盆腔自主神经活体尸体对比研究

A comparative study of the laparoscopic appearance and anatomy of the autonomic nervous in normal males

目的 研究盆腔自主神经的解剖特点. 方法 对来自遗体捐赠的5具成人男性尸体标本进行解剖;同时收集2012年1月至6月就诊于中山大学附属第三医院胃肠外科的10例中低位直肠癌男性患者接受腹腔镜全直肠系膜切除术时的术中录像资料.结合尸体解剖过程,手术录像中重点观察直肠后方、前方、侧方游离过程中所涉及的盆腔自主神经,比较尸体和活体关键解剖结构的异同.结果 尸体解剖观察发现,在腹主动脉表面可见腹主动脉丛,左干与右干在腹主动脉分叉处汇合形成上腹下丛;紧贴骶骨切开骶骨筋膜,来自S2～ S4骶神经前支的一些细小神经纤维构成盆内脏神经;骶交感干的节后纤维组成骶内脏神经,其细小的神经纤维走向前外侧与盆内脏神经汇合后,形成左右侧的下腹下丛.活体腹腔镜下观察发现,腹主动脉丛、上腹下丛多数情况下显示不清楚,靠近骶髂关节水平,疏松网状结缔组织下方可见上腹下丛发出的左右腹下神经,于大约第3骶椎水平转向外侧;左侧腹下神经紧贴直肠系膜后方;Denonvilliers筋膜表现为一层菲薄反光筋膜结构,由于其前方非常疏松,容易连同直肠系膜一并切除.结论 根部结扎肠系膜下动脉是安全的,但避免过度清扫其根部周围腹主动脉表面组织;后方游离直肠时应紧贴直肠系膜,避免损伤上腹下丛、腹下神经;侧方切断直肠侧韧带时应紧贴直肠系膜,避免损伤下腹下丛.游离下段直肠前方时,保证Denonvilliers筋膜的完整性,可保护下腹下丛泌尿生殖器官的传出支.

Objective To further understand the anatomical basis of pelvic autonomic nerve preservation.Methods Autopsy of five adult male donated cadavers was performed.Meanwhile,ten videos of laparoscopic total mesorectal excision for male mid-low rectal cancer admitted from January to June 2012 were observed and studied.Anatomical features of pelvic autonomic nerve were compared between autopsy and laparoscopic appearance.Results Autopsy observations indicated that：the abdominal aortic plexus was situated upon the sides and front of the aorta,between the origins of the superior and inferior mesenteric arteries.The superior hypogastric plexus was a plexus of nerves situated on the the bifurcation of the abdominal aorta to sacrum; after incision of sacrum fascia was done cling to the sacrum; the pelvic splanchnic nerves and sacral splanchnic nerves were demonstrated; pelvic splanchnic nerves were splanchnic nerves that arised from ventral rami of the second,third,and often the fourth sacral nerves to provide preganglionic parasympathetic innervation to the hindgut;sacral splanchnic nerves providing postganglionic fibers,emerged from the sympathetic trunk,were then joined by the pelvic splanchnic nerves to form the inferior hypogastric plexuses which were placed lateral to the rectum.Laparoscopic observations showed that：abdominal aortic plexus and superior hypogastric plexus were unclear; at the level of sacroiliac joint,the hypogastric nerve began where the superior hypogastric plexus split into a right and left plexus,situated under the loose connective tissue,and continued inferiorly on its corresponding side of the body at the level of the 3rd sacral vertebra; left hypogastric nerve was closed to posterior of mesorectum; denonvilliers fascia was thin,reflective fascial structure,and easily removed together with mesorectum excision because of anterior loose structure.Conclusions Ligation of the inferior mesenteric artery at its origin is safe.Excessive dissection of the connective tissue covering the surface of the aorta should be avoided to protect the abdominal aortic plexus.Sharp dissection performed by pursuing the outer surface of the mesorectum maintaining the integrity of mesorectum,could avoid the superior hypogastric plexus and hypogastric nerves injury posteriorly,and protect the inferior hypogastric plexues while cutting lateral ligament laterally.The integrity of Denonvilliers fascia during anterior resection of rectum should be confirmed to avoid urogenitalis aparatus branches damage.