腹腔镜下直肠癌根治术保留自主神经的解剖和技术要点

全直肠系膜切除术（TME）是目前国际公认的直肠癌标准术式,随着腹腔镜技术的推广和TME手术的普及,盆腔植物神经保护（PANP）的理念逐渐受到重视。本文根据作者经验和结合国内外文献,介绍保留PANP相关的新认识和技术进展。笔者认为,在开展直肠癌TME手术时,有六个部位容易发生盆腔植物神经损伤,需要识别和保护：肠系膜下动脉根部的肠系膜下丛,上腹下神经丛及腹下神经的近端,盆丛前丛的近端,盆丛后丛的主干,盆丛后丛的终末支,盆腔内脏神经以及血管神经束（NVB）。要完整保留PANP,需要熟悉盆腔筋膜解剖层次和神经走行在层次部位,在直肠固有筋膜和腹下神经输尿管前筋膜之间分离,可以完好地保留腹盆腔自主神经系统,以筋膜层膜为导向,进行筋膜之间分离,以神经为导向,实现精准直肠癌手术,对于提高手术质量,保护器官功能至关重要。     

Denonvilliers筋膜的微创解剖认识及其临床价值

1836年,法国外科学家Charles-Pierre Denonvilliers首次描述在男性的直肠与膀胱、精囊腺和前列腺之间存在薄层致密组织,后被称为Denonvilliers筋膜。1982年英国外科学家R.J. Heald教授提出全直肠系膜切除术（TME）理念,历经数十年的临床实践,TME已成为中低位直肠癌手术的金标准。根据TME理念,直肠后方及侧方均应在盆筋膜壁层内面与直肠固有筋膜间分离,而在直肠前方于Denonvilliers筋膜前方分离、肿瘤下方2 cm处倒U形离断并切除部分Denonvilliers筋膜。然而,资料显示,由于盆腔自主神经（PAN）的损伤,TME术后排尿及性功能障碍发生率居高不下。因此,进一步理清盆腔筋膜和自主神经解剖的认识,对于改善患者术后功能尤为重要。在国内外众多学者研究的基础上,我们从胚胎发育学、解剖学、组织学和外科手术角度对盆腔筋膜及外科层面进行深入探索,指出Denonvilliers筋膜不属于直肠固有筋膜的范畴、如非肿瘤浸润应予保留,并提出保留Denonvilliers筋膜全直肠系膜切除术（iTME）的理念;并采用多中心临床试验加以验证。在此基础上我们联合国内直肠癌外科领域专家,发布iTME中国专家共识,旨在提高从业者对神经功能保护的认识,规范手术操作,造福广大患者。     

保留耻骨前列腺韧带对前列腺癌根治术后尿失禁的预防

目的探讨耻骨后前列腺癌根治术中保留耻骨前列腺韧带及耻骨直肠悬韧带等对术后尿失禁的预防作用。方法从2008年6月到2009年12月对78例耻骨后前列腺癌根治术患者术中保留耻骨前列腺韧带及耻骨直肠悬韧带等的资料进行回顾性分析。所有患者均经直肠B超引导前列腺穿刺活检获得病理学诊断。方法作下腹正中切口,分层切开进入腹膜外及耻骨后间隙。清除耻骨后的脂肪,显露膀胱颈及前列腺表面的血管。在膀胱与盆壁交界处的筋膜腱弓外侧切开盆筋膜壁层,钝性向深面分离,向外推开肛提肌纤维,即可显露盆壁与前列腺前外侧的间隙。在靠近前列腺尖部横行穿过背血管复合体与前列腺间的平面,缝扎或钳夹、结扎、切断背血管复合体即可显露前列腺尖及膜部尿道,保留附着于此处的耻骨前列腺韧带,贴近前列腺切断尿道前壁。结果所有患者顺利康复,术后尿流率正常,6周内有7例轻度尿失禁,无长期尿失禁者。结论在耻骨后前列腺根治术中按正确的解剖层次操作,保留耻骨前列腺韧带有助于减少尿失禁,取得较好的手术效果。     

