基于外科精细解剖的直肠癌手术策略OA

Based on a series of research findings on the meticulous anatomy related to fascia,mesentery and interstitial spaces in recent years,combined with clinical practice experience,an anatomical framework for"function-sparing total mesorectal excision(TME)"is proposed:(1)The left primitive retroperitoneum is the anatomical substrate of the"wrong-plane"phenomenon during left mesocolic mobilization;an initial lateral approach that exposes the left ureter followed by a central dissection minimizes the convergence distance.(2)Metastasis to No.253 lymph nodes is relatively rare,but the prognosis is extremely poor in patients with such metastasis;selective intrasheath dissection of the inferior mesenteric artery in patients with locally advanced disease can achieve both adequate lymph node dissection and preservation of the inferior mesenteric plexus.(3)Revisiting the classical"two-concentric-rings"model,the rectosacral fascia was found to split laterally and fuse densely with the pelvic plexus.The optimal circumferential dissection sequence is therefore posterior-anterior-lateral:posteriorly,the rectosacral fascia is arcuately incised;anteriorly,a"partial Denonvilliers fascia preservation"technique safeguards the neurovascular bundle while ensuring complete anterior mesorectal excision;finally,residual lateral tethering bands are divided to reach the"terminal line"while preserving the pelvic plexus.This stepwise anatomy-driven strategy secures oncologic radicality while maximizing genito-urinary function,providing a reproducible and standardized plane for laparoscopic/robotic rectal cancer surgery.