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。     

Technique for laparoscopic autonomic nerve preserving total mesorectal excision

With the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three- or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.     

Laparoscopic mesorectal excision with preservation of the pelvic autonomic nerves for rectal cancer

BACKGROUND/AIMS: Laparoscopic mesorectal excision with preservation of the autonomic pelvic nerves for rectal cancer including selected advanced lower rectal cancer is now challenging. The aims of the study were to assess the surgical results and short-term outcomes of this procedure prospectively. METHODOLOGY: Seventy-four of 281 rectal cancer patients, since the introduction of laparoscopic colorectal surgery in our hospital, have undergone laparoscopic rectal surgery. The location of the tumor distributed in upper rectum; 33, middle; 22, and lower 19. The mesorectal excision with preservation of the autonomic pelvic nerves was performed for all the patients. The laparoscopic mesorectal excision was performed under 8 to 10 cmH2O CO2 pneumoperitoneum and lymph node dissection was performed along the feeding artery depend on individuals. Ipsilateral lateral lymph node dissection was added for 5 cases of advanced lower rectal cancer. RESULTS: Open conversion occurred in 4 cases, 2 of those were due to locally advanced tumors and 2 technical difficulties in transaction of the distal rectum. There were 15 postoperative complications, 7 anastomotic leakage (10.6%), 3 transient urinary retention (4.1%), 4 wound infection (5.3%), and 1 small bowel obstruction (1.4%). No mortality was recorded in this series. Time of operation was 203 +/- 54 min in mesorectal excision cases and 270 +/- 42 min mesorectal excision with lateral lymph node dissection cases. Blood loss was 92 +/- 90g and 276 +/- 66 g respectively. The hospital length-of-stay was 11.7 days in average. CONCLUSIONS: Laparoscopic mesorectal excision with preservation of autonomic pelvic nerves for rectal cancer patients including selected advanced lower rectal cancer is favorable.     

Laparoscopic Total Mesorectal Excision for Rectal Cancers

Introduction More and more colorectal surgeons believe that total mesorectal excision can achieve favorable oncologic results for the treatment of rectal cancers. The present study is a feasibility study aiming to evaluate if total mesorectal excision can be safely performed by laparoscopic approach with beneficial functional recovery. Methods A total of 44 patients (from January 2004 to February 2005) with middle rectal cancer (the average distance from anal verge was 7.8 cm, ranging from 5.0 to 10.0 cm) without preoperative chemoradiation therapy were selected to undergo laparoscopic total mesorectal excision. Before the study entry, all patients underwent pelvic magnetic resonance imaging or multislice spiral computed tomography to evaluate the circumferential resection margin of rectal cancer. Only patients whose circumferential resection margin was not involved by rectal cancer were considered as potentially curable by total mesorectal excision procedures and were enrolled for this study. The operation procedures were conducted according to the guidelines advocated by Heald et al.1 and were shown in the video. Posteriorly, the dissection was along the ‘holy plane’ downward to the level of levator ani muscle. Anteriorly, the dissection plane was at the anterior part of Denonvilliers fascia. Laterally, the lateral ligaments were sharply cauterized at the medial part. The resected bowel was reconstructed with stapled end-to-end anastomosis. The surgical outcomes of this procedure were prospectively evaluated. Results The laparoscopic total mesorectal excision was performed with acceptable operation time (234.4±44.4 minutes, mean±standard deviation) and little blood loss (80.0±24.0 ml) through a small wound (5.0±0.5 cm). Histopathology showed that all patients were able to get adequate distal section margins (mean: 2.8 cm; range: 1.6–5.4 cm) and negative circumferential resection margins (mean: 8.4mm; range: 2–14 mm). The number of dissected lymph nodes was 16.0±4.0. The pathologic tumor–node–metastasis stages were as follows: Stage I: n= 4; Stage II: n = 22; Stage III: n = 18. Two patients (4.5 percent) were diverted by protective ileostomy. There was no mortality within 30 days after operation. However, anastomotic leakage occurred in 3 patients. The patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0±12.0 hours), hospitalization (9.0±1.0 days) and degree of postoperative pain (3.5±0.5, visual analog scale). Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay an extra expense of NT$ 65000.08000.0 (1.0US dollars = 32.0 NT$). During the follow-up periods (median: 14 months, range. 2 to 27 months), three patients of Stage III and 1 patient of Stage II developed a recurrent disease (lung metastasis: n = 2; liver metastasis: n = 1, and pelvic recurrence, n = 1). Conclusion By laparoscopic approach, the total mesorectal excision for rectal cancers can be safely performed with good functional recovery. However, with only a median follow-up of 14 months in this case series, the long-term oncologic outcomes for these patients remain a question. Further randomized prospective study is thus mandatory to provide solid evidence of this approach. This multimedia article (video) has been published online and is available for viewing at . Its abstract is presented here. As a subscriber to Diseases of the Colon & Rectum you have access to our SpringerLink electronic service, including Online First. Video presentation in Yonsei Colorectal Cancer International Symposium, Seoul, South Korea, May 28, 2005. Grant support from 94S040, National Taiwan University Hospital. Reprints are not available.     

