男性盆腔内脏神经的解剖学研究及其临床意义

男性盆腔内脏神经与盆筋膜及盆内脏器的毗邻关系复杂,且个体形态学差异大,临床上涉及肛肠外科、泌尿外科、男科等多个学科,应用甚广。近年来,对内脏神经的术中保护越来越受到重视。男性盆腔内脏神经主要包括上腹下丛、腹下神经、下腹下丛(即盆丛)、盆内脏神经、膀胱丛、前列腺丛、直肠丛及其分支等。现已证明盆腔内脏神经的损伤会给患者的排便、排尿及阴茎勃起等造成功能障碍。熟悉男性盆腔内脏神经及其分支的形态特点及其与周围结构的关系,能降低手术并发症,提高患者术后生活质量。     

盆腔内筋膜的解剖结构及神经走形：避免修复中的损伤

背景：盆腔内走行着大量支配泌尿生殖等系统脏器的神经,包括内脏神经和脊神经两种,每一种均由运动神经和感觉神经两种成分组成。其中内脏神经的核心为盆丛。1982年,Heald提出的全直肠系膜切除已经成为直肠癌诊疗的“金标准”。但术中极易损伤神经,导致术后出现尿潴留、性功能障碍等并发症。目的：综述前人的研究,以明确盆腔内筋膜的解剖结构和神经走形。方法：以“splanchnic nerves,superior hypogastric plexus,pelvic plexus,pelvic splanchnic nerve,total mesorectal excision(TME),clinical anatomy”为关键词,检索2000年1月至2015年1月PubMed数据库中关于盆腔内神经及相关脊神经的走形和成分、盆腔内神经节及相关脏器反射等研究,以盆腔内的神经为主。结果与结论：盆腔内的主要内脏神经丛为：①上腹下丛：主体位于由左、右髂总动脉和骶岬围成的髂间三角内,左髂总静脉和第5腰椎前面。②盆丛：腹下神经、盆内脏神经、骶内脏神经在直肠侧面的后下方1/3处汇合形成神经丛,也称下腹下丛,位于输尿管后下方、膀胱及精囊腺的背侧。由内脏神经丛发出的神经包含交感神经、副交感神经及感觉神经3种成分,走行分布在盆腔各脏器表面,支配其运动与感觉功能。明确的盆腔内筋膜的解剖结构和神经走形是全直肠系膜切除成功的关键,可在手术中最大程度避免神经损伤,提高患者预后及生活质量。中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

男性盆丛神经的观察及其临床意义

目的：直肠癌扩大根治术是提高术后生存率，减少癌细胞转移的重要术式，但其术后排尿和性功能障碍并发症较多，其原因是术中损伤了盆丛神经。本文对盆丛的研究可为改进直肠癌扩大根治术，降低并发症，提高生存质量，提供解剖学资料。方法：用３０侧男性盆腔标本，通过冰醋酸松解剥离方法，对盆丛的起源、组成和分支分布进行了详细观测。结果：盆丛长径为４１．６±７．３ｍｍ，宽径２９．８±８．５ｍｍ。盆丛又继续形成直肠丛、膀胱丛和前列腺丛，三个次级丛参与管理排尿功能和性功能。结论：手术中如能对盆丛及其次级丛神经加以保护，免受或减少损伤，可防止或减少术后并发症的发生。     

宫颈癌根治术后神经源性排尿障碍的解剖学因素及预防

在24侧成人女性标本上,解剖观察了盆腔脏器旁结构的内容、分层及脏器旁结构中盆丛的组成、位置、分支和分布,并对盆丛作了分区定位.观察了子宫骶韧带和子宫主韧带与盆丛的相互关系.分析探讨了宫颈癌根治术后神经源性排尿障碍的原因及术中保护部分盆丛的临床应用要点.     

轴向腰椎椎间融合术入路的应用解剖

目的　探讨经骶前间隙轴向腰椎椎间融合术入路的安全性。 方法　(1) 12具（24侧）防腐固定成人骨盆段标本,解剖骶前间隙,观察骶前的筋膜层次,骶直肠筋膜,盆内脏神经等,测量骶直肠筋膜和盆内脏神经的相关解剖数据。(2) 参照Marotta方法,模拟手术置入导针,测量导针在骶前间隙中的相关解剖学数据。 结果　(1)骶前的筋膜可分为5层;(2)骶直肠筋膜的出现率是91.7%,在骶前壁层筋膜的起始部位：S2为16.7%,S3为41.7%,S4为33.3%,它将骶前间隙分为上、下两部分; (3)盆内脏神经限制直肠下段的解剖分离,可作为骶前间隙“矢状安全区域”的指标,其长度是（22.9±3.2）mm; (4)模拟手术时,导针到盆内脏神经的最短距离是（7.8±1.9）mm,到S3/4横线的垂直距离是（15.0±3.6）mm。 结论　经骶前间隙轴向腰椎椎间融合术入路的安全性是相对的,由于骶直肠筋膜、骶前静脉丛横干和骶前血管变异的存在,手术入路面临着较大的风险。     

