肾前筋膜间平面无血化腹腔镜手术层面的解剖学研究  

Anatomic research on retromesenteric planes of bloodless and the anatomical laparoscopic surgery

作　　者：梅傲冰[1] 邱剑光[2] 贾本忠[1] 王德娟[2] 肖恒军[2] 黄文涛[2] 顾昌世[1] 孙发[1] 黄永红[1] 程昊[3] 余资江[3] 沈桂权[4] 

机构地区：[1]贵阳医学院附属医院泌尿外科,贵阳550004 [2]中山大学附属第三医院泌尿外科,广州510630 [3]贵阳医学院解剖教研室,贵阳550004 [4]贵阳医学院附属医院影像科,贵阳550004

出　　处：《中华腔镜泌尿外科杂志（电子版）》2013年第2期6-11,共6页Chinese Journal of Endourology(Electronic Edition)

基　　金：贵州省科技厅基金资助项目(黔科合J字[2012]2053号);贵阳市社会发展与民生科技计划基金资助项目(筑科合同[2012103]37号)

摘　　要：目的探讨腹腔镜下肾前筋膜间平面的活体形态解剖和毗邻关系,总结和阐述肾前筋膜间平面相关的解剖分层,以便为腹腔镜下上尿路手术中寻找安全正确的外科解剖层面,进行无血化解剖性手术操作提供筋膜解剖学依据。方法经腹腔入路3例,经腹膜后腔入路25例,其中肾上腺肿瘤切除术11例、肾切除术8例、肾癌根治术2例、肾部分切除术2例、肾盂输尿管成形术3例、输尿管上段结石2例。术前进行320排CT影像解剖分析肾筋膜结构。术中对镜下肾前筋膜间层面解剖结构及毗邻关系认真分析、仔细辨别。术后反复观看视频,反复讨论,并将研究理论应用于手术实践中。绘制解剖图片、展示肾前筋膜间平面解剖、设计新的手术入路。结果肾前筋膜间平面在胚胎学上也称为系膜后平面,肾前筋膜间平面包括结肠融合筋膜肾前融合筋膜间平面、肾前融合筋膜肾筋膜前叶间平面、肾筋膜前叶肾脂肪囊外平面,是多层次的无血管筋膜结构。在手术中选择经肾旁前间隙解剖大层面入路,循筋膜间隙及肾前筋膜间平面进入正确的解剖层面精细操作,保持镜下术野清晰,进行无血化解剖性手术处理,便捷、精准到达目标器官。在腹腔镜下肾前筋腹间平面内可观察到充满蜘蛛丝网格状白色纤维组织,直视下操作能得到一个更大的手术工作间隙和无血管游离平面。结论肾前筋膜间平面是肾脏和肾上腺外科手术时前入路的安全层面。循肾前筋膜间平面直视下辨别肾前筋膜及毗邻脏器,为无血化解剖性腹膜后脏器微创手术带来新的视野和理念,Objective To explore the anatomical and adjacent relationship of the prerenal inter-fascia plane in laparoscopic, in order to provide faseial anatomic evidence for a holy plane and a correct anatomy level access for laparoscopic upper urinary tract anatomy and bloodless operation by laparoscopic. Methods 28 patients, 3 accepted operation by intraperitoneal access and 25 by retroperitoneal access were analysed, in which adrenalectomy were 11 cases, nephrectomy were 8 cases, ureteropelvic angioplasty were 3 cases, radical nephrectomy were 2 cases, partial nephrectomy were 2 cases, upper ureteral calculi were 2 cases. Previous to the operation, examine each patient by 320-slice spiral CT to analyze the anatomy of renal fascia structure. After rigorous analysis of the anterior renal fascia planeintraoperatively, careful observation of the video after operation, and repeated discussions, we designed the new surgical approach. Results Planes of prerenal inter-fascla are also called retromesenteric planes in embryology, including plane between colonal fusion fascia and prerenal fusion fascia; plane between prerenal fusion fascia and anterior lamella of renal fascia; plane between colonal fusion fascia and prepancreaticduodenal fusion fascia; plane between prerenal fusion fascia and postpancreaticduodenal fusion fascia; plane between perirenal fat and anterior lamella of renal fascia. The planes can be seen as tissues of spider silk screen trellis, between the neighboring fascias form some no vascular structure. Through these planes, surgeons can easily achieve a clean surgical field and a bloodless anatomy in laparoscopic surgery to reach the target orgar, more conveniently and accurately. Conclusion Retromesenteric plane is a security plane for kidney and adrenal gland surgery. Through these planes, renal and adjacent organs can be discrimination directly. Dissection through this planes also easy to perform, and can achieve bloodless anatomy. It brings a new horizon and concept for renal minimally invasive surgery.

关 键 词：腹腔镜 肾前筋膜间平面 肾前融合筋膜 无血化 解剖 层面外科 

分 类 号：R699[医药卫生—泌尿科学]