Liang Xiaobo, Wang Yi, Ma Guolong
Department of Digestive Surgery, Shanxi Tumour Hospital, Taiyuan 030013, China. liangxiaobo@med mail.com.cn.
Zhonghua Wei Chang Wai Ke Za Zhi. 2017 Jun 25;20(6):614-617.
Rectal cancer has become the second most common gastrointestinal tumor in our country. With the development of comprehensive treatment, the long-term survival rate of patients with rectal cancer has greatly increased, meanwhile, higher postoperative quality of life is required. But the genitourinary dysfunction which is mainly caused by intraoperative pelvic autonomic nerve damage haunts postoperative rectal cancer patients. Traditional pelvic autonomic nerve protection technology born in the 1980s only improves urogenital function in a part of postoperative patients. In recent years, NOME(nerve-oriented mesorectal excision) was proposed, which needed to make pelvic autonomic never exposed. However, recovery of urinary function is not ideal due to difficulty identifying pelvic autonomic nerve and unavoidable damage on pelvic autonomic nerve. In clinical practice, we found that pelvic autonomic nerve can be divided into three parts: abdominal cavity, large pelvis, small pelvis. The pelvic autonomic nerve is closely related to the surrounding fascias in each part. The fascias are not only the protection of pelvic autonomic nerve, but also can be used as a good indicator of location of pelvic autonomic nerve. The relationship of pelvic autonomic nerve with Toldt fascia, presacral fascia, the lateral rectal ligaments, and the Denonvilliers fascia is discussed in this paper. Combined with the above theory, a new technology named FOPANP (fascia-orientation of pelvic autonomic nerve preservation) is proposed. In this technique, the fascia around the rectum is used as a guidance to select the appropriate plane in the operation, and the tumor can be removed without exposing the pelvic autonomic nerve. This technology has three advantages. First, it is not necessary to search and expose the pelvic autonomic nerve, so as to avoid secondary injury to it during the operation. Secondly, the pelvic fascias are natural barriers formed between the surgical plane and the pelvic autonomic nerve retained. They can avoid the stimulation of physical and chemical factors to pelvic autonomic nerve. Thirdly, because the fascias are easier to identify, and the texture is more tough, so the technology is easier to master.
直肠癌已成为我国第二大常见的胃肠道肿瘤。随着综合治疗的发展，直肠癌患者的长期生存率大幅提高，同时，对术后更高的生活质量也有了要求。但主要由术中盆腔自主神经损伤引起的泌尿生殖功能障碍一直困扰着直肠癌术后患者。20世纪80年代诞生的传统盆腔自主神经保护技术仅能使部分术后患者的泌尿生殖功能得到改善。近年来，提出了神经导向直肠系膜切除术（NOME），该术式需要暴露盆腔自主神经。然而，由于盆腔自主神经难以辨认且不可避免地会受到损伤，导致其术后尿功能恢复并不理想。在临床实践中，我们发现盆腔自主神经可分为腹腔、大骨盆、小骨盆三部分。盆腔自主神经在各部分与周围筋膜密切相关。这些筋膜不仅是盆腔自主神经的保护结构，还可作为盆腔自主神经定位的良好标志。本文探讨了盆腔自主神经与Toldt筋膜、骶前筋膜、直肠侧韧带及Denonvilliers筋膜的关系。结合上述理论，提出了一种名为盆腔自主神经保留筋膜导向术（FOPANP）的新技术。在该技术中，以直肠周围筋膜为引导在手术中选择合适的层面，在不暴露盆腔自主神经的情况下切除肿瘤。该技术有三个优点。第一，无需寻找和暴露盆腔自主神经，从而避免术中对其造成二次损伤。第二，盆腔筋膜是手术层面与保留的盆腔自主神经之间形成的天然屏障。它们可避免物理和化学因素对盆腔自主神经的刺激。第三，由于筋膜更容易辨认，质地更坚韧，所以该技术更容易掌握。
