Department of Gastrointestinal Surgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
Dis Colon Rectum. 2019 May;62(5):639-641. doi: 10.1097/DCR.0000000000001358.
Previous studies on total mesorectal excision suggested dissection anterior to Denonvilliers' fascia, which might lead to intraoperative pelvic autonomic nerves injury and a high incidence of urogenital dysfunction.
We dissected 4 cases of cadavers, mainly focusing on anatomy of Denonvilliers' fascia, to study the relationship between Denonvilliers' fascia and rectum. In practice, instead of dissection 1 cm above peritoneal reflection, dissection of the peritoneum was performed at the lowest level of peritoneal reflection during laparoscopic resection for mid-low rectal cancer.
The cadaveric study revealed that there were loose tissues between Denonvilliers' fascia and rectal specimen, thus a surgical plane posterior to Denonvilliers' fascia did exist. During laparoscopic resection for mid-low rectal cancer, some loose reticulate structures between Denonvilliers' fascia and proper fascia of rectum would present after dissection of peritoneum at the lowest level of peritoneal reflection. Then dissection within the surgical plane posterior to Denonvilliers' fascia became easy and feasible. In this plane, both the pelvic nerves and postoperative urogenital function could be well protected by Denonvilliers' fascia.
The anterior surgical plane for total mesorectal excision should be reconsidered, and dissection posterior to Denonvilliers' fascia is feasible and practicable for patients without risk of positive anterior circumferential resection margin.
先前关于全直肠系膜切除术的研究建议在 Denonvilliers 筋膜前进行解剖，这可能导致术中盆自主神经损伤和泌尿生殖功能障碍的发生率较高。
我们对 4 具尸体进行了解剖，主要侧重于 Denonvilliers 筋膜的解剖结构，以研究 Denonvilliers 筋膜与直肠之间的关系。在实践中，对于中低位直肠癌的腹腔镜切除术，我们不是在腹膜反折上方 1cm 处进行解剖，而是在腹膜反折的最低水平进行腹膜解剖。
尸体研究显示，Denonvilliers 筋膜和直肠标本之间存在疏松组织，因此存在 Denonvilliers 筋膜后方的手术平面。在中低位直肠癌的腹腔镜切除术中，在腹膜反折的最低水平进行腹膜解剖后，会出现 Denonvilliers 筋膜和直肠固有筋膜之间的一些疏松网状结构。然后，在 Denonvilliers 筋膜后方的手术平面内进行解剖变得容易和可行。在这个平面内，Denonvilliers 筋膜可以很好地保护盆腔神经和术后泌尿生殖功能。
全直肠系膜切除术的前手术平面应重新考虑，在 Denonvilliers 筋膜后进行解剖对于没有前环形切除边缘阳性风险的患者是可行和可行的。
