovered arteries,with 1.0–1.5 mm in diameter,which were not described in previous anatomical works and literature,were named as the pubic posterior trophic branch of the coronary artery of death,the psoas major branch and peritoneal branch of the superior gluteal artery,and the acetabular parietal trophic branch of the iliacus vessel.Conclusion:This study provides five targeted pathways for robotic-assisted orthopedic surgery to achieve precise and minimally invasive treatment of acetabular fractures,which can allow rapid access to the five targeted fracture sites of the acetabulum and reduce the iatrogenic damage to normal tissues in non-fracture areas.The three newly discovered vessels enrich anatomical understanding of acetabular vasculature and are of significant significance to avoid intraoperative vascular injury and bleeding.
作者
肖靖炜
李明
王滇
黄燎原
刘建磊
徐方竹
刘玉新
Xiao Jingwei;Li Ming;Wang Dian;Huang Liaoyuan;Liu Jianlei;Xu Fangzhu;Liu Yuxin(Department of Orhtopedic Trauma,Ningbo No.6 Hospital Affiliated to Ningbo University,Ningbo 315040;Health Science Center,Ningbo University,Ningbo 315211;Department of Anatomy,Ningbo College of Health Sciences,Ningbo 315100,China)
出处
《解剖学杂志》
2025年第2期103-110,共8页
Chinese Journal of Anatomy
基金
浙江省医药卫生科技计划项目(2018PY059)
宁波市科技创新2025重大专项(2021Z128)。
关键词
髋臼
血管
解剖学靶向通道
骨科手术机器人
智慧手术
acetabulum
blood vessel
anatomical targeted pathway
orthopedic surgical robot
intelligent surgery
