| Project context:Rectal cancer is the common malignant tumor, which is the NO.2in the carcinoma of alimentary tract. The application and popularization of Total Mesorectal Excision (TME) makes that the surgery of rectal cancer has a new breakthrough with a significant decrease of local recurrence rate and an obvious increase of the retention rate of patients’anal. TME of the rectal cancer stress a precise surgical dissection of the pelvic cavity in the operation. Finishing the complex and precise operation in the narrow pelvic cavity, we need not only to excise the pathological intestinal tube and mesenterium, to sweep the draining lymph system, but also to protect the important nerves. It is the concrete manifestation of the technological improvement of surgery in anatomy, following the principle of tumor-free technique and improving quality of life in the rectal tumor operations. But it is common that patients have the complication of urinating and sexual dysfunction after the amplified lymph node dissection of rectal tumor (especially in males), whose incidence rate are7%-70%and40%-100%. The incidence rate of sexual dysfunction after Miles operation is over40%. How to decrease the injury to pelvic nerve is the focus of the clinic. The pelvic autonomic preservation (PANP) presented by Tsuchiya of Japan becomes the main measure of protecting patients’sexual function. The laparoscopic colorectal operations have the advantages and characteristics of less trauma to napes, less pain of the wound after operation, earlier time of anal venting, fast time of regaining normal activities, less hospital stays; TME operation’s principle embodies the radical results, PANP operation’s principle embodies the protection to autonomic nerves, laparoscope embodies the minimally invasive and tractability; the operation refers to larger range and is not restricted to one area in clinic, which increase the difficulties of the operation; laparoscope is a new edge tool to rectal tumors in clinical treatments. Meanwhile the laparoscopy technique is perfecting and popularizing constantly during the clinical grope and practice, whose goal is to decrease the influence of operations to patients in the precondition of radical cure. The mode and skill of laparoscope are remaining deeper studies. This research will analyze the admission passage and technique and compare patients having TME+PANP by laparoscope with that by laparotomy, observing the benefits of PANP+TME by laparoscope to patients and analyzing the surgical skills of TME+PANP by laparoscope, which are all on the basis of cadaveric anatomic studies.Objective:Abdomen pelvic autonomic nerve preservation for rectal cancer anatomical analysis of total mesorectum excision, to experience the part of the pelvic autonomic nerve preservation; Pelvic autonomic nerve preservation observation and analysis of male patients with colorectal cancer radical surgery voiding dysfunction and sexual dysfunction, to provide clinical value of laparoscopic resection of rectal cancer total mesorectum.Methods:In anatomy,6cases of complete male specimen anatomic analysis, observation of pelvic nerve and go line; Choice in June2011to October2012treated94cases of colorectal cancer patients, According to the operation mode divided into two groups, treatment group and47cases with TME+PANP, and the control group47underwent miles operating mode. Respectively on two groups of patients with sexual function, voiding dysfunction, and postoperative local recurrence (locally recurrent rectal cancer, LRRC) situation. In the aspect of operations, we need have the stringent assessments of pre-operation and select the appropriate surgical mode on the basis of being familiar with the nerve distribution and anatomic gradation. To select different PANP operation plans due to the patients’situation of tumor infiltration:Type Ⅰ:Refer to pelvic autonomic nerve preservation completely, which is suitable for patients with less possibility of lateral lymphatic metastasis;Type Ⅱ:Refer to excision of one side or both sides of presacral nerve plexus and reservation of both pelvic nerve plexus, which is suitable for patients with tumors located over the peritoneal reflection or patients suspected with lymphatic metastasis or perforation of intestinal wall by rectal cancer.Type Ⅲ:Refer to excision of one side or both sides of presacral nerve plexus and reservation of one side of pelvic plexus, which is suitable for patients with tumors located below the peritoneal reflection and possibility of lymphatic metastasis;Type Ⅳ:Refer to the entire excision of the pelvic autonomic nerves, which is suitable for patients with tumors located below the peritoneal reflection, perforation of intestinal wall or lymphatic metastasis responding a both sides of lymphatic dissection.Observation of indicators of the two group patients after operations:1) operation related indicators(including whole operational time, cadaverine quantity of bleeding during operation, the recovery time of intestinal function after operation, the recovery time of diet after operation, the time of getting out of bed for the activity after operation and the incidence rate of complication after