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。     

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。     

直肠全系膜切除术的前方切除平面

【摘 要】目的 探讨直肠全系膜切除术前方合理的切除平面。 方法 上海交通大学医学院附属瑞金医院对24具尸体的盆腔进行解剖。结果 Denonvilliers筋膜的厚度变化明显,其与精囊的结合比与直肠的结合更为紧密。Denonvilliers筋膜的两侧与盆丛相邻,在5(5/12)具男性尸体中, Denonvilliers筋膜前方有两侧盆丛的交通支。结论 对于非直肠前方的肿瘤,可以采取Denonvilliers筋膜后方的切除平面,以减少自主神经功能损伤。     

保留部分Denonvilliers筋膜的全直肠系膜切除术:肿瘤学和功能学的平衡

直肠前间隙的分离是全直肠系膜切除术(TME)的难点,原因是完整保留Denonvilliers筋膜难以保证直肠前方固有筋膜的完整;不保留Denonvilliers筋膜,又可能伤及血管神经束。如何解决此矛盾是当前直肠癌手术的难点与重点。近年来,膜解剖理念的兴起与发展,为研究者认识并设计最佳手术径路提供新视角。笔者重点论述Denonvilliers筋膜膜解剖的研究进展,并结合笔者中心的研究结果,探讨保留部分Denonvilliers筋膜状态下行直肠前间隙分离的径路和技巧。     

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。     

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目的通过研究直肠系膜的形态学特点和范围来认识直肠系膜全切除(TME)的理论依据。方法上海交通大学医学院附属瑞金医院对24具尸体的盆腔进行解剖。结果在直肠及周围脂肪周围存在两个相互独立的结构,一个是直肠侧后方的脏筋膜,另一个是直肠前方的Denonvilliers筋膜,它们共同组成了直肠周围的环状筋膜,Denonvilliers筋膜并不能构成直肠系膜的前界。结论TME改善预后的原因并不在于其切除平面为肿瘤难以逾越的"Holy plane",而是在于其完全切除了"直肠腔室"。     

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。     

首次发现:Denonvilliers筋膜手术标识线的术中辨识

由于传统的全直肠系膜切除(TME)术后泌尿生殖功能障碍发生率居高不下,以致引起国内外学者对TME理念的争议及质疑,直肠癌手术保留Denonvilliers筋膜的必要性已受到越来越多国内外学者的赞同。然而,术中如何精准定位Denonvilliers筋膜,一直没有定论。通过反复临床实践,结合尸体标本解剖,首次发现Denonvilliers筋膜的顶部位于膀胱直肠陷凹(或直肠子宫陷凹)腹膜返折最低处,呈白色增厚线,这条线是辨认Denonvilliers筋膜最好的手术标记线。在该线前方游离则进入Denonvilliers筋膜的前方,而在线后方游离,则进入Denonvilliers筋膜的后方,从而完整地保留Denonvilliers筋膜,并更好地保护术后泌尿生殖功能。该手术标识线的发现,可为改良的保留Denonvilliers筋膜的TME术式提供标准化手术流程及入路,并为从事盆底手术操作的外科医生提供借鉴。     

直肠周围筋膜和间隙环形分布模式的解剖学观察

目的阐明与全直肠系膜切除术密切相关的直肠周围筋膜和间隙的解剖结构。方法利用21具固定尸体（男15、女6）制作30个半盆腔和6个3／4盆腔．解剖和观察直肠周围筋膜和间隙。结果直肠后方由前至后存在3层筋膜：包绕直肠系膜的直肠固有筋膜、骶前筋膜和与骶骨骨膜相愈着的梨状肌筋膜。直肠系膜包含两个部分：经典的由直肠固有筋膜所包绕的后外侧脂肪为其后部．由Denonvilliers筋膜后叶包绕的直肠前脂肪为其前部。骶前筋膜向前延续于Denonvilliers筋膜前叶．将直肠系膜和梨状肌筋膜之间的间隙分为前方的直肠后间隙和后方的骶前间隙。直肠后间隙向头侧与左结肠后间隙交通,向前与Denonvilliers筋膜两叶之间的间隙（直肠前间隙）交通。结论以直肠系膜为中心,直肠固有筋膜、骶前筋膜和盆壁肌肌膜自内向外呈环形分布。骶前筋膜将直肠周围的间隙分为中心的直肠后间隙和外周的骶前间隙两个环形间隙。直肠后间隙是全直肠系膜切除术的理想外科平面。     

