“膜”引导保护盆腔植物神经技术在直肠癌手术中的应用  

Application of fascia-orientation of pelvic autonomic nerve preservation in rectal cancer surgery

作　　者：梁小波[1] 王毅[1] 马国龙[1] 

机构地区：[1]山西省肿瘤医院消化外科,太原030013

出　　处：《中华胃肠外科杂志》2017年第6期614-617,共4页Chinese Journal of Gastrointestinal Surgery

基　　金：山西省自然科学基金（2016011099）

摘　　要：直肠癌已经成为我国第二常见的消化道肿瘤，随着综合治疗的开展，直肠癌患者的长期生存率大幅提高，对其术后生活质量的要求也越来越高。直肠癌术后的泌尿生殖功能障碍成为困扰患者的公共卫生问题。造成这一问题的主要原因是术中盆腔植物神经的损伤。传统盆腔植物神经保护技术诞生于20世纪80年代，只能部分改善患者术后泌尿生殖功能。近年提出的神经引导盆腔植物神经保护技术需要将盆腔神经游离暴露后再行保护，由于术中辨认神经困难，游离过程中对其不可避免的损伤及术中、术后理化因素对其的刺激，患者术后泌尿生殖功能恢复并不理想。笔者通过对盆腔的解剖研究及腹腔镜手术中发现，盆腔植物神经走行过程中分为腹腔、大骨盆和小骨盆3部分，而在每部分盆腔植物神经都与周围筋膜有密切的联系。这些筋膜不仅保护着盆腔植物神经，也可作为盆腔植物神经良好的标志来指示盆腔植物神经的走行及位置。因此，笔者基于解剖研究并结合临床经验，提出了一种新的＂膜＂引导盆腔植物神经保护技术。该技术以直肠周围的筋膜结构作为引导，在直肠癌手术中选择适合的手术平面，在保证手术效果的前提下，做到不刻意暴露盆腔植物神经而将肿瘤切除。其优势在于：其一，术中不用刻意寻找与暴露盆腔植物神经，避免对盆腔植物神经造成副损伤；其二，术中保留盆腔的筋膜结构，在手术平面与盆腔植物神经之间形成天然屏障，避免能量器械、盆腔积液、炎性介质等理化因素对盆腔植物神经的刺激；其三，由于筋膜较神经更易辨认，质地也更为坚韧，因此技术更容易掌握。Rectal cancer has become the second most common gastrointestinal tumor in our country. With the development of comprehensive treatment, the long-term survival rate of patients with rectal cancer has greatly increased, meanwhile, higher postoperative quality of life is required. But the genitourinary dysfunction which is mainly caused by intraoperative pelvic autonomic nerve damage haunts postoperative rectal cancer patients. Traditional pelvic autonomic nerve protection technology born in the 1980s only improves urogenital function in a part of postoperative patients. In recent years, NOME （nerve-oriented mesorectal excision） was proposed, which needed to make pelvic autonomic never exposed. However, recovery of urinary function is not ideal due to difficulty identifying pelvic autonomic nerve and unavoidable damage on pelvic autonomic nerve. In clinical practice, we found that pelvic autonomic nerve can be divided into three parts： abdominal cavity, large pelvis, small pelvis. The pelvic autonomic nerve is closely related to the surrounding fascias in each part. The fascias are not only the protection of pelvic autonomic nerve, but also can be used as a good indicator of location of pelvic autonomic nerve. The relationship of pelvic autonomic nerve with Toldt fascia, presacral fascia, the lateral rectal ligaments, and the Denonvilliers fascia is discussed in this paper. Combined with the above theory, a new technology named FOPANP （fascia-orientation of pelvic autonomic nerve preservation） is proposed. In this technique, the fascia around the rectum is used as a guidance to select the appropriate plane in the operation, and the tumor can be removed without exposing the pelvic autonomic nerve. This technology has three advantages. First, it is not necessary to search and expose the pelvic autonomic nerve, so as to avoid secondary injury to it during the operation. Secondly, the pelvic fascias are natural barriers formed between the surgical plane and the pelvic autonomic nerve retained. They can avoid t

关 键 词：直肠肿瘤 盆腔植物神经保护 直肠筋膜 

分 类 号：R735.37[医药卫生—肿瘤]