operations).2) Operation safety related indicators:comparison of the total number of the scavenged lymphatic nodes during operations between two group patients, the length of the proximal and distal incisal tumors during operations and the examination situation of the incisal edges’pathologies3) Sexual function indicators, including the rate of erectile dysfunction and ejaculation dysfunction, and erectile dysfunctions have3grades:Grade I Refer to normal erectile function with no difference with pre-operation; Grade Ⅱ Varying degrees decline of patients’erectile function with only segmental erection and obvious decline of the rigidity of erectile after operation;Grade Ⅲ Refer to no erection after the operationEjaculation functions have3grades:Grade Ⅰ Refer to the ability of ejaculation with normal or less ejaculation quantities;Grade Ⅱ Refer to having retrograde ejaculation or having ejaculation dysfunction after operation;Grade Ⅲ Refer to entirely no ejaculation4) Urination dysfunction related indicators:to investigate the time that patients can urinate voluntarily and to detect the residual urine volume of patients before and after operation separately. Due to the Saito grade, the urination dysfunction has4grades.Grade Ⅰ refer to normal condition of patients with no urination dysfunction;Grade Ⅱ Refer to mild urination dysfunction of patients with symptom of frequent urination, but the residual urine volume<50ml;Grade Ⅲ Refer to moderate urination dysfunction, the patients need catheterization once in a blue moon and the residua urine volume>50ml;Grade Ⅳ Refer to severe urination dysfunction, the patients have the symptoms of uracratia and urinary retention, which need catheterization for treatment.The situation of local recurrence after operations, post-operation follow-up for1year, to review the CEA and CA19-9in blood, chest radiography, color Doppler ultrasound for liver and pelvic cavity periodically; DRE conventionally, the assessment of the patients’conditions changes,; colonoscopy, CT/MRI or PET for examination if necessary.ResultsThe dissection to mesorectum and pelvic fascia demonstrates that mesorectum is continuous with sigmoid mesocolon. The reproductive tubes, internal iliac vessels, automatic nerves and the parietal muscles of pelvic cavity are covered with parietal fascia (the anterior sacral fascia is behind the rectum) and exterior face is smooth pelvic fascia. The outside mesorectum was covered with raglan sleeves structure formed by pelvic fascia, which is fascia propria of rectum, in front of the rectum, peritoneum is outside of the pelvic fascia over the peritoneal reflection; below the peritoneal reflection, the Denonvilliers fascia is in front of pelvic fascia (the fascia has two layers, former layer is closely adhesive to the space of seminal vesicle and prostate). Anterior sacral fascia is forwardly continuous with the former layer of the Denonvilliers fascia, which forms the anterior rectal intervals anteriorly and anterior sacral intervals posteriorly between fascia propria of rectum and parietal fascia. Posterior rectal interval is linked with posterior left colonic interval frontally, with interval between both layers of Denonvilliers fascia (anterior rectal interval) forwardly. Focus with mesorectum, fascia propria of rectum, anterior sacral fascia and the myolemma of pelvic wall muscles are annular distribution outwardly, perirectal interval is separated into posterior rectal interval in the middle and anterior sacral interval in outside, which are annular interval; posterior rectal interval is the ideal surgical platform of the total mesorectal excision. In the lateral side of the down1/3rectum, after the incision of peritoneum, following the arteria scapularis dorsalis from lateral walls of posterior pelvic cavity to rectum, pulling the mesorectum upwardly or laterally to reveal connective tissue bind formed with arteria and vein, sacral nerves, fats and fibrous tissues, which is called "lateral ligaments of the rectum" by surgeons and is not constant.The anatomical observation of nerves demonstrates that auto nerves include sympathetic nerve and parasympathetic nerve. Most sympathetic nerves enter into pelvic cavity from plexus aorticus abdominalis down through the fork of aorta abdominalis forming hypogastric nerve plexus then branch to left and right hypogastric nerves downwardly below the sacral promontory. Hypogastric nerves are in the middle of peritoneum and visceral fascia then distribute in front of sacral promontory after entrance into pelvic cavity. So we can look for it in the location of sacral promontory, about1cm from the midline or1.5-2.0from the inner side of ureter. Hypogastric nerve plexus distribute following the ureter and internal iliac artery to lateral, end sides. Parasympathetic nerves which are also called pelvic splanchnic nerve is differentiated from S2-S4nerves, giving out from the anterior sacral foramina, distribution to lateral anterior side through the parietal layer of pelvic fascia, then, at the location that4cm from the midline, it get through the behind of the parietal layer of pelvic fascia. Then it passes through the parietal layer fascia at the antetheca of pelvic cavity