Department of Gastroenterological Surgery, Hakodate Municipal Hospital, Hokkaido, Japan;
Department of Gastroenterological Surgery, Hirosaki University, Graduate School of Medicine, Aomori, Japan.
Anticancer Res. 2023 Apr;43(4):1591-1598. doi: 10.21873/anticanres.16309.
BACKGROUND/AIM: Currently, only a small part of functional lymphatic flow around the anorectal region has been anatomically analyzed. Despite the fact that local recurrence is often experienced in the pelvic floor, the functional lymphatic network in this region has rarely been studied due to difficulties in observation. This prospective observational study aimed to observe anorectal lymphatic flow around the pelvic floor using intraoperative indocyanine green fluorescence imaging during laparoscopic or robot-assisted rectal surgery.
Fourteen patients who underwent laparoscopic (n=7) or robot-assisted (n=7) surgery without any preoperative therapy between April and December 2022 were enrolled. Indocyanine green solution (0.25 mg) was injected into the submucosa at the dentate line of the anterior, posterior, and bilateral walls prior to surgery. During and after total mesorectal excision, lymphatic flow was observed using a near-infrared camera system.
Lymphatic flow visualized by indocyanine green was detected not only in the already-known route from the low rectum to the lateral pelvic lymph nodes via the lateral ligament, but also in the novel route from the low rectum to the surface of the levator ani muscle and hiatal ligament. Fluorescence was widely spread in the pelvic floor between the longitudinal muscle of the low rectum and the surface of the levator ani muscle.
Even though the results are preliminary since histological analyses were not performed, a novel widespread lymphatic network on the surface of the levator ani muscle originating from the longitudinal muscle fibers of the low rectum was revealed.
背景/目的：目前，仅对肛门直肠区域周围的一小部分功能性淋巴液流动进行了解剖学分析。尽管盆腔内经常发生局部复发，但由于观察困难，该区域的功能性淋巴网络很少被研究。本前瞻性观察研究旨在使用腹腔镜或机器人辅助直肠手术期间的术中吲哚菁绿荧光成像来观察盆腔底部周围的肛门直肠淋巴液流动。
2022 年 4 月至 12 月期间，共纳入 14 例未经术前治疗的接受腹腔镜（n=7）或机器人辅助（n=7）手术的患者。手术前，在齿状线的前壁、后壁和双侧壁将吲哚菁绿溶液（0.25mg）注入黏膜下。在全直肠系膜切除术中及术后，使用近红外摄像系统观察淋巴液流动。
吲哚菁绿可视化的淋巴液流动不仅在已知的从低位直肠经侧韧带至侧盆腔淋巴结的途径中被检测到，而且在从低位直肠至提肛肌表面和 hiatus 韧带的新途径中也被检测到。荧光在低位直肠的纵向肌和提肛肌表面之间的盆腔底部广泛扩散。
尽管由于未进行组织学分析，结果尚属初步，但揭示了起源于低位直肠纵行肌纤维的提肛肌表面上一个新的广泛的淋巴网络。
