Denonvilliers筋膜的微创解剖认识及其临床价值

1836年，法国外科学家Charles-Pierre Denonvilliers首次描述在男性的直肠与膀胱、精囊腺和前列腺之间存在薄层致密组织，后被称为Denonvilliers筋膜。1982年英国外科学家R.J. Heald教授提出全直肠系膜切除术（TME）理念，历经数十年的临床实践，TME已成为中低位直肠癌手术的金标准。根据TME理念，直肠后方及侧方均应在盆筋膜壁层内面与直肠固有筋膜间分离，而在直肠前方于Denonvilliers筋膜前方分离、肿瘤下方2 cm处倒U形离断并切除部分Denonvilliers筋膜。然而，资料显示，由于盆腔自主神经（PAN）的损伤，TME术后排尿及性功能障碍发生率居高不下。因此，进一步理清盆腔筋膜和自主神经解剖的认识，对于改善患者术后功能尤为重要。在国内外众多学者研究的基础上，我们从胚胎发育学、解剖学、组织学和外科手术角度对盆腔筋膜及外科层面进行深入探索，指出Denonvilliers筋膜不属于直肠固有筋膜的范畴、如非肿瘤浸润应予保留，并提出保留Denonvilliers筋膜全直肠系膜切除术（iTME）的理念；并采用多中心临床试验加以验证。在此基础上我们联合国内直肠癌外科领域专家，发布iTME中国专家共识，旨在提高从业者对神经功能保护的认识，规范手术操作，造福广大患者。

Understanding the Denonvilliers' fiscia and its clinical application value from the perspective of minimally invasive anatomy

In 1836, the French surgeon Charles-Pierre Denonvilliers first described the existence of a thin layer of dense tissue between the male rectum and the bladder, seminal vesicles and prostate, later known as Denonvilliers' fascia. In 1982, Professor R.J. Heald proposed the concept of total mesorectal excision (TME). After decades of clinical practice, TME has become the gold standard for mid-low rectal cancer surgery. According to the TME concept, the posterior and lateral sides of the rectum should be separated between the inner surface of the pelvic fascia parietal and the rectal fascia propria, while the anterior rectum should be separated in front of the Denonvilliers' fascia, and the inverted U-shaped dissection and excision should be performed at 2 cm below the tumor, and part of the Denonvilliers' fascia should be removed. However, data show that the incidence of urinary and sexual dysfunction after TME remains high due to pelvic autonomic nerve (PAN) damage. Therefore, further clarifying the understanding of pelvic fascia and autonomic nerve anatomy is particularly important for improving postoperative function of patients. On the basis of previous research, we conducted an in-depth exploration of the pelvic fascia and surgical aspects from the perspectives of embryonic development, anatomy, histology and surgery, and pointed out that Denonvilliers' fascia does not belong to the category of rectal fascia propria. We proposed the concept of Denonvilliers' fascia-sparing total mesorectal excision (iTME), and validated it using a multicenter prospective randomized controlled clinical trial. On this basis, we formulated the iTME Chinese expert consensus, aiming to improve practitioners' understanding of neurological protection, standardize surgical operations, and benefit the majority of patients.