Surgical anatomy of the pelvic autonomic nerves. A practical approach

Since the pelvic autonomic nerves are not distinctly seen during mobilization of the sigmoid colon or rectum, the surgeon must have a conceptual picture of the "flow" of these nerves in mind at the time of operation in order to avoid inadvertent nerve injury which may have serious physiologic consequences. The surgical anatomy of the pelvic autonomic nerves is reviewed in a concise fashion highlighted with updated illustrations that help simplify important anatomic relationships.     

盆腔自主神经的解剖学研究及直肠癌手术保留神经的体会

目的 了解盆腔自主神经的解剖，减少直肠癌手术中对自主神经的损伤。方法 通过解剖7例尸体了解盆腔自主神经的分布，并于10例直肠癌手术中进一步验证。结果 上腹下丛紧贴肠系膜下血管的后方；直肠正后方的脏层筋膜与壁层筋膜之间的疏松间隙内无明显自主神经分支；直肠与精囊和前列腺(或子宫、阴道)之间无明显的神经支；盆丛呈网状不规则四边形结构，其四个角不在同一平面。直肠侧韧带主要由盆丛发至直肠的分支及结缔组织构成。结论 当实施保留自主神经的直肠癌根治术时，肠系膜下血管可作为寻找上腹下丛的标志；游离直肠时应先游离其后壁及前壁，后游离其侧方，使直肠侧韧带呈桥状架于直肠与盆丛之间；侧方的游离应于盆丛的内侧，按与其弧面相适应的方向用电刀切断直肠侧韧带。     

Anatomic relationship of the cervical nerves to the lateral masses

Eight cervical specimens were transversely sectioned with slices approximately 2 mm to 3 mm in thickness to evaluate the anatomic relationship of the spinal nerves to the lateral masses. Results showed that the spinal nerve either does not appear or, when it does, is situated anteromedially to the superior facet on the cross sections through the upper portion of the superior facet. The anterolateral aspect of the superior facet is free from the spinal nerve. Cross sections through the lower pedicle of the vertebra showed that the spinal nerve rested on the transverse process anterolateral to the lateral mass. The mean distances between the posterior midline of the lateral mass and the posterior border of the spinal nerve measured 15 degrees in the lateral direction were 16.1+/-1.7 mm for C3, 16.5+/-1.8 mm for CA, 16.8+/-1.2 mm for C5, 16.3+/-2.0 mm for C6, and 8.5+/-0.9 mm for C7. This study suggests that the anterolateral corner of the superior facet and the anterior aspect of the lateral mass lateral to the origin of the transverse process would be safer zones for screw exit. Attention should therefore be paid to the screw orientation for the Magerl technique and to the screw length for the Roy-Camille technique. Care should be taken to insert the screw into the C7 lateral mass.     

Surgical anatomy of pelvic nerves

A good knowledge of the anatomy of the mesorectum and pelvic autonomic nerves allows the colorectal surgeon to reconcile both oncologic and functional results in rectal cancer excision. The author describes the anatomy of the systemic and autonomic pelvic nerves and describes techniques designed to avoid nerve damage during rectal cancer excision.     

Anatomic principles of lumbar intervertebral disk operations

The important anatomical structures and the topographic relationships of lumbar disc surgery are described. Recent examinations about the epidural venous plexuses, the vascular supply of the spinal cord and nerve roots in the spinal canal enlarged our knowledge. Anterior and posterior spinal nerve roots differ in reaction to horizontally directed pull. The prevertebral anatomical structures which can be damaged by iatrogenic ventral perforation of the lumbar disc are demonstrated and their clinical importance is discussed.     

腹腔镜直肠癌全直肠系膜切除术中保护盆自主神经的手术技巧

Laparoscopic radical resection of rectal neoplasms is still under clinical research currently due to the following 2 reasons. Firstly, compared with open surgery, the longterm efficacy of laparoscopic surgery remains unclear; secondly, the pelvic autonomic nerves are difficult to be exposed and easy to be damaged during the surgery under laparoscope. Till present time, our department has completed 800 cases of laparoscopic radical resection of colorectal neoplasms, in which rectal neoplasms accounted for 70%. For most cases, the pelvic autonomic nerves have been exposed and protected properly. This paper summarized the skills to protect the pelvic autonomic nerves in the laparoscopic total mesorectal excision used for the treatment of rectal neoplasms.     

Anatomic characteristics of the pelvic girdle]

The most recent methods of investigation (CT osteoabsorptiometry) were applied in an attempt to reconstruct from their morphological structure the way in which connections between the bones of the pelvic girdle undergo stress. Thus, both sacroiliac articulation and symphysis pubis show characteristic distribution of the subchondral bone density and layout of the tensile collagen fibrous material as expression of a strongly varying qualitative pattern of stress during walking. In the region of sacroiliac articulation are the highest subchondral densities, both at the cranial and caudal edges, whereas the central part of the two auricular surfaces is less heavily mineralized. This distribution matches the thickness of the hyaline cartilage of the joint. There are striking sexual differences in the distribution of the subchondral bone density at the bordering surfaces of the symphysis pubis. During walking, all components of sacroiliac articulation and the symphysis pubis are apparently subjected to sudden changes in stress. Independent of this, the os sacrum is constantly exposed to torque on account of the weight of the upper body, and this is balanced out by the sacrospinal and sacrotuberal ligaments.     

