盆部内脏神经血管的解剖特点及临床应用

The anatomical characteristics and clinical significance of pelvic splanchnic nerves and vessels

目的:探讨经腹腔镜行全直肠系膜切除术中盆部内脏神经和血管的保护。方法:解剖32具成人躯干标本(女15、男17)和31侧成人男性骨盆矢状标本,结合腹腔镜手术,观测有关的盆腔血管神经的形态及定位。结果:(1)骶中静脉大多1支,61%偏左,骶外侧静脉53%为两支,骶前静脉丛在骶曲处密集粗大,骶椎椎前穿通静脉在第4、5骶椎前方形成静脉窦,且与骨膜结合紧密。(2)盆丛位于距直肠外侧约1.1cm和距直肠膀胱陷凹上外测约4.7cm处的骨盆侧壁。左右腹下神经分别于骶骨岬上下1.0～2.0 cm的范围内分出,其夹角约95.9°。上腹下丛位于腹主动脉分叉周围至骶骨岬下2 cm之间。(3)腹腔镜下骶前间隙主要由少量的疏松结缔组织填充容易分离,解剖层面清晰。结论:手术中应找准解剖层面,根据血管神经的定位以神经为导向进行分离,可避免损伤盆部的内脏神经及骶前静脉丛。

Objective： To discuss the protection of pelvic splanchnic nerves and vessels during the total mesorectal excision by using abdominal speculum. Methods： 32 normal adult trunk specimens （15 females, 17 males） and 31 adult male sagital pelvis specimens were dissected. Combining with the laparoscopic operation, the appearance and location of pelvic vascular nerve were observed. Results：（1）Most of the vena sacralis media was single, and 61% of them deviated to the left, however, both of the venae sacrales laterals appeared on 53% specimens. Presacral venous plexus, located anteriorly to the sacral curure, became enlarged and densed. The venous sinus formed by perforating veins in front of the fourth and fifth sacral vertebrae which combined tightly with periosteum. （2）Pelvic plexus located at the lateral wall of pelvis, about 1.1 cm from rectum lateral side and 4.7 em from the upper lateral rectovesical pouch; Left and right hypogastric nerve diverged at the level of the cochlear of sacral bone, with the included angle of 95.9 degree. Superior hypogastric plexus located between the abdominalis aorta bifurcation and 2 cm under the cochlear of sacral bone. （3）Under abdominal speculum, presacral space formed by loose connective tissue, which was easy to be separated. Conclusions： The correct anatomical cross-section should be identified, while operational separation should be performed according to location of vascular nerve during operation. In this way, the impairment of pelvic nerve and presacral venous plexus can be avoided.