直肠手术“Holyplane”应用解剖和病理学研究及其临床意义

Physiological anatomy characteristics of the 'Holy plane' of rectal surgery and its clinical significance

目的研究直肠手术的"Holyplane"范围界定,探讨其病理学特点及临床意义。方法将21具成人尸体完整骨盆均从正中矢状面剖开,共42个半骨盆,按一定步骤进行解剖,界定并测量"Holyplane"范围;取盆壁层筋膜做免疫组化检查。结果"Holyplane"位于直肠系膜与盆壁层筋膜之间,起于L5～S1,向下两层筋膜融合止于会阴部的盆膈筋膜,两侧以髂内血管及直肠侧韧带为界。"Holyplane"测量结果:男性最大高度为(16.7±1.4)cm,最大宽度为(7.2±0.6)cm;女性最大高度为(15.4±1.2)cm,最大宽度为(6.7±0.6)cm,男女比较差异无统计学意义(P>0.05)。免疫组织化学结果提示盆壁层筋膜有密集的神经和微血管分布,见淋巴细胞,但无淋巴结。结论"Holyplane"为上宽下窄的直肠后无血管解剖间隙,两侧基本对称;临床上对低位直肠癌手术途径和清扫范围有重要的指导意义。

Objective To define range of the ＂Holy plane＂of rectal surgery, and to study its physiological anatomy characteristics and clinical significance. Methods Pelvises of 21 cadavers were all cut into two half pelvises through the median sagittal plane, thus 42 half pelvises specimens were studied by topographic dissection. All half pelvises were dissected according to a certain steps. The range of ＂Holy plane＂ was defined and measured. Rectosacral fasciae were taken and examined by immunohistochemistry, and the nerves and lymph nodes were ehecked. Results The ＂Holy plane＂ is between the mesorectum and the rectosacral fascia, it begins at L5-S1 and ends at pelvic fascia with fusion of the two fasciae. The lateral borders are internal iliac-vessels and lateral ligaments. Under bare eyes, the connection tissue inside the ＂Holy plane＂ is very loose and avascular. The biggest height of ＂Holy plane＂ was 16.7±1.4 cm in male pelvis and 15.4±1.2 cm in female pelvis respectively, and the biggest width of ＂Holy plane＂ was 7.2±0.6 cm in male pelvis and 6.7±0.6 cm in female pelvis respectively. There was no significant difference between them （P〉0.05）. Immunohistochemical results： dense nerve fibers and tiny vessels were observed in rectosacral fascia; lymphocytes could be seen occasionally, but lymph node could not be seen in it. Conclusion ＂Holy plane＂ is a symmetrical avascular anatomical space behind the rectum with a wide upper part and a narrow low part. It is a very important clue to guide the operative way and the range of clearance during rectal surgery.