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     

男性盆腔神经丛的外科应用解剖

目的　探讨泌尿外科术中避免损伤盆腔神经丛 (盆丛 )的解剖标志。方法　对 42具盆腔器官作盆腔解剖或组织切片 ,观察盆丛与盆腔脏器的毗邻关系。结果　盆丛位于直肠的前外侧 ,距肛门口 ( 9.5± 1.6)cm ,精囊的后外侧 ,在前列腺基底部与前列腺血管形成神经血管束 ,于尿道膜部外侧和后外侧 ,穿尿生殖膈。结论　精囊和前列腺神经血管束可作为泌尿外科术中防止损伤盆丛的一个标志。     

经皮腹腔神经丛穿刺的应用解剖

目的：为提高腹腔神经丛穿刺阻滞的成功率、减少并发症提供形态学基础。方法：在１８具成人尸体腹部横断层标本上对腹腔神经丛的位置、毗邻，穿刺部位、角度、深度进行观测。结果：腹腔神经丛平对胸十二至腰－椎体高度者为９４．４％。该丛最佳显示层面为腹部第九横断层面。腹腔神经丛左、右穿刺点距后正中线分别为４．０±０．６ｃｍ；５．９±１．１ｃｍ，穿刺角度分别为１４．０°±４．５°；２８．８°±３．７°，穿刺深度为９．７±１．１ｃｍ；１１．６±１．４ｃｍ。结论：穿刺点应选在第十二胸椎棘突下缘，中线向外旁开左４ｃｍ、右６ｃｍ处。穿刺角度较大时易损伤主动脉、腰升静脉、脊神经，反之易损伤肾、肾上腺和下腔静脉     

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。     

Mile′s术怎样保护盆内脏神经的解剖学研究

Mile’s术通常引起排尿障碍和性机能障碍等术后并发症,其部分原因是手术损伤了盆内脏神经。在40侧成人尸体上观察测量了盆内脏神经的来源、支数、长度、横径,并对该神经作了定位调查,为手术保护提供了依据。     

手术中对喉返神经定位的应用解剖

目的：为甲状腺手术中对喉返神经的定位和保护提供解剖学基础。方法：在５０具（１００侧）成人标本上，对术中喉返神经易损伤部位进行定位观测。结果：①甲状腺下极区，喉返神经位于气管食管沟内，在气管与颈总动脉之间的浅面平面深度，左侧为１０．４±２．０ｎ１ｍ，右侧为１２．０±２．０ｍｍ；②环甲关节区，喉返神经入喉处距甲壮软骨下角尖为８．２±６ｍｍ，距喉结突出点水平相交点为３３．３±４．３ｍｍ；③腺体侧叶后侧区，９５％的喉返神经在甲状腺外侧韧带后方经过，５％穿甲状腺外侧韧带；④甲状腺下动脉弓形弯曲恒定存在，其最高点至神经与该动脉交叉点的距离为１４．６±４．４ｍｍ。结论：上述喉返神经定位观测结果，是术中防止神经损伤的应用解剖学基础。     

与子宫颈癌手术有关的盆丛解剖学基础

解剖了9例18侧女性盆腔标本,着重观察了盆丛与子宫颈癌根治术有关的子宫骶骨韧带、主韧带的关系。提出了在术中保留盆丛和减少并发症的方法,并与过去术中没有注意保护盆丛的效果作了对比.     

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。     

侧方淋巴结清扫保留植物神经术治疗直肠癌的效果分析

目的分析腹腔镜下侧方淋巴结清扫保留植物神经术在治疗直肠癌中的效果。方法将46例中低进展期直肠癌患者分为侧方清扫组和对照组,侧方清扫组行腹腔镜下侧方淋巴结清扫保留植物神经术,在清除淋巴结时注意对腹前神经丛、盆神经丛和盆内脏神经的保护。对照组行传统的直肠癌根治术（不作侧方淋巴结清扫）。对两组手术时间、出血量、严重并发症、性功能、排尿情况、机体的免疫状况及淋巴结转移率进行比较。结果两组的平均手术时间、出血量差异具有统计学意义（P〈0.05）;术后两组排尿、性功能、外周血CD3＋、CD4＋、IL-6、IgM、IgA、IgG水平两组间差异具有统计学意义（P〈0.05）;侧方清扫组23例中发生侧方转移5例,占21.7%,对照组的侧方转移率为53.8%。结论侧方淋巴结清扫保留植物神经术在直肠癌患者的治疗中有一定的临床价值,其创伤小,大大提高了患者的术后生活质量,值得推广。     