Vascular organization in the mesorectum: angiography of rectal resection specimens

The technical advances in rectal cancer surgery are known as the total mesorectal excision. The resection in an anatomically defined plane under direct vision and with sharp dissection distinguishes it conventional rectal surgery. The result must be a complete mesorectum without deep gouges. We performed specimen angiography to confirm completeness of the removed mesorectum. Thirteen total mesorectal excision specimens were examined by angiography after continence-preserving resection of rectal carcinoma. In 11 of the 13 cases the vascular supply was exclusively via the superior rectal artery. In two cases with hypoplastic left terminating branches of the superior rectal artery there was additional perfusion via a caudally ascending vessel or via smaller vessels connected laterally. In all specimens both arterial supply and venous outflow were located within the mesorectal fascial sheath. There was no radio-opaque substance leaking from the mesorectal surface in the case of a complete mesorectal specimen. Tiny vascular branches running laterally occurred in 7 of the 13 cases. We found no larger vascular connections branching off in the lateral direction. The rectal blood supply comes almost exclusively through the superior rectal vessels. Thus the fascia covering the mesorectum forms, as far as rectal vascularization is concerned, a closed compartment. The mesorectal vessels are enclosed in the fibrous avascular mesorectal fascia. They run close above the fascia. In the case of an incomplete mesorectal excision the specimen angiography shows a stain leaking from the mesorectal fascia. Our method can be used to confirm the completeness of the removed mesorectum.     

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.     

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.     

Laparoscopic lateral lymph node dissection in two fascial spaces for locally advanced lower rectal cancer

BACKGROUNDThe procedure for lateral lymph node (LLN) dissection (LLND) is complicated and can result in complications. We developed a technique for laparoscopic LLND based on two fascial spaces to simplify the procedure.AIMTo clarify the anatomical basis of laparoscopic LLND in two fascial spaces and to evaluate its efficacy and safety in treating locally advanced low rectal cancer (LALRC).METHODSCadaveric dissection was performed on 24 pelvises, and the fascial composition related to LLND was observed and described. Three dimensional-laparoscopic total mesorectal excision with LLND was performed in 20 patients with LALRC, and their clinical data were analyzed.RESULTSThe cadaver study showed that the fascia propria of the rectum, urogenital fascia, vesicohypogastric fascia and parietal fascia lie side by side in a medial-lateral direction constituting the dissection plane for curative rectal cancer surgery, and the last three fasciae formed two spaces (Latzko''s pararectal space and paravesical space) which were the surgical area for LLND. Laparoscopic LLND in two fascial spaces was performed successfully in all 20 patients. The median operating time, blood loss and postoperative hospitalization were 178 (152-243) min, 55 (25-150) mL and 10 (7-20) d, respectively. The median number of harvested LLNs was 8.6 (6-12), and pathologically positive LLN metastasis was confirmed in 7 (35.0%) cases. Postoperative complications included lower limb pain in 1 case and lymph leakage in 1 case.CONCLUSIONOur preliminary surgical experience suggests that laparoscopic LLND based on fascial spaces is a feasible, effective and safe procedure for treating LALRC.     

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.     

Total mesorectal excision and preservation of autonomic nerves]

The procedure of total mesorectal excision (TME) becomes a gold standard for the treatment of rectal cancer. The reason is the marvelously low incidence of local recurrence after TME even without other adjuvant treatment, which has been reported by several independent groups. Although controversy still exists about the role of TME in upper rectal cancer, it is now widely accepted for cancers of the middle and lower third. There are number of histopathological evidences that cancer cells can spread distally several centimeters from the lower margin of cancer, and cancer bearing lymph nodes are found in the distal portion of the mesorectal tissues far from the cancer. Therefore, the distal clearance of mesorectum should be performed downwardly to the level of pelvic diaphragm (puborectalis) and the rectum is divided within a few centimeters from the pelvic floor musculature. TME defines an en-bloc procedure, along the plane between parietal and visceral pelvic fasciae. If the dissection plane is breached, the chance of visceral pelvic fascia tearing is raised and mesorectal tissue might reside in the pelvis. There are problems in auditing the procedure. As many surgeons agree, this procedure requires a learning curve. Theoretically, the autonomic nerves run between the visceral and parietal pelvic fasciae since the nerves must be preserved to make visceral fascial envelop. Any patient who become incontinent or impotent after the surgery should have received decorticating surgery other than TME. Thus, the high quality of TME should fulfill two clinical measurements: absence of impotence or incontinence and at least single digit, 5-year, cumulative recurrence rate regardless of adjuvant therapy.     

