3D与2D腹腔镜直肠癌根治术中对膜解剖优势所在

Advantages of 3D and 2D laparoscopic surgery for rectal cancer based on pelvic membrane anatomy

全直肠系膜切除术(TME)是治疗中低位直肠癌的金标准,要求是直视下锐性分离,将直肠连同直肠固有筋膜包被的脂肪组织、神经血管和淋巴结整体完整切除。强调脏壁层之间锐性分离,而膜解剖理论与其不谋而合。外科膜解剖概念的提出,明确了人们常说的“间隙”或“层面”,结合腹腔镜放大作用和3D腹腔镜的纵深感,将膜解剖应用于直肠手术,对系膜认识更加深刻,辨认盆底自主神经更加有效。腹膜筋膜融合退化后,在直肠后方形成疏松结缔组织所填充,在S4椎体前方融合增厚形成Waldeyer筋膜,同时将直肠后方间隙分为上方的直肠后间隙和下方的肛提肌上间隙。直肠侧方的膜解剖的关键结构是侧韧带,侧韧带正好是直肠系膜固有筋膜“门”,由髂内动脉发出的直肠中动脉,盆丛发出的直肠支与及淋巴管共同形成。Denonvilliers筋膜是腹膜的融合产物,是直肠前方膜解剖关键结构。保留Denonvilliers筋膜对降低直肠癌术后排尿和性功能障碍发生率有非常重要的意义,切开腹膜返折如位于最低处标志性“卫”氏线后方,则进入Denonvilliers筋膜的后方,可保留Denonvilliers筋膜。

Total mesorectal excision(TME)is now considered the gold standard for surgical treatment of middle/lower rectal cancers,which required sharp dissection under direct vision with the en bloc resection of the tumor along with mesorectum including fat tissue,neurovascular and lymph nodes covered by the rectal proper fascia.This coincidence with the theory of membrane anatomy which demands sharp separation of visceral and parietal fascia based on embryonic anatomy.Combining laparoscopic magnification and the 3D image with depth perception,applying membrane anatomy to rectal surgery could achieve a better understanding of the mesentery with more effective identification of the pelvic autonomic nerves.After peritoneal fusion fascia degenerates,the posterior space of rectum is filled with the loose connective tissue.Waldeyer’s fascia was observed in this space at the S4 level,originating from the presacral parietal fascia fusing with the rectal visceral fascia at the posterior aspect of the rectum.The Waldeyer’s fascia divides the retrorectal space into a superior and inferior compartments.The key structure of lateral rectum is lateral ligament,which is exactly the“port”of the proper fascia of rectum.The lateral ligament containing the middle rectal artery,the pelvic plexus rectal branch and the adipose tissue is surround by the proper fascia of the rectum.Denonvilliers’fascia is the product of peritoneal fusion,and the most important structure in front of the rectum.Preservation of Denonvilliers’fascia during laparoscopic resection for mid\|low rectal cancer have a good effect on protection of urinary and sexual functions of patients.Dissection behind the Wei’s line in the lowest level of peritoneal reflexcan enter into the back plane of Denonvilliers’fascia,and Denonvilliers’fascia could be preserved entirely,as well as the protection of postoperative urogenital function.