经肛全直肠系膜切除术中周围脏器损伤的预防及处理

Prevention and treatment of peripheral organ injury during transanal total mesorectal excision

经肛全直肠系膜切除(taTME)相比传统的腹腔镜全直肠系膜切除(TME)手术,提供了更好的盆底手术视野和更开阔的操作空间,尤其是对于男性、肥胖、前列腺肥大、骨盆狭窄等“困难骨盆”的病人,可以实现更为精准的盆底操作。但是,作为一种全新的术式,taTME自下而上的独特视角需要术者重新认识盆底解剖,加之操作平面毗邻关系复杂,如操作失误,很容易造成周围脏器的损伤。尿道和神经血管束(NVB)是taTME术中较容易被损伤的器官及结构,其他如输尿管、膀胱、前列腺或阴道等脏器的损伤,基本均是早期的个例报道。术中一旦发生周围脏器损伤,应根据损伤程度及专科医师的建议采取不同的应对措施,尽可能降低不良影响。建议拟新开展taTME手术的医师需接受结构化培训,以期缩短taTME手术的学习曲线,降低术中及术后并发症的发生率。

Compared to conventional laparoscopic total mesorectal excision(TME)surgery,transanal total mesorectal excision(taTME)can provide a better surgical field of the pelvic floor and more open operating space,especially for patients with a"difficult pelvis"such as male,obesity,prostate hypertrophy,and pelvic stenosis,which allows for more accurate pelvic floor operation.However,as a new surgical method,taTME has a uniquely bottom-up perspective which requires the surgeon to re-understand the anatomy of the pelvic.In addition,the adjacent relationship of the operating plane is so complex that it is easy to cause damage to the surrounding organs due to misoperation.The urethra and neurovascular bundle(NVB)are organs and tissues that are easy to be injured during taTME.Other injuries of organ such as ureter,bladder,prostate,and vagina,are generally reported as early individual cases.Once the peripheral organ injury occurs during the operation,different measures should be taken according to the degree of injury and the recommendations of specialists to reduce the adverse effects as much as possible.It is suggested that colorectal surgeons who plan to perform taTME surgery should receive structured training to shorten the learning curve of taTME surgery and reduce the incidence of intraoperative and postoperative complications.