基于膜解剖的直肠癌侧方淋巴结"两间隙"清扫术的模式化操作

"Two spaces"lateral lymph node dissection based on fascia anatomy for low rectal cancer

侧方淋巴结清扫作为直肠癌的一种治疗手段, 一直因手术风险大、术后泌尿生殖功能障碍发生率高而饱受争议。基于膜解剖的直肠癌侧方淋巴结"两间隙"清扫术采取由膜至间隙的手术方式, 依据膜解剖标记, 层面容易辨识, 血管和神经定位明确, 从而提高了手术的安全性和精准性。同时简化了手术操作, 手术方法可重复和模式化。与侧方淋巴结清扫相关的膜为泌尿生殖筋膜、膀胱腹下筋膜和壁筋膜;两间隙指Latzko直留旁间隙和膀胱旁间隙。在建立膜平面时, 能够完成髂外淋巴结(No.293)、髂总淋巴结(No.273)以及腹主动脉分叉部淋巴结(No.280)的切除, 而在间隙清扫时, 能够完成髂内淋巴结(No.263)、闭孔淋巴结(No.283)、骶外侧淋巴结(No.260)以及骶正中淋巴结(No.270)的切除, 可以依据病情需要, 完成日本结肠直肠癌学会所规定的LD2或LD3侧方淋巴结清扫。本文基于对关键解剖的认识, 概述侧方淋巴结"两间隙"清扫术的模式化操作。

As a treatment of rectal cancer,lateral lymph node dissection(LLND)is still a controversial issue.The argument against LLND is that the procedure is complicated,and consequently results in a high incidence of postoperative urogenital dysfunction.The surgical modality from fascia to space is adopted by lateral lymph node dissection in"two spaces".This operation has significant advantages of clear location of nerves and blood vessels and simplified surgical procedures,so the surgical procedure can be repeated and modulated.The fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia constitute the dissection plane for lateral lymph node dissection.Two spaces refer to Latzko's pararectal space and paravesical space.During the establishment of fascia plane,the dissection of external iliac lymph node(No.293),commoniliac lymph node(No.273)and abdominal aortic bifurcation lymph node(No.280)can be performed.While in the"space"dissection,internal iliac lymph node(No.263),obturator lymph node(No.283),lateral sacral lymph node(No.260)and median sacral lymph node(No.270)can be removed.LD2 or LD3 lateral lymph node dissection prescribed by the Japanese Society of Colorectal Cancer can be completed according to the needs of the disease.This article describes the anatomical basis and standardized surgical procedures.