【作者】 贺敬虎；

【导师】 王强； 胡志前； 孙延平； 蔡清萍； 阮灿平；

【作者基本信息】 第二军医大学 ， 外科学， 2009， 博士

【摘要】 背景:直肠癌患者在直肠癌根治术中行全直肠系膜切除(TME)时,尽管实施了保留盆腔自主神经丛术,但术后患者仍然经常会出现泌尿、性功能障碍,所以术后维持患者泌尿、性功能很大程度上依赖于临床医师对于盆腔自主神经丛结构掌握的情况。本研究旨在明确盆腔自主神经丛及次级神经丛的来源、分布特征、定位、走行等。通过演示腹腔镜保留盆腔自主神经丛直肠癌根治术的操作,来提示腹腔镜下如何保留盆腔自主神经丛,并对术后患者术后泌尿生殖功能进行评估。该手术具有可行性和优势性。方法:通过解剖10例男性成人尸体观测盆腔自主神经丛及次级神经丛的来源、分布、定位、走行。测量左右两侧次级神经丛各起点与耻骨联合、骶岬和直肠侧壁之间的距离以及各神经主纤维的横经和长度,并进行统计学分析。取2例新鲜的男尸盆腔脏器标本。甲醛溶液固定后。取盆腔脏器做连续切片,进行HE染色和免疫组化。观察盆腔神经及其分支的分布特征、类型与其邻近器官的关系。选择适合本研究的24例临床患者,演示手术操作过程,12例行腹腔镜保留盆腔自主神经丛的全直肠系膜切除术(LANP-TME),12例行常规开腹手术(OTME)。用国际前列腺症状评分和国际勃起功能指数对患者实验组和对照组术前、术后泌尿生殖功能进行评估。结果:左侧腹下神经较右侧细而短;左侧神经束长度5.3±0.98 cm,横经1.67±0.17 mm;右侧神经束长度7.38±1.94 cm,横经1.91±0.03 mm。还发现肠系膜下丛参与了盆腔自主神经丛的构成;10例标本中有3例出现肠系膜下丛直接发出分支进入盆丛,出现率为30%。两侧的次级神经丛的起点除直肠丛外,前列腺丛和膀胱丛与耻骨联合、骶岬和直肠侧壁之间的距离无明显差异;左侧膀胱丛、前列腺丛的主神经纤维较右侧粗、长;右侧膀胱丛横径1.12±0.11 mm,长度15.3±7.89 mm;左侧横径1.41±0.24 mm,长度18.2±3.77 mm。右侧前列腺丛横径1.15±0.24 mm,长度15.1±9.50 mm;左侧前列腺丛主神经纤维横径1.50±0.24 mm,长度20.4±6.60 mm。左侧直肠丛的主神经纤维的横经和长度较右侧细、短,右侧直肠丛神经主纤维横径1.07±0.22 mm,长度24.5±11.2 mm;左侧横径0.86±0.18 mm,长度15.2±2.66 mm。左右两侧盆丛的头肛径、背腹径、次级神经丛神经纤维支数有所不同;左右两侧神经纤维到达效应器的级数无明显差异。Denonvilliers’筋膜是直肠、前列腺、精囊腺之间重要的组织结构,其内有神经血管束穿过。阴茎海绵体神经位于尿道的前外侧约15 mm,穿盆隔进入海绵体。盆丛神经元多为混合型神经元。术后导尿管拔除:实验组患者(LTME-ANP)术后平均3天(1-6 d)拔除导尿管,而对照组(OTME)术后平均5天(3-8 d)拔除导尿管。尿流动力学平均最大尿流量,实验组患者(LTME-ANP)术前18.9±5.7,术后13.7±7,对照组(OTME)Qmax (ml/s)术前18.7±6.1,术后11.5±6.3;P<0.05。平均膀胱剩余容积(mean voided volume Vcomp (ml)),实验组患者(LTME-ANP)术前240±91.9,术后163±78;对照组(OTME)Vcomp (ml)术前228±102,术后143±69;P<0.05。平均残余尿量(mean residual volume RV (ml)),实验组患者(LTME-ANP)术前4.4±5.6,术后8.1±11.4,对照组(OTME)RV (ml)术前4.8±6.1,术后12.2±11.9;P>0.05。IPSS总平均积分实验组(LTME-ANP)术后8.3±5.6;对照组(OTME)术后10.2±7.3。不论是对照组还是实验组术后性功能均明显低于术前,而对照组又低于实验组。结论:通过一些解剖标志明确次级神经丛定位,明确了盆丛分布特征,为TME术中保留盆腔自主神经丛或尽量避免盆丛损伤提供形态学依据。熟练掌握盆腔自主神经丛的解剖结构,采用先进的外科手术方式针对合适的患者,在经济条件允许的情况下可以明显提高直肠癌患者术后生活质量。更多还原

