腹腔镜直肠癌低位前切除术

腹腔镜直肠癌低位前切除术。术中首先经中间入路打开乙状结肠系膜内侧浆膜,循Toldt’s间隙向头侧游离至肠系膜下动脉根部,夹闭离断肠系膜下动脉,并清扫253组淋巴结;继续向外侧、尾侧游离左侧Toldt’s间隙,并向下延续至直肠后间隙,分离过程中注意保护左侧输尿管、左侧生殖血管。沿左结肠旁沟打开结肠系膜与侧腹壁的融合筋膜,向上游离左侧结肠至脾曲。向下继续沿直肠后间隙分离,并向两侧拓展;前方在腹膜返折略上水平打开腹膜,在邓氏筋膜前间隙向下游离,从前、后及两侧交替游离并完整切除直肠系膜;双吻合器法切除直肠肿瘤及重建肠道。     

腹腔镜直肠癌根治术(Dixon)

在结肠系膜与后腹膜移行处切开后腹膜,分离系膜至肠系膜下动脉根部,清扫253组淋巴结,在距腹主动脉根部1 cm处夹闭并切断血管,切断肠系膜下静脉。由内侧向外侧分离结肠系膜至结肠旁沟,切开其左侧后腹膜,将降结肠及乙状结肠系膜从后腹壁游离。沿直肠固有筋膜与盆壁筋膜的间隙按照TME原则锐性分离直肠系膜,先游离后壁,再游离两侧壁及前壁,直至盆底。在肿瘤下方2 cm处用阻断夹夹闭肠管,冲洗远端直肠,用切割缝合器切断直肠。取脐部弧形切口。提出近端肠管,于肿瘤近端15 cm处离断肠管。近端置入管型吻合器抵钉座,还纳腹腔,重建气腹。经肛置入管型吻合器,在腹腔镜直视下作乙状结肠－直肠端端吻合,冲洗腹腔,置引流管,手术结束。     

超低位直肠癌保肛术

5孔法,仰卧,取头低足高30°的右侧倾斜膀胱截石位。1探查腹腔。2内侧入路从乙状结肠系膜与盆底腹膜交界处切开,自内向外分离Toldt's间隙。3距腹主动脉0.5 cm处Hem-o-lock断结扎肠系膜下动脉,在近屈氏韧带下方分离出肠系膜下静脉,切断,保护肠系膜下神经丛。4乙状结肠系膜裁剪及游离。5直肠后间隙分离:保护腹下神经丛。6直肠前壁及侧方分离:腹膜返折上0.5~1.0 cm切开,沿邓氏筋膜前分离直肠前壁,精囊腺底部切开邓氏筋膜,侧方分离全程以盆神经作为指引。7直肠末端系膜分离:将直肠系膜从肛提肌裂孔边缘切断,进入括约肌间隙,顺直肠壁向肛侧分离,距肿瘤2 cm切割闭合直肠。切除近端肠管行直肠乙状结肠端端吻合,回肠末端预防性造口。     

腹腔镜低位直肠癌根治术

松解乙状结肠与侧腹膜间的粘连。沿直肠系膜根部内侧打开浆膜,钝、锐性向上分离至肠系膜下动脉根部。分离打开Toldt’s筋膜下间隙,解剖肠系膜下动静脉,清扫血管根部周围的淋巴脂肪组织。提起乙状结肠,向上继续分离Toldt’s间隙至结肠脾曲,向下分离结直肠后间隙至盆腔,进入盆腔脏、壁筋膜间隙直至骶前间隙,离断两侧直肠侧韧带。分离直肠前侧,沿腹膜反折打开,沿直肠系膜间隙分离完整切除直肠系膜(TME)。术中于肿瘤下方约2 cm处离断直肠。取6 cm长左旁正中切口,将游离的直肠移至腹腔外,在肿瘤上方约10 cm处离断,移去标本,残端置入吻合器抵针座后,荷包缝合固定,将肠管回纳腹腔后逐层关腹。经肛门置入28 mm吻合器,行乙状结肠-直肠端端吻合。     

腹腔镜辅助直肠癌根治术

中央入路于乙状结肠系膜内侧切开后腹膜,解剖Toldt’s间隙,分别向左、向尾侧、向头侧进一步游离、扩大该间隙,显露并注意保护左侧输尿管、左侧生殖血管。充分游离Toldt’s间隙后,放入小纱布以作标记。提起肠系膜下血管根部系膜组织,彻底分离清扫肠系膜下动脉根部淋巴脂肪组织。夹闭、切断肠系膜下动脉,注意保护生殖神经。向下游离,首先游离后方的直肠后间隙和前方的邓氏间隙,然后离断直肠侧韧带。最后按腹腔镜下全直肠系膜切除法+双吻合器法切除直肠肿瘤及重建肠道。     

