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  • Title: [Anatomical observation and clinical significance of rectosacral fascia in total mesorectal resection].
    Author: Wang XJ, Ghareeb WM, Chi P, Huang Y.
    Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2020 Jul 25; 23(7):689-694. PubMed ID: 32683831.
    Abstract:
    Objective: To observe the anatomical architecture of rectosacral fascia and discuss the best plan for accurate peri-rectal dissection in laparoscopic/robotic total mesorectal resection (TME). Methods: A descriptive cohort study was carried out. A total of 127 patients with rectal cancer who underwent TME in the Department of Colorectal Surgery at the affiliated Union hospital of Fujian Medical University were included, patients' demographics with their pathological details and operation videos were collected for analysis. Another 20 high-definition images of post-TME surgical specimens were collected from our digital database. A total of 28 cadaveric models were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University, to observe the anatomical details of rectosacral fascia. Results: (1) Anatomical observation showed that the pre-hypogastric fascia attaches to the proper fascia of the mesorectum in a horizontal arc posteriorly, forming the rectosacral fascia. If this fusion couldn't be identified and appropriately transected during posterior space dissection, it would be easy to destroy the proper fascia and dissect through the mesorectum resulting in residual mesorectum tissue. After the fascia transaction, the proper fascia of the mesorectum is still intact distally. The upper part of rectosacral fascia bilaterally re-separated again into the proper fascia and pre-hypogastric fascia. The pre-hypogastric fascia acts as a "fascia barrier" when dissecting the lateral space constantly from posterior to anterior. The right attachment of the rectosacral fascia was gradually transected. The pelvic plexus from the right S2-S4 was covered by the pre-hypogastric fascia which is considered the outer side layer of rectosacral fascia laterally. It was observed that the fascia continued with the anterior layer of the Denonvilliers' fascia, which has been transected during anterior space dissection. The proper fascia, which is the inner side layer of rectosacral fascia laterally, was still intact. The edge of the right rectosacral fascia attachment ran obliquely from the back and upward into the front direction. The left extension was similar to the right. (2) Cadaveric specimens: at the level of the lower edge of S4 vertebral body, the pre-hypogastric fascia fused with the proper fascia to form the rectosacral fascia. The right attachment margin of the rectosacral fascia was cut off step by step. The attachment margin of the rectosacral fascia went from the back and upward to the front downward direction. The right edge of rectosacral fascia attachment continued with the anterior layer of the Denonvilliers' fascia at the pre-rectal space and attached to the pre-hypogastric fascia laterally. The pelvic plexus sends out many tiny rectal branches on the anterolateral side, which pass through the transitional area between pre-hypogastric fascia and the anterior layer of the Denonvilliers' fascia to innervate the rectum. (3) TME specimens observation: the posterior attachment of rectosacral fascia was curved around the mesorectum with bilateral oblique attachments. The mesorectum was covered by fusion fascia below the posterior and bilateral attachment margin while it was covered only by the proper fascia above it. Conclusion: according to the morphological characteristics of rectosacral fascia, the rectosacral fascia should be dissected at the level of S4 vertebral body posterior to the rectum in an arc, shape and then enter the superior-levator space. Before dissecting the bilateral spaces, the anterior space of the rectum should be dissected first. The anterior layer of the Denonvilliers' fascia should be cut off into an inverted "U" shape, and then the lateral space should be dissected from anterior to posterior. Finally, the lateral attachment of rectosacral fascia was transected to ensure the integrity of the mesorectum without damaging the pelvic plexus branches and NVB. 目的： 熟悉直肠骶骨筋膜形态及走行，对于在全直肠系膜切除术（TME）中，保证直肠系膜完整性及保护自主神经盆丛至关重要，但目前尚缺乏对直肠骶骨筋膜的全面完整描述。本文通过高清腹腔镜或机器人TME中的临床观察和尸体标本解剖，对直肠骶骨筋膜形态及走行进行观察总结，并讨论该区域的最佳游离路径。 方法： 采用描述性病例系列研究方法，回顾性分析2018年1—12月期间就诊于福建医科大学附属协和医院结直肠外科的127例直肠癌患者的临床病理资料和手术录像，及同期科室数码数据库的20例TME术后直肠标本的高清照片，同时纳入来源于福建医科大学解剖学教研室的28例人体尸体标本，观察直肠骶骨筋膜形态和移行情况。 结果： （1）总结手术录像提示，127例患者均可观察到直肠骶骨筋膜从后方呈水平弧形附着于直肠固有筋膜，形成融合筋膜。融合区域无法直接分离，如不离断，则容易破坏直肠固有筋膜。离断后，沿着直肠后方直肠骶骨筋膜附着缘向右侧观察，见该水平以下右侧间隙下半部仍为融合筋膜，该融合筋膜在侧方上半部重新分开为直肠固有筋膜与腹下神经前筋膜，该分开处的腹下神经前筋膜为侧方间隙分离时的刚性障碍。沿着其分开处逐步切断该筋膜，可见由右骶（S）2~S4发出的盆丛被灰白色腹下神经前筋膜覆盖，观察到该筋膜与Denonvilliers筋膜前间隙已被切断的Denonvilliers筋膜前叶相延续；而内侧的直肠固有筋膜仍完整。右侧直肠骶骨筋膜附着缘从后上向前下斜行走行。左侧直肠骶骨筋膜形态与右侧对称。（2）观察28例半骨盆尸体标本发现，于S4椎体下缘水平，腹下神经前筋膜向前与直肠固有筋膜融合成直肠骶骨筋膜。向直肠右侧间隙进行分离，逐步切断直肠骶骨筋膜的右侧附着缘，见直肠骶骨筋膜附着缘从后上走行至前下，呈斜行走向。附着缘向头侧移行为腹下神经前筋膜，向前移行为Denonvilliers筋膜前叶。盆丛在前侧方发出多支细小直肠支，呈束状穿过腹下神经前筋膜和Denonvilliers筋膜前叶的相互移行区，支配直肠。（3）对20例TME标本进行观察，见后方直肠骶骨筋膜附着缘围绕着直肠系膜呈弧形，两侧附着缘呈斜行。后方和两侧附着缘后下方的直肠系膜被直肠骶骨筋膜包绕，附着缘水平的前上方直肠系膜被直肠固有筋膜包绕。 结论： 结合直肠骶骨筋膜形态学特点，术中应于S4椎体水平在直肠后方弧形切断直肠骶骨筋膜，从直肠后间隙进入肛提肌上间隙；进行两侧间隙分离前应先行直肠前方间隙的分离，倒"U"型切断Denonvilliers筋膜前叶，沿着Denonvilliers筋膜后间隙从上向下分离侧前方间隙，最后切断直肠骶骨筋膜的两侧附着缘，方可保证直肠侧方筋膜的完整，且并不损伤盆丛分支与神经血管束。.
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