筋膜穿支血管在髋关节OCM入路中解剖学定位的研究

目的探寻在髋关节前外侧(OCM)入路中筋膜穿支血管与肌间隙及神经界面的关系。方法解剖经甲醛溶液常规防腐固定处理33侧髋部,均无肢体畸形及手术史。探查髂前上棘至大转子外侧最凸处连线附近血管穿筋膜点并探明该血管与臀中肌阔筋膜张肌肌间隙的位置及臀上神经的关系;观察在2011-06~2013-06间在我科行87台髋关节前外侧入路手术中发现筋膜穿支血管及其与臀中肌阔筋膜张肌肌间隙的位置关系。结果臀中肌与阔筋膜张肌肌间隙所在附近筋膜表面血管位置较为恒定。在尸体标本中约91%(30例)的标本在肌间隙中部可见穿支血管,穿支血管均来自肌间隙深面。在髋关节置换手术中发现有筋膜穿支血管的约为90.8%(79例),血管均来自肌间隙深面。臀上神经入肌点与筋膜穿支血管最短距离为(5.62±1.18)cm,安全范围与股骨长度及髂嵴最高点与大转子外侧最凸处的距离均有明显相关关系,相关系数分别为0.84、0.61。结论筋膜穿支血管与臀中肌阔筋膜张肌肌间隙关系恒定,在髋关节置换OCM入路中采用筋膜穿支血管定位准确,安全。     

直肠癌全直肠系膜切除术后直肠阴道瘘的原因与防治

随着直肠癌保肛手术的推广尤其是直肠癌低位及超低位前切除术开展以及双吻合器的普遍使用，吻合口瘘的发生率略有增加趋势，尤其是女性患者术后直肠阴道瘘有所增加，且不易愈合，对女性病人的生活质量和心理造成严重影响。虽然目前国内针对直肠癌全直肠系膜切除术（TME）后直肠阴道瘘采取了一些防治办法，但效果不甚理想，本文通过对我院行直肠癌TME保肛手术后发生的直肠阴道瘘患者资料进行分析，旨在探讨低位或超低位直肠癌行TME术后直肠阴道瘘发生的病因，需进一步提供切实可行的防治方法。     

直肠癌全直肠系膜切除术中盆腔植物神经的易损区域及保护

全直肠系膜切除术（TME）是目前国际公认的直肠癌标准术式,随着TME手术的推广和认识,盆腔植物神经保护（PANP）的理念逐渐受到重视。笔者认为,在开展直肠癌TME手术时,有六个区域容易发生盆腔植物神经损伤,需要识别和保护：肠系膜下动脉根部的肠系膜下丛、上腹下神经丛及腹下神经的近端、盆丛前丛的近端、盆丛后丛的主干、盆丛后丛的终末支及盆腔内脏神经。熟悉盆腔筋膜、植物神经解剖,开展以TME手术层面为主导,盆腔植物神经为引导的精准直肠癌手术,对于提高手术质量,保护器官功能至关重要。     

腹腔镜前切除术中游离大网膜并填塞治疗女性中低位直肠癌的效果及直肠阴道瘘风险观察

目的探讨对接受腹腔镜前切除术的女性中低位直肠癌患者,术中游离大网膜并填塞至直肠与阴道间隙对手术效果及术后直肠阴道瘘风险的影响。方法将2016年1月至2018年4月于重庆市开州区人民医院普外科接受腹腔镜前切除术的58例女性中低位直肠癌患者按信封随机法均分为观察组和对照组,各29例。观察组术中游离带血管蒂大网膜,并填塞于直肠与阴道间;对照组术中不对直肠与阴道间隙进行特殊填塞。对比两组手术指标及直肠阴道瘘发生情况。结果观察组手术时间(198. 38±30. 58) min明显长于对照组(173. 69±32. 71) min,差异有统计学意义(P 0. 05)。观察组直肠阴道瘘发生率0. 00%明显低于对照组20. 67%,差异有统计学意义(P 0. 05)。结论对女性中低位直肠癌患者,在腹腔镜前切除术中游离大网膜并填塞至直肠与阴道间隙,能够有效预防术后直肠阴道瘘。该措施可能延长手术时间,但不会对术后恢复造成严重不良影响。     

