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基于外科精细解剖的直肠癌手术策略——筋膜、系膜和间隙
Precision anatomy-guided rectal cancer surgery——Fasciae, mesenteries, and spaces
基于近年围绕筋膜、系膜和间隙相关精细解剖的系列研究结果与临床实践经验，提出功能保留性全直肠系膜切除的解剖学框架：（1）左原始后腹膜是左结肠后间隙分离“错层”的根本原因，优先外侧入路分离至左输尿管显露，再行中央入路分离可缩短内外会师错层距离。（2）No.253淋巴结转移率低，但转移者预后极差，对局部进展期病人行选择性肠系膜下动脉鞘内分离可兼顾淋巴结清扫与肠系膜下丛保护。（3）修正直肠环周“双环圈”假说，发现直肠骶骨筋膜侧方再分叶并与盆丛致密融合，据此制定“后方—前方—侧方”的直肠最佳分离顺序，即后方弧形离断直肠骶骨筋膜，前方保留部分Denonvilliers筋膜以保护神经血管束并完整切除直肠前方系膜，最后切断侧方残留附着缘，保护盆丛神经，环周分离至终点线。该策略在确保肿瘤学根治的同时，最大限度地保留排尿及性功能，为腹腔镜/机器人辅助直肠癌手术提供了可重复、标准化的解剖学路径。
Based on a series of research findings on the meticulous anatomy related to fascia, mesentery and interstitial spaces in recent years, combined with clinical practice experience, an anatomical framework for “function-sparing total mesorectal excision (TME)” is proposed: (1) The left primitive retroperitoneum is the anatomical substrate of the “wrong-plane” phenomenon during left mesocolic mobilization; an initial lateral approach that exposes the left ureter followed by a central dissection minimizes the convergence distance. (2) Metastasis to No.253 lymph nodes is relatively rare, but the prognosis is extremely poor in patients with such metastasis; selective intrasheath dissection of the inferior mesenteric artery in patients with locally advanced disease can achieve both adequate lymph node dissection and preservation of the inferior mesenteric plexus. (3) Revisiting the classical “two-concentric-rings” model, the rectosacral fascia was found to split laterally and fuse densely with the pelvic plexus. The optimal circumferential dissection sequence is therefore posterior-anterior-lateral: posteriorly, the rectosacral fascia is arcuately incised; anteriorly, a “partial Denonvilliers fascia preservation” technique safeguards the neurovascular bundle while ensuring complete anterior mesorectal excision; finally, residual lateral tethering bands are divided to reach the “terminal line” while preserving the pelvic plexus. This stepwise anatomy-driven strategy secures oncologic radicality while maximizing genito-urinary function, providing a reproducible and standardized plane for laparoscopic/robotic rectal cancer surgery.
total mesorectal excision / fascia / mesentery / anatomical spaces / rectal cancer
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中华人民共和国国家卫生健康委员会医政司,中华医学会肿瘤学分会. 国家卫生健康委员会中国结直肠癌诊疗规范(2025版)(精简版)[J]. 中国实用外科杂志, 2025, 45(12):1353-1359. DOI: 10.19538/j.cjps.issn1005-2208.2025.12.01.
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The efficacy of laparoscopic vs open surgery for patients with low rectal cancer has not been established.
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王枭杰, 郑志芳, 池畔, 等. 左原始后腹膜的解剖观察及其在术中左结肠后间隙分离时的临床意义[J]. 中华胃肠外科杂志, 2021, 24(7): 619-625. DOI:10.3760/cma.j.cn.441530-20210121-00033.
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To investigate the relationship between the left trunk of the inferior mesenteric plexus (IMP) and the vascular sheath of the inferior mesenteric artery (IMA) and to explore anatomical evidence for autonomic nerve preservation during high ligation of the IMA in colorectal cancer surgery.
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篠原尚, 水野惠文, 牧野尚彦, 等. 图解外科手术: 从膜的解剖解读术式要点[M]. 沈阳: 辽宁科学技术出版社, 2013.
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The high rate of urogenital dysfunction after traditional total mesorectal excision (TME) has caused doubts among scholars on the standard fashion of dissection. We have proposed the necessity to preserve the Denonvilliers’ fascia in patients with rectal cancer. However, how to accurately locate the Denonvilliers’ fascia is unclear. This study aimed to explore anatomical features of the Denonvilliers’ fascia by comparing autopsy findings and observations of surgical videos so as to propose a dissection method for the preservation of pelvic autonomic nerves during rectal cancer surgery.
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王枭杰, 邓煜, 郑志芳, 等. 直肠环周筋膜分布模式的解剖学观察及其临床意义[J]. 中华胃肠外科杂志, 2024, 27(9):919-927.DOI:10.3760/cma.j.cn441530-20240710-00242.
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方佳峰, 卫洪波. 卫氏线引导的保留邓氏筋膜直肠癌根治术(iTME)的实施标准及应用现状[J]. 中国普外基础与临床杂志, 2024, 31(5): 518-522. DOI: 10.7507/1007-9424.202401077.
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Pre-operative assessment with high-resolution magnetic resonance imaging (MRI) is useful for assessing the risk of local recurrence (LR) and survival in rectal cancer. However, few studies have explored the clinical importance of the morphology of the anterior mesorectum, especially in patients with anterior cancer. Hence, the study aimed to investigate the impact of the morphology of the anterior mesorectum on LR in patients with primary rectal cancer.
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池畔, 王枭杰. 保留部分Denonvilliers筋膜的全直肠系膜切除术: 肿瘤学和功能学的平衡[J]. 中华消化外科杂志, 2021, 20(1):78-84. DOI:10.3760/cma.j.cn115610-20201207-00765.