全直肠系膜切除相关盆自主神经的解剖学观察

目的：阐述全直肠系膜切除术相关盆自主神经的局部解剖学特点，探讨盆自主神经保留的部位和对策。方法：对20具男性盆腔固定标本进行解剖观察。结果：腹主动脉丛远离肠系膜下动脉起点；上腹下丛贴近骶岬表面；腹下神经部分毗邻输尿管；盆内脏神经伴行直肠中动脉外侧部；下腹下丛位于直肠系膜后外侧；其直肠侧支走行于直肠侧韧带内，直肠前支向前穿过Denonvilliers筋膜后叶；勃起神经位于Denonvilliers筋膜前叶外侧部。结论：盆自主神经保留的部位是：离断肠系膜下血管时的腹主动脉丛左干，直肠后分离时的上腹下丛和腹下神经，直肠侧面分离时的下腹下丛和盆内脏神经，直肠前分离时的勃起神经。共同原则是：在直肠后间隙中贴近直肠系膜操作；直视下操作；避免过度牵引直肠系膜。     

与坐骨神经和盆神经对应的后根节中CGRP,SP,NOS样阳性神经元？…

为了探索大鼠坐骨神经（躯体性）和盆神经（内脏性）内与传递痛信号有关的初级传入神经元在后根节内的分布特点，本研究采用荧光金逆行追踪与免疫荧光组化技术相结合的方法，对ＣＧＲＰ能、ＳＰ能和ＮＯＳ样神经元在相应的根节内（坐骨神经，Ｌ４￣Ｌ６；盆神经，Ｌ６￣Ｓ１）的分布状况进行了分析。结果表明：（１）坐骨神经和盆神经初级传元中有相当数量的ＣＧＲＰ和ＳＰ样阳性细胞，与这二者相比，ＮＯＳ样细胞数量稀少；（２）盆     

大鼠骶副交感核的形态学测量和三维重建

目的:研究大鼠盆内脏神经的初级中枢骶副交感核(SPN)的形态学特征及空间三维立体结构,为准确定位SPN并探索其功能提供形态学依据.方法:经背侧入路显露SD大鼠的盆内脏神经,在其中枢断端采用Alexa594结合的霍乱毒素b(CTb)逆行示踪.将标记后的脊髓L6～S1节段分别进行连续的水平面和矢状面切片.荧光显微镜下观察C...     

直肠和膀胱的盆丛神经支配

为了配合盆腔脏器手术保护脏器神经支配的需要,作者在20具男性成人盆腔标本上观测了直肠和膀胱神经支的分布。直肠盆段神经支穿入点集中分布在该段自身长度10等份的Ⅳ—Ⅶ段和Ⅹ段。膀胱神经支穿入点集中分布在输尿管穿入膀胱处的外下方。讨论了与盆腔手术保护脏器神经支配有关的应用要点。     

人海绵体神经的应用解剖及临床意义

海绵体神经起源于盆神经丛的次级神经丛-前列腺丛,含有交感神经纤维和副交感神经纤维两种成分。该神经与尿道血管形成神经血管束,沿前列腺两侧向远端走形,穿尿生殖膈后,发出分支进入海绵体,或与阴茎背神经交通,最后管理阴茎勃起组织。在盆内手术如膀胱、前列腺的根治性手术和全直肠系膜切除术后因海绵体神经损伤而导致患者术后勃起功能障碍时有发生。熟悉海绵体神经及其分支的走行特点及其与周围结构的关系,能降低手术并发症。在海绵体神经损伤后的重建方面也取得了一定的成果。     

Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis

Bladder, bowel, and sexual dysfunction caused by iatrogenic lesions of the inferior hypogastric plexus (IHP) are well known and commonly tolerated in pelvic surgery. Because the pelvic autonomic nerves are difficult to define and dissect in surgery, and their importance often ignored, we conducted a gross anatomic study of 90 adult and four fetal hemipelves. Using various non-surgical approaches, the anatomic relations and pathways of the IHP were dissected. The IHP extended from the sacrum to the genital organs at the level of the lower sacral vertebrae. It originated from three different sources: the hypogastric nerve, the sacral splanchnic nerves from the sacral sympathetic trunk (mostly the S2 ganglion), and the pelvic splanchnic nerves, which branched primarily from the third and fourth sacral ventral rami. These fibers converge to form a uniform nerve plate medial to the vascular layer and deep to the peritoneum. The posterior portion of the IHP supplied the rectum and the anterior portion of the urogenital organs; nerve fibers traveled directly from the IHP to the anterolateral wall of the rectum and to the inferolateral and posterolateral aspects of the urogenital organs. The autonomic supply from the IHP was supplemented by nerves accompanying the ureter and the arteries. An understanding of the location of the autonomic pelvic network, including important landmarks, should help prevent iatrogenic injury through the adoption of surgical techniques that reduce or prevent postoperative autonomic dysfunction.     

Thoracic splanchnic nerves: implications for splanchnic denervation

Splanchnic neurectomy is of value in the management of chronic abdominal pain. It is postulated that the inconsistent results of splanchnicectomies may be due to anatomical variations in the pattern of splanchnic nerves. The advent of minimally invasive and video-assisted surgery has rekindled interest in the frequency of variations of the splanchnic nerves. The aims of this study were to investigate the incidence, origin and pattern of the splanchnic nerves in order to establish a predictable pattern of splanchnic neural anatomy that may be of surgical relevance. Six adult and 14 fetal cadavers were dissected (n = 38). The origin of the splanchnic nerve was bilaterally asymmetrical in all cases. The greater splanchnic nerve (GSN) was always present, whereas the lesser splanchnic nerve (LSN) and least splanchnic nerve (lSN) were inconsistent (LSN, 35 of 38 sides (92%); LSN, 21 of 38 sides (55%). The splanchnic nerves were observed most frequently over the following ranges: GSN, T6–9: 28 of 38 sides (73%); LSN, when present, T10–11: (10 of 35 sides (29%); and lSN, T11–12: 3 of 21 sides (14%). The number of ganglionic roots of the GSN varied between 3 and 10 (widest T4–11; narrowest, T5–7). Intermediate splanchnic ganglia, when present, were observed only on the GSN main trunk with an incidence of 6 of 10 sides (60%) in the adult and 11 of 28 sides (39%) in the fetus. The higher incidence of the origin of GSN above T5 has clinical implications, given the widely discussed technique of undertaking splanchnicectomy from the T5 ganglion distally. This approach overlooks important nerve contributions and thereby may compromise clinical outcome. In the light of these variations, a reappraisal of current surgical techniques used in thoracoscopic splanchnicectomy is warranted.     

Myelinated nerve fiber analysis of the human greater splanchnic nerve.

The purpose of the present study is to analyze the human greater splanchnic nerve in relation to aging. We adopted a new staining method which makes it possible to discriminate various structures of the nervous tissue. We examined 25 human greater splanchnic nerves from cadavers for anatomy dissection. We measured the number, area and perimeter of axons. The results reveal that: (1) there is no correlation between age and the number of axons; (2) the mean area and perimeter of axons increase with age, but not the total area and perimeter. We compared these results with those for the lesser splanchnic nerve. These morphological changes in the greater splanchnic nerve may indicate a kind of compensation through axon hypertrophy for hypofunctions in abdominal organ control.     

Extrinsic innervation of the pelvic organs in the lesser pelvis of human embryos

Realistic models to understand the developmental appearance of the pelvic nervous system in mammals are scarce. We visualized the development of the inferior hypogastric plexus and its preganglionic connections in human embryos at 4–8 weeks post-fertilization, using Amira 3D reconstruction and Cinema 4D-remodelling software. We defined the embryonic lesser pelvis as the pelvic area caudal to both umbilical arteries and containing the hindgut. Neural crest cells (NCCs) appeared dorsolateral to the median sacral artery near vertebra S1 at ~5 weeks and had extended to vertebra S5 1 day later. Once para-arterial, NCCs either formed sympathetic ganglia or continued to migrate ventrally to the pre-arterial region, where they formed large bilateral inferior hypogastric ganglionic cell clusters (IHGCs). Unlike more cranial pre-aortic plexuses, both IHGCs did not merge because the 'pelvic pouch', a temporary caudal extension of the peritoneal cavity, interposed. Although NCCs in the sacral area started to migrate later, they reached their pre-arterial position simultaneously with the NCCs in the thoracolumbar regions. Accordingly, the superior hypogastric nerve, a caudal extension of the lumbar splanchnic nerves along the superior rectal artery, contacted the IHGCs only 1 day later than the lumbar splanchnic nerves contacted the inferior mesenteric ganglion. The superior hypogastric nerve subsequently splits to become the superior hypogastric plexus. The IHGCs had two additional sources of preganglionic innervation, of which the pelvic splanchnic nerves arrived at ~6.5 weeks and the sacral splanchnic nerves only at ~8 weeks. After all preganglionic connections had formed, separate parts of the inferior hypogastric plexus formed at the bladder neck and distal hindgut.     