直肠癌TME和ELAPE手术质量控制

解剖层面明确、手术质量可控制是手术进步的重要体现。在直肠癌的手术的发展上,全直肠系膜切除术（TME）和肛提肌外腹会阴联合切除术（ELAPE）属于手术质量控制的里程碑式手术。TME手术目前是中低位直肠癌的标准术式,要求直肠和直肠系膜作为一个解剖单位整体切除;ELAPE手术在减少传统腹会阴联合切除时存在"外科腰"方面（可能导致环周切缘阳性）可能具有一定价值。外科医师要做到手术质量控制,需要做好包括术前多学科专家组（MDT）评估、术中手术技术质控、术后标本质量病理学评估在内的一整套直肠癌手术质量控制体系。本文从上述三个方面对两种术式的手术质量控制进行论述。     

咽后脓肿196例分析

咽后和咽旁间隙是咽部解剖上的潜在间隙,上起自颅底枕骨,下抵胸腔纵隔,后壁为颈椎体及椎前筋膜,前壁为颅咽筋膜,两者仅隔以薄层的不完整筋膜。因此,一个间隙感染化脓后可穿破筋膜而和另一间隙融合成一大脓腔。正常时咽后间隙内有散在的淋巴结,两侧有颈内动静脉、交感神经和第9、10、11、12颅神经。由于咽粘膜下有丰富的淋巴网状结构,较大的淋巴组织在四周     

前列腺癌根治术中生理功能的保护

目的　保护前列腺癌根治术后患者的排尿和阴茎勃起功能 ,提高术后病人的生活质量。方法　选择 1 4例早期前列腺癌患者 (T1 )。在前列腺癌根治术中 ,采用解剖式手术方法 ,通过保护尿道外括约肌、膀胱颈成形保护患者的排尿功能。对 4例患者保留支配阴茎勃起的神经血管束 ,以保护勃起功能。结果　术后随访 6～ 2 6个月 (平均 1 2 .7个月 ) ,1 4例患者排尿功能恢复良好。 4例保留血管神经束患者 ,3例恢复性功能。结论　保护尿道外括约肌、膀胱颈成形术可有效地保护排尿功能。保留血管神经束可有效地保留性功能 ,提高生活质量。     

间介中胚层、泌尿-生殖层与直肠周围筋膜

由胚胎期间介中胚层-泄殖腔发育形成了一个包含肾脏（肾周脂肪）、输尿管、生殖血管并延续包含膀胱、输精管、精囊腺、前列腺等泌尿、生殖器官的功能层面,我们命名为"泌尿-生殖层",其表面的内脏筋膜是泌尿-生殖筋膜。直肠周围被泌尿-生殖层所围绕,泌尿-生殖筋膜脏层构成了直肠周围筋膜,直肠固有筋膜与泌尿-生殖筋膜脏层之间形成直肠周围间隙。直肠中、下段全系膜切除的游离平面跨越了泌尿-生殖层,前后游离平面的交汇点在直肠侧方结构。     

The surgical anatomy of the rectum — a review with particular relevance to the hazards of rectal mobilisation

The major complications of rectal surgery that are wholly or partially avoidable by the use of an anatomically based dissection are haemorrhage from presacral veins, perforation of the rectum, damage to pelvic autonomic nerves and inadequate clearance of a rectal cancer. Important technical points in minimising the incidence of these complications are: (1) posterior dissection in the presacral space; (2) entry to this space by sharp dissection immediately posterior to the superior rectal artery; (3) deliberate incision of the rectosacral fascia; (4) anterior dissection posterior to Denonvilliers fascia in benign disease; (5) removal of the entire mesorectum for low rectal cancer. Other anatomical points not widely appreciated are: 1. The middle rectal artery does not run in the lateral ligaments of the rectum, but below them, on levator ani. It reaches the rectum by penetrating Denonvilliers' fascia. 2. The lateral ligaments may contain an accessory middle rectal artery in 25% of cases. 3. The pelvic autonomic nerves are buried in endopelvic fascia on the pelvic side wall, but come to lie close to the anterior aspect of the rectum at the level of the prostate or upper vagina.     

