Stokes R B, Whetzel T P, Sommerhaug E, Saunders C J
Division of Plastic and Reconstructive Surgery, University of California, Davis, Medical Center, Sacramento 95817, USA.
Plast Reconstr Surg. 1998 Sep;102(3):761-4. doi: 10.1097/00006534-199809030-00021.
The rare occurrence of umbilical necrosis after performance of a transverse rectus abdominis muscle (TRAM) flap prompted this investigation into the specific arterial anatomy of the umbilicus using multiple anatomic techniques. Sixteen fresh cadavers were studied by using dissection of blue latex-injected specimens, radiography of barium latex-injected specimens, and selective ink injection of individual perforators. It was discovered that the umbilicus receives arterial inflow by means of three distinct deep sources in addition to the subdermal plexus. These deep sources are (1) the right and left deep inferior epigastric arteries that each give off several small branches, and a large ascending branch, which courses between the muscle and the posterior rectus sheath passing directly to the umbilicus; (2) the ligamentum teres hepaticum; and (3) the median umbilical ligament. The clinical implications of this study are that the umbilicus should have robust arterial inflow if only one rectus muscle is removed, such as during a unilateral TRAM flap, because the contralateral side should still provide large direct vessels from the deep inferior epigastric arteries to the umbilicus. During bilateral TRAM elevation, all of the large arterial sources are removed from the umbilical inflow and circulation must depend on small vessels from the ligamentum teres and median umbilical ligament. Care should be taken in this latter clinical situation to preserve these sources of blood flow during umbilical flap creation.
横行腹直肌肌皮瓣（TRAM瓣）术后罕见的脐坏死情况促使我们采用多种解剖技术对脐部的特定动脉解剖结构进行了这项研究。通过对16具新鲜尸体进行研究，采用了对注入蓝色乳胶的标本进行解剖、对注入钡剂乳胶的标本进行放射摄影以及对各个穿支进行选择性墨水注射的方法。研究发现，除了皮下丛外，脐部还通过三种不同的深部来源获得动脉血供。这些深部来源包括：（1）左右腹壁下深动脉，每条动脉发出几条小分支和一条大的升支，升支在肌肉和腹直肌后鞘之间走行，直接通向脐部；（2）肝圆韧带；（3）脐正中韧带。这项研究的临床意义在于，如果只切除一块腹直肌，如在单侧TRAM瓣手术中，脐部应该有充足的动脉血供，因为对侧仍应提供从腹壁下深动脉到脐部的大的直接血管。在双侧TRAM瓣掀起术中，所有大的动脉来源都从脐部血供中被切断，血液循环必须依赖于来自肝圆韧带和脐正中韧带的小血管。在这种临床情况下，在制作脐瓣时应注意保留这些血流来源。
