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Denonvilliers 筋膜解剖学研究及其在直肠癌手术中的应用

Anatomic study of denonvilliers fascia and its application in rectal surgery

摘要:

目的:探讨 Denonvilliers 筋膜的解剖特点,为直肠癌手术前方切除平面的选择提供解剖学依据。方法2012年7月—2014年1月对16例健康成人骨盆标本进行前瞻性研究,其中全骨盆标本4例,男性3例、女性1例;纵行剖开半骨盆标本12例,男性10例、女性2例。解剖观察Denonvilliers 筋膜头侧、尾侧及侧方附着点位置,Denonvilliers 筋膜与盆腔自主神经位置关系以及与周围筋膜毗邻关系等。回顾性分析2013年4月—2013年9月山西省肿瘤医院收治的26例采用全直肠系膜切除术治疗的男性直肠癌患者的临床资料,选择术中影像资料完整、直肠癌侵犯直肠前方、Denonvilliers 筋膜完整的直肠切除标本4例,并进行常规石蜡包埋、切片及 HE 染色,光镜下观察Denonvilliers 筋膜的层次及结构。结果骨盆标本解剖可见 Denonvilliers 筋膜头侧起自腹膜反折,尾侧融入会阴体,两侧附着于盆壁筋膜2点、10点方向,并穿过盆壁筋膜附着于骨盆肌性结构。Denonvilliers 筋膜与盆壁筋膜附着处下方可见盆腔自主神经丛的泌尿生殖支向前穿行,并与泌尿生殖血管融合形成泌尿生殖神经血管束,在 Denonvilliers 筋膜表面可见盆腔自主神经丛的交通支。在Denonvilliers 筋膜后方0.5~0.8 cm 处可观察到栅栏样组织,连接直肠固有筋膜与盆壁筋膜。而Denonvilliers 筋膜与其余组织之间的关系在靠近会阴处也越发密切,难以游离。直肠癌患者直肠切除标本光镜下可见 Denonvilliers 筋膜主要由交错融合形成的胶原纤维与弹性纤维组成的略致密结缔组织构成,其中可见神经、血管结构。结论 Denonvilliers 筋膜与泌尿生殖神经关系密切,直肠癌根治术中在确定直肠前方手术切除平面时应遵循个体化原则,应充分考虑到 Denonvilliers 筋膜的屏障作用及其与盆丛的关系,以免选择错误的手术切除平面,在切除 Denonvilliers 筋膜时损伤到泌尿生殖神经,导致术后排尿功能、性功能障碍。

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abstracts:

Objective To explore the anatomic characteristics of Denonvilliers fascia, and provide a theoretical basis for the selection of colorectal cancer resection in front plane. Methods Sixteen healthy adult pelvic anatomy specimens were observed from July 2012 to January 2014, including 4 cases of whole pelvis specimens (3 males and 1 female); 12 specimens were performed longitudinal incision(10 males, 12 females). The attachment points and adjacent structures of Denonvilliers fascia, and the relationship of Denonvilliers fascia and pelvic plexus were observed. Four cases of Denonvilliers fascia specimens were selected in 26 male patients, who underwent surgery in Shanxi Tumor Hospital from April 2013 to September 2013. The specimens were embedded in paraffin, sliced, and stained by HE to observe Denonvilliers fascia structure under light microscopy. Results Denonvilliers fascia went from the cephalicsince the peritoneal reflection, the vertical integration of the caudal traveled perineal body, through the pelvic wall fascia on both sides to continue to walk the line laterally, eventually splitting the pelvic muscles attached to the structure. Visible beneath the fascia attachment Denonvilliers fascia and pelvic wall covered by the pelvic wall fascia urogenital nerves passed through, and the confluence with the formation of vascular bundle urogenital neurovascular bundle. Some small nerves visible traffic branch connecting the left and right pelvic plexus went on Denonvilliers fascia. A column of the tissues like fence, which connected the inherent fascia of the rectum and the fascia of the pelvic wall, could be observed back to the Denonvilliers fascia 0. 5 - 0. 8 cm. And the relationship between Denonvilliers fascia and the other tissues was also more intimate to free at the bottom. Conclusions The relationship between Denonvilliers fascia and urogenital nerve is very close. Wrong plane resection of Denonvilliers fascia may damage the genitourinary nerves, which leads to postoperative urinary function, and sexual dysfunction. Therefore, the choice should be based on individual programs, and avoid being close to the outer edge of the fascia Denonvilliers resection.

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作者: 王毅 [1] 马国龙 [1] 梁小波 [1]
栏目名称: 应用解剖与临床
DOI: 10.3760/cma.j.issn.2095-7041.2015.06.012
发布时间: 2016-01-19
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