| The traditional radical hysterectomy is the surgical treatment of choice in patients with early cervical cancer and shows a better clinical efficacy. However, it also brings various irreversible complications such as bladder, anorectal, sexual dysfunction, as the damage of the pelvic autonomic nerves at the same time. Pelvic autonomic nerve consists of hypogastric nerve, pelvic splanchnic nerves and pelvic plexus. Research shows that hypogastric nerve lie in the below of the uterosacral ligament, pelvic splanchnic nerves and pelvic plexus lie in the lower half of the cardinal ligament, and the branches of the pelvic plexus lie in the vaginal adjacent complex. While the nerve fibers damage traveling in cardinal ligament is one of the major cause of complication metioned above. Japanese scholars Okabayashi proposed the nerve-sparing idea in RH firstly in1921. Mibayashai made improvements on the basis of Okabayashi, and he proposed to retain parasympathetic nerve dominating the bladder when cardinal ligament removal, which reduce the incidence of bladder dysfunction from a certain extent. In1988,Sakamoto reported the pelvic autonomic nerve preservation technolog for the first time in English, namely Tokyo operation, and he proposed to divided cardinal ligament into blood vessels and nerves portion, and surgeon can identify blood vessels and nerves and retain the nerves in cardinal ligament through touching. Yabuki formally gave the operation named nerve sparing radical hysterectomy in1991. NSRH retain the pelvic splanchnic nerves and part of the pelvic plexus on the basis of traditional pelvic surgical procedures, which largely reducing the occurrence of the complications above-mentioned. However, due to the retained of part of the cardinal ligament, its curative effect is been questioned by experts and scholars. In order to remove more cardinal ligament and retain the pelvic autonomic nerve as well, It is necessary to make detailed research on the nerves and vessels in cardinal ligament.The literature and our previous studies have demonstrated that the cardinal ligament was mainly composition of PAN, blood vessels, lymphatic vessels and a variety of connective tissue, and we also conducted a preliminary qualitative and quantitative studies on cardinal ligament. However, the three-dimensional structure of the nerves and vessels in cardinal ligament is still lack and not reported at home and abroad, which is exactly the key operation in anatomy. Therefore we construst the digital three-dimensional model of nerve vascular tissue for cardinal ligament by computer reconstruction technology, to provide three-dimensional anatomy basis for the NSRH operation improvement.Digital three-dimensional reconstruction technique is an important technology of the digital medicine, it refers to convert the continuous2d image into a3d image by using computer technology, and obtain intuitive3d graphics for clinicians to observational study more easily. At recently, the main available2d data sets are digital data sets, CT or MRI data sets and serial sections data sets. Digital human obtain two-dimensional human data set by a thin layer of milling of specimen and then attain3d visualization of the human body data by computer3d reconstruction. It has the advantages of color and intuitive, but difficult to acquisition and reconstruction,which limits its extensive application in clinical. In recent years, with the development of imaging technology, the3d reconstruction based on CT or MRI data sets has played its important role in medicine gradually. Due to its sources and Individualization,it has been widely used in clinical practice and obtained good results, and shows its superiority in anatomical study. But due to the limitation of layer and resolution, and the restriction of the image intensity, it has yet to complete the blood vessels, nerves, construction of lymphatic vessels below millimeter.The three-dimensional reconstruction of biological tissue by serial slices refers to obtain2D images of organization structure of continuous thin sections, then import into a computer to get the three-dimensional morphological structure of the tissues. The methodology is the solution for structure reconstruction millimeter below, which can not clearly, system display in CT and MRI. And it has been successfully applied in the3d reconstruction of the renal tubules in mice, endometrial capillaries and fetal pelvic nerve. This study aims to construct the three-dimensional structure model of the cardinal ligament by using stained serial sections data sets, combines of image recognition, location registration and three-dimensional reconstruction technology, based on the previous research on digital three-dimensional reconstruction, and then provide a cardinal ligament stereo anatomy basis for NSRH operation.The first part:Research on locating material for three-dimensional reconstruction of nerve vascular tissue for cardinal ligamentObjective:To compare the adhesion ability of four positioning material on the slices after using different kinds of staining methods, and