Chinese Journal of Practical Surgery

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  • Online:2020-08-01 Published:2020-08-10

基于膜解剖的低位直肠癌侧方淋巴结“两间隙”清扫术安全性研究

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  1. 1同济大学附属杨浦医院普通外科，上海200090；2 同济大学医学院胃肠外科和转化医学研究所, 上海200090；

Abstract: Study on the safety of lateral lymph node dissection in “two spaces” based on fascia anatomy for low rectal cancer        LIU Hai-long*, LI A-jian, WANG Wen-chao, et al. *Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, China
Corresponding author: LIN Mou-bin, E-mail: lmbin@hotmail.com
Abstract    Objective    To investigate the anatomical theory of “two spaces” of lateral lymph node dissection (LLND) based on membrane anatomy and its feasibility and safety in low rectal cancer. Methods    Detailed pelvic dissections were performed in 24 cadavers at the Anatomy Department of Shanghai Jiaotong University School of Medicine, and the fasciae and spaces related to LLND were observed and described. Fourteen patients with low rectal cancer received three-dimensional (3D)-laparoscopic total mesorectal excision (TME) combined with LLND at Yangpu Hospital of Tongji University School of Medicine between July 2018 and March 2020, and their surgical videos and clinical data were retrospectively reviewed. Results    In all 24 cadavers, the fascia propria of rectum, urogenital fascia, vesicohypogastric fascia and obturator fascia (parietal fascia) were located lateral to the rectum in a medial-to-lateral direction. The fascia propria of rectum was the thin fascia layer surrounding the mesorectum. The urogenital fascia lied posterolateral to the rectum and presented as the densest connective tissue in the pelvis. In 20 of the 24 cadavers (83.3%), the hypogastric nerve was observed to be enveloped in the urogenital fascia, and another 4 cadavers (16.7%) lied dorsal side of the urogenital fascia. The vesicohypogastric fascia showed a triangle shape formed by the umbilical artery, the inferior vesical artery and the lateral border of the bladder. 3D-laparoscopic LLND was performed successfully in all 14 patients. The median operating time was (175 ± 27) minutes, with a median blood loss of (50 ± 18) mL, and the median postoperative hospitalization was (11 ± 2) d. Postoperative complications included lymph leakage and lower limb pain in 1 case, respectively. The median number of lateral lymph nodes was 8.4 ± 1.3. Conclusion    Three layers of fasciae (urogenital fascia, vesicohypogastric fascia and obturator fascia) form the two spaces of LLND: paravesical space and Latzko's pararectal space. Performing two spaces of lateral lymph node dissection with the guidance of membrane anatomical landmarks offers significant advantages in clearly identifying the surgical plane and locating the nerves and blood vessels. The preliminary surgical experience has showed that it is a feasible surgical approach, which improves surgical safety while ensuring radical tumor resection. It is worthy of further verification.

Key words: rectal cancer, lateral lymph node dissection, membrane anatomy, visceral pelvic fascia

摘要： 目的    通过尸体解剖分析基于膜解剖的 “两间隙”侧方淋巴结清扫术的解剖学理论，探讨对低位直肠癌病人行“两间隙”清扫的安全性和可行性。方法    解剖观察24具来源于上海交通大学医学院解剖教研室的成人尸体标本，对与侧方淋巴结清扫术相关的筋膜和间隙进行记录和描述。回顾性分析同济大学附属杨浦医院2018年7月至2020年3月行3D腹腔镜下直肠全系膜切除+“两间隙”侧方淋巴结清扫术的14例低位直肠癌病人的临床资料。结果    所有24具尸体均可以明确解剖出直肠固有筋膜、尿生殖筋膜、膀胱腹下筋膜和闭孔筋膜（壁筋膜），并在直肠侧方从内至外依次排列。直肠固有筋膜表现为覆盖在直肠及其周围脂肪表面的最内侧薄层筋膜。尿生殖筋膜是位于直肠侧后方的盆腔最为致密的筋膜，其中20例（83.3%）腹下神经位于尿生殖筋膜内；4例（16.7%）腹下神经位于尿生殖筋膜的深面。膀胱腹下筋膜是由脐动脉、膀胱下动脉和膀胱壁组成的“三角形”筋膜。临床实践表明，14例病人均在3D腹腔镜下完成侧方淋巴结清扫。侧方淋巴结清扫术时间为（175±27） min，术中出血量为（50±18）mL，2例病人出现并发症，淋巴漏和下肢疼痛各1例，术后住院时间（11±2） d。3例（21.4%）病人病理学检查证实为侧方淋巴结转移，其中1例为单纯性髂内淋巴结转移，平均侧方淋巴结检出数目（8.4±1.3）枚。结论    “三筋膜”（尿生殖筋膜、膀胱腹下筋膜和闭孔筋膜）构成了侧方淋巴结清扫术的两间隙（膀胱旁间隙和Latzko直肠旁间隙）。基于膜解剖的低位直肠癌侧方淋巴结“两间隙”清扫术依据膜解剖标记完成，层面容易辨识，血管、神经定位明确，初步的手术经验证实临床切实可行，不但可以提高手术的安全性，而且可以保证手术的根治性，值得进一步积累病例验证。

关键词: 直肠癌, 侧方淋巴结清扫, 膜解剖, 脏筋膜