腹腔镜直肠癌低位前切除术

腹腔镜直肠癌低位前切除术已在临床上受到广泛认可。术中手术层面的识别与游离、盆腔自主神经的保护对于手术成功与否以及患者术后生活质量尤为重要。腹腔镜直肠癌低位前切除术中需注意：(1)直肠系膜与神经前筋膜之间游离;(2)紧贴直肠系膜游离间隙;(3)保证直肠系膜后方、两侧方和前方的完整;(4)TME手术直肠系膜终止线位于肛门直肠环,游离应到位,不能残留直肠系膜。实践证实,基于膜解剖的直肠癌全系膜切除有助于盆腔自主神经保护以及实现肿瘤的根治性切除。     

直肠切除术中保留盆腔内脏神经的解剖学基础及要点

目的了解盆腔内脏神经的走行及与盆腔筋膜的关系,寻找安全的操作平面,减少直肠癌手术中对内脏神经的损伤。方法通过解剖12例人骨盆标本,观察盆腔内脏神经的走向分布及与筋膜间隙的关系。结果腹下神经全程走行于骶前筋膜内,下腹下丛走行于盆壁层筋膜内,并于直肠2点及10点处（截石位）在多个平面交叉穿入Denonvilliers筋膜汇入泌尿生殖血管束,Denonvilliers筋膜内存在横行的神经交通支。结论直肠后方及侧方的手术操作平面在直肠固有筋膜与骶前筋膜之间靠近直肠固有筋膜一侧,在直肠前方的手术操作应注意保护直肠2点及10点位置的泌尿生殖神经血管束及Denonvillers筋膜内的神经交通支。     

Pelvic anatomy for colorectal surgeons

INTRODUCTION: recent advances in rectal surgery include total mesorectal excision and preservation of the autonomic pelvic nerves, so that colorectal surgeons have to get some information on the embryology of the rectum, on the complex anatomy of the pelvic floor and on the distribution of lymphatic nodes. Embryology includes the formation of the hindgut during the first month of the embryo and the subsequent formation of the rectum and anal canal. The mesorectum contains the blood vessels and the lymphatic nodes. To totally excise the mesorectum, the surgeon should follow the "holy plane" described by Heald, between the perirectal fascia and the pelvic fascia. Doing this, the surgeon has the best chance to preserve the autonomic pelvic nerves that comprise the superior hypogastric plexus, the right and left hypogastric nerves and the right and left inferior hypogastric plexuses.     

腹腔镜直肠癌全直肠系膜切除术中保护盆自主神经的手术技巧

Laparoscopic radical resection of rectal neoplasms is still under clinical research currently due to the following 2 reasons. Firstly, compared with open surgery, the longterm efficacy of laparoscopic surgery remains unclear; secondly, the pelvic autonomic nerves are difficult to be exposed and easy to be damaged during the surgery under laparoscope. Till present time, our department has completed 800 cases of laparoscopic radical resection of colorectal neoplasms, in which rectal neoplasms accounted for 70%. For most cases, the pelvic autonomic nerves have been exposed and protected properly. This paper summarized the skills to protect the pelvic autonomic nerves in the laparoscopic total mesorectal excision used for the treatment of rectal neoplasms.     

功能性直肠癌扩大根治术对男性性功能的影响

目的 观察盆腔自主神经的解剖,减少直肠癌扩大根治术中对自主神经的损伤。分析在全直肠系膜切除基础上行保留神经的功能性直肠癌扩大根治性术对男性直肠癌患者性功能的应用价值,并与传统扩大根治术比较。方法 采用对6例盆腔器官作解剖学研究,观察盆腔自主神经的走行及分布结果,并通过调查表的方式调查306例男性中下段直肠癌扩大根治术病例保留神经组和传统扩大根治术组性功能障碍的发生率。结果 分析两组患者术后勃起功能障碍、性兴趣减退、射精功能障碍的发生率分别35.2％ (44/125)、62.2％ (46/74),76.8％( 19/125)、52.7％( 30/74),15.2％(29/125)、40.5％(35/74),差异有统计学意义(P＜0.05)。结论 保留盆腔自主神经的直肠癌扩大根治术可以改善患者的性功能障碍率。     

Pelvic Anatomy for Colorectal Surgeons

Introduction: recent advances in rectal surgery include total mesorectal excision and preservation of the autonomic pelvic nerves, so that colorectal surgeons have to get some information on the embryology of the rectum, on the complex anatomy of the pelvic floor and on the distribution of lymphatic nodes.

Embryology includes the formation of the hindgut during the first month of the embryo and the subsequent formation of the rectum and anal canal.

The mesorectum contains the blood vessels and the lymphatic nodes. To totally excise the mesorectum, the surgeon should follow the “holyplane” described by Heald, between the perirectal fascia and the pelvic fascia. Doing this, the surgeon has the best chance to preserve the autonomic pelvic nerves that comprise the superior hypogastric plexus, the right and left hypogastric nerves and the right and left inferior hypogastric plexuses.     

