膜解剖在全盆腔脏器联合切除术中的应用

Application of fascia anatomy in total pelvic exenteration

局部晚期和局部复发性直肠癌是直肠癌治疗的难点,虽然以新辅助放化疗、靶向治疗为基础的综合治疗措施不断创新,但手术治疗仍然是这部分患者获得良好预后的唯一途径。组织学切缘性质是患者长期生存的独立预测因素,通过手术获得阴性切缘具有重要意义。全盆腔脏器联合切除术通常被用于局部晚期和局部复发性直肠癌累及泌尿生殖系统的患者,手术有望使局部晚期患者获得与无壁外侵犯患者相似的肿瘤学预后,40%~50%的局部复发性直肠癌患者可获得满意的5年生存率。然而,全盆腔脏器联合切除术手术复杂、难度大,并发症发生率高,大部分外科医师望而却步。随着筋膜解剖研究的发展,盆腔筋膜间无血间隙逐渐被认识和应用,为简化复杂的全盆腔脏器联合切除术提供了解剖学基础。笔者团队在此基础上提出了层面优先入路全盆腔脏器联合切除术,即在进行全盆腔脏器切除手术时,将全盆腔脏器看作一个整体,通过分离脏器周围的天然无血间隙,优先处理供应血管、支配神经,使手术程序化、层面清晰、安全、可重复。

Locally advanced and locally recurrent rectal cancer pose significant challenges in their treatment. Although the comprehensive treatment approaches based on neoadjuvant chemoradiotherapy and targeted therapy are constantly innovated, surgery remains the only way for these patients to achieve promising oncological outcomes. Negative resection margin is an independent predictor of long-term survival. Total pelvic exenteration is commonly used for patients with locally advanced and locally recurrent rectal cancer involving the genitourinary system. It is expected that patients with locally advanced rectal cancer can achieve similar oncological prognosis as those without extramural invasion, and about 40%-50% of patients with locally recurrent rectal cancer can achieve satisfactory 5-year survival. However, due to its complexity and difficulty, total pelvic exenteration carries a higher morbidity rate and most surgeons are hesitant to perform it. With the development of fascial anatomy, the avascular spaces between pelvic fasciae have been gradually recognized and applied, which provides an anatomical basis for simplifying the surgery. We have summarized the approach of“fascia space priority approach”for total pelvic exenteration. During the total pelvic exenteration, the whole pelvic organs are considered as a whole. By separating the avascular spaces around the organ and preferentially controlling supply vessels and nerve branches, the surgical procedure is procedural, anatomically clear, safe, and reproducible.