中国实用外科杂志

中国实用外科杂志

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盆筋膜解剖及其与直肠固有筋膜关系研究

魏    波1，黄盛鑫1，古翔鹏1，刘    靖2，邹俊涛3，刘小花2，周大贵1，黄江龙1，郑宗珩1，卫洪波1   

  1. 1中山大学附属第三医院胃肠外科，广东广州 510630；2广东药科大学生命与生物制药学院人体解剖与胚胎学系，广东广州 510006；3中山大学中山医学院人体解剖学教研室，广东广州 510080
  • 出版日期:2021-07-01 发布日期:2021-07-12

  • Online:2021-07-01 Published:2021-07-12

摘要： 目的    探讨盆筋膜的结构、范围及其与直肠固有筋膜的层次关系。方法    2020年12月至2021年3月对由广东药科大学生命与生物制药学院人体解剖与胚胎学系及中山大学中山医学院人体解剖学教研室提供的12具（男性5具、女性7具）骨盆标本进行大体观察，并对Denonvilliers筋膜进行组织学观察。结合2019年12月至2021年3月中山大学附属第三医院胃肠外科收治的20例直肠癌病人（男性10例、女性10例）的盆腔磁共振图像和手术视频进行解剖学印证。结果    12具骨盆大体标本显示，盆筋膜与Gerota筋膜相延续，部分纤维于S4水平构成直肠骶骨筋膜，向下与直肠固有筋膜融合终止于联合纵肌；部分纤维与后方骶前筋膜融合构成肛提肌上筋膜及肌间纤维。Denonvilliers筋膜在盆腔前外侧约2点、10点处与盆筋膜相延续构成完整筒状结构，包绕内层由直肠固有筋膜封套的直肠系膜；除“侧韧带”处有盆腔自主神经直肠支、淋巴管、直肠中动脉相连外，两层筋膜形成完整的双筒状结构，横断面呈同心圆状。除直肠支进入直肠固有筋膜外，盆腔自主神经主要分支均位于盆筋膜内层及Denonvilliers筋膜以外，沿直肠固有筋膜轮廓游离能够避免损伤盆腔自主神经。在7具女性骨盆标本中均能见到菲薄的Denonvilliers筋膜结构。直肠癌病人的横断面磁共振图像能够看到直肠固有筋膜与外侧盆筋膜、Denonvilliers筋膜的轮廓和间隙，手术视频资料也可见到完整盆壁筋膜和Denonvilliers筋膜的轮廓。结论    直肠癌手术中，在盆筋膜、Denonvilliers筋膜与直肠固有筋膜两层结构的间隙进行分离，并保持两层筋膜的完整性，对于保证肿瘤根治性和保护排尿及性功能至关重要。

关键词: 盆筋膜, Denonvilliers筋膜, 直肠固有筋膜, 直肠癌

Abstract: Anatomy of pelvic fascia and its relationship with fascia propria of rectum        WEI Bo*，HUANG Sheng-xin，GU Xiang-peng，et al. *Department of Gastroentestinal Surgery，the Third Affiliated Hospital of Sun Yat-sen University，Guangzhou 510630，China
Corresponding author：WEI Hong-bo，E-mail：weihb@mail.sysu.edu.cn
Abstract    Objective    To explore the structure and scope of the pelvic fascia and its hierarchical relationship with the fascia propria of rectum（FPR）. Methods    From December 2020 to March 2021，the pelvic specimens of 12 cases (including 5 males and 7 females) provided by Department of Human Anatomy and Histoembryology，School of Life Sciences and Biopharmaceutics，Guangdong Pharmaceutical University，and Department of Human Anatomy，Zhongshan School of Medicine，Sun Yat-Sen University，were grossly observed. And the Denonvilliers’ fiscia (DVF) were observed histologically. The above-mentioned fascia and the anatomical spaces were verified，combining the pelvic magnetic resonance images (MRI) and surgical videos of 20 rectal cancer patients (10 males and 10 females) admitted to Department of Gastrointestinal Surgery，the Third Affiliated Hospital of Sun Yat-sen University，from December 2019 to March 2021. Results    Twelve gross pelvic specimens showed that the pelvic fascia (PF) continued with Gerota’s fascia. Partial fibers of PF formed the rectal sacral fascia at the level of S4，and then fuse with the fascia propria of rectum，ended at the joint longitudinal muscle. The other part of fibers fused with the posterior presacral fascia，and constituted the upper fascia and intermuscular fibers of the levator ani muscle. Denonvilliers’ fascia concatenates with the PF at about 2 and 10 o’clock to formed a complete cylindric structure，enclosing the inner mesorectum enveloped by the fascia propria of rectum. Except for the “lateral ligaments”，there were branches of pelvic autonomic nerve (PAN)，lymphatic and blood vessels entered into the FPR，the two layers of fascia formed a complete double cylindrical structure，with a concentric cross-section. The main branches of PAN were located outside of the inner layer of the PF and DVF，and dissection along the contour of FPR could avoid PAN injury. The thin DVF structure could be seen in the pelvic specimens of 7 female patients. The cross-sectional MRI images of 20 patients with rectal cancer could see the contours and spaces of the FPR，PF，and DVF. The surgical video could also see the complete PF and DVF outline. Conclusion    In rectal cancer surgery，dissecting between the space of PF，DVF and FPR，and maintaining the integrity of the two-layer structure，are essential to ensure the radical resection of the tumor and protect urination and sexual function.

Key words: pelvic fascia；Denonvilliers&rsquo, fascia；fascia propria of rectum；rectal cancer