直肠系膜全切除的相关应用解剖及实用手法技巧

直肠系膜全切除治疗中低位直肠癌可显降低局部复发率。本根据会阴、肛管、直肠、结肠、膈膜、盆筋膜、血管、神经、输尿管的解剖介绍直肠系膜全切除的手法技巧。     

Where does pelvic nerve injury occur during rectal surgery for cancer?

Aim Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve‐preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk. Method The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words ‘autonomic nerve’, ‘pelvic nerve’, ‘colorectal surgery’, and ‘genitourinary dysfunction’. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis. Results The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the ‘lateral ligament’ area and division of Denonvilliers’ fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve. Conclusions In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.     

直肠癌根治术后膀胱排空障碍原因及处理

在直肠全系膜切除术提出前,直肠癌术后膀胱排空障碍的发生率高达40．0％～60．0％,目前该并发症的发生率现已降至不足5．0％。外科手术是直肠癌术后膀胱排空障碍的主因：盆腔神经损伤、经腹会阴联合手术均会影响排尿功能,而术前排尿功能障碍等因素亦是引起该并发症的原因。对于该并发症的处理主要应注意术中仔细操作,人工神经管再造及骶神经电刺激亦为治疗直肠癌术后膀胱排空障碍提供了新的思路。     

从解剖学角度谈中低位直肠癌术式选择

直肠癌在我国是最常见的恶性肿瘤之一,其中大约70%的肿瘤是中低位直肠癌。在过去的几十年中,放射治疗以及近来出现的放化疗与外科手术结合共同成为直肠癌治疗的主要手段.基于解剖的直肠癌根治术,包括了直肠癌的血管结扎,盆腔自主神经的保留,以及淋巴结的清扫和标准的全直肠系膜切除术,以及保留肛门括约肌的手术选择。     

腹腔镜直肠癌根治术中保留盆自主神经的关键技术与意义

直肠癌术中盆自主神经(PAN)的损伤是患者术后排尿功能和性功能障碍的主要原因之一。术中盆自主神经的精准辨认和保护始终是直肠癌根治术的要点与难点。术者应熟悉PAN的走行，把握直肠周围筋膜的解剖层次，才能维持正确的外科平面(surgical plane)，最大程度降低盆神经损伤概率。高清腹腔镜设备及应用解剖技术的进展使外科医生更精准地辨认PAN、血管、筋膜等重要解剖结构。本文对腹腔镜下直肠癌根治术中保留PAN的关键技术和意义作一综述。     

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??Decision-making on surgical therapy of low-third rectal cancer based on anatomy GU Jin??DU Chang-zheng. Peking University School of Oncology, Beijing Cancer Hospital &Institute??Beijing100142,China Corresponding author:GU Jin, E-mail:zlguj@yahoo.com.cn Abstract Rectal cancer is one of the most common cancers, and 75% locate at low-third rectum. Surgery is predominant therapy for rectal cancer. During the past decades,radiotherapy and more recently radiochemotherapy have been increasingly used together with surgery in the primary management of patients with rectal caner. Radical procedure of rectal cancer based on anatomy involves vascular ligation, pelvic autonomic nerve preservation(PANP), lymph nodes resection, total mesorectal excision(TME) and sphincter preservation.     

Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.     

Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer

BACKGROUND: The feasibility of laparoscopic rectal resection in patients with mid or low rectal cancer was studied prospectively with regard to quality of mesorectal excision, autonomic pelvic nerve preservation and anal sphincter preservation. METHODS: Laparoscopic rectal excision was performed in 32 patients (21 men) with rectal carcinoma located 5 cm from the anal verge. Most patients had T3 disease and received preoperative radiotherapy. The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, intersphincteric resection, transanal coloanal anastomosis with coloplasty and loop ileostomy. RESULTS: Three patients needed conversion to a laparotomy. Postoperative morbidity occurred in ten patients, related mainly to coloplasty. Macroscopic evaluation showed an intact mesorectal excision in 29 of 32 excised specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in 31 patients. The hypogastric nerves and pelvic plexuses were identified and preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18 evaluable men. CONCLUSION: A laparoscopic approach can be considered in most patients with mid or low rectal cancer.     

