全直肠系膜切除术(TME)是直肠癌手术治疗的基本原则,其要求就是将肿瘤及其区域淋巴结作为一个整体完整切除,这与强调整块切除、防止癌泄漏的膜解剖理论不谋而合.膜解剖的理论基础是腹膜的融合,对于融合及融合筋膜的理解需要抓住3个核心要点:(1)融合只发生在腹膜;(2) 融合筋膜的内部结构绝对无法分离;(3)融合具有多样性.充分掌握上述3点,才能辨证地理解和运用膜解剖,将其应用于直肠手术.直肠解剖位置特殊,故膜解剖在直肠的应用不完全同于胃或结肠:直肠后方间隙由腹膜融合退化后形成的疏松结缔组织所填充,骶前筋膜前叶在S4水平与直肠固有筋膜融合形成直肠骶骨筋膜,将后方间隙分为直肠后间隙和肛提肌上间隙;Denonvilliers筋膜是直肠前方间隙中的融合筋膜,其将直肠前方间隙分为直肠前间隙和前列腺后间隙并向两侧延伸与盆壁层筋膜融合覆盖着血管神经束表面;直肠侧方在10点及2点位置靠近盆底处,由直肠固有筋膜包绕直肠中动脉、盆丛神经直肠支及和脂肪组织构成直肠侧蒂;肛提肌裂孔水平则是由肛提肌筋膜及直肠固有筋膜融合形成裂隙韧带,起到固定肛管并封闭肛提肌裂口的作用.本文拟从膜解剖角度上述要点进行讨论,以期能够更好地指导外科医生完成腹腔镜直肠癌全直肠系膜切除术.%Total mesorectal excision (TME) is the basic principle of surgery in rectal cancer which requires en bloc removal of the tumor and its regional lymph nodes. This conincides with the theory of membrane anatomy that emphasizes en bloc resection and avoids cancer leakage. The basis of membrane anatomy is the fusion of peritoneum and three key pointsare needed to understand the fusion and fusion fascia: (1) the fusion only occursin peritoneum; (2) the inside of fusion fascia cannot be separated; (3) the fusion can be diversiform. Only mastering these key points can we comprehend and apply this theory dialectically. The membrane anatomy in rectum is different from stomach or colon because of its specific location. The posterior space of rectum is filled with the loose connective tissue which is the degeneration of peritoneum fusion. In this space, the anterior lay of presacral fascia fuses with the proper fascia of rectum at the S4 level and separates the space into the retrorectal space and the supralevator space. Denonvilliers fascia is the fusion fascia in front of rectum, which forms the prerectal space and retroprostatic space, and extends to lateral pelvic wall with fusion of the parietal fascia of pelvis, covering the neurovascular bundle (NVB) together. The proper fascia of rectum surrounds the middle rectal artery, the pelvic plexus rectal branch and the adipose tissue to form the lateral rectal pedicle at 10 o′clock and 2 o′clock near the pelvic floor. At the level of levator ani hiatus, the fusion of levator ani muscle fascia and the proper fascia of rectum forms the Hiatal ligament, which fixs the anal canal and closes the levator ani hiatus. This article intends to discuss the above points from the perspective of membrane anatomy, in order to better guide surgeons to complete laparoscopic total mesorectal excision for rectal cancer.
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