腹腔镜全直肠系膜切除术中输尿管保护的临床解剖

Clinical anatomy on ureter protection in laparoscopic total mesorectal excision

目的：探讨与腹腔镜全直肠系膜切除术（LTME）有关的左输尿管解剖学特点和保护方法.方法：利用腹腔镜对2004年10月～2005年5月接受LTME的24例直肠癌患者进行解剖学观察.结果：左输尿管腹段偏向中线侧走行,与左半乙状结肠系膜关系密切;输尿管盆段靠外侧走行,与直肠系膜和直肠侧韧带距离较远;输尿管位于肾前筋膜/骶前筋膜后外侧,而乙状结肠直肠系膜位于肾前筋膜前面,两者处于不同的解剖间隙.结论：左输尿管腹段损伤的几率较大,盆段较安全.LTME中保护输尿管的方法是：保持正确的外科平面,紧贴结直肠系膜,避免突破肾前筋膜/骶前筋膜,与输尿管保持安全距离;充分暴露,直视下锐性解剖;避免在盆侧壁盲目电凝止血等.

Objective： To explore the anatomical characteristics and the methods to prevent injuries of ureter in laparoscopic total mesorectal excision （LTME）. Methods： Live anatomical observation was carried out on 24 rectal cancer patients undergoing LTME from Oct 2004 to May 2005. Results： The abdominal segment of the left ureter ran medially and was close to the left mesocolon. The pelvic segment of ureter ran laterally and was far away from the mesorectum and the lateral rectal ligaments. The ureter located postero-lateral to the prerenal/presacaral fascia, while the colorectal mesenteries located anterior. Conclusion： The left ureter is more easily injured in the abdominal cavity than that in the pelvis. Methods to avoid ureter injures in the LTME are following： 1. Dissect adjacently to the colorectal mesenteries in right surgical planes and keep safe distances to the ureter. Do not wear through the prerenal/presacral fascia. 2. Full exposure and operation in direct vision are recommended. 3. Sharp dissection is recommended and aimless traction is avoided. 4. Avoid electro-coagulation aimless in the lateral pelvic walls.