成人尸体肋间臂神经解剖学特点及其临床意义

目的:为乳腺癌腋清扫术中保留肋间臂神经(JCBN)提供解剖学基础。方法:对5具成人尸体(2男3女)的10侧腋区进行了解剖,进行肋间臂神经观察和准确测量。并且对肋间臂神经周围组织结构及毗邻关系(血管、神经等)进行了仔细研究。结果:1)成人尸体的肋间臂神经直径较患者活体术中肋间臂神经直径为粗。2)成人尸体肋间臂神经的起止点以及与周围组织结构的距离和乳腺癌患者术中测量值基本相同。3)成人尸体肋间臂神经的形态学特点比较单一,均为单干分二支型,考虑原因是解剖尸体例数较少。4)由于解剖较彻底,比活体肋间臂神经分支复杂。结论:明确成人尸体JCBN解剖特点可指导乳腺癌腋清扫术中对肋间臂神经的保留,减少乳腺癌术后疼痛综合征(PMPS)的发生。     

Laparoscopic total mesorectal excision with autonomic nerve preservation

Laparoscopy has greatly influenced abdominal surgery. We hypothesize that the benefits of minimally invasive surgery are applicable to rectal cancer. A cadaver model of laparoscopic rectal resection with total mesorectal excision (TME) and autonomic nerve preservation was utilized to explore this hypothesis. The principles of TME were followed, including high vascular ligation, sharp mesorectal dissection, and identification and preservation of the autonomic pelvic nerves. After proving feasibility in the cadaver model, a clinical study was performed on patients with mid to low rectal cancers. We observed acceptable morbidity with this minimally invasive technique of rectal resection and TME. We conclude that there is growing evidence that laparoscopic methods can be applied to patients with rectal cancer.     

肠系膜下动脉根部结扎及淋巴廓清对直肠癌根治术的临床评价

研究进展期直肠癌肠系膜下动脉（ＩＭＡ）根总结中扎和区域性淋巴廓清对患者生存率的影响。方法：分析行肠系膜下动脉根部结扎的Ｄ３式淋子清术６９例和同期行非根总结中扎根治上肠癌５６例。结果：肠系膜下动脉根部及腹主动脉周围淋巴结转移率为１１．６％，肿瘤浸润深度ＰＴ３和ＰＴ４期发生转移明显增多。     

Verification of blood flow path reconstruction mechanism in distal sigmoid colon and rectal cancer after high IMA ligation through preoperative and postoperative comparison by manual subtraction CTA

IntroductionWe aimed to investigate manual subtraction computed tomography angiography (MS-CTA) to further confirm the distribution and classification of LCA (left colic artery) ascending/descending branches, then observe the postoperative blood flow path to illustrate how the above branches evolved to postoperative blood path.Material and methods89 patients with distal sigmoid and rectal cancer were referred in our observation and underwent MS-CTA between June 2020 and March 2022. We classified the distribution of LCA and confirmed whether there exists AMCA (accessory middle colic artery). Then we planned blood flow path based on the classification of LCA branches before operation. High ligation was applied in regular radical surgery. During operation, we carefully protect the bifurcation of ascending and descending LCA. Then we compared the planned blood flow path with the actual postoperative blood flow path to verify the mechanism we proposed previously.ResultsOf 89 patients, 82 cases met our criteria, we summarized 6 distribution pattens of LCA ascending and descending branches. These preoperative pattens are consistent with the inspection during operation. The postoperative blood flow path of 6 pattens is evolved from the above adjacent anastomotic branches and is consistent with the planned blood flow path. We also found 2 cases with IMA stenosis and 1 case with SMA stenosis under pathological condition, and their compensatory blood flow path is in accordance with our theory. The rate of the anastomotic leakage in our study group is relatively low (7.3%).ConclusionMS-CTA could confirm the distribution of LCA and AMCA, display accurate postoperative blood reconstruction path after IMA high ligation, and it further verified the mechanism we proposed previously, which is the proximal anastomotic branches forming new blood flow path from high-pressure area to the low-pressure area. This mechanism might be helpful for performing accurate laparoscopic sigmoid and rectal cancer surgery.     