Denonvilliers’ Fascia Lies Anterior to the Fascia Propria and Rectal Dissection Plane in Total Mesorectal Excision

PURPOSE Opinion is divided whether Denonvilliers fascia lies anterior or posterior to the anatomic fascia propria plane of anterior rectal dissection in total mesorectal excision. This study was designed to evaluate this anatomic relationship by assessing the presence or absence of Denonvilliers fascia on the anterior surface of the extraperitoneal rectum in specimens resected for both nonanterior and anterior rectal cancer in males.METHODS Surgical specimens were collected prospectively from males undergoing total mesorectal excision for mid and low rectal cancer, with a deep dissection of the anterior extraperitoneal rectum to the pelvic floor. Specimens were histopathologically analyzed using best practice methods for rectal cancer. The anterior aspects of the extraperitoneal rectal sections were examined microscopically for the presence or absence of Denonvilliers fascia.RESULTS Thirty rectal specimens were examined. Denonvilliers fascia was present in 12 (40 percent) and absent in 18 specimens (60 percent). Denonvilliers fascia was significantly more frequently present when tumor involved (55 percent) rather than spared the anterior rectal quadrant (10 percent; difference between groups 45 percent; 95 percent confidence interval, 30–60 percent; P = 0.024, Fishers exact test).CONCLUSIONS When tumors were nonanterior, rectal dissection was conducted on fascia propria in the usual anatomic plane, and Denonvilliers fascia was not present on the specimen. It was almost exclusively found in anterior tumors, deliberately taken by a radical extra-anatomic anterior dissection in the extramesorectal dissection plane. Denonvilliers fascia lies anterior to the anatomic fascia propria plane of anterior rectal dissection and is more closely applied to the prostate than the rectum.Presented at the meeting of the Association of Coloproctology of Great Britain and Ireland, Brighton, United Kingdom, July 10 to 12, 2000.Reprints are not available.     

Identification of the fascia propria by magnetic resonance imaging and its relevance to preoperative assessment of rectal cancer

PURPOSE: If rectal cancer does not penetrate the fascia propria of the rectum and the rectum is removed with the fascial envelope intact (extrafascial excision), then local recurrence of the cancer will be minimal. Modern imaging techniques have identified a fascial plane surrounding the rectum and mesorectum, and it has been suggested that this is the fascia propria. The aim of this study was to identify whether this plane is the rectal fascia propria and whether tumor invasion through this fascia can be identified preoperatively. METHODS: Two separate experiments were performed: 1) pelvic magnetic resonance imaging was performed before and after dissection and marking of the plane of extrafascial dissection of the rectum of a cadaver; and 2) magnetic resonance imaging was performed in 43 rectal cancer patients preoperatively. Two radiologists independently reported the depth of tumor invasion in relation to the fascia propria. The tumors were resected by extrafascial excision, and a pathologist independently reported the relation of the tumor to the fascia propria. RESULTS: The marker inserted in the extrafascial plane showed that the plane visualized on pelvic magnetic resonance imaging was the fascia propria dissected in extrafascial excision of the rectum. The magnetic resonance imaging detected tumor penetration through the fascia propria with a sensitivity of 67 percent, a specificity of 100 percent, and an accuracy of 95 percent. CONCLUSION: The surgical fascia propria can be identified on preoperative magnetic resonance imaging in patients with rectal cancer. Tumor invasion through this fascia can be detected on magnetic resonance imaging. This method of assessment offers a new way to select those patients who require preoperative radiotherapy.Supported by a research grant from The Maurice and Phyllis Paykel Trust, Parnell, Auckland, New Zealand.     

