腹腔镜下直肠癌根治术保留自主神经的解剖和技术要点

Anatomy and technical points of pelvic autonomic nerves preservation in laparoscopic radical resection of rectal cancer

全直肠系膜切除术(TME)是目前国际公认的直肠癌标准术式,随着腹腔镜技术的推广和TME手术的普及,盆腔植物神经保护(PANP)的理念逐渐受到重视。本文根据作者经验和结合国内外文献,介绍保留PANP相关的新认识和技术进展。笔者认为,在开展直肠癌TME手术时,有六个部位容易发生盆腔植物神经损伤,需要识别和保护:肠系膜下动脉根部的肠系膜下丛,上腹下神经丛及腹下神经的近端,盆丛前丛的近端,盆丛后丛的主干,盆丛后丛的终末支,盆腔内脏神经以及血管神经束(NVB)。要完整保留PANP,需要熟悉盆腔筋膜解剖层次和神经走行在层次部位,在直肠固有筋膜和腹下神经输尿管前筋膜之间分离,可以完好地保留腹盆腔自主神经系统,以筋膜层膜为导向,进行筋膜之间分离,以神经为导向,实现精准直肠癌手术,对于提高手术质量,保护器官功能至关重要。

Total mesorectal excision(TME)is considered as the standard surgical procedure for rectal cancer worldwide.With the popularization and cognition of laparoscopic technology and TME procedure,the pelvic autonomic nerves preservation(PANP)in proctectomy is valued gradually.Based on the author′s experience and combined with published literatures,this paper introduces the new understanding and technological progress of preserving PANP.In the authors′opinion,there are six areas which are easily injured in the TME procedure:inferior mesorectal plexus at the root of inferior mesorectal artery,superior hypogastric plexus and the proximal part of hypogastric plexus,proximal part of anterior branches of pelvic plexus,main trunk of posterior branches of pelvic plexus,terminal part of posterior branches of pelvic plexus,pelvic splanchnic nerves and neurovascular bundle(NVB).Familiarity with the anatomy of pelvic fascia and autonomic nerves,development of TME plane dominated and pelvic autonomic nerves guided precise radical proctectomy play an important role in promoting the quality of operation and protecting the function of organ.