背景：传统全直肠系膜切除后伴随高的泌尿生殖功能障碍，学者们因此对标准手术分解方式产生质疑。我们提出在直肠癌手术中保留邓氏筋膜的必要性。但是，如何准确找到邓氏筋膜？本研究旨在通过比较尸体解剖结果和手术录像观察来探讨邓氏筋膜的解剖特征，从而提出一种在直肠癌手术中保留盆腔自主神经的分离方法。
方法：2009年1月至2019年1月之间，进行了5个成年男性尸体解剖，并回顾了135例因中低位直肠癌接受直肠全系膜切除手术的患者手术录像，从而寻找和比较邓氏筋膜的结构。
结果：在5具男性尸体标本中观察到邓氏筋膜的单层结构，其位于直肠、膀胱底、精囊、输精管和前列腺之间。邓氏筋膜起源于直肠膀胱反折，向尾侧与前列腺顶端的直肠尿道肌融合，并在两侧与侧方韧带融合。在中部该筋膜变薄，厚度为1.06+-0.1mm。邓氏筋膜的皇冠形状有一点呈三角形，中间的高度大约在5.42+-0.16cm。神经在邓氏筋膜前方分布比后方密集，特别在两侧。在腹腔镜下，邓氏筋膜起源于直肠膀胱陷凹的最低点，形成一个增厚的白线，可以做为寻找邓氏筋膜的良好标志。
结论：找到邓氏筋膜的手术指示线可以帮助我们找到邓氏筋膜，提高我们在直肠癌行全系膜切除术中保留盆腔自主神经功能的能力。
In 1982,Heald et al. proposed the theory of total mesorectal excision as the gold standard surgery for rectal cancer. However, after traditional TME, the occurrence rate of urogenital dysfunction was still high. The reason is that the surgery directly damages the pelvic autonomic nerves.
在1982年，Heald等提出了直肠全系膜切除，作为直肠癌手术的标准术式。但是，在传统直肠全系膜切除术后，泌尿生殖功能障碍的发生率仍很高。原因是手术医生直接损伤了盆腔自主神经。
Because the pelvic autonomic nerve is thick in the retrorectal and lateral space, it is easy to be identified at this site in a TME surgery, especially under laparoscopy. However, the distribution of the pelvic autonomic nerves in front of the rectum is clump-like and difficult to identify, challenging the dissection of the anterior wall of the rectum.
因为盆腔自主神经在直肠后和侧方间隙厚，因此可以在直肠全系膜切除术中轻松找到该神经，特别是在腹腔镜下，但是，在直肠前方，盆腔自主神经的分布呈束状，难以定位，因此在直肠前壁分离时非常困难。
Autopsy identification of the Denonvilliers’fascia
TME was performed by incisively dissociating the rectum using the intermediate approach, pulling the rectum forward, dissecting the mesorectum along the retroperitoneum, continuing the dissection along the rectum intrinsic fascia, posteriorly entering the retrorectal space until reaching the pelvic floor. The left side of thin layered retroperitoneum was dissected and opened, reaching the back side, followed by dissecting through the anterior peritoneum,dissociating the bladder and the rectal preperitoneum until reaching the Douglas fossa and joining the top of Denonvilliers’ fascia. The Denonvilliers’ fascia was dissociated between the seminal vesicle and the rectum to maintain its integrity.
Dissection was performed between the fascia propria of the rectum and the presacral fascia posteriorly in the retrorectal space that contains loose areolar tissue and is devoid of vessels and nerves, leaving the dense and tough tissue strips laterally which are the lateral ligaments. The medial pelvis was divided into the left and right parts along the median sagittal plane, pulling the lateral rectum laterally, and the posterior lateral plexus was further dissociated to expose the hypogastric nerve to find the anatomical relationship between the Denonvilliers’ fascia and the lower abdomen. The start and end points of the Denonvilliers’ fascia were confirmed, the fascia was extracted, and the length of the fascia was measured and recorded.
