中低位直肠癌腹腔镜下TME切除终止线再认识
1982年Heald提出应用全直肠系膜切除术(total mesorectal excision,TME)治疗中低位直肠癌以来,直肠癌术后复发率大幅下降。直肠系膜切除的完整程度与患者的预后相关。但直肠系膜分离至何处为全直肠系膜切除?其终点标志在哪里?随着现在微创手术临床实践,那么对于中低位直肠癌,有的需要分离到接近TME终止线,行R0切除术后再行低位吻合,保留肛门功能,有的需要分离之TME终止线以下,再行会阴部切除,每个中心都有自己的心得体会,那么我们就TME终止线,以一例腹腔镜下Miles手术患者,用手术图片谈一下我们自己的看法。
一、首先看下直肠后间隙TME终止线
先进入骶骨前直肠后间隙看,在腹下神经前筋膜和直肠固有筋膜间向下游离,在S4椎体水平打开直肠骶骨筋膜,进入肛提肌后间隙,渐渐暴露盆底肌,离断Hiatal韧带,直至肛提肌裂孔,到达终止线。













对于需要行会阴部切除的患者,行腹腔镜下ELAPE术。



二、直肠前方间隙TME终止线、左侧侧方间隙TME终止线、右侧侧方间隙TME终止线,见下图













总结
对于中低位直肠癌患者,腹腔镜下完整的TME切除至关重要,熟悉TME直肠周围间隙的终止线,对于各种手术方式,不管是低位游离至终止线处,离断直肠,行超低位吻合,还是行腹腔镜下ELAPE手术,才能做到游刃有余,既能达到R0切除,又能尽量保留脏器功能,提高术后生活质量。
赞 (0)