Church J M, Raudkivi P J, Hill G L
Department of Surgery, University of Auckland, New Zealand.
Int J Colorectal Dis. 1987 Aug;2(3):158-66. doi: 10.1007/BF01648000.
The major complications of rectal surgery that are wholly or partially avoidable by the use of an anatomically based dissection are haemorrhage from presacral veins, perforation of the rectum, damage to pelvic autonomic nerves and inadequate clearance of a rectal cancer. Important technical points in minimising the incidence of these complications are: (1) posterior dissection in the presacral space; (2) entry to this space by sharp dissection immediately posterior to the superior rectal artery; (3) deliberate incision of the rectosacral fascia; (4) anterior dissection posterior to Denonvilliers fascia in benign disease; (5) removal of the entire mesorectum for low rectal cancer. Other anatomical points not widely appreciated are: 1. The middle rectal artery does not run in the lateral ligaments of the rectum, but below them, on levator ani. It reaches the rectum by penetrating Denonvilliers' fascia. 2. The lateral ligaments may contain an accessory middle rectal artery in 25% of cases. 3. The pelvic autonomic nerves are buried in endopelvic fascia on the pelvic side wall, but come to lie close to the anterior aspect of the rectum at the level of the prostate or upper vagina.
通过基于解剖学的分离方法可全部或部分避免的直肠手术主要并发症包括骶前静脉出血、直肠穿孔、盆腔自主神经损伤以及直肠癌清除不彻底。将这些并发症的发生率降至最低的重要技术要点如下：（1）在骶前间隙进行后方分离；（2）在直肠上动脉正后方通过锐性分离进入该间隙；（3）有意切开直肠骶骨筋膜；（4）对于良性疾病，在Denonvilliers筋膜后方进行前方分离；（5）对于低位直肠癌，切除整个直肠系膜。其他未被广泛认识的解剖学要点如下：1. 直肠中动脉并不走行于直肠侧韧带内，而是在其下方，位于肛提肌上。它通过穿透Denonvilliers筋膜到达直肠。2. 在25%的病例中，侧韧带可能包含一支副直肠中动脉。3. 盆腔自主神经埋于盆腔侧壁的盆内筋膜中，但在前列腺或上阴道水平靠近直肠前方。