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.     

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。     

The surgical stress response and postoperative immune function after laparoscopic or conventional total mesorectal excision in rectal cancer: a randomized trial

Purpose  

This study evaluated differences in stress response and immunological function following laparoscopic and conventional total mesorectal excision (TME) for rectal cancer.     

Laparoscopy-assisted lateral pelvic lymph node dissection for advanced rectal cancer

In Japan, there has been no indication of laparoscopic surgery for advanced lower rectal cancer because of the problem about the treatment of lateral pelvic lymph node metastasis. We report a new technique which allows lateral pelvic lymph node dissection like in open surgery for advanced rectal cancer. After laparoscopic total mesorectal excision for rectal cancer, a surgical incision of approximately 8 cm is placed in the supra-pubic area. Then, the latero-vesical area of the retroperitoneum, latero-vesical space is dissected bluntly with forceps. The external iliac artery and vein are taped and lymph node dissection is performed. As the external iliac vein is pulled internally, fatty tissue including lymph nodes in the obturator space is separated from the psoas major muscle. After completing of such a procedure, the obturator nerve is indentified in the fatty tissue with surrounding lymph nodes. As the external iliac vein is pulled laterally, fatty tissue including lymph nodes in the oburator space is dissected by fat aspiration procedure (FAP) using a suction tip. FAP is helpful to confirm the vascular system, by which the obturator space is skeletonized and anatomical structures are identified clearly.     

Combined transanal total mesorectal excision (taTME) with laparoscopic instruments and abdominal robotic surgery in rectal cancer

Laparoscopic surgery for rectal cancer can be technically challenging. We describe a hybrid technique combining abdominal robotic dissection and transanal total mesorectal excision. This procedure was performed in a 50-year-old man with rectal adenocarcinoma at 5 cm from the dentate lane. Preoperative staging was T2N0M0. Surgery went well without complications, and estimated blood loss was less than 50 mL. Robotic surgical time was 90 min, and total operative time was 160 min. The patient was discharged on postoperative day 3. Pathology analysis revealed an intact mesorectum (TME grade 3) and a T2N0 tumor with negative margins. Hybrid surgery with pelvic robotic dissection and transanal total mesorectal excision was feasible, quick and safe in this patient and may be a method that can be developed further.     

Impact of fat obesity on laparoscopic total mesorectal excision: more reliable indicator than body mass index

Background  

The aim of this study was to evaluate the impact of visceral fat obesity (VFO) on early surgical and oncologic outcomes of laparoscopic total mesorectal excision (LTME) for rectal cancer.     

Transanal versus laparoscopic total mesorectal excision: a comparative study of long-term oncological outcomes

Techniques in Coloproctology - Transanal total mesorectal excision (TaTME) is the most recent approach developed to improve pelvic dissection in surgery for mid and low rectal tumors. There are...     

全直肠系膜切除术切缘血管内皮生长因子检测的临床意义

目的:探讨血管内皮生长因子(VEGF)在直肠癌及其切缘的表达及其临床意义.方法:取实施TME的60例直肠癌患者直肠癌组织(Ⅰ)、直肠系膜远端切缘(Ⅱ)、直肠系膜周围切缘(Ⅲ)、盆筋膜壁层(Ⅳ)病理标本,采用免疫组化SP法对标本进行VEGF检测;并回顾性分析临床病理学资料.结果:直肠癌组织中VEGF高度表达(54/60),肿瘤相对的盆筋膜脏层(直肠系膜周围切缘)中有VEGF存在(9/60),在直肠系膜远端切缘及盆筋膜壁层标本中未见VEGF表达.VEGF在直肠癌组织中的表达有高度特异性.VEGF表达与直肠癌分化程度、Dukes分期及淋巴结转移密切相关(P<0.05或P<0.01).结论:VEGF在直肠癌组织中高度表达,直肠远端系膜切缘及直肠系膜周围切缘不表达或表达为弱阳性.     

腹腔镜TME术中直肠前间隙的解剖分离技巧

直肠前间隙的解剖是腹腔镜直肠全系膜切除术（total mesorectal excision,TME）的一个难点。术中若解剖层面不当,容易造成直肠前壁固有筋膜破损或损伤邻近的神经血管束。对于直肠前壁的肿瘤,直肠固有筋膜破裂可能造成环周切缘阳性及局部复发;神经血管束损伤则可能导致术后性功能障碍,特别是在男性患者。掌握直肠前间隙的解剖技巧有利于提高TME手术的手术质量及患者的术后生存质量。