Deep Pelvic Anatomy Revisited for a Description of Crucial Steps in Extralevator Abdominoperineal Excision for Rectal Cancer
Deep Pelvic Anatomy Revisited for a Description of Crucial Steps in Extralevator Abdominoperineal Excision for Rectal Cancer
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DOI：
10.1097/dcr.0b013e31821c4bac
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发表时间：
2011-08
影响因子：
3.9
通讯作者：
S. Stelzner;T. Holm;B. Moran;R. Heald;H. Witzigmann;D. Zorenkov;T. Wedel
中科院分区：
文献类型：
--
作者：
S. Stelzner;T. Holm;B. Moran;R. Heald;H. Witzigmann;D. Zorenkov;T. Wedel
背景：腹会切除可为进展期低位直肠癌带来更好的肿瘤预后。手术切除平面的准确定义是实现负周切缘的关键。目的：本研究旨在描述在腹会阴外切术中存在意外损伤风险的周围解剖结构。设计和地点：在一所大学的临床解剖实验室进行关节外科和大体解剖解剖。方法：在4具成人身体骨盆标本上，采用会阴腹会阴联合腹会阴外翻式切除技术，进行阶段性解剖研究。肌肉、筋膜、肌腱和神经结构被仔细暴露，并与相应的手术切除平面相关联。结果：除了在全直肠系膜切除术中需要识别和保留的自主神经外，还可以清楚地识别在会阴外翻器切除术中受到危害的进一步结构。阴部末梢神经分支在耻骨直肠吊带的外表面接近手术切除平面。同样，盆丛及其神经血管束嵌在顶盆筋膜内，延伸到前列腺尖，在那里必须分割顶盆筋膜。这些神经结构汇聚在会阴体区域，该区域没有为外科解剖提供“自开”平面。因此，需要将肛门直肠标本从会阴体和会阴浅横肌前方急剧分离，既有无意中损坏上述解剖结构的风险，也有标本穿孔的风险。局限性：这项研究主要集中在与外科手术相关的宏观地形图上，因此以前发表的组织学检查没有进行。结论：目前的解剖研究突出了那些需要明确识别的解剖标志，以便在腹会阴联合切除术中成功地获得负环切缘和保留泌尿生殖功能。
BACKGROUND: Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins. OBJECTIVE: This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision. DESIGN AND SETTING: Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy. METHODS: A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes. RESULTS: In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no “self-opening” planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen. LIMITATIONS: The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed. CONCLUSION: The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.