【Abstract】 Background: The total mesorectal excision (TME) often cause a incidence of pelvic organ dysfunction, even though the autonomic nerves preservation was performed. Undoubtedly, maintenance of integral functions after surgery for rectal carcinoma relies on the best understanding of the pelvic neural structures. The purpose of this cadaver study was to highlight the organization and localization of the pelvic autonomic plexus and the secondary pelvic visceral nervous plexuses.To test the feasibility of laparoscopic approach in performing the simultaneous pelvic autonomic nerve preservation during standard anterior resection of rectal cancer. To assess the succession of laparoscopic total mesorectal excision with pelvic autonomic nerve preservation in terms of voiding and sexual function in males with rectal cancer.Methods:Ten cadavers were dissected to observe the courses of the pelvic plexus and distribution of its branches including the seconary pelvic visceral nervous plexuses. The transverse diameter and length, as well as the distances of origin of the secondary pelvic autonomic plexuese to the sacral promontory, pubic symphysis and lateral wall of rectum were measured and analyzed statistically. Two cadavers were sliced horizontally. Specimens were harvested and processed for light microscopy and immunohistochemistry to analyze the types of nerves and their localization. 24 male patients meeting appropriate eligibility criteria were recruited for the present study.12 patients underwent laparoscopic pelvic autonomic nerve preservation total mesorectal excision, The other 12 patients underwent open total mesorectal excision(control). The genitourinary function was evaluated on the basis of validated questionnaires including International Prostate Symptom Score (IPSS), and International Index of Erectile Function (IIEF).Results: The right hypogastric nerve was longer and thicker than left one .Beside of anatomosis with the pelvic plexus, the inferior mesentric plexus directly gave off a fiber to participat in the formation of the pelvic plexus. Three specimens in 10 specimens were found the inferior mesentric plexus directly gave off a fiber to participat in the formation of the pelvic plexus, about 30%. Excluding the distances from the origin of rectal plexus to sacral pomontory , no side differences were found origin of vescial plexus, and rectal pelxus to the sacral promontory, pubic symphysis and to the lateral wall of rectum. Furthermore, the main fibers of left vesical plexus and prostatic plexus were thicker than right one, transverse diameter of right vesical 1.12±0.11 mm,length 15.3±7.89 mm;transverse diameter of left 1.41±0.24 mm,length 18.2±3.77 mm. transverse diameter of right prostatic plexus main fibers 1.15±0.24 mm,length 15.1±9.50 mm;transverse diameter of left 1.50±0.24 mm,length 20.4±6.60 mm. and main fiber of the rectal plexus was shorter and thinner than right one. transverse diameter of righ trectal plexus main fiber 1.07±0.22 mm,length 24.5±11.2 mm;transverse diameter of left 0.86±0.18 mm,length 15.2±2.66 mm.The pelvic plexus was differed in craniaoanal diameter and dorsovental diameter from right to left. In addition, the fiber number from the secondary pelvic visceral plexuses to specific organs was varied , while the stage numbers were constant in both sides. A total of 24 patients (group 1 LTME-ANP laparoscopic autonomic nerve preserving total mesorectal excision n =12; group 2 (control) OTME open total mesorectal excision n =12) with good baseline genitourinary function were operated on with the intent of total preservation of pelvic autonomic nerves and curative resection of rectal cancer. The patients were prospectively followed (median time of follow-up 6 months). In patients with a successful nerve-preserving surgery (83.3%, 12), 24 patients completed the evaluation of urinary function. The median duration for indwelling urine Foley catheter was respectively LTME-ANP 3.0 days (range, 1.0–7.6 days); OTME 5 (range, 3–8 days). The voiding function after operation of LTME-ANP was better than OTME( LTME-ANP Qax(ml/s), Vcomp(ml), RV(ml) was respectively 13.7±7, 163±78, 8.1±11.4; OTME 11.5±6.3, 143±69, 12.2±11.9). Total IPSS (LTME-ANP 8.3±5.6, OTME 10.7±7.3). Before and after surgery, there were no significant changes of IPSS scores in the present patient series. Sexual function of LTME-ANP and OTME after operation were both decreased, and LTME-ANP was better than OTME.Conclusion: These finding suggest that quantitive localization of the secondary pelvic plexusese via some landmarks is helpful and feasible to avoid the pelvic autonomic nerve damage, and it will ssupplies base on morphology to the total mesorectal excision (TME). Under laparoscopy, we can clearly identify and preserve the pelvic autonomic nerves to retain genitourinary function in most patients undergoing oncologic resection of rectal cancer. As advaced technical of surgery is available, patients undergoing oncologic resection of rectal cancer would be elevated their quality of life non-consideration economy.更多还原