Anatomic study of the cervicothoracic spinal nerves and their relation to the pedicles

Twelve cadavers were dissected for the study of the cervicothoracic junction. The results showed that the mean heights and widths of the ganglia tend to decrease from the C-6 to T-4 nerve. The mean distances between the dura and the ganglion and the mean spinal nerve angles increased consistently from C-5 to T-4. The mean distances from the spinal nerves to the superior and inferior pedicles ranged 0.8-2.3 mm. It was noted that the mean value was significantly greater for the distance from the spinal nerve to the superior pedicle than that to the inferior pedicle for the spinal nerves C5-7 (P< or =.05). This information, in conjunction with imaging studies, may minimize spinal nerve injury during posterior pedicle screw fixation in the cervicothoracic spine.     

下腹壁横行腹直肌肌皮瓣及腹壁下动脉穿支皮瓣乳房再造的相关肋间神经解剖学研究

目的　为开展保留感觉神经和部分腹直肌功能的下腹壁横行腹直肌肌皮瓣 (TRAM皮瓣 )及腹壁下动脉穿支皮瓣 (DIEP皮瓣 )乳房再造手术方法提供解剖学依据。方法　对 9具 18侧 10 %甲醛溶液防腐固定的成年女尸腹前外侧壁进行大体及显微解剖 ,观察T8～T12 肋间神经的走行及分布 ,重点解剖腹直肌区域内肋间神经分支。在 15例DIEP皮瓣乳房再造术中 ,观察肋间神经在腹直肌内的走行分布特点及其与腹壁下血管穿支的关系。结果　肋间神经在腹直肌外侧 1/3区域内穿入腹直肌 ,其运动支在腹直肌内有交通支形成 ,相邻神经可重叠支配节段性腹直肌。感觉神经支分为内侧穿支和外侧穿支 ,与腹壁下血管穿支形成血管神经束进入皮下组织。纯感觉神经蒂长为 (2 7.6± 12 .2 )mm。结论　在应用TRAM皮瓣和DIEP皮瓣进行乳房再造时 ,可以保留感觉神经蒂进行神经吻合以恢复乳房感觉功能 ;而在切取TRAM皮瓣时 ,保留外侧 1/3腹直肌不会导致术后肌肉失神经萎缩。     

Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis

The anatomical location of the branches of the pelvic plexus that innervate the corpora cavernosa has been identified previously in stillborn male neonates and fetuses. Based upon these observations, the techniques of radical retropubic prostatectomy and cystectomy have been modified to avoid injury to the autonomic innervation of the corpora cavernosa. However, the exact anatomical relationships of these nerves to the prostate, urethra and other pelvic structures in adults are unclear, since the initial anatomical studies of the pelvic plexus were performed in stillborn neonates in whom the accompanying vessels and fascia had been removed. Because these nerves are microscopic in size and can only be identified by their association with other pelvic structures, it was believed that a more refined understanding of the anatomy was necessary. In an effort to identify precisely the relationship of the cavernous branches of the pelvic plexus to the lateral pelvic fascia and the branches of the prostatovesicular arteries and veins, the following study was performed. Shortly after death a 60-year-old man was perfused completely with Bouin's fixative solution. The entire bladder, prostate, urethra, penis, corpora cavernosa, rectum, and pelvic sidewall fascia and musculature were removed en bloc. The specimen was serially sectioned transversely at 10 mu thickness, and every tenth section was stained with hematoxylin and eosin. An anatomical reconstruction in 3 dimensions was performed and illustrated. Thus, the specific location of the nerves that innervate the corpora cavernosa and their important relationships to the urethra, prostatic capsule, Denonvilliers' fascia and pelvic floor vasculature have been identified.     

Anatomic course of the medial cutaneous nerves of the arm

The medial antebrachial cutaneous nerve and the medial brachial cutaneous nerve were dissected in twenty fresh cadaver extremities. These nerves have a variable number of cutaneous branches ranging from four to twelve, with an average of eight. Branches always originated medially in both nerves and ran in an anterolateral direction. In all the medial antebrachial cutaneous nerves, there were three to five terminal branches directly overlying the medial epicondyle and supplying the skin over the olecranon. The course of this nerve is predictable relative to the basilic vein and the medial epicondyle. There was a ninety percent incidence of communication between the medial brachial cutaneous nerve and the intercostobrachial cutaneous nerve. The standard incision used for surgery of the ulnar nerve at the elbow will cut the terminal branches of the medial antebrachial cutaneous nerve one hundred percent of the time, and the terminal branches of the medial brachial cutaneous nerve eighty percent of the time, if they are not identified. A posterior approach for transposition of the ulnar nerve would avoid damage to these nerves.     

Conservative operations for pelvic bone tumours

Summary This paper outlines our experience of partial pelvic resection for benign tumours or those of low grade malignancy. The entire half of the pelvis may be removed with preservation of the limb. Pelvic resection must only be undertaken when the surgeon is sure that the removal of the tumour will be as radical as in an inter-ilio abdominal amputation.Various methods of creating a rest for the superior end of the femur against the remaining parts of the pelvic bones are shown. Special attention is devoted to preservation of the limb movement and restoration of the locomotor function of the leg.

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Résumé Cet article rapporte l'expérience de l'auteur en matière d'exérèse partielle du bassin pour tumeurs bénignes ou faiblement malignes. L'hémi-bassin peut être réséqué en totalité tout en conservant le membre inférieur. Cette exérèse pelvienne ne doit être effectuée que si le chirurgien est certain de pouvoir réaliser une résection tumorale aussi radicale que par désarticulation inter-ilio-abdominale.L'auteur présente les différents moyens de créer un appui entre l'extrêmité supérieure du fémur et la partie restante du bassin. Il porte une attention toute particulière à la préservation de la mobilité et à la restauration de la fonction locomotrice du membre inférieur.