直肠癌盆腔的膜解剖与网络保留自主神经手术  

Pelvic membrane anatomy and surgery with network preservation of autonomic nervous system for rectal cancer

作　　者：韩方海[1] 周声宁 Han Fanghai;Zhou Shengning(Department of Gastrintestinal Surgery,Sun Yat-Sen Memorial Hospital,Sun Yat-Sen University,Guangzhou 510199,China)

机构地区：[1]中山大学孙逸仙纪念医院胃肠外科,广州510199

出　　处：《中华胃肠外科杂志》2021年第7期587-592,共6页Chinese Journal of Gastrointestinal Surgery

摘　　要：全直肠系膜切除(TME)的提出,规范了直肠癌根治术的切除范围和手术分离平面,降低了局部复发率,提高了患者的生存率,是直肠癌根治术的"金标准"。随着近年来腹腔镜外科器械和技术的进步,对盆腔膜解剖和自主神经系统的认识加深,TME手术平面更加精准,自主神经系统可以得到比较完好的保留。根据尸体解剖和组织学研究确认,在直肠固有筋膜和盆腔壁层筋膜之间存在一层膜,即腹下神经前筋膜鞘,膜鞘内走行自主神经系统包括上腹下神经丛、左、右腹下神经、盆丛以及血管神经束。分布范围从腹膜后走向盆腔,沿直肠固有筋膜后面下行到骶前,到耻骨直肠肌上缘与直肠系膜末端融合,围绕直肠系膜侧面向前与邓氏筋膜后叶相连续。我们在解剖学研究和实证解剖学观察基础上,提出了网络性保留自主神经系统的概念:在保留自主神经系统主干的同时,保留神经分支和伴行血管,确保神经反射弧完整。该概念的提出,使得直肠癌根治术遵循TME原则的同时,可以最大程度地保护患者的排尿功能和性功能,改善患者术后生活质量。The principle of total mesorectal excision(TME)standardizes the resection range and surgical dissection plane in radical rectal cancer surgery,reduces the local recurrence rate and improves the long-term survival.TME is the"gold standard"in radical rectal cancer surgery.However,with the progress of laparoscopic surgical instruments and techniques in recent years,further understanding of pelvic membrane anatomy and autonomic nervous system has been gained,which makes the surgical plane of TME more accurate and the autonomic nervous system better preserved.According to anatomical discovery and histological confirmation,there is a fascia between the mesorectal fascia and pelvic parietal fascia,called pre-hypogastric nerve sheath,in which autonomic nervous system courses,including the superior hypogastric plexus,left and right hypogastric nerves,pelvic plexus and the neurovascular bundles,from the abdominal to the pelvic cavity behind the mesorectal fascia.It fuses with the end of the mesorectum at the superior border of musculi puborectalis,and goes around the mesorectum to join with Denonvillier fascia.On the basis of anatomical studies and empirical anatomical observations,we put forward the concept of network preservation of the autonomic nervous system:the main trunk as well as the nerve branches of the pelvic autonomic nervous system and accompanying blood vessels should be preserved to ensure the integrity of the nerve reflex arc.The concept allows the radical resection of rectal cancer to follow the principle of TME,and meanwhile,protect patient's urination function and sexual function to the greatest extent,improving the quality of life of patients after surgery.

关 键 词：直肠肿瘤 膜解剖 腹膜下筋膜鞘 网络保留自主神经 

分 类 号：R735.37[医药卫生—肿瘤]