直肠切除术中保留盆腔内脏神经的解剖学基础及要点

Anatomical basis and main points of pelvic autonomic nerve preserving in proctectomy

目的了解盆腔内脏神经的走行及与盆腔筋膜的关系，寻找安全的操作平面，减少直肠癌手术中对内脏神经的损伤。方法通过解剖12例人骨盆标本，观察盆腔内脏神经的走向分布及与筋膜间隙的关系。结果腹下神经全程走行于骶前筋膜内，下腹下丛走行于盆壁层筋膜内，并于直肠2点及10点处（截石位）在多个平面交叉穿入Denonvilliers筋膜汇入泌尿生殖血管束，Denonvilliers筋膜内存在横行的神经交通支。结论直肠后方及侧方的手术操作平面在直肠固有筋膜与骶前筋膜之间靠近直肠固有筋膜一侧，在直肠前方的手术操作应注意保护直肠2点及10点位置的泌尿生殖神经血管束及Denonvillers筋膜内的神经交通支。

Objective To elucidate the course of pelvic autonomic nerves and its relationship with pelvic fascia in order to identify the safe plane to reduce the damage of pelvic autonomic nerves in total mesorectaI excision（TME）. Methods The course and distribution of pelvic autonomic nerves were observed and their relationship with pelvic interfascial space was examined through the anatomy of 12 adult pelvic specimens. Results The entire course of hypogastric nerves ran within the anterior sacral fascia and the inferior hypogastric plexus ran within parietal fascia. Inferior hypogastric plexus crossed the fusion line of Denonvilliers fascia and parietal fascia in the 10 o＇clock and 2 o＇clock directions of the rectum, and joined urogenital vessel bundle finally. Laterigrade traffic nerves could be found in Denonvilliers fascia. Conclusion The safe plane should be chosen between rectal proper fascia and anterior sacral fascia near rectal proper fascia in posterior dissection and lateral dissection of rectum. More attention should be paid to protect the nervovascular bundle in the 10 o＇ clock and 2 o＇ clock directions of rectum and traffic nerve within Denonvilliers fascia in anterior dissection.