全直肠系膜切除相关盆自主神经的解剖学观察

Anatomical observations of pelvic autonomic nerves concerning with total mesorectal excision

目的:阐述全直肠系膜切除术相关盆自主神经的局部解剖学特点,探讨盆自主神经保留的部位和对策。方法:对20具男性盆腔固定标本进行解剖观察。结果:腹主动脉丛远离肠系膜下动脉起点;上腹下丛贴近骶岬表面;腹下神经部分毗邻输尿管;盆内脏神经伴行直肠中动脉外侧部;下腹下丛位于直肠系膜后外侧;其直肠侧支走行于直肠侧韧带内,直肠前支向前穿过Denonvilliers筋膜后叶;勃起神经位于Denonvilliers筋膜前叶外侧部。结论:盆自主神经保留的部位是:离断肠系膜下血管时的腹主动脉丛左干,直肠后分离时的上腹下丛和腹下神经,直肠侧面分离时的下腹下丛和盆内脏神经,直肠前分离时的勃起神经。共同原则是:在直肠后间隙中贴近直肠系膜操作;直视下操作;避免过度牵引直肠系膜。

Objective：To elucidate the underlying topographic characteristics of pelvic autonomic nerves concerning with the total mesorectal excision （TME）, and get insight into the sites of the pelvic autonomic nerve preservation （PANP） and the corresponding operational strategies. Methods： Twenty fixed male pelvises were dissected and observed. Results： The abodominal aortic plexuses （AAP） were far off the origin of the inferior mesenteric artery. The superior hypogastric plexus （SHP） adhered closely to the surface of the sacral promontory. The hypogastric nerves （HN） partly closed to the ureter. The pelvic splanchnic nerves （PSN） were accompanied by the outer part of the middle rectal artery. The inferior hypogastric plexues （IHP） were postolateral to the mesorectum. The lateral rectal branches of the IHP ran in the lateral rectal ligaments, while the anterior branches ran forward and drilled through the posterior leaf of Denonvilliers fascia. The nervi erigentes ran in the lateral part of the anterior leaf of Denonvilliers fascia. Conclusions： The sites where PANP should be performed are： the left trunk of AAP during the IMA ligation, the SHP and the HN during the posterior dissections of the rectum, the IHP and the PSN during the lateral dissections, and the nervi erigentes during the anterior dissections. The common operational principles are： operating close to the mesorectum in the posterior rectal space, as well as operating in direct sight and avoiding countertraction for the mesorectum excessively.