Recent progress in diagnosis and treatment of rectal cancer]

Rectal cancer is an emerging health issue in Korea because its incidence is rapidly increasing with changes in life styles and diets. The optimal treatment of rectal cancer is based on multimodality. Among them, surgical treatment is the corner-stone. In the past, local recurrence rate has been reported as high as 30-40%, but the concept of total mesorectal excision (TME) lowered the rate of local recurrence down to less than 10%. TME focuses on sharp pelvic dissection and complete removal of rectal cancer with surrounding mesorectum inside the rectal proper fascia. TME is now considered as a standard procedure for surgical treatment of mid and low rectal cancer. With the introduction of pelvic magnetic resonance imaging (MRI) for preoperative staging of rectal cancer, risk factors for local recurrence can be predicted before surgery to distinguish patients who are in high risk for recurrence that requires preoperative neoadjuvant chemoradiation therapy. Early rectal cancer was assessed by transrectal ultrasonography (TRUS) and endorectal MRI with coil. Transanal local excision can be applied with anal sphincter preservation safely. Neoadjuvant chemoradiation therapy was performed in patients with locally advanced rectal cancer, and this resulted in tumor size reductions and histopathologic downstaging effect. As far as the quality of life is concerned, sexual and voiding function are much improved by techniques preserving nerve. Many experts have dealt with challenging practical problems of managing rectal cancer from diagnosis to quality of life. This issue contains recent progresses in the diagnosis and treatment of rectal cancer which will serve as a comprehensive reference for those who manage rectal cancer in their medical practice.     

Operating Behind Denonvilliers’ Fascia for Reliable Preservation of Urogenital Autonomic Nerves in Total Mesorectal Excision: A Histologic Study Using Cadaveric Specimens, Including a Surgical Experiment Using Fresh Cadaveric Models

Purpose Little is known about which urogenital nerves are liable to be injured along surgical planes in front of or behind Denonvilliers’ fascia. Methods and Results Using semiserial histology for five fixed male pelves, we demonstrated that: 1) left/right communicating branches of bilateral pelvic plexuses run immediately in front of Denonvilliers’ fascia; and 2) a lateral continuation of Denonvilliers’ fascia separates the urogenital neurovascular bundle from the mesorectum. Notably, the mesorectum contains no or few extramural ganglion cells. At the level of the seminal vesicles, incision in front of Denonvilliers’ fascia seems likely to injure superior parts of the pelvic plexus and the left/right communication. Moreover, at the prostate level, this incision misleads the surgical plane into the neurovascular bundle. Fresh cadaveric dissections of five unfixed male pelves confirmed that the surgical plane in front of Denonvilliers’ fascia continues to a fascial space for the pelvic plexus containing ganglion cell clusters lateral and/or inferior to the seminal vesicles. Conclusions To preserve all autonomic nerves for urogenital function, optimal total mesorectal excision for rectal cancer requires dissection behind Denonvilliers’ fascia.     

Definition of total mesorectal excision, including the perineal phase: technical considerations

BACKGROUND: Total mesorectal excision (TME) has contributed to a decline in local recurrence. The operation is difficult because of the complicated anatomy of the pelvis and the narrow spaces in the pelvis. We review the anatomy related to TME and we present our surgical technique. ANATOMY: The pelvis can be divided into a parietal compartment and a visceral compartment. Both compartments are covered by a fascial layer: the parietal and the visceral fascia. A space between these fascial layers can be opened by dividing loose areolar tissue. The pelvic autonomic nerves consist of the sympathetic hypogastric nerve and the parasympathetic sacral splanchnic nerve. At the pelvic sidewall these nerves join in the inferior hypogastric plexus. SURGERY: We present our surgical technique based on careful dissection under direct vision and describe our approach to abdominoperineal resection in the knee-chest position. This position enables en bloc resection of the levator ani muscle with the mesorectum, preventing positive circumferential margins in distal rectal tumor. CONCLUSION: TME is a difficult and challenging operation. Continuous attention to surgical technique and anatomy is important to keep up the high standards of contemporary rectal surgery.