text: 文献笔记（422）腹腔镜下广泛子宫切除术中解剖标志的更新：从手术解剖到解剖性手术(一)
  研究目的：评估腹腔镜下广泛子宫切除术中暴露解剖标志所需要的分离技术设计与条件：回顾性单中心研究，回顾性分析腹腔镜下广泛子宫切除术的录像。手术解剖的经典工作和近期盆腔解剖的工作均被用来阐明解剖标志，研究在西班牙的一家综合性医院进行。措施、测量指标和主要结果：回顾性分析了40例广泛子宫切除手术的视频录像。对该手术术中识别解剖标志所需的技术进行了描述。结论：经腹广泛子宫切除术包括一系列手术操作，可能发生出血或者盆腔结构损伤。许多风险可以避免，因为腹腔镜下可以在经腹手术难以到达的地方进行精准操作。需要对手术解剖的经典概念进行更新，从而适应腹腔镜的手术操作。后者相比经腹手术，更接近显微手术的操作特点。All of them shared the same surgical approach, consisting of the development of the paravesical and pararectal spaces and exposure of the uterine reticulum in the anterior (vesicouterine ligament), medial (parametrium), and posterior (uterosacral ligament) portions followed by radical resection of each of these elements separately.所有这些术式都具有同一特点，包括打开膀胱侧间隙和直肠侧间隙，暴露子宫前系膜（膀胱子宫韧带）、中系膜（宫旁）和后系膜（宫骶韧带），然后分别广泛切除这些系膜。The development of laparoscopic technique, incorporating better optical systems together with the capability to record easily all interventions for later analysis, has enabled the establishment of a system of feedback learning.腹腔镜技术的发展，具备了更好的光学系统，以及录像便利的条件可用于后期分析，从而建立了一个反馈学习系统。Pelvic lymphadenectomy  Pelvic lymphadenectomy is initiated at the level of the aortic bifurcation. At the height of the sacral promontory, a fibous bundle can be identified that corresponds to the superior hypogastric plexus, which bifurcates into 2 branches, each flowing in the caudal direction adjacent to the lateral wall of the rectum. The lymphadenectomy is extended to the entrance of the external iliac artery in the inguinal canal. At this level, the origin of the inferior epigastric artery can be identified. The following conventional strucutures are then exposed: the psoas muscle; the genitofemoral nerve; the bifurcation of the common iliac artery; the external iliac vein and artery; the superior vesical artery; and the obturator vein artery and nerve. The dissection can be extended toward the pelvic wall, under the external iliac vein, respecting the adipose tissue surrounding the parietal veins and sciatic nerve.盆腔淋巴清扫术盆腔淋巴清扫术在腹主动脉分叉水平开始，在骶骨岬水平，可以见到下腹上丛的神经纤维，分为两支，向尾侧靠近直肠侧壁走行。淋巴清扫术扩展到髂外动脉进入腹股沟管。在这一水平，可以看到腹壁下动脉的起始部，并暴露下列结构：腰大肌、生殖股神经、髂总分叉、髂外动静脉、膀胱上动脉和闭孔动静脉及神经。分解扩展到盆壁，在髂外静脉下方，包括围绕体静脉和坐骨神经的脂肪组织。The paravesical space  Development of the paravesical space is initiated with localizaiton of the superior vesical artery(also called the obliterated umbilical artery), which is separated toward the uterus, exposing a virtual space whose external limit is marked by the external iliac vessels. The dissection is continued through the areolar tissue that fills the virtual space of the paravesical space until the internal obturator muscle is reached and the endopelvic fascia is seen at the bottom. It is now possible to localize as a reference the tendinous arc that forms a more fibrous thickening of the endopelvic fascia and extends from the posterior face of the pubis to the sciatic spine. The endopelvic fascia is a fibrous support structure for the pelvic organs covering the musculature of the levator ani muscle. At this level, the endopelvic fascia extends from the tendinous arc and fuses with the vaginal fascia. The development of the paravesical space enables exposure of the anterior face of the parametrium, which comprises connective and adipose tissue partially covered by a fibrous lamina neither very visible nor always present. The vesicohypogastric fascia extends from the superior vesical artery to the lateral edge of the bladder and vesicouterine ligament. In the Piver III level of radicality, this fascia should be sectioned to preserve the superior vesical artery.膀胱侧间隙  打开膀胱侧间隙，首先从找到闭锁脐动脉开始，暴露一个虚拟空间，外界是髂外血管。分解疏松组织，直至到达闭孔内肌和底部的盆腔内筋膜。现在可以找到盆腔内筋膜形成的腱弓，从耻骨后方到达坐骨棘。盆腔内筋膜是盆腔内脏的支持结构，覆盖肛提肌。在这一水平，盆腔内筋膜从腱弓延伸与阴道筋膜融合。打开膀胱侧间隙，暴露宫旁的前方，由结缔组织和脂肪组成，并被纤维组织覆盖。膀胱下腹筋膜从闭锁脐动脉开始延伸到膀胱外侧和膀胱宫颈韧带。在III型广泛手术中，这一筋膜要切开从而保留闭锁脐动脉。