腮腺良性肿瘤手术中耳大神经的解剖与保留

目的对腮腺良性肿瘤患者耳大神经进行解剖、保留,由此提高患者术后生活质量。方法2001年9月~2006年6月以改良术式治疗成年腮腺良性肿瘤患者20例,术中解剖、保留耳大神经;对耳大神经的位置、毗邻关系、直径、走行、分支、分布等解剖要素进行解剖观察,保留耳大神经主干及耳后、耳垂、耳前支,腮腺支部分或全部切除。术后观察、随访,了解术区及面神经恢复情况、肿瘤有无复发、耳大神经支配区感觉恢复情况。结果耳大神经的分支、分布有其规律性。耳大神经在下颌角水平之上0~2cm依次分为耳后支、耳垂支、耳前支、腮腺支,神经主干末段和分支起始段均分布于腮腺筋膜浅层表面。术后患者有暂时性的外耳廓区轻度麻木,术后1周~4月后患者的外耳廓感觉基本恢复正常,无1例发生外耳廓区皮肤长期麻木。患者在面神经功能恢复、肿瘤复发、术区外形等方面与常规术式无明显差异。结论耳大神经及各分支具有不可代替的解剖生理功能,改良术式能将其较好保留,显著降低术后并发症,提高患者生活质量。     

Lateral ligament: its anatomy and clinical importance

Since Miles proposed abdominoperineal excision as a radical surgery for rectal cancer in 1908, surgeons have recognized the lateral ligament in the pararectal space of their patients and attached clinical importance to it, although anatomists did not describe any such configuration in cadavers. By analyzing an experience of 421 lower rectal cancer cases at the Cancer Institute Hospital in Tokyo, discussion of the lateral ligament was focused on its relationship to the fascial arrangements in the pelvis, the pelvic autonomic nervous system, and the lymphatic drainage of the rectum. The lateral ligament is not an anatomical term, but a clinical or surgical one. It exists in a living pelvis as a condensation of connective tissue around the middle rectal artery and is divided into two segments by the inferior hypogastric nerve plexus inside it and the visceral endopelvic fascia around it. The lateral ligament is a pathway of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes. Therefore, the lateral ligament plays a critical role in surgery for lower rectal cancer in two respects: the anatomic extent of resection for curing rectal cancer, and the preservation of sexual function.     

Avoiding long-term disturbance to bladder and sexual function in pelvic surgery, particularly with rectal cancer

Urinary and sexual dysfunction are common problems after rectal cancer surgery, and the likely cause is damage to the pelvic autonomic nerves during surgery. In recent years, attention has been focused on preserving the autonomic nerves through a technique which is usually combined with total mesorectal excision or radical pelvic lymphadenectomy. The autonomic nerves consist of the paired sympathetic hypogastric nerve, sacral splanchnic nerves, and the pelvic autonomic nerve plexus. We will demonstrate the anatomy of the pelvic autonomic nerves and the relation of these nerves to the mesorectal fascial planes, and review the medical literature on sexual and urinary dysfunction after rectal cancer surgery with and without autonomic nerve preservation.     

膝关节周围皮神经与关节置换术后疼痛关系的解剖研究

目的：通过明确膝关节周围皮神经各个分支的相对位置为临床通过去神经化手术治疗关节置换术后疼痛提供解剖学依据。方法对2具成年防腐尸体（4下肢）及2具新鲜成年尸体（2个下肢）进行解剖,明确各个神经支及皮神经走行的毗邻关系。并通过对这些神经进行磁共振扫描,给临床提供直观立体的形态学参考。结果膝关节周围恒定出现三支皮神经,其分别为股内侧皮神经、隐神经髌下支、股中间皮神经。这些神经位置表浅、直径较细,局部视图较难分辨。通过磁共振三维成像,能够进一步明确神经的走行关系,使各个分支与膝关节周围骨性标志和相对位置易于观察。结论通过膝关节周围皮神经的解剖,可明确在实施膝关节置换术后引起疼痛的病变神经,为指导临床实施去神经化手术解除膝关节置换术后的神经源性疼痛提供指导。     

直肠癌手术中低位结扎肠系膜下动脉的争议

肠系膜下动脉（inferior mesenteric artery,IMA）的结扎是直肠癌手术中至关重要的一步,但其结扎水平却一直难以达成统一的认识。主要争议点是,关于术中左结肠动脉（left colic artery,LCA）是否保留,其吻合口漏发生率、IMA根部淋巴结（253站淋巴结）清扫、术中神经损伤及术后排便、排尿及性功能的影响等在各研究中心不能达成一致,这就造成了在手术时术者对于手术术式的选择难以形成统一的规范,因此不论对术者或是患者都会产生不同程度的影响。随着腹腔镜辅助下手术技术及高清镜、3D腹腔镜、4K高清镜、显微外科、三维CT血管造影技术的发展,之前术中的一些解剖难题及难以实施的精细手术操作也得到了很大程度的解决和改进,这些都为术者选择更加安全合理可行的术式提供了支撑。     

A prospective study on radical and nerve-preserving surgery for rectal cancer in The Netherlands

