CAJ | 학술논문

目的研究盆腔自主神经的解剖特点. 方法对来自遗体捐赠的5具成人男性尸体标本进行解剖;同时收集2012年1月至6月就诊于中山大学附属第三医院胃肠外科的10例中低位直肠癌男性患者接受腹腔镜全直肠系膜切除术时的术中录像资料.结合尸体解剖过程,手术录像中重点观察直肠后方、前方、侧方游离过程中所涉及的盆腔自主神经,比较尸体和活体关键解剖结构的异同.结果尸体解剖观察发现,在腹主动脉表面可见腹主动脉丛,左干与右干在腹主动脉分叉处汇合形成上腹下丛;紧贴骶骨切开骶骨筋膜,来自S2～ S4骶神经前支的一些细小神经纤维构成盆内脏神经;骶交感干的节后纤维组成骶内脏神经,其细小的神经纤维走向前外侧与盆内脏神经汇合后,形成左右侧的下腹下丛.活体腹腔镜下观察发现,腹主动脉丛、上腹下丛多数情况下显示不清楚,靠近骶髂关节水平,疏松网状结缔组织下方可见上腹下丛发出的左右腹下神经,于大约第3骶椎水平转向外侧;左侧腹下神经紧贴直肠系膜后方;Denonvilliers筋膜表现为一层菲薄反光筋膜结构,由于其前方非常疏松,容易连同直肠系膜一并切除.结论根部结扎肠系膜下动脉是安全的,但避免过度清扫其根部周围腹主动脉表面组织;后方游离直肠时应紧贴直肠系膜,避免损伤上腹下丛、腹下神经;侧方切断直肠侧韧带时应紧贴直肠系膜,避免损伤下腹下丛.游离下段直肠前方时,保证Denonvilliers筋膜的完整性,可保护下腹下丛泌尿生殖器官的传出支.
목적 연구분강자주신경적해부특점. 방법 대래자유체연증적5구성인남성시체표본진행해부;동시수집2012년1월지6월취진우중산대학부속제삼의원위장외과적10례중저위직장암남성환자접수복강경전직장계막절제술시적술중록상자료.결합시체해부과정,수술록상중중점관찰직장후방、전방、측방유리과정중소섭급적분강자주신경,비교시체화활체관건해부결구적이동.결과 시체해부관찰발현,재복주동맥표면가견복주동맥총,좌간여우간재복주동맥분차처회합형성상복하총;긴첩저골절개저골근막,래자S2～ S4저신경전지적일사세소신경섬유구성분내장신경;저교감간적절후섬유조성저내장신경,기세소적신경섬유주향전외측여분내장신경회합후,형성좌우측적하복하총.활체복강경하관찰발현,복주동맥총、상복하총다수정황하현시불청초,고근저가관절수평,소송망상결체조직하방가견상복하총발출적좌우복하신경,우대약제3저추수평전향외측;좌측복하신경긴첩직장계막후방;Denonvilliers근막표현위일층비박반광근막결구,유우기전방비상소송,용역련동직장계막일병절제.결론 근부결찰장계막하동맥시안전적,단피면과도청소기근부주위복주동맥표면조직;후방유리직장시응긴첩직장계막,피면손상상복하총、복하신경;측방절단직장측인대시응긴첩직장계막,피면손상하복하총.유리하단직장전방시,보증Denonvilliers근막적완정성,가보호하복하총비뇨생식기관적전출지.
Objective To further understand the anatomical basis of pelvic autonomic nerve preservation.Methods Autopsy of five adult male donated cadavers was performed.Meanwhile,ten videos of laparoscopic total mesorectal excision for male mid-low rectal cancer admitted from January to June 2012 were observed and studied.Anatomical features of pelvic autonomic nerve were compared between autopsy and laparoscopic appearance.Results Autopsy observations indicated that:the abdominal aortic plexus was situated upon the sides and front of the aorta,between the origins of the superior and inferior mesenteric arteries.The superior hypogastric plexus was a plexus of nerves situated on the the bifurcation of the abdominal aorta to sacrum; after incision of sacrum fascia was done cling to the sacrum; the pelvic splanchnic nerves and sacral splanchnic nerves were demonstrated; pelvic splanchnic nerves were splanchnic nerves that arised from ventral rami of the second,third,and often the fourth sacral nerves to provide preganglionic parasympathetic innervation to the hindgut;sacral splanchnic nerves providing postganglionic fibers,emerged from the sympathetic trunk,were then joined by the pelvic splanchnic nerves to form the inferior hypogastric plexuses which were placed lateral to the rectum.Laparoscopic observations showed that:abdominal aortic plexus and superior hypogastric plexus were unclear; at the level of sacroiliac joint,the hypogastric nerve began where the superior hypogastric plexus split into a right and left plexus,situated under the loose connective tissue,and continued inferiorly on its corresponding side of the body at the level of the 3rd sacral vertebra; left hypogastric nerve was closed to posterior of mesorectum; denonvilliers fascia was thin,reflective fascial structure,and easily removed together with mesorectum excision because of anterior loose structure.Conclusions Ligation of the inferior mesenteric artery at its origin is safe.Excessive dissection of the connective tissue covering the surface of the aorta should be avoided to protect the abdominal aortic plexus.Sharp dissection performed by pursuing the outer surface of the mesorectum maintaining the integrity of mesorectum,could avoid the superior hypogastric plexus and hypogastric nerves injury posteriorly,and protect the inferior hypogastric plexues while cutting lateral ligament laterally.The integrity of Denonvilliers fascia during anterior resection of rectum should be confirmed to avoid urogenitalis aparatus branches damage.