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腹腔镜全直肠系膜切除术(TME)的发展推动外科医师对直肠前间隙解剖认识的不断深入.直肠前间隙解剖分离不当,术者进入错误的解剖平面,容易导致直肠固有筋膜破裂及神经血管束损伤,降低手术根治性以及引起患者排尿及性功能障碍,影响患者预后.对于直肠前间隙手术路径,结合相关文献报道的经验,可在腹膜返折上方0.5 cm处切开腹膜.笔者认为:待发现Denonvillers筋膜(DVF)明显增厚时即可横断之,进入DVF后方与直肠固有筋膜间进行游离,形成典型的“三线特征”:腹膜返折切开线、DVF切开的近端线及DVF切开的远端线,可作为对直肠前间隙的进入标志线与维持标志面.这不仅保护了直肠固有筋膜的完整性,亦最大程度保留了DVF.本文从DVF的胚胎起源及解剖学特征、神经血管束结构、直肠前间隙分离、手术路径及DVF与腹腔镜TME的临床疗效进行探讨.

The development of laparoscopic total mesorectal excision (TME) has been promoting the better understanding of the anatomy in pre-rectal space for surgeons.If the dissection in pre-rectal space was inappropriate and entered into wrong anatomic planes,it would be easier to cause the proper fascia of rectum incomplete and damage the neurovascular bundies,and reduce the radical surgery outcome and induce urinary and sexual dysfunction,finally,affect the prognosis in patients.For surgical approach in pre-rectal space,the author proposed:Based on the related literatures,transecting the Denonvilliers' fascia (DVF) when it's definitely thickened after cutting the peritoneum 0.5 cm anterior to peri-toneal reflection,entering and dissecting in the space between DVF and the proper fascia of rectum,and forming a typical "Three-line feature",including the cutting line of peritoneal reflection,the proximal and distal cutting lines of DVF,which can serve as the mark line and mark plane of the entrance to pre-rectal space.Not only this approach can keep the proper completeness of rectal fascia,but also it maximally reserves the DVF.Here,this article discussed the embryonic origins and anatomic characters of DVF,the structures of neurovascular bundles,dissection in the pre-rectal space,surgical approach and clinical outcomes between DVF and laparoscopic TME.