and distribute in the interval of visceral layer fascia, which converge with hypogastric nerves to pelvic automatic nerves in the anterior lateral pelvic wall. The location is on the level of seminal vesicle vessels with arteria haemorrhoidalis media passing through. The visceral nerve fibers emitted by pelvic automatic nerve plexus distribute on the urinary and genital organs, realizing the domination to bladder and sexual organs, among which there are some tiny branches getting into the mesorectum and dominating its function.Comparison of operations related indicators between two group patients:in the control group and observation group, the whole operational time (min), cadaverine quantity of bleeding during operation (ml), the recovery time of intestinal function after operation (d), the recovery time of diet after operation (d), the time of getting out of bed for the activity after operation (d) and the incidence rate of complication after operations (%) are(133.79±25.06VS154.00±24.32)、(194.64±9.37VS58.30±11.00)、(3.96±0.72VS2.91±0.78)、(5.98±1.22VS3.68±0.78)、6.26±1.11VS4.04±1.04)、(9.52%VS9.38%). The cadaverine quantity of bleeding during operation, the recovery time of intestinal function after operation, the recovery time of diet after operation, the time of getting out of bed for the activity after operation in the control group are obvious higher than that in the observation group, the whole operational time of control group is shorter than that of observation group; there are no difference of the incidence rate of complication after operations between the two groups. The groups’patients reach to RO excision with no positive incisal edge. The number of scavenged lymphonodi during operation in the control group is13.53±1.73, which in the observation group is13.36±1.80; the length of the proximal incisal tumors during operations in control group is18.53±2.09cm, that in observation group is19.44±1.64cm; the length of the distal incisal tumors during operations in the control group is4.21±0.95cm, that in the observation group is4.76±1.11cm; there are no differences in the total number of the scavenged lymphatic nodes during operations and the length of the proximal and distal incisal tumors during operations between the two group(P<0.05). The clinical revisit observation after operations:the cases of erectile dysfunction in control group is30, the incidence rate is63.83%, which in observation group is15, the incidence rate is31.91%; The cases of ejaculation dysfunction in control group are31, the incidence rate is65.95%, which in the observation group are10, the incidence rate is21.27%, the incidence rate of erectile dysfunction and ejaculation dysfunction in observation group’s patients are obvious less than that in the control group (P<0.05) The cases of urination dysfunction in the control group are28, the incidence rate is59.57%, which in the observation group are7, the incidence rate is15.56%, the urination dysfunction in the control group is obvious higher than that in the observation group. The cases of local recurrence in the control group are5, the recurrence rate is10.63%, which in the observation group are4, the recurrence rate is8.89%, there are no differences between two groups.Conclusion1. Dissect the pelvic cavity of the male corpse. The innervation of the viscera in the pelvis and its course are approximately constant, mainly distributing in the Toldt’s gaps. You can use your eyes to distinguish most of the gaps that exist in the lymphatic system of the arteria rectalis inferior and in the mesorectum and can be dissected through operations. Dissecting the gaps behind the recta carefully can avoid harm to the superior hypogastric plexus and the pelvic plexus.2. Through dissection of corpse, we find that as to the radical resection of rectal carcinoma for patients of the early phase, the role of distinguishing the superior hypogastric plexus during detaching the Toldt’s gaps is as important as that of distinguishing the ureter and the blood vessel of genital. When dissecting the mesorectum, you must obey TME principle. At the front side of the pelvic plexus, sharp dissection of gaps behind the rectum can protect the ejaculation nerve and the erectile nerve. Through protection of the completeness of the pelvic nerve, urinary function and sex function of the male patients after operations can be protected. As for the rectal cancer patients who is at the phase over T3and has transferred or invasion situation in mesentery, or patients whose nerves are invaded, partial or the whole pelvic nerve inevitably needs cutting for the purpose of the radical treatment of the cancer.3. The laparoscopic surgery not only has the minimally invasive advantage, but can easily reach the pelvic floor structure through amplifying the surgery filed of the camera in the operation. Some operations are more accurate than the laparotomy, as they explicitly show the course of the pelvic nerves in the surgery field and whereby reduce the accidental injury. It also should be pointed out that TEM and PANP operations of rectal cancer should be operated by experienced laparoscopic surgery physicians. |
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