直肠癌全直肠系膜切除术中易损伤神经的定位及应用

目的 :探讨直肠癌全系膜切除术中容易损伤的有关内脏神经丛及分支的定位。方法 :在成人男性骨盆矢状标本及男性躯干标本上解剖观测有关内脏神经丛及分支的形态及位置。结果 :上腹下丛位于腹主动脉分叉至骶骨岬下约 2cm的范围内 ;左右腹下神经的夹角约为 95 .9° ;两侧神经的投影点分别位于骶骨岬中点至左右坐骨大切迹下缘 (近坐骨棘 )内侧一横指处 ;盆丛上、下端的投影点分别位于直肠膀胱陷凹上外侧约 4.71cm和 2 .98cm的盆壁 ,盆丛内侧缘距直肠外侧约 1 .1 1cm处。结论 :手术中应根据神经的定位分离或保护各神经丛及分支 ,就能最大限度的避免损伤神经 ,防止术后性功能及排尿功能障碍。     

电刺激狗盆神经诱导阴茎勃起血流动力学研究

本文介绍了电刺激狗盆神经诱导阴茎勃起其阴部动静脉血流量变化，为植入式神经刺激器的研究予以临床的理论支持。     

盆神经刺激器的研制

本文介绍了一种部分植入式盆神经刺激器，它主要由体外脉冲发射装置与体内感应接收器和刺激电极组成。文中描述该刺激器的电路设计原理及动物实验结果。     

骨盆后环骨折神经损伤的临床解剖学研究

目的：了解骨盆后环骨折易损神经的相对解剖位置及其与骨折的关系。方法：解剖20具骨盆标本，神经外膜下置管造影CT扫描5例，测量腰区各神经的走行特点、与骨盆壁和骶髂关节的距离。结果：腰4腰骶干支、腰5神经和腰骶干与骶骨翼的距离不超过1cm，距离骶髂关节不超过2．5cm。闭孔神经、股神经、股外侧皮神经与骨壁的距离依次渐远。CT测量结果和人工测量结果无显著性差异。结论：腰4腰骶干支、腰5神经和腰骶干是与骨盆壁和骶髂关节的关系最为紧密的神经，它们在骨盆后环骨折及其治疗时最易受损。     

The intramural pelvic nerves immunoreactive for calcitonin gene-related peptide in the rectum of normal and aganglionosis rat

Summary The distribution of calcitonin gene-related peptide-like immunoreactive (CGRP-LI) nerves was investigated immunohistochemically in the rectum of normal, capsaicin-treated and congenital aganglionosis rats. The rectum of the normal rat was densely supplied with both extrinsic and intrinsic nerves exhibiting CGRP-like immunoreactivity. Numerous CGRP-LI nerve fibres were seen in both the myenteric and submucous plexuses. Intrinsic CGRP-LI nerve cell bodies were sparsely found in both the ganglionated plexuses, while a large inflow of extrinsic CGRP-LI nerves was characteristically observed in the rat rectum. CGRP-like immunoreactive fibres were abundant in the intramural pelvic nerves which ascend proximally in the intermuscular zone and connect with the myenteric plexus of the rat distal bowel. As compared with CGRP-positive fibres, SP- or SK-positive fibres in the intramural pelvic nerves were far less frequent. The treatment with capsaicin in the neonatal period led to a marked depletion of CGRP-immunoreactivity in these extrinsic nerves as well as in the most terminal varicose fibres seen in the whole layers of the rectal wall. These findings suggest that the vast majority of CGRP-LI fibres in the intramural pelvic nerves are sensory in nature, and that the positive nerve fibres of extrinsic origin directly innervate each layer of the rat rectum. These CGRP-LI sensory fibres associated with the intramural pelvic nerves, may be of importance in the regulation of rectal and colonic function in normal rats. A dense innervation of CGRP-LI nerve fibres, some of which showed the varicose appearance, was also found in the rectum of congenital aganglionosis rats. Thus, it is suggested that there is a large inflow of extrinsic CGRP-LI fibres from the pelvic plexus in the affected rectum. The extrinsic CGRP-LI nerves in the aganglionic segment of the mutant rat might also be related to the regulation of rectal function, providing afferent pathways.     

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。     

Fascial structures and autonomic nerves in the female pelvis: A study using macroscopic slices and their corresponding histology

We investigated the topographical anatomy of the pelvic fasciae and autonomic nerves using macroscopic slices of five decalcified female pelves. The lateral aspect of the supravaginal cervix uteri and superior-most vagina issued abundant thick fiber bundles. These visceral fibrous tissues extended dorsolaterally, joined another fibrous tissue from the rectum (the actual lateral ligament of the rectum) and attached to the parietal fibrous tissues at and around the sciatic foramina (i.e. the sacrospinous ligament, thick fasciae of the coccygeus and piriformis and dorsal end of the covering fascia of the levator ani). The inferior or ventral vagina also issued thick fiber bundles communicating with the levator ani fascia. This connection between the vagina and levator fascia, when stretched, seemed to provide a macroscopic morphology called the arcus tendineus fasciae pelvis. The overall morphology of the visceroparietal fascial bridge exhibited a bilateral wing-like shape. The fascial bridge complex was adjacent but dorso-inferior to the internal iliac vascular sheath and located slightly ventral to the pelvic splanchnic nerve. However, the pelvic plexus and its peripheral branches were embedded in the fascial complex. The hypogastric nerve ran along and beneath the uterosacral peritoneal fold, which did not contain thick fibrous tissue. During surgery, in combination with the superficially located vascular sheath, the morphology of the visceroparietal fascial bridge and associated nerves seemed to be artificially changed and developed into the so-called cardinal, uterosacral, uterovesical and/or rectal lateral ligaments. The classical and original concepts of these pelvic fascial structures may need to be altered to adjust to these surgical observations.     

