Huang S, Wang Z Q
Department of Gastrointestinal and Colorectal Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2021 Aug 25;24(8):722-726. doi: 10.3760/cma.j.cn441530-20210613-00235.
Colorectal surgery for malignancies has evolved into an era of careful and precise dissection along mesorectal or mesocolic fascia to achieve the so-called total mesorectal excision or complete mesocolic excision. The wide use of laparoscopic technique prompted more anatomical, histological, and embryological studies. This leads to a deeper and more precise understanding of fascial anatomy concerning colorectal surgery, though controversies exist. The complicated anatomy of multilayer parietal fasciae and dense adhesion between fasciae at specific sites still represent a major hindrance to perform a precise inter-fascial dissection. Colorectal surgeons should be familiar with the onion-like arrangement of the visceral and parietal fasciae. The dedicated assistants should provide three-directional traction and adjust the direction of forces timely in a manner that the resultant forces are always in a direction perpendicular to the fasciae that are to be dissected. The fixation of the mesorectum and the mesocolon to the pelvic and abdominal wall can also be exploited as a natural counter-retraction. To separate loosely attached visceral and parietal fasciae, the application of splitting forces on opposite fasciae or sliding the forceps along the interface will provide quick separation and maintenance of the integrity of the fasciae. In summary, careful attention to the direction and strength of three directional retractions on parietal and visceral fasciae will help stretch and open up the areolar surgical tissue plane, skillful maneuver in separation and dividing of the attachment of two fasciae will ensure a precise inter-fascial dissection and help achieve total mesorectal excision or complete mesocolic excision, reducing the risk of the residual of the mesentery and inadvertent injuries to adjacent tissues and autonomic nerves.
恶性结直肠手术已进入一个沿直肠系膜或结肠系膜筋膜进行精细解剖的时代，以实现所谓的全直肠系膜切除或完整结肠系膜切除。腹腔镜技术的广泛应用促使了更多的解剖学、组织学和胚胎学研究。这使得人们对结直肠手术相关的筋膜解剖有了更深入、更精确的理解，尽管仍存在争议。多层壁层筋膜的复杂解剖结构以及特定部位筋膜之间的紧密粘连仍然是进行精确筋膜间解剖的主要障碍。结直肠外科医生应熟悉脏层和壁层筋膜的洋葱样排列。专业助手应提供三个方向的牵引，并及时调整力的方向，使合力始终垂直于待解剖的筋膜。直肠系膜和结肠系膜与盆腔和腹壁的固定也可作为一种自然的反向牵引。为了分离松散附着的脏层和壁层筋膜，在相对的筋膜上施加劈裂力或沿界面滑动镊子将有助于快速分离并保持筋膜的完整性。总之，仔细关注壁层和脏层筋膜三个方向牵引的方向和力度将有助于拉伸和打开蜂窝状手术组织平面，熟练地分离和切断两层筋膜的附着将确保精确的筋膜间解剖，并有助于实现全直肠系膜切除或完整结肠系膜切除，降低肠系膜残留以及对相邻组织和自主神经意外损伤的风险。
