腹腔镜直肠癌根治术的相关解剖要点分析

目的根据直肠癌根治术全直肠系膜切除（total mesorectal excision,TME）的要求,从肿瘤根治和膀胱功能、性功能保护的角度探讨腹腔镜直肠癌根治术关键步骤的解剖学要点。方法2006年11月～2008年8月施行32例腹腔镜直肠癌根治术,从Toldt间隙的分离、肠系膜下动脉的处理、侧腹膜的解剖、骶前间隙和骶直肠筋膜的分离、直肠侧韧带的分离及直肠前方间隙的分离6个关键性步骤对TME手术的相关解剖进行观察和描述。结果Toldt间隙和骶前间隙是一个相互延续的筋膜间隙,走行于该间隙的腹下神经与直肠固有筋膜关系密切。骶直肠筋膜是盆壁筋膜和直肠固有筋膜在盆底部的融合,是TME手术盆腔分离的重要标志。在精囊腺平面以下,直肠前方和前侧方的解剖层面最为致密,适度的牵拉暴露和锐性分离有利于寻找正确解剖间隙和保护神经丛。结论紧贴直肠固有筋膜分离并保持该筋膜的完整是直肠癌根治手术中贯彻TME概念并保护膀胱功能和性功能的基本策略。

Anatomical Characteristics of the Rectal Cancers for Laparoscopic Radical Operation

Objective To analyze the anatomical characteristics of the rectal cancers for laparoscopic radical operation basing on the total mesorectal excision （TME） , for the purpose of oneological curative resection and preservation of sexual and voiding functions. Methods From November 2006 to August 2008, 32 patients with rectal cancers received laparoscopic radical operations in our hospital. The anatomical characteristics were observed and described by the six critical steps of TME including the dissection along the Toldt＇ s fascia, management of the inferior mesenteric artery, dissection of the lateral peritoneum, dissection along the presacral gap and rectosacral fascia, dissection of the rectal lateral ligament, and anterior dissection of the rectum. Results Presacral gap was an extension of the Toldt＇ s fascia, under which the hypogastrie nerves had a close relationship with the rectal proper fascia. The reetosacral fascia, which was a fusion fascia of the parietal pelvic fascia and the rectal proper fascia in the pelvic floor, played an important role as a marker for pelvic dissection in TME. Under the level of the seminal vesicle, dense tissue was observed anterior and anterolateral to the rectum, which made the proper traction and sharp dissection a favorable method for the exploration of the correct anatomical gap and preservation of the nerves. Conclusions Dissection tightly along the rectal proper fascia and keeping the integrity of it are basic strategies to put into effect of TME and to preserve the sexual and voiding functions in laparoseopie radical operation.