to find an ideal locating material for three-dimensional reconstruction of nerve vascular tissue for cardinal ligament.Methods:A fresh ligament specimen was obtained from a stage IB1cervical cancer patient who underwent abdominal radical hysterectomy. The common suture (3-0), hair, absorbable suture (8-0) and biological tissue (about0.6mm in diameter) were embedded with ligament specimen using paraffin as embedding material. Then serial tissue paraffin sections were made. Sliced were randomly divided into four groups, and conventional HE staining, TH staining, VIP staining and D2-40staining was made separately. At last, remnants of the number of locating points were recorded under the microscope and four different materials in different staining results were compared.Results:1. The overall patch rate of biological tissue is highest in the four locating materials, and the difference was statistically significant (χ2=115.12, P<0.01);2. The difference of patch rate of biological tissue after using different kinds of staining methods was not significant(χ2=0.16, P=0.98).Conclusion: Acquiring biological tissue by puncture needle as localization material has successfully solved the problem of location material loss, which have good effect on the adhesion of HE staining and immunohistochemical staining.The second part:Three-dimensional reconstruction of nerve vascular tissue for cardinal ligamentObjective:Construct the digital three-dimensional model of nerve vascular tissue for cardinal ligament.Methods:A fresh cardinal ligament specimen was obtained from a stage IB1cervical cancer patient who underwent abdominal radical hysterectomy. The direction of the cardinal ligament fixed with dewatering box. Tissue dehydration was performed after fixed8-12h in10%Formalin. Four biological tissues (diameter of about0.6mm) take advantage of the needle wore were embedded in paraffin with the specimen as a positioning rod. The processed cardinal ligament was then cut coronally at a5um thickness,4successive layers as a group and each interval of80um. All slices were stained after65℃oven baked stratified2-3h. In the first layer, the slices were stained with HE. In the second layer, the slices were stained with TH, to specific marker sympathetic fibers. In the third layer, the slices were stained with VIP, to specific marker parasympathetic fibers. In the fourth layer, the slices were stained with D2-40, to specific marker lymphatic vessels.All sections were placed under the microscope to observe the various components of the microstructure. Digital slice scanning system is used for slice scanning.2×10times were used to determine the scanning range, and then go to automatic section scan under10×10times. Four groups slice images were automatic registrated by using Photoshop software and Matlab software. All slices data set images after registration were import into Photoshop software to draw contours of blood vessels sympathetic, parasympathetic and lymphatic vessels with the brush tool.Each group of pictures were import into ACDSEE software to transferred to the appropriate size. Import images into Mimics software, select the appropriate threshold after positioning and interpolation processing, and then construct the three-dimensional digital model of nerve vascular tissue for cardinal ligament.Results:1. Based on continuous slice data sets, we successfully constructed the large vessel three-dimensional digital model in the cardinal ligament:large vessel mainly walk in the department of vascular of cardinal ligament.2.Based on continuous slice data sets, we successfully constructed the sympathetic three-dimensional digital model in the cardinal ligament:sympathetic mainly walk in the bottom of the cardinal ligament, gradually increased from the cervical lateral pelvic side wall.3.Based on continuous slice data sets, we successfully constructed the parasympathetic three-dimensional digital model in the cardinal ligament: parasympathetic mainly walk in the bottom of the cardinal ligament, gradually increased from the cervical lateral pelvic side wall.4. Based on continuous slice data sets, we successfully constructed the cardinal ligament three-dimensional digital model, and after registrate with the large vessel, sympathetic, parasympathetic and lymphatic vessels, we successfully constructed the digital three-dimensional model of nerve vascular tissue for cardinal ligament.By the measure tool, the cardinal ligament is26.77mm bandwidth, from the cervical lateral to the pelvic side wall nerve and blood vessel distance were4.87mm,7.18mm,8.59mm.Conclusion:Based on continuous slice data sets, we can not only construct the large vessel, sympathetic, parasympathetic and lymphatic vessels, we can also clearly shows the spatial relationship between them after registration. By the measure tool of Mimics, we can also measure the length, nerve and blood vessel to the cardinal ligament of distance, the distance calculated vascular, nerve and the main ligament, and then provide a reference for NSRH operation. |
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