尸体解剖中寻找邓氏筋膜
中间入路切开分离直肠进行直肠全系膜切除手术，将直肠向前牵引，将直肠系膜沿着后腹膜分离，持续沿着直肠内筋膜分离，后方进入直肠后间隙，直至到达盆底。分离打开薄的左侧后腹膜，到达后方，然后分离前方腹膜，分离膀胱和直肠前腹膜，直至到达子宫直肠陷凹，接入邓氏筋膜的顶端。将该筋膜在精囊和直肠之间分离，从而维持其完整性。
在直肠筋膜和骶前筋膜之间的直肠后间隙内，分离疏松无血管神经组织，保留两侧致密坚硬的组织，即侧方韧带，中盆腔沿着正中平面分为左右侧，将直肠向侧方牵拉，进一步分离后侧丛，暴露腹下神经，从而发现邓氏筋膜和下腹的解剖关系。确定邓氏筋膜的起始点，然后去除该筋膜，测量并记录该筋膜的长度。
There weren’t controversies regarding the separation of the posterior and lateral rectal walls. The correct plane for separation of the posterior and lateral rectal walls was avscular in most cases except where it was crossed by the lateral ligaments. By pursuing the lipoma-like outer surface of the mesorectum, the autonomic nerve pelxuses could be preserved. The lateral ligaments could simply be cut by Harmonic Ultrasonic Knives. Hoever, the distribution of the pelvic autonomic nerves in the anterior rectal wall is complicated and difficult to recognize.
对于直肠后壁和侧壁的分离没有争议。在大多数病例中，侧方和后方的分离平面是无血的，除了在侧方韧带跨过处。通过遵循直肠系膜的脂肪样外表面，可以保留自主神经丛。侧方韧带可以用超声带离断。但是，在直肠前方的盆腔自主神经就很复杂，难以识别。
Heald et al. believed that the Denonvilliers’ fascia is the front boundary of the rectal intrinsic fascia and acts as a barrier to rectal cancer. Therefore, TME should be performed in front of the Denonvilliers’ fascia to completely remove the mesorectum so that no residual tumor is left. This operative procedure is widely accepted all over the world.
Heald等相信邓氏筋膜是直肠内筋膜的前方边界，可以作为直肠癌的屏障。因此，直肠系膜切除术应该在邓氏筋膜前方进行，从而完全切除直肠系膜，确保没有肿瘤残留。这一手术操作被全世界所认可。
According to our anatomical observations, the Denonvilliers’fascia terminates at the lateral ligaments, which present as constant, dense connective bundles that are located on the lateral sides of the lower part of the rectum and extend between the rectal visceral fascia and pelvic parietal fascia, above the levator ani. The lateral ligaments constitue the inferior hypogastric plexus that gives rise to the rectal plexus, extends toward the rectum and the vessels from the lower part of the rectum toward the iliac lymph nodes. A small branch of the internal pudendal artery lies in front of the fascia, and nerve fibers from the lateral ligaments form a neurovascular bundle in the anterolateral side of the Denonvilliers’fascia. The components of the inferior hypogastric plexus include some parasympathetic nerves and are closely related to urogenital function.
根据我们的解剖观察，邓氏筋膜终止于侧方韧带，后者是一个恒定的致密结缔组织纤维束，位于直肠下部的两侧，在直肠脏层筋膜和盆腔壁层筋膜之间延伸，在肛提肌上方。侧方韧带包含下腹下神经丛，其发出直肠丛，延伸到直肠和直肠下部的血管，朝着髂内内淋巴结。阴部内动脉的一个小分支位于邓氏筋膜前方，侧方韧带的神经形成一个神经血管束，位于邓氏筋膜的前外侧。下腹下神经丛的组成包括一些副交感神经，和泌尿生殖功能密切相关。
If the dissection is performed behind the Denonvilliers’fascia, it would damage the rectal intrinsic fascia, destroy the mesangial tissue, and affect radical tumor resection. If the dissection is performed in front of the Denonvilliers’fascia, well-defined, bead-like plump seminar vesicles and the prostate could be located. However, if a slight inadvertent injury to the neurovascular bundle occurs in the anterolateral side of the Denonvilliers’fascia, the visual field would be stained by blood, and the anatomical structures would be unclear, resulting in damage to the parasympathetic corpus cavernosum. Additonally, it is easy to damage the parasympathetic corpus cavernosum from the pelvic plexus in front of the Denonvilliers’fascia, which plays an important compensatory role in the damage of the pelvic wall and cause urogenital dysfunction. We believe that the preservation of the Denonvilliers’ fascia is of great significance in reducing the rate of postoperative urogenical dysfunction in rectal cancer patients, which is supported by the results from other studies.