The vesicouterine spacePreparation of the vesicouterine space is initiated by sectioning the peritoneum fold at the level where it reflects over the anterior face of the uterus. Dissection of the space continues in the central wall of the cervix to avoid lesioning the vessels of the vesicouterine ligaments, which are situated more laterally. Exposure of the anterior vaginal fascia is facilitated to display a pearly white color. Identification of the vaginal fascia enables an avascular, safe dissection of the vesicouterine plane. Dissection of this plane continues until exposure of the anterior vaginal fascia up to 3 to 4 cm of the cervix. At this point, the vesicouterine ligaments can be identified in the form of a dense connective tissue that extends from the posterior face of the bladder, on each side, to the anterior vaginal fascia, with which it is joined. Lateral dissection of the anterior vaginal fascia can continue below the vesicouterine ligament until the ureter is localized at its entrance in the trigone. This maneuver can help to define the anterior leaf of the vesicouterine ligament by means of visualizaiton of the entrance and exit of the ureter(the so-called ureteral tunnel).膀胱子宫间隙打开膀胱子宫间隙从切开子宫膀胱腹膜反折开始。在宫颈中部开始分离，避免两侧膀胱子宫韧带的出血。暴露阴道前筋膜，其为白色。找到这一筋膜，就可以找到一个无血管的平面进行分离。向下分离至距离宫颈3-4cm。此时，膀胱宫颈韧带呈从膀胱后方延伸的致密结缔组织，到达阴道前壁融合。在膀胱宫颈韧带下方向两侧分离阴道前筋膜，直至输尿管进入膀胱的三角区。这可以通过看到输尿管的入口和出血来确定膀胱宫颈韧带的前叶。The pararectal space The classic development of the pararectal space, described by Latzko and Schiffman, is realized by seperating the external leaf of the broad ligament of the pelvic wall. The external side of the pararectal space remains delimited by the common iliac vessels and, on the internal side, the ureter and mesoureter, which adhere to the external leaf of the broad ligament. The dissection continues below until reaching the plane of the levator ani muscle, which is covered by the endopelvic fascia. This dissection should proceed progressively, taking advantage of the image magnification and following the areolar tissue that fills this virtual space, which is delimited by the parametrial fascia(anterior face), pelvic wall and internal iliac vein (posterolateral side), sacrum (posterointernal side), and mesoureter and rectosigmoid(internal side). Once development of the pararectal space is complete, the posterior face of the recovered parametrium is left exposed by the so-called parametrial fascia, which is simply the posterior extension of the endopelvic fascia.直肠侧间隙 Latzko和Schifman描述的直肠侧间隙，通过分离阔韧带的外侧叶来进入。其外侧界为髂总血管，内侧为输尿管及其系膜，贴附在阔韧带后叶。向下分离直至到达肛提肌平面，表面被盆腔内筋膜覆盖。分离应该逐步进行，利用腹腔镜放大作用，在疏松组织中进行。其前方为宫旁筋膜，后侧方为盆壁和髂内静脉，后内方位骶骨，内侧为输尿管及其系膜。完成该间隙分离后，宫旁的后方就被暴露了，其表面为宫旁筋膜，是盆腔内筋膜的后方延伸。The pelvic ureter and mesoureter can be separated easily from the lateral leaf of the broad ligament until the crossing of the uterine artery by means of soft traction-contraction movement. The space created between the broad ligament and the mesoureter is named Okabayashi's cranial pararectal chamber. In this space we find the hypogastric nerve, which originates in the superior hypogastric plexus and provides sympathetic innervation to the bladder. The dissection of the Okabayashi space can be enlarged between the cervix and the posterior face of the parametrium, following the ureter and stopping at the entrance of the vesicouterine ligament. At this level, the vesicohypogastric fascia fuses with the external face of the vesicouterine ligament.输尿管及其系膜可以轻松从阔韧带后叶分离，直至到输尿管子宫动脉交叉。输尿管内侧的这一间隙称为冈林间隙。这里可以找到起源于下腹上丛的腹下神经，提供到膀胱的交感神经。在宫颈和宫旁后方之间扩大冈林间隙，沿着输尿管，止于膀胱子宫韧带入口。在这一水平，膀胱腹下筋膜与膀胱宫颈筋膜的外面融合。来源：Jiménez AM, Colomer AT. An update of anatomical references in total laparoscopic radical hysterectomy: from surgical anatomy to anatomical surgery. J Minim Invasive Gynecol. 2008 Jan-Feb;15(1):4-10. doi: 10.1016/j.jmig.2007.07.009. PMID: 18262136.点评：从手术解剖，走向解剖手术！