Colorectal Surgery Unit, Hospital Universitario y Politécnico "La Fe", Av.da Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain.
Department of Human Embryology and Anatomy Department, University of Valencia, Valencia, Spain.
Surg Endosc. 2019 Nov;33(11):3842-3850. doi: 10.1007/s00464-019-06869-w. Epub 2019 May 28.
The fusion fascia of Toldt is a well-known landmark used by colorectal surgeons. On the contrary, the fusion fascia of Fredet (the plane between the ascending mesocolon and the visceral duodenal-pancreatic peritoneum) still remains a neglected embryological structure. Aim of this study was to provide an anatomic description of this fascia and its application to minimally invasive D3-lymphadenectomy (D3-L) and complete mesocolic excision (CME) for right colon cancer.
First phase: Cadaveric dissection and anatomic description of the fascia of Fredet. Second phase: prospective evaluation of its surgical application in a consecutive series of laparoscopic right hemicolectomies with CME and D3-L at a tertiary hospital.
The fascia of Fredet was identified and dissected in one fresh and two formalin-fixed cadavers. The trunk of Henle and the medial border of the superior mesenteric vein defined the medial limit of this embryologic plane. Seventeen patients were operated on. Laparoscopic dissection of the fascia of Fredet was possible in every patient. Median operative time was 210 (120-380) min. There were no major postoperative complications. All cases were adenocarcinomas, except one adenomatous polyp. T stage was Tis in three, T2 in two, T3 in seven, and T4 in five patients. Median number of harvested lymph nodes was 24 (9-39). Lymphatic invasion was found in six patients. All resections were classified as satisfactory mesocolic excision and R0. Median postoperative length of stay was 6 (4-20) days. Median follow-up time was 28 (16-41) months. Local and distal recurrence rate was 0.
The fusion fascia of Fredet is useful to achieve CME and D3-L in right colon cancers with reduced risk of intraoperative complications. This structure is particularly suitable for minimally invasive surgery; therefore, we encourage awareness of the fascia of Fredet by colorectal surgeons.
Toldt 融合筋膜是结直肠外科医生熟知的标志。相反，Fredet 融合筋膜（升结肠系膜与内脏十二指肠-胰腺腹膜之间的平面）仍然是一个被忽视的胚胎学结构。本研究的目的是提供该筋膜的解剖描述及其在右半结肠癌微创 D3 淋巴结清扫术（D3-L）和完整结肠系膜切除术（CME）中的应用。
第一阶段：尸体解剖和 Fredet 筋膜的解剖描述。第二阶段：在一家三级医院对连续的腹腔镜右半结肠切除术 CME 和 D3-L 进行前瞻性评估。
在一具新鲜尸体和两具福尔马林固定尸体中识别并解剖了 Fredet 筋膜。Henle 干和肠系膜上静脉的内侧缘确定了该胚胎平面的内侧界限。17 名患者接受了手术。每位患者均可行腹腔镜 Fredet 筋膜解剖。中位手术时间为 210（120-380）分钟。无重大术后并发症。除 1 例腺瘤性息肉外，所有病例均为腺癌。Tis 期 3 例，T2 期 2 例，T3 期 7 例，T4 期 5 例。中位淋巴结清扫数为 24（9-39）枚。6 例发现淋巴血管侵犯。所有切除均归类为满意的结肠系膜切除和 R0。中位术后住院时间为 6（4-20）天。中位随访时间为 28（16-41）个月。局部和远端复发率为 0。
Fredet 融合筋膜有助于降低术中并发症风险，实现右半结肠癌的 CME 和 D3-L。该结构特别适合微创手术；因此，我们鼓励结直肠外科医生认识到 Fredet 筋膜的存在。
