经肛全直肠系膜切除术的膜解剖特点与盆腔自主神经保护策略

Perirectal fascial anatomy and pelvic autonomic nerve preservation during the transanal total mesorectal excision

经肛全直肠系膜切除术的难点在于寻找直肠周围间隙的正确分离平面,作为一种复杂的新术式,实施过程中经肛操作的筋膜解剖标志容易被忽略,待出现术中副损伤时才发现游离平面有误,从而导致盆腔自主神经受损;若是游离平面过于靠近直肠,可能造成直肠系膜受损,则无法实现完整的TME标本质量,从而导致肿瘤学安全无法得到保证。膜解剖理论的推动与发展,为经肛腔镜手术的精准实施提供了一种新的思路。基于膜解剖的经肛全直肠系膜切除术可精确识别经肛操作解剖标志并加以神经保护,为上述难题提供了一个解决方案。本中心以直肠周围筋膜解剖的理论为基础,结合经肛腔镜全直肠系膜切除手术经验,探讨经肛操作中直肠周围筋膜分离的特点和盆腔自主神经保护的技巧。

The difficulty of transanal total mesorectal excision(TME)is to find the correct dissection plane of perirectal space.As a complex new surgical procedure,the fascial anatomic landmarks of transanal approach operation are more likely to be ignored.It is often found that dissection plane is false after the secondary injury occurs during the operation,which results in the damage of pelvic autonomic nerves.Meanwhile,the mesorectum is easily damaged if the dissection plane is too close to the rectum.Thus,the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality.The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery.Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation.In this paper,the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy,and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.