直肠癌根治解剖学基础a.ppt

* * * * * * * The left colon and rectum receive sympathetic supply from the preganglionic lumbar splanchnics of L1 to L3. These synapse in the preaortic plexus located above the aortic bifurcation, and the postganglionic elements follow the branches of the IMA and superior rectal artery to the left colon, sigmoid, and rectum. 围绕在腹主动脉分叉部上方的腹主动脉丛为交感神经丛，沿肠系膜下动脉和直肠上动脉进入降结肠、乙状结肠和直肠。 * 下腹下神经在盆侧壁的走向与输尿管和髂内动脉平行，最终进入盆神经丛。下腹下神经在盆侧壁与来自S2～4的副交感神经融合形成盆神经丛。由盆神经丛发出至生殖器的细小神经血管束在10点和2点位置通过精囊腺。手术中也可以发现盆神经丛的神经纤维在精囊腺的外侧尖部下降进入生殖器官，因此在该部位的分离应当非常细致。 * The pelvic parasympathetic nerves, or nervi erigentes, arise from S2 to S4. Preganglionic parasympathetic nerves merge with postganglionic sympathetics after the latter emerge from the sacral foramina. These nerve fibers, via the pelvic plexus, surround and innervate the prostate, urethra, seminal vesicles, urinary bladder, and muscles of the pelvic floor. Rectal dissection may disrupt the pelvic plexus and its subdivisions, resulting in neurogenic bladder and sexual dysfunction. Rates of bladder and erectile dysfunction after rectal surgery are as high as 45%. Degree and type of dysfunction is affected by the level of the neurologic injury. A high IMA ligation severing the hypogastric nerves near the sacral promontory results in sympathetic dysfunction characterized by retrograde ejaculation and bladder dysfunction. Injury to the mixed parasympathetic and sympathetic periprostatic plexus results in impotence and atonic bladder. 盆副交感神经来自S2～S4，其节前副交感神经与节后交感神经在骶孔前融合，其神经纤维经过盆丛围绕并支配前列腺、尿道、精囊腺、盆底肌肉。直肠切除过程中可能损及盆丛及其分支，导致神经源性膀胱无功能和性功能障碍。直肠手术后膀胱功能和勃起功能障碍的发生率高达45％，其发生的程度和类型决定与神经损伤的水平。肠系膜下动脉高位结扎时如果损伤了位于骶岬部位的腹下神经会导致交感功能障碍，特征性表现为后向射精和膀胱功能障碍。前列腺周围神经丛的交感和副交感复合损伤会导致阳痿和膀胱无力症。 * * * * * * * * * * * * * * * * * 生殖器及膀胱的神经 腹下神经 直肠及筋膜 前列腺及精囊腺 盆壁筋膜 盆丛 Denonvilliers 筋膜 支配生殖器的神经 Denonvillier’s筋膜 是直肠前方分离的界限，突破此界就可能引起出血和损伤生殖器及膀胱的支配神经。 盆神经丛局部解剖 由盆神经丛发出至生殖器的神经血管束在10点和2点位置通过精囊腺。并下降进入生殖器官，损伤后可致性功能和膀胱功能障碍，因此在该部位的分离应当非常细致。 盆神经丛局部解剖 盆副交感神经来