端口放置和套管针背景下的腹部解剖结构

虽然人体解剖结构没有改变，但手术材料和方法的技术发展要求手术管理也同步发展。电子和光学技术的发展使得许多妇科手术可以通过腹腔镜进行。任何其他手术方法与腹腔镜之间的一个根本区别是，无论是用针、套管还是套管针，初次进入大多是盲进。然而，盲进可能会导致血管或器官损伤。与进入并发症相关的困难之一是，任何损伤都可能无法立即被发现，从而导致大型腹部修复手术，最坏的情况是暂时性结肠造口术。因此，腹腔镜手术的技术和手术质量始于端口放置和套管针。可视访问系统可用，但尚未广泛使用。本综述旨在介绍不同的端口放置和套管针系统以及它们与腹部功能解剖学相关的正确和专业使用方法。

端口放置和套管针背景下的腹部解剖结构

图 1
a–d. 脐下区域的典型触诊点。指尖指向脐岬。脐下切口和局部触诊显示皮肤与脊柱之间的距离很短 (a)，透视检查照亮辅助套管针插入区域，同时划定浅腹壁动脉和旋髂浅动脉 (b–d)

端口放置和套管针背景下的腹部解剖结构

图 2
a–c. 从外部插入点（前上棘内侧两个拇指），与表面成 90° 角，穿透所有腹壁层 (a)，套管针插入部位位于脐外侧皱襞外侧 (b)，插入腹腔镜和三个辅助套管针后的概览 (c)，(a) 和 (b) 的图示

端口放置和套管针背景下的腹部解剖结构

图 3
a–c。从内部概览腹壁 (a)，脐正中皱襞包含闭塞的脐尿管，脐内侧皱襞包含闭塞的脐动脉，脐外侧皱襞包含下腹壁血管。在腹腔镜视图下用食指从外部触诊 (b)，用锋利的套管针严格从下腹壁血管外侧进入 (c–d)

端口放置和套管针背景下的腹部解剖结构

图 4
a–c。透视检查照亮辅助套管针插入区域，同时划定浅腹壁动脉和旋髂浅动脉 (a)，视野取决于腹壁厚度。从外部插入点（前上棘内侧两个拇指），与表面成 90° 角，穿透所有腹壁层。辅助套管针直接进入可避免皮下组织严重出血（b），一次性套管针严格位于脐外侧皱襞外侧和下腹壁血管外侧（c）

套管针插入位置
应尽可能将腹腔镜和光学套管针插入脐下区域，使用半月形或直切口（图 1）。仅当无法放置套管针时（例如由于严重粘连或大型腹腔内肿瘤），才可协商替代入口位置，例如脐上方或 Palmer 点（图 5），作为前体入口位置。

端口放置和套管针背景下的腹部解剖结构

图 5
a–d。替代入口位置的描述。对于较大的子宫，特别是在脐水平或脐水平以上，建议使用 Lee-Huang 点进行视频腹腔镜检查（a），Palmer 点，位于锁骨中线，肋缘下方约 3 厘米（b–d）

工作套管针的放置取决于手术。如果手术焦点位于骨盆内，且预计没有大肿瘤接触脐区，则可将两个工作套管针插入下腹壁无血管区域，并经透析镜检查确认。任何辅助套管针均可放置在中线上方或中线左侧。应达到视神经套管针和工作套管针之间的最大距离。此外，工作套管针不应位于头尾线，而应略微偏移。除了下部区域的闭塞脐尿管和膀胱外，未发现任何显著的解剖结构（图 6）。

端口放置和套管针背景下的腹部解剖结构

图 6
a–d. 重复开腹手术后，在既往腹膜炎病例（包括左上腹部）下视入路（a–d）EndopathTM 或 EndotipTM 是一次性和可重复使用的下视入路端口（c–d）

端口放置和套管针背景下的腹部解剖结构

图 7
a–d. 欧米伽形（Ω）脐切口 (a)、使用无创夹的“折叠”端口夹紧技术引入单点端口 (b)、单端口簇 (c)、脐部放置单点端口后诱导气腹，并将 12 毫米润滑套管针定位为 30 度内窥镜 (d)

端口放置和套管针背景下的腹部解剖结构

图 8
a–c. Veress 针和充气压力 (a)、抬起腹壁，插入角度为 45° (b)、Veress 针穿过腹壁 (c1)、尖头穿透皮肤和筋膜 (c2)、刺穿腹膜后，钝头由于阻力释放而向前弹起，从而避免器官（肠道）损伤 (c3)

端口放置和套管针背景下的腹部解剖结构

图 9
a-ı。 Hohl 子宫操纵器 (Storz) (a)、Dionisi 子宫操纵器 (Storz) (b)、Mangeshikar 子宫操纵器 (Storz) (c)、RfQ 子宫操纵器 (d)、Clermont-Ferrand 子宫操纵器 (Storz) (e)、Braun 子宫操纵器 (f)、Koninckx 子宫操纵器 (Storz) (g)、Tintara 子宫机械手 (Storz) (h)、Donnez 子宫机械手 (Storz) (ı)

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Published online 2015 Nov 2. doi: 10.5152/jtgga.2015.0148