Branches of the thoracic sympathetic trunk in the human fetus

Summary The segmental organization of the thoracic sympathetic trunk and all its ramifications was studied in 6 human fetuses (16–22 weeks) by means of the acetylcholinesterase in toto staining method. Each trunk was divided into 12 sympathetic segments. A segment is defined as that part of the sympathetic trunk which is connected via its rami communicates with one spinal nerve, without discriminating between grey and white rami. The diameter of the rami communicantes and their direction towards the spinal nerves are variable. The number of peripheral segmental ramifications of the trunk is much larger than assumed previously. Each thoracic sympathetic segment gives off at least 4–5 nerves. Three categories of nerves are discerned: (1) large splanchnic rootlets confined to the greater, lesser and least thoracic splanchnic nerves, (2) medium-sized splanchnic nerves directed towards thoracic viscera, some of which give off branches towards costovertebral joint plexuses and, described for the first time in man, (3) small nerves which ramify extensively and form nerve plexuses in the capsule of the costovertebral joints. The majority of the ramifications is formed by the nerves of the third category. The existence of Kuntz's nerve, connecting the 2nd intercostal nerve and 1st thoracic spinal nerve, is confirmed in four specimens. The nerve plexuses of the costovertebral joints receive a segmentally organized innervation: they receive their input from the neighbouring sympathetic segment and the one cranial to it.It is concluded that the thoracic sympathetic branches in man show a complex, segmentally organized pattern and may have a considerable component of somatosensory nerve fibers. The complex relationships must be taken into account in surgical sympathectomies.     

Efferent paths of the esophago-intestinal reflex

Summary It was shown that in chronically esophagotomized dogs, when the splanchnic nerves are left intact, the excitatory effect on movements of the small intestine produced by esophageal stimulation are eliminated by bilateral transdiaphragmal vagotomy, but are still present if the vagi are left intact and the splanchnic nerves divided. After division of both the vagi and the splanchnic nerves, stimulation of the esophagus does not influence movements of the small intestine. In animals with divided vagi and intact splanchnic nerves, pronounced inhibition of intestinal movements is caused by esophageal stimulation whereas when both vagus and splanchnic nerves are intact, the inhibition seldom occurs and it is thought that the reason for the failure is the prevalence of the excitatory effect of esophageal stimulation. It is concluded that the excitatory effect from the esophagus (esophagointestinal reflex) is transmitted through the vagi, and the inhibitory influences through the sympathetic nerves.(Presented by Active Member AMN SSSR V. I. Chernigovskii) Translated from Byulleten Èksperimental' noi Biologii i Meditsiny Vol. 49, No. 4, pp. 24–27, April, 1960     

Anatomy of thoracic splanchnic nerves for surgical resection

Thoracic splanchnic nerves conduct pain sensation from the abdominal organs around the celiac ganglion. Splanchnicectomy is the procedure used mainly for the control of intractable visceral pain. Forty-six human posterior thoracic walls were dissected. The formation pattern, course, and incidence of communication of the thoracic splanchnic nerves were investigated. The greater splanchnic nerves (GSNs) were formed by nerve branches from the T4-T11 thoracic sympathetic ganglia and the most common type was formed by T5-T9 (21.7%). The uppermost branches originated from T4-T9 while the lowermost branches emanated from the T7-T11. Two to seven ganglia contributed to the GSNs. In 54.3% of the specimens, at least one ganglion in the GSN-tributary ganglionic array did not branch to the GSN. The lesser splanchnic nerves (LSNs) were formed by the nerve branches of the T8-T12 thoracic sympathetic ganglia and the most common type was formed by T10 and T11 (32.6%). One to five ganglia were involved in the LSNs. The least splanchnic nerves (lSNs) were composed of branches from the T10-L1 thoracic sympathetic ganglia and the most common type was composed of nerve branches from T11 and T12 or from T12 only (each 30.4%). One to three ganglia were involved in the lSNs. In 54.3% of the specimens, interconnection between the GSNs and the LSNs existed, bringing the possible bypass around the transection of the GSNs. The splanchnic nerves that appear in textbooks occurred in a minority of our specimens. We provided expanded anatomical data for splanchnicectomy in this report.     

A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet‐Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)‐guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful. Clin. Anat. 23:512–522, 2010. © 2010 Wiley‐Liss, Inc.