INTRODUCTION: Preservation of the pelvic autonomic nerves is thought to lower bladder and sexual dysfunction after rectal cancer surgery. A prospective study was undertaken in a Dutch population to evaluate functional outcome, local recurrence and survival of a Japanese operative technique combining nerve preservation with radical tumour resection. METHODS: Forty-seven patients were operated upon by a Japanese surgeon. Voiding and sexual function were prospectively analysed using questionnaires. Two-year follow-up on urinary function was complete in 73%, and 2-year follow-up of male sexual function was complete in 77%. Median follow-up for survival and recurrence was 42 months and was complete in all patients. RESULTS: Five patients (19%) developed minor urinary incontinence in the period between 1 and 2 years of follow-up. Six patients (22%) had a persistently elevated frequency of voiding. There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunctions. None of the patients reported major incontinence of urine. Impotence was related to sacrifice of the inferior hypogastric plexus and ejaculatory dysfunction was related to sacrifice of the superior hypogastric plexus. Sexual function did not change during follow-up. Of 42 curatively-operated patients, three (7.1%) developed local recurrence. Sixty-seven per cent were overall free of recurrence. Disease-free survival was 57%. CONCLUSIONS: Preservation of the pelvic autonomic nerves minimizes bladder dysfunction after rectal cancer surgery. The preservation of the total autonomic nerve system is essential for normal sexual function in male patients. Nerve preservation does not compromise radicality in mesorectal excision. Mesorectal excision should involve identification and preservation of the pelvic autonomic nerves.     

Laparoscopic-specific procedure using dorsal approach to the middle hepatic vein in laparoscopic left hemihepatectomy

BackgroundExposing the middle hepatic vein (MHV) is required in left hemihepatectomy [1]. Laparoscopy enables us to perform unique approach in performing hepatectomy [2,3]. Herein we show a video of dorsal approach in left hemihepatectomy and measure anatomical parameters useful for approaching to the MHV.PatientA 79-year-old man with colorectal liver metastasis underwent laparoscopic left hemihepatectomy.TechniqueAfter mobilizing left lateral section and encircling left Glissonian trunk, we firstly flipped up left lateral section inside and began parenchymal transection from dorsal surface around the root of left hepatic vein (LHV). Immediately we touched the MHV and, by cutting the left Glissonian trunk, could extend complete MHV exposure in central-to-peripheral direction without split injuries of MHV branches [2]. Next, we flipped down the left lateral section and divided ventral remaining parenchyma in caudal-to-cranial direction without risk of MHV injury. As this is not one-way procedure [4], as if open a book, we adjusted the ventral cutting plane to match with the dorsal one. Finally, by cutting the LHV, we completed left hemihepatectomy.Measuring anatomical parametersWe divided a sectional image into four zones (cranio-dorsal, caudal-dorsal, caudal-ventral, and cranio-ventral zones) and measured each anatomical parameter to expose the MHV. The area of cranio-dorsal zone was smallest to expose the MHV (3.5cm²). The distance from the Arantius’ ligament to the MHV was also shortest (1.1cm).ConclusionsDorsal approach might be the nearest and safe road way to the MHV. This approach might make it easy to complete laparoscopic left hemihepatectomy.     

Preliminary results of pelvic autonomic nerve-preserving surgery combined with intraoperative and postoperative radiation therapy for patients with low rectal cancer

BACKGROUND: In Japan, lateral lymphadenectomy was widely performed for patients with stage II-III rectal tumors because it was thought to contribute to good local control, but the pelvic autonomic nerves were thus sacrificed. Although autonomic nerve-sparing surgery with lateral lymph node dissection has been tried from around 1987, the type of nerve sparing varied and the indications were not established. To examine the possibility of expanding the indications for total pelvic autonomic nerve preservation for patients with low rectal cancer, we conducted a pilot study. METHODS: Between 1993 and 1997, a total of 50 patients with low rectal cancer underwent pelvic autonomic nerve preservation with lateral lymphadenectomy of both sides and intraoperative radiation therapy followed by postoperative radiation therapy. RESULTS: The median follow-up period for surviving patients was 41 months. The 3-year local control rates for all patients, with stage I-II and stage III tumors were 88% (95% confidence interval, 78-97%), 97% (90-100%) and 73% (52-94%), respectively. The site of local recurrences was not near or within the preserved plexus. CONCLUSIONS: The preliminary results showed good local control rate for patients with stage I-II tumors. For patients with stage III tumors, the local control rate was unsatisfactory, but nerve sparing was not the cause of local recurrence. Further investigation of function-preserving surgery without decreasing curability is needed.     

