Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, China.
Int J Surg. 2022 Mar;99:106263. doi: 10.1016/j.ijsu.2022.106263. Epub 2022 Feb 14.
Total mesorectal excision (TME) is conventionally performed according to Heald's principles through the so-called 'holy plane', between the visceral and parietal fasciae. However, urinary and sexual dysfunctions remain frequent postoperative complications. We proposed to preserve urogenital fascia (UGF) in TME, and this study aimed to clarify the anatomical basis of this technique and evaluate its efficacy and safety.
Cadaveric dissection was performed on 26 pelvises, and laparoscopic TME with UGF preservation was performed in 212 patients with mid-low rectal cancer. The fasciae and spaces related to TME were observed and described, and the clinical effect of UGF-preserving TME was analyzed.
In the 26 cadavers, fascia propria of the rectum (FPR) presents as a fibrous capsule enveloping the mesorectum. UGF extends postero-laterally to the rectum, enveloping the hypogastric nerves and ureters. We demonstrated that the visceral fascia is actually the UGF, and FPR and visceral fascia (i.e. UGF) are two independent layers of fascia. Thus, FPR, UGF and parietal fascia form two avascular spaces behind the rectum. The plane ventral to the UGF is the real 'holy plane' for TME, rather than that dorsal to the UGF as is traditionally thought. Laparoscopic TME with UGF preservation was successfully performed in all 212 patients, with low perioperative complications (10.8%) and a low 3-year local recurrence rate (4.2%). Furthermore, the incidences of urinary and sexual dysfunctions at postoperative 6 months were only 6.1% and 10.8%, respectively.
The avascular plane between the FPR and UGF (i.e. visceral fascia) is the real 'holy plane'. Laparoscopic TME with UGF preservation is a feasible radical surgery for mid-low rectal cancer, with better protection of urinary and sexual functions.
全直肠系膜切除术（TME）传统上按照 Heald 的原则通过所谓的“圣带”进行，即脏层筋膜和壁层筋膜之间。然而，尿和性功能障碍仍然是常见的术后并发症。我们提出在 TME 中保留泌尿生殖筋膜（UGF），本研究旨在阐明该技术的解剖学基础，并评估其疗效和安全性。
对 26 具骨盆进行尸体解剖，并对 212 例中低位直肠肿瘤患者进行腹腔镜 TME 联合 UGF 保留。观察和描述与 TME 相关的筋膜和间隙，并分析 UGF 保留 TME 的临床效果。
在 26 具尸体中，直肠固有筋膜（FPR）表现为包裹直肠系膜的纤维囊。UGF 向直肠的后外侧延伸，包裹下腹神经和输尿管。我们证明脏层筋膜实际上是 UGF，FPR 和脏层筋膜（即 UGF）是两个独立的筋膜层。因此，FPR、UGF 和壁层筋膜在直肠后方形成两个无血管间隙。UGF 腹侧平面是 TME 的真正“圣带”，而不是传统认为的 UGF 背侧平面。所有 212 例患者均成功完成腹腔镜 TME 联合 UGF 保留，围手术期并发症低（10.8%），3 年局部复发率低（4.2%）。此外，术后 6 个月尿和性功能障碍的发生率分别仅为 6.1%和 10.8%。
FPR 和 UGF（即脏层筋膜）之间的无血管平面是真正的“圣带”。腹腔镜 TME 联合 UGF 保留是中低位直肠癌可行的根治性手术，能更好地保护尿和性功能。
