腹腔镜下结直肠癌手术筋膜解剖层面显露与组织分离的力学原理

Inter-fascial dissection in laparoscopic colorectal cancer surgery:principles of retraction and exposure and techniques in fascial separation

结直肠癌的外科手术已进入到基于膜解剖的完整系膜切除时代,腔镜外科技术的应用进一步推动了对筋膜结构的解剖、组织及胚胎学研究,带来对结直肠周围脏壁层筋膜的解剖结构更精细、深入、但仍充满争议的认识。复层的壁层筋膜及特殊部位筋膜间的致密粘连仍是完成精准筋膜间分离的最大障碍。充分理解脏壁层筋膜的"洋葱皮"样结构,采用以三角形牵拉为主要框架的牵拉-对抗-牵拉模式,正确利用组织间的粘连固定作为对抗张力,将牵拉的合力随时调整到外科医生的操作点,并垂直于被分离的两层筋膜,以获得最大限度的外科手术层面暴露。采用垂直于脏壁层筋膜的"撕开"手法或平行于筋膜间隙的滑动手法,可保证被分离筋膜的完整性,准确展开外科手术平面。正确、充分地牵拉暴露筋膜间隙,以及正确的筋膜间隙分离手法,能确保结直肠癌手术中脏壁层筋膜完整性,最大程度降低系膜残留或肠周围重要结构以及自主神经损伤的机会。

Colorectal surgery for malignancies has evolved into an era of careful and precise dissection along mesorectal or mesocolic fascia to achieve the so-called total mesorectal excision or complete mesocolic excision.The wide use of laparoscopic technique prompted more anatomical,histological,and embryological studies.This leads to a deeper and more precise understanding of fascial anatomy concerning colorectal surgery,though controversies exist.The complicated anatomy of multilayer parietal fasciae and dense adhesion between fasciae at specific sites still represent a major hindrance to perform a precise inter-fascial dissection.Colorectal surgeons should be familiar with the onion-like arrangement of the visceral and parietal fasciae.The dedicated assistants should provide three-directional traction and adjust the direction of forces timely in a manner that the resultant forces are always in a direction perpendicular to the fasciae that are to be dissected.The fixation of the mesorectum and the mesocolon to the pelvic and abdominal wall can also be exploited as a natural counter-retraction.To separate loosely attached visceral and parietal fasciae,the application of splitting forces on opposite fasciae or sliding the forceps along the interface will provide quick separation and maintenance of the integrity of the fasciae.In summary,careful attention to the direction and strength of three directional retractions on parietal and visceral fasciae will help stretch and open up the areolar surgical tissue plane,skillful maneuver in separation and dividing of the attachment of two fasciae will ensure a precise inter-fascial dissection and help achieve total mesorectal excision or complete mesocolic excision,reducing the risk of the residual of the mesentery and inadvertent injuries to adjacent tissues and autonomic nerves.