腹腔镜直肠癌全系膜切除术的应用解剖学研究

Study of Applied anatomy of Laparoscopic Total Mesorectal Excision(LTME) for Rectal Cancer

目的为腹腔镜全直肠系膜切除术（LTME）治疗直肠癌提供解剖学基础。方法利用10例成年防腐固定的盆腔标本结合28例腹腔镜TME手术对直肠周围筋膜及间隙等结构的解剖特点进行观察测量。结果①直肠系膜中、上段较厚,与直肠连接疏松,有纤维束伸入直肠壁;下段逐渐变薄至2.2±1.1mm,并有1.58±0.46cm长的系膜与直肠肌层连结紧密。②Denonvilliers筋膜薄而致密,最薄处为1.3±0.6mm。③上腹下丛紧贴肠系膜下血管的后方,直肠后方的脏层筋膜与壁层筋膜之间的疏松间隙内无明显自主神经分支。④本组手术时间126～235min,平均156min。手术出血量平均59ml（60～350ml）。28例均获随访2～36个月,平均16个月,无局部复发。结论直肠系膜及Denonvilliers筋膜是包裹直肠的独立结构,沿骶前间隙及直肠两侧壁锐性分离可完整游离直肠系膜。掌握腹腔镜直肠手术的解剖学特点,能减少该手术的失误及并发症。

Objective To provide anatomic foundation for laparoscopic total mesorectal excision （ LTME） for rectal cancer. Methods Ten adult corpses fixed by 10% formalin.Twenty-eight cases of patients received LTME. The special structure of fasciae and lacuna around rectum were observed and measured. The anatomy closely related with operation was analyzed. Results （1）The middle and superior segments of mesorectum are thicker and loosely connect with rectum, and have fibrous bands inserting in rectal wail; The inferior segment gradually becomes thinner to 2.2 ± 1. 1cm and connects tightly with muscle lamina of rectum. The length of this part of the mesorectum is 1.58 ± 0.46cm. （2）Denonvilliers fascia is thin and compact. Its thinnest part is 1 . 3 ± 0.6mm. （3）The Superior hypogastric plexus adheres to the back of inferior mesenteric vessels. There are no obvious branches of autonomic nerve in the loose space between visceral and parietal fascia of the direct back of the rectum. （4）The average operation time was 156min（ 126 ～ 235min）, the intraoperative blood loss was 59ml（60 ～ 350ml） . Postoperative follow-up for 2 - 39 months （ mean, 16months） found no local recurrence. Conclusions The mesorectum and Denonvilliers fascia are independent structures wrapping rectum.The mesorectum can be completely dissociated through sharp separating along sacral space and two sidewalls of rectum. Mastering the anatomical characteristics of laparoscopic rectum surgery can make us reduce the operative mistakes and complications.