The development of laparoscopic total mesorectal excision (TME) has been promoting the better understanding of the anatomy in pre-rectal space for surgeons.If the dissection in pre-rectal space was inappropriate and entered into wrong anatomic planes,it would be easier to cause the proper fascia of rectum incomplete and damage the neurovascular bundies,and reduce the radical surgery outcome and induce urinary and sexual dysfunction,finally,affect the prognosis in patients.For surgical approach in pre-rectal space,the author proposed:Based on the related literatures,transecting the Denonvilliers' fascia (DVF) when it's definitely thickened after cutting the peritoneum 0.5 cm anterior to peri-toneal reflection,entering and dissecting in the space between DVF and the proper fascia of rectum,and forming a typical Three-line feature,including the cutting line of peritoneal reflection,the proximal and distal cutting lines of DVF,which can serve as the mark line and mark plane of the entrance to pre-rectal space.Not only this approach can keep the proper completeness of rectal fascia,but also it maximally reserves the DVF.Here,this article discussed the embryonic origins and anatomic characters of DVF,the structures of neurovascular bundles,dissection in the pre-rectal space,surgical approach and clinical outcomes between DVF and laparoscopic TME.

Objective To explore the curative effect of the microsurgical excision and spinous process and vertebral plate complex orthotopic replantation to spinal canal plasty for the treatment of spinal canal schwannoma.Methods The clinical data of 18 patients with spinal schwannomas,admitted to our hospital from September 2011 to June 2014,were analyzed retrospectively.All these 18 patients were treated by microsurgical excision and spinous process and vertebral plate complex orthotopic replantation to spinal canal plasty,and were followed up for 3-18 months (mean:10 months).After the surgery,vertebral canal MRI was adopted to evaluate the tumor,and CT three-dimensional reconstruction or X-ray of the spine was used for assessing the vertebral canal formation,and Frankel grading standard was employed to evaluate the recovery of spinal cord function.Results All tumors in 18 patients were excised with the help of a microscope,and no endorachis and nerve roots were damaged during the surgery.After the surgery,the patients showed significantly improved symptoms and signs without the leakage of cerebrospinal fluid,infection of incisional wound,tumor recurrence,spinal stenosis and spinal instability.At 3 months after the surgery,Frankel grading standard was adopted to assess the recovery of the spinal cord function,and the results showed grade D in 4 patients and grade E in 14 patients.Conclusion Microsurgical excision and spinous process and vertebral plate complex orthotopic replantation to spinal canal plasty is an effective way in treating spinal canal schwannoma as it can completely expose the tumor,maximize the excision extension and decrease the spinal cord injury;meanwhile,the spinal canal is formed well and the spine is stable after the surgery.

The advancement of laparoscopic surgery serves as a trigger for better understanding of the vascular structure at the inferior border of the pancreas, especially Henle trunk. Henle trunk was first found as convergence to superior mesenteric vein (SMV) conjoined by sub-right colon vein (SRCV) and right gastroepiploic vein (RGEV), but decades later, anterior superior pancreatic duodenal vein (ASPDV) was described as another conjoint vein of Henle trunk. These tributaries are the basic elements of Henle trunk in early years' study. A proper surgical procedure for Henle trunk can significantly reduce the complications of radical right hemi-colectomy (Japanese D3 resection and European complete mesocolic excision, CME). There are four variations of Henle trunk according to the colic venous tributaries that consists the anatomic variations in transverse colon posterior space(TRCPS). These variations are like "fingerprint and pattern" of CME. The recognition and extension of the TRCS is the key to the dissection of Henle trunk in laparoscopic right hemi-colectomy. Our medical center proposed four feasible approaches for extension:(1) hybrid medial approach; (2) completely medial approach; (3)completely medial access by "page-turning" approach; (4) completely medial approach along RCV. Mostly, RCV ended in Henle trunk, and completely medial approach along RCV is efficient to identify the Henle trunk in CME. We suggest dissecting the inferior margin of pancreas along SMV in a bottom-to-top fashion, followed by the dissection of middle colic vessels to reveal the root of Henle trunk. And it's better to dissect Henle trunk by branch rather than at its root for safety. Here, we describe the anatomic characters of Henles trunk, the surgical approach and strategies of Henle trunk in laparoscopic surgery.

Objective To investigate the safety and short-term outcomes of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LARP-PPC) for low rectal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 132 patients with low rectal cancer who were admitted to Ruijin Hospital of Shanghai JiaoTong University School of Medicine from January 2014 to December 2017 were collected.There were 81 males and 51 females,aged from 45 to 83 years,with an average age of 62 years.Among the 132 patients,60 undergoing LARP-PPC were allocated into LARP-PPC group,and 72 patients undergoing conventional LARP were allocated into LARP group.All the patients received standardized preoperative and postoperative treatments.Observation indicators:(1) surgical and postoperative conditions;(2) postoperative pathological examination;(3) postoperative complications.The measurement data with normal distribution were expressed as Mean±SD,and the t test was used for comparison between groups.The measurement data with skewed distribution were expressed as M (range),and the Mann-Whitney U test was used for comparison between groups.The count data were expressed as absolute numbers,and the chi-square test or the Fisher exact probability was used for comparison between groups.Mann-Whitney U test was used for comparison of ordinal data between groups.Results (1) Surgery and postoperative conditions:all the patients in the two groups underwent successful surgery without conversion to open surgery.The operation time,volume of intraoperative blood loss,time to first flatus,and time to first liquid intake of the LARP-PPC group were (163±45) minutes,168 mL(range,85-280 mL),2 days(range,1-5 days),3 days(range,2-6 days),versus (155±39) minutes,160 mL(range,100-305 mL),3 days(range,1-7 days),4 days(range,2-7 days) of the LARP group;there was no differencebetween the two group (t =1.113,Z =-1.623,-1.468,-0.321,P＞0.05).The duration of postoperative hospital stay in the LARP-PPC group and the LARP group were 16 days (range,11-21 days) and 19 days (14-24 days),respectively,with a significant difference between the two groups (Z =-5.888,P＜0.05)].In the LARP-PPC group,time of PPC was (13± 3) minutes.(2) Postoperative pathological examination:the length of specimen,the number of lymph node dissection,tumor diameter,cases with high-,middle-,and low-differentiated tumor in the LARP-PPC group was (18±4)cm,16±t5,(3.7±1.4)cm,10,34,16 in the LARP-PPC group,and (18±4)cm,16±5,(3.9±1.5) cm,13,41,18 in the LARP group,showing no significant difference between the two groups (t =0.779,0.390,0.703,Z=-0.267,P＞0.05).(3) Postoperative complications:cases with perineal wound infection,delayed perineal wound healing,intestinal obstruction,and perineal hernia were 2,1,1,0 in the LARP-PPC group,and 12,10,8,6 in the LARP group,showing significant differences between the two groups (x2 =6.137,6.400,P＜0.05).There were 2 and 4 patients with urinary tract infection in the LARP-PPC group and the LARP group,respectively,showing no significant difference between the two groups (P ＞ 0.05).Conclusion LARP-PPC is safe and feasible for the treatment of low rectal cancer,which can significantly reduce postoperative perineal-related complications and consequently shorten postoperative hospital stay.