High tie versus low tie of the inferior mesenteric artery in colorectal cancer: A RCT is needed

Nowadays left colon and rectal cancer treatment has been well standardized in both open and laparoscopy. Nevertheless, the level of the ligation of the inferior mesenteric artery (IMA), at the origin from the aorta (high tie) or below the origin of the left colic artery (low tie), is still debated. The objective of the systematic review is to evaluate the current scientific evidence of high versus low tie of the IMA in colorectal cancer surgery. The outcomes considered were overall 30-days postoperative morbidity, overall 30-days postoperative mortality, anastomotic leakage, 5-years survival rate, and overall recurrence rate. A total of 8.666 patients were included in our analysis, 4.281 forming the group undergoing high tie versus 4.385 patients undergoing low tie. Neither the high tie nor the low tie strategy showed an evidence based success, as no statistically significant differences were identified for all outcomes measured. Future high powered and well designed randomized clinical trials are needed to draw definitive conclusion on this dilemma.     

Autologous microsurgical breast reconstruction and coronary artery bypass grafting: an anatomical study and clinical implications

Objective To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. Background Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women??s health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise. Methods The largest clinical and cadaveric anatomical study (n = 315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review. Results Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80?mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87?C91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces. Conclusion We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.     

外阴恶性肿瘤保留大隐静脉的腹股沟淋巴结清扫术改良术式的探讨

背景与目的:外阴恶性肿瘤传统手术方式为外阴广泛切除术 双侧腹股沟淋巴结清扫术伴大隐静脉的结扎和切除,术后多种并发症的发生严重影响了患者的生存质量.本研究探讨外阴恶性肿瘤行腹股沟淋巴结清扫术保留大隐静脉对手术操作、预后及并发症的影响.方法:将1989年1月至2005年12月期间收住院并行双侧腹股沟淋巴结清扫术的64例外阴恶性肿瘤患者分为两组,31例行双侧腹股沟淋巴结清扫术时保留双侧大隐静脉主干(简称保留组),33例结扎、切除一段大隐静脉(简称切除组),对两组患者的手术时间、术中出血量、5年生存率、复发率及术后急慢性并发症进行比较.结果:(1)保留组中,双侧腹股沟淋巴结清扫术手术时间为130～170 min,中位时间155 min:出血量100～450 ml,中位出血量295 ml.切除组中,手术时间为120～170 min,中位时间140 min;出血量150～390 ml,中位出血量270 ml.两组比较,两个参数差异均无显著性,P值均＞0.05;(2)两组患者总的5年生存率为67.3%,切除组为66.7%,保留组为68.0%,两组比较差异无显著性,P＞0.05.随访至2006年3月,保留组共发现3例5侧腹股沟淋巴结复发,切除组5例7侧复发,复发率分别为8.9%(5/56)、12.1%(7/58),两者比较差异无显著性,P＞0.05;(3)保留组急性下肢静脉炎,急性下肢淋巴水肿的发生率分别为11.3%,43.5%;切除组分别为25.8%,66.7%,两组比较差异有显著性(P值分别＜0.05,＜0.01).保留组迟发性下肢水肿和下肢疼痛的发生率分别为25.0%,23.2%,切除组48.3%,46.6%,两组比较差异均具有非常显著性(P值均＜0.01);两组下肢蜂窝组织炎及感觉异常的发生率差异亦具有显著性(P值均＜0.05).结论:外阴恶性肿瘤行腹股沟淋巴结清扫术时保留双侧大隐静脉主干不延长手术时间,不增加手术难度,不降低患者长期生存率,但能明显降低术后并发症的发生率,提高患者的生活质量,是值得推广的手术方式.     

Anatomical and Surgical Study to Evaluate the Accuracy of “C-M-S” Technique in Facial Nerve Identification During Parotid Surgery