直肠癌根治术中保留骨盆自主神经的神经解剖学基础及临床意义

目的　探讨直肠癌根治术中保留神经的解剖学基础。　方法　解剖 6例完整尸体标本(男 4例 ,女 2例 )和 4例直肠及盆腔未受破坏的矢状半骨盆标本 ,观察骨盆神经组成及走行。　结果　显露下腹神经干 ,确定其在第 5腰椎处分为左、右下腹神经。其特点是较为粗大 ,位置固定 ,在腹主动脉分叉处易找到 ,呈网状联系 ,质地较实 ,为灰白色 ,与腹主动脉较近。分叉后左右下腹神经还有较粗大分支。骨盆内脏神经在大体标本上较难辨认 ,在矢状半骨盆标本中见到发自骶前孔 2～ 4的骨盆内脏神经 ,该神经较纤细 ,在侧韧带处呈丛状的细小纤维。　结论　保留下腹神经临床上较易完成。保留骨盆内脏神经则须细心操作 ,预保留神经的一侧在侧韧带水平的手术操作应尽量贴近直肠进行。     

腹腔镜辅助中低位直肠癌手术治疗的体会

目的：探讨腹腔镜辅助治疗中低位直肠癌的安全性与可行性。方法：回顾分析76例中低位直肠癌患者腹腔镜手术的临床资料。结果：73例成功施行了腹腔镜手术,保肛率84.9%（62/73）,局部复发率0.06%（5/73）,均至少保留了一侧盆腔自主神经,无严重并发症发生。结论：遵循全直肠系膜切除（total mesorectal excision,TME）原则施行保留自主神经的腹腔镜手术可提高疗效及保肛率。     

腹腔镜保留Denonvilliers 筋膜全直肠系膜切除术

Heald 教授提出的全直肠系膜切除术（TME）成为中低位直肠癌手术的金标准,然而因TME手术导致术中盆腔自主神经损伤,术后患者泌尿生殖功能障碍发生率居高不下,严重影响患者术后生活质量。笔者团队从解剖、生理、组织、手术实践等多方面,对直肠癌保留盆腔自主神经开展了一系列系统研究,在国际首创保留Denonvilliers筋膜全直肠系膜切除术（iTME）,并形成中国专家共识并向国际推广;同时提出邓氏筋膜术中标记线——“卫氏线”,确保iTME术式的可操作性和推广性。本例手术视频为男性患者Denonvilliers筋膜保留的iTME术式。     

Intraoperative parasympathetic nerve stimulation with tumescence monitoring during total mesorectal excision for rectal cancer

BACKGROUND: Unilateral or bilateral division of the parasympathetic nerves during resection of rectal cancer may result in sexual erectile dysfunction. The purposes of this project were twofold: to determine the ability to demonstrate penile tumescence in response to parasympathetic nerve stimulation after rectal cancer resection and to correlate the nerve stimulation response with clinical sexual function 6 months after operation. STUDY DESIGN: In 21 consecutive male patients with normal erectile function undergoing total mesorectal excision, cavernous nerve identification and integrity before and after pelvic dissection were assessed intraoperatively, both visually by an experienced surgeon and by using the CaverMap nerve stimulator. The minimal effective current necessary to produce a 2% increase in penile tumescence was recorded for both the left- and right-sided nerves, primarily the largest nerve trunk, S3. Postclearance stimulation data were then correlated with sexual function outcomes, specifically erection and orgasm at 6 months after surgery. RESULTS: The operating surgeon's visual assessment of the pelvic autonomic nerve's integrity after pelvic dissection was deemed intact in 20 of the 21 patients (95.2%). Of the 20 patients who were evaluated with CaverMap after completion of total mesorectal excision, 17 (85%) had tumescence response after nerve stimulation on either side, and 3 patients (15%) had unilateral response only. Of the 19 patients evaluated for sexual function 6 months after surgery, 18 (94.7%) had normal function, including the 3 patients with only unilateral nerve stimulation tumescence response. CONCLUSIONS: Intraoperative mapping of the parasympathetic nerve trunks with the CaverMap nerve stimulator may be a valuable aid to less experienced pelvic surgeons and may help in autonomic nerve preservation during total mesorectal excision clearance.     

The indications for autonomic nerve-sparing surgery in rectal cancer patients

Although extended lymph node dissection was developed to improve the therapeutic result in advanced rectal cancer in the 1970s, postoperative dysfunction remained problematic. Informed consent of cancer is generalized at present. The balance between complete cure and functional preservation is important. Therefore the autonomic nerve-sparing surgical technique for rectal cancer was introduce din the 1980s. The success of nerve-sparing surgery depends on a thorough knowledge of pelvic anatomy, especially the anatomic relationship between the pelvic plexus and internal intestinal vessels. Further investigation is required to clarify the indications for autonomic nerve-sparing surgery in rectal cancer patients.     

低位直肠癌保功能手术的解剖学基础

尽管全直肠系膜切除术（TME）是直肠癌根治术的金标准．但术后有一定的泌尿生殖功能障碍发生率。我们通过盆腔筋膜的解削研究明确了TME正确的手术层次,并进一步界定了手术层次与盆腔神经的关系．以期减少术巾神经损伤。值得注意的是,盆丛存在两种形态。如果盆丛为弥散状,完整的切除直肠系膜将不可避免地损伤盆丛,因而需通过深入的研究明确盆丛不同的功能单位。