Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Louisville, Louisville, KY.
Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, University of Louisville, Louisville, KY.
Am J Obstet Gynecol. 2020 May;222(5):480.e1-480.e7. doi: 10.1016/j.ajog.2019.12.009. Epub 2020 Apr 1.
As a result of the vaginal mesh controversy, surgeons are performing more nonmesh, autologous fascia pubovaginal slings to treat stress urinary incontinence in women. The rectus abdominis fascia is the most commonly harvested site for autologous pubovaginal slings, so it is crucial that surgeons are familiar with the relationship between this graft harvest site and the ilioinguinal and iliohypogastric nerves, which can be injured during this procedure.
The aims of this study were as follows: (1) to estimate the safest area between the bilateral courses of the ilioinguinal and iliohypogastric nerves in which a rectus abdominis fascia graft could be harvested with minimal risk of injury to these nerves and (2) to determine the location and dimensions of a graft harvest site that maximized graft length while remaining close to the pubic symphysis.
The ilioinguinal and iliohypogastric nerves were dissected bilaterally in 12 unembalmed female anatomical donors. The distances of these nerves to a 10 × 2 cm rectus abdominis fascia graft site located 4 cm above the pubic symphysis were measured. Nerve courses inferior to the graft site were determined for each donor by linearly extrapolating measurement points; analysis was performed with and without extrapolation. Average nerve trajectories were estimated assuming a linear regression function to predict the horizontal measurement as a quadratic function of the vertical distance; 95% confidence bands were also estimated. An estimated safety zone was determined to be the region between all credible nerve bounds.
The largest safety zone that was closest to the pubic symphysis was located at 5.4 cm superior to the pubic symphysis. At this location, the inferior border of the graft could measure 9.4 cm in length (4.7 cm bilaterally from the midline). Extrapolated nerve courses below the study graft site yielded a smaller safety zone located 2.7 cm superior to the pubic symphysis, allowing for the inferior border of the graft to be 4.8 cm (2.4 cm bilaterally from the midline).
A rectus abdominis fascia graft harvested 5.4 cm superior to the pubic symphysis with the inferior border of the graft measuring 9.4 cm in length should minimize injury to the ilioinguinal and iliohypogastric nerves. These dimensions allow for the longest graft while remaining relatively close to the pubic symphysis. The closer a graft is harvested to the pubic symphysis, the smaller in length the graft must be to avoid injury to the ilioinguinal and iliohypogastric nerves.
由于阴道网片争议，外科医生正在进行更多的非网片、自体筋膜耻骨阴道吊带手术，以治疗女性压力性尿失禁。腹直肌筋膜是最常用于自体耻骨阴道吊带的采集部位，因此外科医生必须熟悉该采集部位与髂腹股沟和髂腹下神经之间的关系，因为在这个过程中，这些神经可能会受伤。
本研究的目的如下：（1）估计在双侧髂腹股沟和髂腹下神经的路径之间，以最小的风险采集腹直肌筋膜移植物而不损伤这些神经的最安全区域；（2）确定采集部位的位置和尺寸，使移植物长度最大化，同时保持靠近耻骨联合。
在 12 具未经防腐处理的女性解剖供体中，双侧解剖髂腹股沟和髂腹下神经。测量这些神经与位于耻骨联合上方 4 厘米处的 10×2 厘米腹直肌筋膜移植物部位之间的距离。通过线性外推测量点，确定每个供体中位于移植物部位下方的神经路径；分析有无外推两种情况。假设线性回归函数来估计平均神经轨迹，以预测水平测量作为垂直距离的二次函数；还估计了 95%置信带。估计安全区是指所有可信神经边界之间的区域。
最靠近耻骨联合的最大安全区位于耻骨联合上方 5.4 厘米处。在这个位置，移植物的下边缘可以测量 9.4 厘米长（中线两侧各 4.7 厘米）。在研究移植物部位下方进行外推神经路径会产生一个较小的安全区，位于耻骨联合上方 2.7 厘米处，允许移植物的下边缘为 4.8 厘米（中线两侧各 2.4 厘米）。
在耻骨联合上方 5.4 厘米处采集腹直肌筋膜移植物，移植物的下边缘长度为 9.4 厘米，应能最大程度地减少髂腹股沟和髂腹下神经的损伤。这些尺寸允许最长的移植物，同时保持相对靠近耻骨联合。移植物越靠近耻骨联合，为避免损伤髂腹股沟和髂腹下神经，移植物的长度就必须越短。
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