Facial nerve identification is considered to be a crucial step in parotid surgery as inadvertent injury to the nerve will lead to facial paralysis. Multiple landmarks are described in literature to identify the facial nerve during parotid surgery but controversies remain as the consistency and accuracy of these landmarks vary. Numerous studies exist in literature but they fail to address a single landmark that is most reliable to identify the facial nerve during parotid surgery. The purpose of this study is to find reliable landmarks for identification of the main trunk of facial nerve during parotid surgery by evidence gathered by cadaveric dissection and intraoperative study during parotid surgery and develop a systematic approach to identify the facial nerve trunk. This prospective study included 41 cadavers (82 parotid regions) and 20 patients with parotid pathology who underwent parotidectomy. We evaluated the feasibility of our C-M-S technique to identify the main trunk of facial nerve in both anatomical and surgical study. The relationship of landmarks (tragal pointer, tympanomastoid suture, superior border of posterior belly of digastric muscle) to the facial nerve trunk was assessed and the shortest distance between them from the facial trunk was measured using a slide caliper. The measurements were compared between the anatomical and surgical study. The main trunk of facial nerve was successfully identified in all cases using C-M-S technique in both anatomical and surgical study. Distance of facial nerve trunk to tragal pointer was more in the cadaveric sample (13.04 ± 5.238 mm) compared to live patients (9.95 ± 3.967 mm) with statistically significant difference (p = 0.036). The mean distance of tympanomastoid suture and posterior belly of digastric muscle to the facial nerve trunk was similar in anatomical and surgical study with p value of 0.877 and 0.083 respectively. The tympanomastoid suture, posterior belly of digastric muscle and tragal pointer are the most useful landmarks for facial nerve identification during parotid surgery. In our study we found that the tympanomastoid suture line is the most consistent landmark present in all our cases and being closest to the facial nerve trunk in both anatomical and surgical study. Further we recommend using the “C-M-S technique” in order to locate the main trunk of the facial nerve.     

直肠癌保留盆腔自主神经手术辅助术后放疗对提高患者生活质量的评估

Objective:Preservation of the pelvic autonomic nerves in order to lower bladder and sexual dysfunction after radical rectal cancer surgery & to evaluate functional outcome,local recurrence.Methods:A prospective study was undertaken on Egyptian patients.Forty one patients participated in the study in the period from December 2002 till June 2004 where they underwent radical surgery but with preservation of the pelvic autonomic nerves this was followed by adjuvant pelvic radiotherapy.Results:Six months,1-year and 2-year follow-up of urinary function was complete in 32 out of 41(78%),30 out of 41 (73%) and 27 out of 41 patients (65%) respectively There was no statistically significant correlation between the extent of nerve preservation and the reported minor voiding dysfunction.None of the patients reported major incontinence.Six months,1-year and 2-year follow-up of sexual function revealed that 22 out of 41 patients (53%) were sexually active.Three out of 41 patients (7.3%) developed local recurrence.38 (92.7%) patients were free of local recurrence,regarding patients who received adjuvant radiotherapy 3 out of the 34 (8.8%) patients developed local pelvic recurrence while 9 patients (26.5%) developed distant metastases (3 of them did not receive adjuvant chemotherapy),while patients who received adjuvant chemotherapy,2 out of 20 patients (10%) developed local recurrence while distant metastases developed in 6 patients (30%).Conclusion:Preservation of the pelvic autonomic nerves minimizes bladder and sexual dysfunction especially in male patients after rectal cancer surgery.     

颈部筋膜的解剖学认识及临床应用研究进展北大核心

颈部筋膜及其周围间隙结构精密又复杂,当前解剖学认识尚不完全,且存在诸多争议。精细颈部筋膜解剖结构、合理运用筋膜间隙于临床指导锁骨手术麻醉方面意义重大;于颈部手术术中规范化操作,保护重要血管神经、减少术后并发症发生、改善预后等方面意义重大;于临床监测与诊治颈深部间隙感染等方面意义重大。     

腹腔镜下保留盆腔自主神经平面根治性子宫切除术的初步临床研究

目的 探讨保留盆腔自主神经平面的腹腔镜下根治性子宫切除术的技术要点、可行性及其对降低术后膀胱功能障碍的作用。方法 将2010年1月至2011年5月30例宫颈癌患者分为两组,一组（15例）根据盆腔自主神经的标志性结构行保留“神经平面”法,于腹腔镜下保留盆腔自主神经的根治性子宫切除术（LNSRH）,另一组（15例）行腹腔镜下根治性子宫切除术（LRH）作为对照。结果 LNSRH 组15例患者中2例因出血较多保留单侧神经,1例为ⅡA期选择性保留病灶对侧盆腔神经,其余成功保留了双侧神经。全组30例患者均顺利完成手术,LNSRH组的手术时间为（301.8±47.6）min,长于LRH组的（178.3±17.0）min（P＜0.05）。术中出血量、术后肠道恢复时间、切除盆腔淋巴结的数目、宫旁和阴道切除范围两组比较差异无统计学意义（P＞0.05）。术后LNSRH组的住院时间为（10.9±2.0）d,明显少于LRH组的（15.1±0.8）d（P＜0.05）。LNSRH组术后拔除尿管的平均时间为（10.8±3.2）d,明显短于LRH组的（17.4±3.2）d（P＜005）。随访3～19个月,全组无复发和转移病例。结论 LNSRH在技术上安全、可行,可明显减少术后膀胱功能障碍,既不降低根治性标准,又有利于患者术后恢复及生活质量提高。