盆腔内筋膜的解剖结构及神经走形:避免修复中的损伤

Understanding on the anatomy of the pelvic fascia and nerve structure: avoiding intraoperative nerve damage

背景:盆腔内走行着大量支配泌尿生殖等系统脏器的神经,包括内脏神经和脊神经两种,每一种均由运动神经和感觉神经两种成分组成。其中内脏神经的核心为盆丛。1982年,Heald提出的全直肠系膜切除已经成为直肠癌诊疗的"金标准"。但术中极易损伤神经,导致术后出现尿潴留、性功能障碍等并发症。目的:综述前人的研究,以明确盆腔内筋膜的解剖结构和神经走形。方法:以"splanchnic nerves,superior hypogastric plexus,pelvic plexus,pelvic splanchnic nerve,total mesorectal excision(TME),clinical anatomy"为关键词,检索2000年1月至2015年1月Pub Med数据库中关于盆腔内神经及相关脊神经的走形和成分、盆腔内神经节及相关脏器反射等研究,以盆腔内的神经为主。结果与结论:盆腔内的主要内脏神经丛为:1上腹下丛:主体位于由左、右髂总动脉和骶岬围成的髂间三角内,左髂总静脉和第5腰椎前面。2盆丛:腹下神经、盆内脏神经、骶内脏神经在直肠侧面的后下方1/3处汇合形成神经丛,也称下腹下丛,位于输尿管后下方、膀胱及精囊腺的背侧。由内脏神经丛发出的神经包含交感神经、副交感神经及感觉神经3种成分,走行分布在盆腔各脏器表面,支配其运动与感觉功能。明确的盆腔内筋膜的解剖结构和神经走形是全直肠系膜切除成功的关键,可在手术中最大程度避免神经损伤,提高患者预后及生活质量。

BACKGROUND： The pelvic nerves innervate the pelvic viscera as well as bring sensory information to the central nerve system, including splanchnic nerves and spinal nerves. Each of them comprises both motor fibers and sensitive fibers. Mostly, the key part of splanchnic plexus is pelvic plexus. Total mesorectal excision proposed by Heald in 1982 has been the ＂gold standard＂ for diagnosis and treatment of colorectal cancer. However, it carries a high risk of nerve damage during surgery, which results in urinary retention, sexual ＇ dysfunction and other complications. OBJECTIVE： To summarize the former researches so as to get a precise understanding of the pelvic fascia and nerve structure.METHODS： Using ＂splanchnic nerves, superior hypogastric plexus, pelvic plexus, pelvic splanchnic nerve, total mesorectal excision （TME）, clinical anatomy＂ as key words, a computer-based search Of PubMed was done for articles related to the pelvic nerves, including its pathway, consistent, ganglia, and reflection in pelvic viscera, published from 2000 to 2015.RESULTS AND CONCLUSION： The main splanchnic plexus in the pelvic cavity includes superior hypogastric plexus （it is located in the triangle formed by left and right common lilac artery and the sacral promontory）, and pelvic plexus （hypogastric nerve, pelvic splanchnic nerve and sacral splanchnic nerve converge at the bottom of rectum, formed pelvic plexus, also known as the inferior hypogastric plexus）. It is flattened against the lateral aspect of the rectum, the dorso-lateral bladder wall and the seminal vesicles. Nerves come from the plexus contain the sympathetic nerve, parasympathetic nerve and sensory nerve. They are in charge of the motions and sensations of the pelvic organs. The definite knowledge on the anatomy of pelvic fascia and nerve structures can avoid nerve damage during operation, which can help to improve the life quality of patients.