腓腸內(nèi)側(cè)動(dòng)脈穿支皮瓣臨床應(yīng)用進(jìn)展

張功林,葛寶豐

(甘肅省蘭州軍區(qū)總醫(yī)院骨科研究所,甘肅 蘭州 730050)

近年來(lái),以穿支為基礎(chǔ)的皮瓣在臨床應(yīng)用與解剖學(xué)研究發(fā)展較快,其定義是皮瓣由肌皮穿支供養(yǎng),切取時(shí)不連帶其下肌肉,這是由傳統(tǒng)的肌皮瓣逐漸發(fā)展而來(lái)的[1]。典型的穿支皮瓣有:a)腹壁下動(dòng)脈穿支皮瓣;b)臀上動(dòng)脈穿支皮瓣;c)胸背動(dòng)脈穿支皮瓣等[2～5]。根據(jù)解剖和臨床研究,有學(xué)者又提出應(yīng)用腓腸內(nèi)側(cè)動(dòng)脈的 1個(gè)肌皮穿支為血供切取皮瓣,形成腓腸內(nèi)側(cè)動(dòng)脈穿支皮瓣 ,可行帶蒂轉(zhuǎn)移或游離移植[1,6]。這是近年來(lái)較新的穿支皮瓣供區(qū),在臨床的應(yīng)用逐漸增多,本文就近幾年國(guó)外在這方面的進(jìn)展進(jìn)行綜述。

1 解剖學(xué)研究

如果將腓腸肌內(nèi)側(cè)頭按Ⅰ型肌肉(單源血供)分類(lèi) ,有作者提出,切取穿支皮瓣時(shí)若將整個(gè)腓腸內(nèi)側(cè)動(dòng)脈切取后,有發(fā)生腓腸肌內(nèi)側(cè)頭壞死的可能。近年來(lái)的解剖學(xué)研究表明,該肌肉為Ⅱ型(多源血供),有多個(gè)血供來(lái)源:a)25%的標(biāo)本在近端有第二個(gè)血管蒂。b)腓腸肌內(nèi)側(cè)頭與外側(cè)頭之間有交通支。c)脛后動(dòng)脈有分支至腓腸肌內(nèi)側(cè)頭。d)腓動(dòng)脈也有分支供給其血運(yùn)。因此,整個(gè)腓腸內(nèi)側(cè)動(dòng)脈切取后,不會(huì)發(fā)生腓腸肌內(nèi)側(cè)頭缺血壞死[1]。

2 手術(shù)方法

取平臥位,膝與髖關(guān)節(jié)稍屈曲并外展外旋。也有作者主張采用俯臥位[11],這種體位更有利于血管解剖,游離好皮瓣后再改換成側(cè)臥位或平臥位修復(fù)受區(qū)創(chuàng)面。先用超生多普勒在距皺褶10～ 17 cm,距后正中線 2～ 5 cm范圍內(nèi)探測(cè)腓腸內(nèi)側(cè)動(dòng)脈的肌皮穿支,多數(shù)為 1～ 4支,選擇較大的一支為皮瓣中心點(diǎn),比受區(qū)創(chuàng)面稍大設(shè)計(jì)皮瓣,在充氣止血帶下手術(shù),但可不驅(qū)血,有利于術(shù)中辨認(rèn)肌皮血管穿支。先切開(kāi)皮瓣內(nèi)側(cè)緣至腓腸肌內(nèi)側(cè)頭肌膜下,提起皮瓣創(chuàng)緣,很容易發(fā)現(xiàn)穿支血管經(jīng)腓腸肌內(nèi)側(cè)頭穿出后,垂直進(jìn)入深筋膜至皮膚。確定至皮瓣的穿支后,再次確定穿支至皮瓣的位置,以確保皮瓣與血管蒂相連。為增加血管蒂的有效長(zhǎng)度,應(yīng)將皮瓣稍向遠(yuǎn)側(cè)設(shè)計(jì),將穿支血管置于皮瓣上半部[1,6]。然后順血管穿支,縱行分開(kāi)肌肉,向腓腸內(nèi)側(cè)動(dòng)脈解剖,用雙極電凝處理沿途至肌肉的細(xì)小分支,為防止在解剖中誤傷血管蒂,可連帶少許肌肉在血管蒂上,一旦游離出的血管蒂達(dá)到受區(qū)要求后,再切開(kāi)皮瓣四周。放松止血帶,觀察皮瓣血運(yùn)良好后可斷蒂或經(jīng)皮下隧道轉(zhuǎn)移到受區(qū)。但應(yīng)注意皮瓣充盈時(shí)間要比其他類(lèi)型的皮瓣較長(zhǎng),可能與蒂長(zhǎng)、血管痙攣有關(guān)。供區(qū)缺損小于 5cm時(shí),可直接縫合,否則需行游離植皮修復(fù)供區(qū)創(chuàng)面[11～13]。

3 優(yōu) 點(diǎn)

