Zusammenfassung
Hintergrund
Die totale mesorektale Exzision (TME) entlang der viszeralen Faszie („holy plane“) ist die chirurgische Standardoperation für das mittlere und tiefe Rektumkarzinom. Diese schichtorientierte Dissektion hat ein erhebliches Potenzial für die Verletzung der viszeralen Faszie, nachweislich durch inadäquate Präparatequalität, und der parietalen Faszie, nachweislich durch Störung der autonomen Nervenfunktion. Wir haben eine Operationstechnik entwickelt, bei der die autonomen Nerven als zusätzliche anatomische Leitstrukturen im kleinen Becken verwendet werden.
Methoden
Für die zentrale Lymphknotendissektion dient der präaortale Plexus hypogastricus superior als Leitschiene und für die mesorektale Exzision am Beckeneingang der seitliche N. hypogastricus superior. Die Nervi splanchnici sind die laterale Begrenzung im mittleren Becken. Die lateral-ventral verlaufenden Paraproktien werden erst nach Präparation des kaudalen Mesorektums hinter der Prostata/Vagina und des urogenitalen Nervenbündels (Fenster) scharf am Plexus pelvicus abgesetzt.
Schlussfolgerung
Diese Technik wird als nervenorientierte mesorektale Exzision (NOME) bezeichnet. Weitere prospektive Studien müssen zeigen, inwieweit die Darstellung der pelvinen Nerven die TME-Qualität verbessert und diese vor Funktionsverlust schützen kann.
Abstract
Background
Total mesorectal excision (TME) along the fascial (“holy”) planes is the curative standard procedure for cancer of the middle and lower rectum. This layer-oriented dissection has a significant risk of injury of the visceral fascia resulting in an inadequate quality of the surgical specimen, and the parietal fascia leading to autonomic nerve dysfunction, respectively. We have developed a TME technique that uses the autonomic nerves as additional anatomical landmarks.
Methods
The anatomical landmarks for central lymph node dissection and upper rectal excision are the preaortal superior hypogastric plexus and the superior hypogastric nerves. The splanchnic nerves are the lateral margin of the middle rectum. The lateral ligaments are sharply dissected from the lower pelvic nervous plexus after identification of the urogenital nerve bundle Walsh and its separation from the visceral fascia (window).
Conclusion
This TME concept was named nerve-oriented total mesorectal excision (NOME). Further prospective studies must test the hypothesis that routine visualization improves the quality of the surgical specimen as well as preservation of autonomic nervous function.
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N. Runkel und H. Reiser geben an, dass kein Interessenkonflikt besteht.
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Runkel, N., Reiser, H. Technik der laparoskopischen nervenorientierten totalen mesorektalen Exzision. coloproctology 37, 248–252 (2015). https://doi.org/10.1007/s00053-015-0027-6
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DOI: https://doi.org/10.1007/s00053-015-0027-6