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黄哲昆, 池畔, 黄颖. 低位直肠癌保留部分邓氏筋膜的机器人与腹腔镜全直肠系膜切除术近期疗效与泌尿和勃起功能对照研究[J]. 中华胃肠外科杂志, 2021, 24(4):327-334. DOI:10.3760/cma.j.cn.441530-20200724-00444.
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| [15] |
Total mesorectal excision (TME) has been the gold standard for the surgical treatment of mid-low rectal cancer, but traditional TME removal of Denonvilliers’ fascia (DVF) is too low and is prone to damage the connecting branches of the bilateral neurovascular bundles, which can lead to posturogenital dysfunction. A recently published multicenter randomised controlled trial revealed that TME with complete preservation of DVF (CP-DVF) has protective effects on postoperative urogenital function for male patients with rectal cancer with specific staging and location (preoperative staging T1-4N0-2M0, but T1-2 for anterior rectal wall). Our previous studies have confirmed that TME with partial preservation of DVF (PP-DVF) could also achieve satisfactory results regardless of the circumferential location of the tumour. However, there is a lack of randomised controlled trials to prove that the efficacy of TME with PP-DVF is equivalent to that with CP-DVF with respect to postoperative urogenital function.
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| [16] |
Ongoing debate exists about whether the rectovaginal septum (Denonvilliers' fascia) is myth or reality. This study evaluates magnetic resonance images (MRI) of women with Müllerian agenesis for the presence of fascial layers between the rectum and the bladder to test the hypothesis that this layer exists in the absence of the vagina.This is a secondary analysis of a study describing MRI aspects in women with vaginal agenesis before and after laparoscopic Vecchietti procedure. Study participants (n =16) had a multiplanar pelvic MR scan. Images were evaluated independently by two investigators (MH, JOLD) for the appearance of layers separate from the bladder and rectum in the area of interest, with characteristic anatomical features of the septum.Participants' mean age was 19.4±2.6 years ± standard deviation (SD). In 12 of 16 patients (75 %) a distinct layer between rectum and bladder was identified in either the axial(4/16; 25 %) or sagittal (12/16; 75 %) scan or both. Characteristic anatomical features included lateral attachment to the levator ani muscle, cranial fusion to the cul-de-sac peritoneum,and caudal insertion into the perineal body.Conclusions Three quarters of women with Müllerian agenesis have a visible layer between bladder and rectum. As none of the participants had a vagina, these results support the existence of a rectovaginal septum, separate from a vaginal adventitia.
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| [17] |
Since 1836 and the first description of the recto-genital fascia by Charles Denonvilliers, many anatomists have shown interest in this subject. Recently, pelvic surgeons have in turn shown similar interest, for they consider that perfect knowledge of this anatomical domain is crucial for optimal nerve conservation during surgery. Thanks to new anatomical description techniques, fascia location and relationships with pelvic nerves now appear clearer.To describe and represent Denonvilliers' fascia and its relationships in the female foetus at different stages of gestation and in three-dimensional space (3D).Computer-assisted anatomical dissection technique was used. Serial histological sections were made from four human female foetuses. Sections were treated with conventional staining, as well as with nerve and smooth muscle immunostaining. Finally, the sections were digitalized and reconstructed in 3D.Denonvilliers' fascia was clearly located and visualized in three dimensions. It was present in the female foetus, being distinct from the fascia propria of the rectum. It appeared to be composed of multiple parallel layers situated between the vagina and the rectum. From a lateral view, it had an asymmetrical "Y-shaped" aspect that seemed to play the role of a protective sheet for the neurovascular bundles.This study betters our comprehension of the Denonvilliers' fascia in the female foetus and of its connections with pelvic nerves. It also provides a better understanding of safe planes during pelvic dissection. These findings also suggest a biomechanical theory for embryological origin of the Denonvilliers' fascia.
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| [18] |
池畔. 基于膜解剖的腹腔镜与机器人结直肠肿瘤手术学[M]. 第2版. 北京: 人民卫生出版社, 2024: 180-226.
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池畔, 王枭杰. 机器人和腹腔镜全直肠系膜切除术中Denonvilliers筋膜解剖的意义及技巧[J]. 中国实用外科杂志, 2017, 37(6):609-615. DOI:10.19538/j.cjps.issn1005-2208.2017.06.05.
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王枭杰, 郑志芳, 池畔, 等. 右原始后腹膜在右半结肠癌完整结肠系膜切除术中的解剖学观察和临床意义[J]. 中华胃肠外科杂志, 2021, 24(8):704-710. DOI:10.3760/cma.j.cn.441530-20210121-00034.
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| [21] |
王枭杰,
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| [22] |
林谋斌, 李健文, 姚宏伟. 膜解剖理论与实践: 基于现代精细解剖的腹盆腔外科指导[M]. 北京: 人民卫生出版社, 2023.
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| [23] |
池畔, 王枭杰, 官国先, 等. 全直肠系膜切除术中直肠系膜分离终点线的发现和解剖及其临床意义[J]. 中华胃肠外科杂志, 2017, 20(10): 1145-1150. DOI:10.3760/cma.j.issn.1671-0274.2017.10.013.
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| [24] |
Although the clinical importance of complete, intact total mesorectal excision (TME) is the widely accepted standard for decreasing local recurrence of rectal cancer, the residual mesorectum still represents a significant component of resection margin involvement. This study aimed to use a visible intraoperative sign to detect the distal mesorectal end to ensure complete inclusion of the mesorectum and avoid unnecessary over-dissection.
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利益冲突 所有作者均声明不存在利益冲突
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