直肠全系膜切除术中安全平面的解剖学观察

目的 明确直肠固有筋膜与周围结构的关系,寻找无血管、神经的间隙,为直肠全系膜切除术中＂安全平面＂的选择提供解剖学依据.方法 选择26例10%甲醛固定的成年男性盆腔标本进行研究,20例沿正中切开行局部解剖观察,6例行断层解剖观察.结果 直肠固有筋膜腹侧与Denonvilliers筋膜相邻,共同构成直肠膀胱隔,两者之间为无血管、神经的潜在间隙.直肠固有筋膜背侧与骶前筋膜水平走行,构成无血管、神经的骶前间隙,此间隙解剖变异较大,16例（80%）标本筋膜间隙明显,内有板层状直肠骶骨韧带走行（分层型） 4例（20%）无筋膜间隙,由肌肉样组织填充或骶前筋膜融合、增厚（融合型）.直肠固有筋膜外侧与盆腔壁层筋膜构成直肠外侧间隙,间隙内可见直肠侧韧带和盆腔神经丛,依据神经丛与直肠固有筋膜的关系分为紧密融合型（17例,85%）和疏松连接型（3例,15%）.结论 直肠腹侧的＂安全平面＂介于直肠固有筋膜与Denonvilliers筋膜之间,后外侧位于直肠固有筋膜与壁层筋膜之间.     

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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.     

低位直肠癌根治术中Denonvilliers筋膜切除的争议

结直肠癌是人类消化系统常见的恶性肿瘤之一,严重威胁着人类的身体健康,其治疗措施仍是以外科为主的综合治疗。然而结直肠癌术后出现的排尿和性功能障碍发生率一直居高不下,严重影响了病人术后的生活质量。目前外科学界对于直肠前方手术层面Denonvilliers筋膜保留与否仍存在争议。该文就直肠癌术中Denonvilliers筋膜保留的必要性依据进行详细阐述,并就如何完成保留Denonvilliers筋膜直肠癌根治术进行详细讲解。笔者认为:Denonvilliers筋膜是独立的解剖学结构,其周围具有丰富的神经丛,一旦切除该筋膜易造成排尿和性功能障碍,因此不应在直肠癌根治术中进行一并切除。该筋膜的后方存在较为稀疏的结缔组织间隙,该间隙与直肠后间隙相贯通,沿此间隙进行手术更符合全直肠系膜切除的手术原则。然而对于直肠前壁肿瘤病人,或肿瘤已侵直肠前方系膜时,Denonvilliers筋膜应一并切除以保证手术的根治性。     

男性泌尿生殖层的层面解剖及其临床意义研究

目的 观察并描述男性泌尿生殖层的层面解剖学形态,探讨该层面在结直肠手术中的临床意义.方法 采用层面解剖学方法解剖10具男性尸体躯干与20具盆腔标本,系统地描述泌尿生殖层的解剖形态,并与相应腹腔镜下解剖结构相比较.结果 男性泌尿生殖层为泌尿生殖筋膜包被,整体结构可分3段——腹段、盆段和精索段.泌尿生殖层腹段头侧由泌尿生殖...     

Ultrasonic diagnosis of 3,2′-dimethyl-4-aminobiphenyl induced tumors in the urogenital organs of F344 rats

The usefulness of transabdominal ultrasonography in the diagnosis of 3,2′-dimethyl-4-aminobiphenyl- and testosterone propionate-induced tumors of the urogenital organs was evaluated in F344 rats. Seven mass lesions (1 ventral prostate, 1 dorsolateral prostate, 3 seminal vesicles, and 1 kidney) in the urogenital organs could easily be diagnosed concerning size and localization by ultrasound. Histological examination revealed a lesion in the ventral prostate to be an abscess and the other tumors to be malignant. Three hydronephroses by tumor invasion to the ureter, and six tumors in organs other than the urogenital organs could be detected by ultrasound. The threshold of malignant tumor detection by ultrasound was 7 mm in actual length. The size of the mass lesion estimated by ultrasound correlated well with the direct measurement (r = 0.96). Transabdominal ultrasonography is useful for diagnosing the localization of experimental tumors and accurately measuring their size in the urogenital organs of rats. © 1993 Wiley-Liss, Inc.     

Anatomy of the pelvic floor for translevatoric-transsphincteric operations

The parasacral transsphincteric-translevatoric approach has proved of great interest in surgery of the lower rectum and urogenital organs. Due to this experience, anatomic specimens of the pelvic floor and pelvic organs were prepared in order to perfect the operative technique. The anatomic specimens show the pelvic floor and sphincter muscles and the blood supply by the pudendal vessels and nerve, as well as the topography of pelvic organs and fascias from the view of a surgeon performing parasacral surgery. The clinical experience with 118 cases of parasacral translevatoric-transsphincteric interventions at the Departments of Surgery of the University Hospital, Basel, and the Canton Hospital, Luzern, Switzerland, is presented. The results were mainly good. The operation technique is illustrated with selected cases of rectum resection, procedures for treatment of urethrorectal fistulas, reconstruction of pelvic floor for malformations, and reconstruction of injured urethra.     