以腓腸內(nèi)側(cè)動(dòng)脈為血供的腓腸肌肌瓣或肌皮瓣在臨床應(yīng)用近 30年,其主要的缺點(diǎn)是需切取肌肉,對(duì)供區(qū)有一定的損傷,且較臃腫。利用腓腸內(nèi)側(cè)動(dòng)脈的肌皮穿支作為穿支皮瓣切取,由于不犧牲肌肉,擴(kuò)大了手術(shù)適應(yīng)證,主要優(yōu)點(diǎn)有[1,6～9,14]:a)腓腸內(nèi)側(cè)血管穿支皮瓣,血運(yùn)豐富 ,血管穿支較恒定;b)由于血管蒂?gòu)募∪庵薪馄食?不連帶肌肉,不犧牲肌肉功能,不損傷其運(yùn)動(dòng)神經(jīng)。從理論上講,由于保留了肌肉,且在切取腓腸動(dòng)脈穿支皮瓣過(guò)程中,不損傷肌肉近端血供,日后還允許再行腓腸肌內(nèi)側(cè)頭肌瓣或肌皮瓣移植;c)皮瓣較薄,修復(fù)后的外形較好,適宜修復(fù)足背及手背的軟組織缺損;d)該皮瓣可連帶腓腸內(nèi)側(cè)皮神經(jīng)或隱神經(jīng),可用于足負(fù)重面的修復(fù);e)由于血管蒂長(zhǎng),帶蒂轉(zhuǎn)移是修復(fù)膝關(guān)節(jié)周?chē)蛐⊥戎小⑸隙诬浗M織缺損的理想方法;f)用于游離移植時(shí),利用血管蒂長(zhǎng)的特點(diǎn),血管吻合部位可遠(yuǎn)離受區(qū)損傷部位或放射性損傷區(qū);g)不犧牲肢體主要血管,因而可以從傷肢或伴有血管損傷的肢體切取皮瓣;h)受區(qū)為足或小腿時(shí),可在一個(gè)手術(shù)野由一組人員操作,既省時(shí)也節(jié)省人力與物力。由于創(chuàng)傷小,修復(fù)后的外形明顯優(yōu)于傳統(tǒng)的腓腸肌內(nèi)側(cè)頭或比目魚(yú)肌肌瓣局部轉(zhuǎn)移的術(shù)式[15～17]。

4 缺 點(diǎn)

對(duì)于兒童與女性患者,該皮瓣仍覺(jué)偏厚;切取面積有限,不適宜較大創(chuàng)面修復(fù);供區(qū)植皮后外形不滿意是其缺點(diǎn)。對(duì)供區(qū)外形要求高者可作為筋膜瓣切取[14～16],這樣局部?jī)H為一線性切口線。穿支需從肌肉內(nèi)解剖出,對(duì)術(shù)者的操作要求高是該術(shù)式的另一缺點(diǎn)。但這一缺點(diǎn)可經(jīng)訓(xùn)練有素的醫(yī)生與得力的助手而解決,在文獻(xiàn)中尚未見(jiàn)解剖中損傷穿支血管而中止手術(shù)的報(bào)道。不少作者認(rèn)為,這是一處很有特色的新的皮瓣供區(qū)[1,6,10]。

5 手術(shù)適應(yīng)證

腓腸內(nèi)側(cè)動(dòng)脈穿支皮瓣的一個(gè)優(yōu)點(diǎn)是,能從肌肉中解剖出較長(zhǎng)的血管蒂,長(zhǎng)度可達(dá) 10～17 cm,利用這一特點(diǎn),可使帶蒂皮瓣到達(dá)脛骨上 3/4、窩和膝關(guān)節(jié)[1,6,14～17]。 因而 ,腓腸內(nèi)側(cè)動(dòng)脈穿支皮瓣行帶蒂轉(zhuǎn)移修復(fù)上述部位軟組織缺損是最好的適應(yīng)證,在選擇術(shù)式時(shí),優(yōu)先考慮該術(shù)式,可作為傳統(tǒng)的腓腸肌肌皮瓣或肌瓣以及比目魚(yú)肌肌瓣的替代手術(shù)[18～20]。但是血管蒂的長(zhǎng)度有限,不適宜修復(fù)小腿遠(yuǎn)側(cè) 1/3軟組織缺損。盡管小腿后側(cè)皮瓣較薄,但從事體力勞動(dòng)者仍較厚,因?yàn)楣﹨^(qū)不隱蔽,植皮修復(fù)后的外觀不甚滿意。用于吻合血管移植時(shí),所切取的面積有限,不作為首選。作為小皮瓣切取,仍是較好的皮瓣供區(qū)。用于修復(fù)同側(cè)足部軟組織缺損,由于同一手術(shù)野,皮瓣血管蒂也較長(zhǎng),操作相對(duì)方便,因而,吻合血管移植應(yīng)限制在下肢[21～24]。

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