机器人直肠癌根治术

术中自肠系膜下动脉下方切开乙状结肠系膜,游离Toldts间隙,暴露并保护左侧输尿管及生殖血管。切断肠系膜下动脉根部,清扫253组淋巴结。切开乙状结肠侧腹膜,游离乙状结肠下段。提起肠系膜下动脉血管蒂(已切断),沿Toldts层面分离直肠系膜与骶前间隙,环形完整游离直肠系膜,于肿瘤标记处远端约5cm处以直线切割闭合期切断直肠肠管。肠管断端提出体外,距离肿瘤近端约10cm,切断乙状结肠肠管,并包埋吻合器钉座。行乙状结肠-直肠端端吻合(Dixon手术)     

盆筋膜解剖及其与直肠固有筋膜关系研究

目的 探讨盆筋膜的结构、范围及其与直肠固有筋膜的层次关系。方法 2020年12月至2021年3月对由广东药科大学生命与生物制药学院人体解剖与胚胎学系及中山大学中山医学院人体解剖学教研室提供的12具（男性5具、女性7具）骨盆标本进行大体观察，并对Denonvilliers筋膜进行组织学观察。结合2019年12月至2021年3月中山大学附属第三医院胃肠外科收治的20例直肠癌病人（男性10例、女性10例）的盆腔磁共振图像和手术视频进行解剖学印证。结果 12具骨盆大体标本显示，盆筋膜与Gerota筋膜相延续，部分纤维于S4水平构成直肠骶骨筋膜，向下与直肠固有筋膜融合终止于联合纵肌；部分纤维与后方骶前筋膜融合构成肛提肌上筋膜及肌间纤维。Denonvilliers筋膜在盆腔前外侧约2点、10点处与盆筋膜相延续构成完整筒状结构，包绕内层由直肠固有筋膜封套的直肠系膜；除“侧韧带”处有盆腔自主神经直肠支、淋巴管、直肠中动脉相连外，两层筋膜形成完整的双筒状结构，横断面呈同心圆状。除直肠支进入直肠固有筋膜外，盆腔自主神经主要分支均位于盆筋膜内层及Denonvilliers筋膜以外，沿直肠固有筋膜轮廓游离能够避免损伤盆腔自主神经。在7具女性骨盆标本中均能见到菲薄的Denonvilliers筋膜结构。直肠癌病人的横断面磁共振图像能够看到直肠固有筋膜与外侧盆筋膜、Denonvilliers筋膜的轮廓和间隙，手术视频资料也可见到完整盆壁筋膜和Denonvilliers筋膜的轮廓。结论 直肠癌手术中，在盆筋膜、Denonvilliers筋膜与直肠固有筋膜两层结构的间隙进行分离，并保持两层筋膜的完整性，对于保证肿瘤根治性和保护排尿及性功能至关重要。     

腹腔镜直肠癌手术中神经血管束显露保护及其损伤防治

全直肠系膜切除的提出推动了结直肠外科进入膜解剖时代,极大降低了直肠癌的局部复发率及改善了泌尿及性功能的保护。但由于盆丛及神经血管束与直肠系膜间存在多处微血管及神经的支配关系,导致直肠系膜在侧前方及侧后方与盆壁均存在致密粘连,神经血管束被分为多层的Denonvilliers筋膜包裹及分割,Denonvilliers筋膜后叶向后与盆筋膜壁层的前叶相延续,盆筋膜壁层分层包绕腹下神经、盆丛及神经血管束,保护Denonvilliers筋膜后叶及盆筋膜壁层的完整性是保护神经血管束的重要原则,神经纤维周围有微血管并行,来自髂内血管系统走向直肠系膜的滋养血管具有不同于盆筋膜壁层表面微血管的走行特征,可作为辅助筋膜辨识的重要标志。适当的牵拉暴露、分离手法,优化的手术流程,熟悉筋膜解剖以及微血管对筋膜辨认的作用是避免神经血管束损伤的关键措施。     

3D与2D腹腔镜直肠癌根治术中对膜解剖优势所在

全直肠系膜切除术(TME)是治疗中低位直肠癌的金标准,要求是直视下锐性分离,将直肠连同直肠固有筋膜包被的脂肪组织、神经血管和淋巴结整体完整切除。强调脏壁层之间锐性分离,而膜解剖理论与其不谋而合。外科膜解剖概念的提出,明确了人们常说的"间隙"或"层面",结合腹腔镜放大作用和3D腹腔镜的纵深感,将膜解剖应用于直肠手术,对系膜认识更加深刻,辨认盆底自主神经更加有效。腹膜筋膜融合退化后,在直肠后方形成疏松结缔组织所填充,在S4椎体前方融合增厚形成Waldeyer筋膜,同时将直肠后方间隙分为上方的直肠后间隙和下方的肛提肌上间隙。直肠侧方的膜解剖的关键结构是侧韧带,侧韧带正好是直肠系膜固有筋膜"门",由髂内动脉发出的直肠中动脉,盆丛发出的直肠支与及淋巴管共同形成。Denonvilliers筋膜是腹膜的融合产物,是直肠前方膜解剖关键结构。保留Denonvilliers筋膜对降低直肠癌术后排尿和性功能障碍发生率有非常重要的意义,切开腹膜返折如位于最低处标志性"卫"氏线后方,则进入Denonvilliers筋膜的后方,可保留Denonvilliers筋膜。     