Study of antibodies to adenoviruses in patients with tumors of the urogenital system

The presumable relationship between viruses and malignant disease has been studied. Approximately 4000 assays for antibodies to adenovirus were carried out with sera of patients with malignant and nonmalignant diseases of the urogenital organs and other organic diseases. The search was directed in the first place at antibodies to the early non-virion antigens of adenovirus-12 of oncogenic properties. On the evidence of the complement fixation reaction antibodies to adenoviruses were found to be less frequent in malignant tumors and in hypertrophy of the prostate than in the control group. Antibody to the non-virion antigen of adenoviruses was found in 53 per cent of patients with neoplastic diseases and prostatic hypertrophy, in 18 per cent of those with urogenital diseases other than tumors and in 4 per cent of those with other organic diseases. The results point to a possible role of adenoviruses in tumors of the urogenital organs.     

高分辨率MRI显示直肠周围筋膜结构

目的观察直肠周围筋膜高分辨率MRI成像表现。方法对50名正常志愿者行盆腔MRI常规T1WI、T2WI及高分辨率T2WI扫描,观察直肠周围筋膜结构,比较各序列对直肠周围筋膜的显示情况。结果高分辨率T2WI序列对前、后、左、右方直肠系膜筋膜显示率分别98%、100%、94%、90%;对Denonvilliers筋膜、骶前筋膜及腹膜返折显示率分别为58%、54%、70%。高分辨率T2WI对前、左、右方筋膜、Denonvilliers筋膜及腹膜返折的显示率明显高于盆腔常规T1WI、T2WI(P均0.05);对后方直肠系膜筋膜、骶前筋膜显示率略高于常规T1WI、T2WI,但差异无统计学意义(P均0.05)。结论高分辨率T2WI显示直肠周围筋膜结构优于盆腔常规MRI序列。     

Prostatic tumors in Iran.

1. Among all tissue examinations, 8.6% were on male urogenital organs, of which 2.9% were for carcinoma of the prostate. Biopsies of the prostate comprised a large percentage of all male urogenital biopsies. Since the specimens examined by various pathological laboratories in Tehran were received from all over the country, comparison of these statistics is significant. 2. Male urogenital tumors comprised 6.7% of male biopsies, of which 2.7% were for tumors of the prostate. 3. Male urogenital cancers comprised 2.3% of biopsies examined, of which only four were prostatic carconomas. Carcinoma of the prostate was the rarest cancer of the male urogenital organs in Iran. 4. We found 933 cases of cancer of male urogenital organs in 31 years. This comprised 6% of all male cancers, of which only 0.33% were carcinoma of the prostate. 5. Bladder carcinomas were the commonest and prostate carcinomas the rarest among males. 6. We found that 97% of prostate tumors were benign and 3% were malignant. Prostatic carcinoma was four times more prevalent among high income patients than among low income patients. 7. Benign tumors were most common in the 40 to 70 age groups, whereas the peak incidence for carcinoma of this organ was 50 to 70 years of age. 8. No particular clinical symptoms were found. Most patients reported pollakiuria, dysuria or urinary retention. 9. The initial growth site of tumors in the few cases that we were able to study was in the cortex region, especially from the posterior lobe. 10. Histological types of tumor found did not differ from other figures reported. We found no sarcomas. 11. No systematic study of asymptomatic nodules of carcinoma of the prostate has been made and we have never found any signs of such solitary nodules. This may be due to the low average age and the rarity of malignancy of the prostate in Iran. 12. The frequency of death in Iran due to carcinoma of the prostate is impossible to state since death certificates, in the majority of cases, specify secondary symptoms of the disease and not the original disease. 13. The incidence of prostatic carcinoma in the provice of Fars was five times greater and in Isfahan four times greater than in the province of Tehran. However, the figures for Tehran were compiled over the last 31 years, whereas the figures for Isfahan and Shiraz are only for the last ten years, and comparison of these three sets of figures may not be accurate. 14. Carcinoma of the prostate is not as common in Iran as it is in Europe and America. It is rather rare in Iran and compares favorably with figures for the Near Eastern and Far Eastern countries. The Middle Eastern countries of Lebanon, Israel and Afghanistan are very similar in incidence to Iran. In other countries in our region, the incidence is 1.8%.