如果解剖在邓氏筋膜后方进行，就会损伤直肠内在筋膜，破坏膜组织，影响肿瘤广泛切除。如果解剖在邓氏筋膜前方进行，边界清楚的，柱子样的精囊和前列腺就可以看到。但是，轻微的意外损伤到邓氏筋膜前外侧的神经血管束，血液就会破坏术野，解剖结构就会模糊，导致损伤周围的副交感海绵体。此外，很容易损伤起源于邓氏筋膜前方盆丛的副交感神经海绵体，其对于盆壁损伤有重要的代偿作用，从而导致泌尿生殖功能失调。我们相信保留邓氏筋膜，对于减少直肠癌患者术后泌尿生殖功能障碍非常重要，这一点得到其它研究的支持。
In clinical practice, most surgeons are unable to accurately identify the Denonvilliers’fascia, leading to the destruction of the Denonvilliers’fascia and damage to the pelvic autonomic nerves. At present, a popular practice is to incise the rectovesical pouch at the point of 1cm above the peritoneal reflection. It would enter the surgical plane in front of the Denonvilliers’fascia and then sperarates in the loose space in front of the Denonvilliers’fascia. This process coincides with the modified ‘U’-shaped resection of the Denonvilliers’fascia proposed by Heald et al. Although this method preserves the anterolateral side of the Denonvilliers’fascia to avoid damage to the inferior hypogastric plexus, it still damages the ramus communicans in front of the Denonviiliers’fascia and damages the pelvic autonomic nerves. Our clinical observations showed that this method did not cause significant sexual dysfunction.
在临床实践中，大多数手术医生不能准确找到邓氏筋膜，导致损伤邓氏筋膜和盆腔自主神经。目前，一个常用的方法是在直肠膀胱陷凹处腹膜反折上方1cm切开，然后进入邓氏筋膜前方的手术平面，然后在此处的疏松间隙筋膜分离。这一过程与Heald等提出的U形切开相似。尽管这一方法保留了邓氏筋膜前外侧，从而避免损伤下腹下神经丛，但仍然损伤了邓氏筋膜前方的分支，损害盆腔自主神究竟。我们的临床观察发现这一方法不会导致明显的性功能障碍。
We combined cadaver dissection with surgical video observations and found that the Denonvilliers’fascia was originated at the rectovesical pouch, presenting as a thickened white strip/line. The thickened white line is a good mark for identifying the Denonvilliers’fascia. Our results indicate that if a dissection is made in front of the white line, the ramus communicans in front of the Denonvilliers’fascia woudl be damaged. However, if a dissection is performed behind the white line, damages to the inferior hypogastric plexus and the ramus communicans in front of the Denonvilliers’fascia could be avoided.
我们联合尸体解剖和手术录像观察，结果发现邓氏筋膜起源于直肠膀胱反折，表现为一个增厚的白色条带。增厚的白线是一个确定邓氏筋膜的良好标志。我们的结果提示，如果在白线前方分离，邓氏筋膜前方的神经分支就会损伤，但是如果在白线后方分离，就可以避免损伤下腹下神经丛和邓氏筋膜前方的神经分支。
来源：Huang J, Liu J, Fang J, Zeng Z, Wei B, Chen T, Wei H. Identification of the surgical indication line for the Denonvilliers’ fascia and its anatomy in patients with rectal cancer. Cancer Commun (Lond). 2020 Jan;40(1):25-31. doi: 10.1002/cac2.12003. Epub 2020 Feb 18. PMID: 32067419; PMCID: PMC7163926.
点评：逻辑非常清楚的一篇文章，非常高兴能够在国际杂志上看到越来越多的中国临床医生发表的手术文献。解剖是手术的灵魂，简单单纯的重复没有意义，更何况，错误重复一千次，也依然还是错误。
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