机器人和腹腔镜全直肠系膜切除术中Denonvilliers筋膜解剖的意义及技巧

直肠前间隙的分离一直是机器人和腹腔镜全直肠系膜切除(TME)的难点。基于膜解剖原理,系统地认识Denonvilliers筋膜及血管神经束(NVB)的相关解剖,有助于外科医师在保证肿瘤根治的前提下,尽量保护相关自主神经。在行TME时,应行个体化的Denonvilliers筋膜部分切除。进行直肠前方分离时,应在腹膜反折上方1 cm弧形切开膜桥,进入Denonvilliers筋膜前间隙。此后男性在距两侧精囊腺底部0.5 cm,女性距腹膜反折约5 cm,相当于两侧NVB内侧,呈倒"U"形弧形切开离断Denonvilliers筋膜前叶,进入Denonvilliers筋膜后间隙,向下继续分离。     

腹腔镜辅助直肠癌根治术

于2020-04-24全身麻醉下行腹腔镜辅助直肠癌根治术(低位直肠前切除术)。探查腹腔无远处转移后提起乙状结肠系膜,超声刀游离出肠系膜下动脉。肠系膜下静脉,分别结扎切断。继续游离乙状结肠以及直肠,游离直肠后间隙,于肿瘤下方使用腔镜下直线切割吻合器切断直肠。再切断肿瘤上方乙状结肠。使用管型吻合器作直肠-乙状结肠端端吻合。切除直肠上段以及部分乙状结肠。     

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。     

直肠癌根治术中是否切除Denonvilliers筋膜的争议与展望

全直肠系膜切除（TME）是中低位直肠癌手术的金标准。传统的TME手术要求在Denonvilliers筋膜前方解剖并切除Denonvilliers筋膜,然而术后居高不下的排尿及性功能障碍发生率引起国内外学者对该理念的争议及质疑。对中低位直肠癌病人,应施行个体化治疗方案。对于肿瘤不位于直肠前壁及侧壁,或肿瘤局部分期较早的病人,应在保证肿瘤根治性的前提下,选择Denonvilliers筋膜后方施行TME手术,尽可能保留Denonvilliers筋膜的完整性,从而保护盆腔自主神经,避免术后排尿及性功能障碍,提高病人术后生活质量。     

完全腹腔镜下低位直肠前切除术+预防性回肠造口术

（1）暴露乙状结肠系膜根部与后腹膜粘连形成的黄白线,由此进入Toldt's间隙,拓展间隙至肠系膜下动脉根部,完成D3淋巴结清扫;（2）在直肠固有筋膜和腹下神经前筋膜之间分离,可以完好地保留盆腔自主神经系统从而完成全直肠系膜切除术;（3）完全腹腔镜下乙状结肠-直肠端端吻合;（4）预防性回肠袢式造口,皮内浆肌层连续缝合术在完全腹腔镜下直肠癌根治术中的应用。     

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??Controversy and expectation on preservation or excision of Denonvilliers fascia during radical rectal cancer resection FANG Jia-feng??WEI Hong-bo. Department of Gastrointestinal Surgery??the Third Affiliated Hospital of Sun Yat-sen University??Guangzhou 510630??China
Corresponding author??WEI Hong-bo??E-mail: drweihb@126.com
Abstract Total mesorectal excision (TME) is the golden standard of surgery for mid-low rectal cancer. Traditional TME surgery requires dissection in front of the Denonvilliers’ fascia??as well as excision of Denonvilliers’ fascia. However??the high incidence of postoperative urogenital dysfunction has led to worldwide controversy and query on TME surgery. Individualized treatment should be applied to patients with middle and low rectal cancer. For patients whose tumors are not located in the anterior and lateral walls of rectum or local stages are early??TME should be performed at the back of Denonvilliers fascia to preserve the integrity of Denonvilliers fascia as far as possible??so as to protect the pelvic autonomic nerve??avoid postoperative urination and sexual dysfunction??improve postoperative life quality of patients.     

Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery

BACKGROUND: The aim of this study was to assess the impact of inferior mesenteric artery (IMA) root nodal dissection before high ligation of the artery on survival in patients with sigmoid colon or rectal cancer. METHODS: Data on 1188 consecutive patients who underwent resection for sigmoid colon or rectal cancer, with high ligation of the IMA, were identified from a prospective database (April 1965 to December 1999). Survival of patients with involvement of nodes along the IMA proximal to the origin of the left colic artery (root nodes, station 253) through the bifurcation of the superior rectal artery (trunk nodes, station 252) was determined. RESULTS: Twenty patients (1.7 per cent) had metastatic involvement of station 253 lymph nodes and 99 (8.3 per cent) had metastases to station 252. The 5- and 10-year survival rates of patients with metastases to station 253 were 40 and 21 per cent, and those for patients with metastases to station 252 were 50 and 35 per cent, respectively. CONCLUSION: High ligation of the IMA allows curative resection and long-term survival in patients with cancer of the sigmoid colon or rectum and nodal metastases at the origin of the IMA.