Topography and landmarks for the nerve supply to the levator ani and its relevance to pelvic floor pathologies

The aim of this study was to explore the anatomical variations of the nerve to the levator ani (LA) and to relate these findings to LA dysfunction. One hundred fixed human female cadavers were dissected using transabdominal, gluteal, and perineal approaches, resulting in two hundred dissections of the sacral plexus. The pudendal nerve and the sacral nerve roots were traced from their origin at the sacral foramina to their termination. All nerves contributing to the innervation of the LA were considered to be the nerve to the LA. Based on the spinal nerve components, the nerve to the LA was classified into the following categories: 50% (n = 100) originated from S4 and S5 (type I); 19% (n = 38) originated from S5 (type II); 16% (n = 32) originated from S4 (type III); 11% (n = 22) originated from S3 and S4 (type IV); 4% (n = 8) originated from S3, S4, and S5 (type V). Two patterns of nerve termination were observed. In 42% of specimens, the nerve to the LA penetrated the coccygeus muscle and assumed an external position along the inferior surface of the LA muscle. In the remaining 58% of specimens, the nerve crossed the superior surface of the coccygeus muscle and continued along the superior surface of the iliococcygeus muscle. Damage to the nerve to LA has been associated with various pathologies. In order to minimize injuries during surgical procedures, a thorough understanding of the course and variations of the nerve to the LA is extremely important. Clin. Anat. 29:516–523, 2016. © 2015 Wiley Periodicals, Inc.     

Relationship between endometriotic foci and nerves in rectovaginal endometriotic nodules

The histological relationships between fibrotic tissue, endometriotic foci and nerves in the rectovaginal septum endometriotic or adenomyotic nodule were studied. This is considered to be one of the most severe forms of deep endometriosis. Masson's trichrome staining for fibrosis detection and immunohistochemistry with the S100 monoclonal antibody for nerve detection were performed in 28 rectovaginal endometriotic nodules from patients presenting with severe dysmenorrhoea and deep dyspareunia (23 patients with no other endometriotic location or potential cause of pain at laparoscopy and ultrasonography; five patients with multiple pelvic endometriotic localizations and other potential causes of pain at laparoscopy). Patients were allocated to two groups on the basis of their preoperative pain scores for pelvic pain, dysmenorrhoea and deep dyspareunia (group 1, score >7; group 2, score < or =7). For each symptom, the mean number of nerves and endometriotic lesions per high-power field and the mean largest diameter of the lesions were not statistically different in groups 1 and 2. The mean percentages of nerves located within the fibrosis of the nodule and within endometriotic lesions were significantly higher in group 1 than in group 2. Among nerves located within endometriotic lesions, there was a significantly higher proportion showing intraneurial and perineurial invasion by endometriosis in group 1 than in group 2. In rectovaginal endometriotic nodules, there was a close histological relationship between nerves and endometriotic foci, and between nerves and the fibrotic component of the nodule. We postulate that such topographical relationships could at least partially explain the strong association between this lesion and pain.     

The bikini area and bikini line as a location for anterior subcutaneous pelvic fixation: An anatomic and clinical investigation

Anterior external fixation for pelvic fractures has been the standard for acute stabilization but definitive treatment often leads to pin tract infection, is uncomfortable, and limits patient mobility. We recently developed a subcutaneous anterior pelvic fixator which addresses these issues (INFIX). The objective of this study is to introduce the Bikini Area and Bikini Line as the subcutaneous anatomical location where this apparatus is placed. A study was preformed on eight cadaveric specimens to define the location of the subcutaneous device with respect to anatomic structures. We examined 23 people of various body mass indexes to examine the anterior pelvic anatomy. This was followed by implantation on 42 individuals in whom we reviewed CT scans to assess the location of the implant. We asked these same 42 individuals whether they could sit, stand, and lie on their sides and if they had any discomfort. We measured the dimensions of 26 retrieved rods to approximate the curve of the Bikini Line. Finally in 14 individuals we performed vascular ultrasound to assess the flow in the iliac and femoral vessels with the implant in place in the sitting and standing position. Neurovascular structures are not affected by placing the INFIX device at the Bikini Line, patients are comfortable, mobile and complications are minimized by this procedure. A rod placed on the Bikini Line which connects screws inserted into the anterior inferior iliac spine on each side does not interfere with sitting, standing, or the neurovascular structures. Clin. Anat., 2013. © 2012 Wiley Periodicals, Inc.