The presacral component of the visceral pelvic fascia and its relation to the pelvic splanchnic innervation of the bladder.код для вставкиСкачать
The Presacral Component of the Visceral Pelvic Fascia and its Relation to the Pelvic Splanchnic Innervation of the Bladder W. H. ROBERTS A N D W. HOLMES TAYLOR Department of Anatomy, Schools of Medicine and Dentistry, Lorna Linda University, Lorna Linda, California 92354 ABSTRACT The relation of the autonomic nerve supply of the pelvis to the visceral pelvic fascia and i n particular that of the parasympathetic supply to the bladder musculature is of particular consequence i n pelvic operations. It is observed that the pelvic splanchnics, including those bramhes supplying the bladder, are embedded in the peripheral component of the visceral pelvic fascia or presacral fascia throughout a considerable part of their course. Early anatomists made no distinction between the presacral fascia and the fascial sheath OF the rectum proper. Consequently their illustrations shown only a single fascial layer which they call the “rectal fascia” or “posterior fibrous sheath of the rectum” separating the middle sacral vessels from the superior rectal vessels which lie in the pararcctal fat. While such a distinction has since been made i n the surgical literature, most anatomical descriptions are still rather vague in this respect. It is essential to develop the plane of cleavage between the presacral fascia and the fascial sheath of the rectum if injury to the pelvic splanchnic nerves is to be avoided. The subperitoneal fascia of the posterior body wall at the pelvic brim becomes the presacral fascia and finally fuses with thc fascial sheath of the rectum just above the ano-rectal junction, as stated by Wilson (’67). The true parietal fascia fuses with the sacral periosteum after passing off the parietal musculature, i.e., the obturator internus and piriformis muscles. Waldeyer and Joessel (1899) did not differentiate between the presacral fascia and the fibrous sheath of the rectum proper so speak simply of a “rectal fascia,” corresponding to the “posterior fibrous sheath of the rectum” of Paitre, Giraud and Dupret (’35). Pernkopf (’64) and the translator of the German text of 1943, likewise show these layers as a single entity. Close (’47), Bruce, Walmsley and Ross (’64) and Goligher (’67) recognize the importance from an applied standpoint of differentiating what the first-mentioned calls the “presacral component of the visceral pelvic fascia” and the others the “parietal fascia of Waldeyer” from the fascial sheath of the rectum. Paitre, Giraud and Dupret (’35) in their drawings of dissections made from below, ANAT. REC., 166: 207-212 show the pelvic splanchnics outside the “posterior fibrous sheath of the rectum” and hence outside the presacral fascia. Goligher (’67) and Ballantyne and Smith (’68) likewise state that these nerves, in particular those supplying the bladder, lie outside the “parietal pelvic fascia of Waldeyer,” at least until they enter the vesicovaginal septum. However, our findings are in accord with those of Ashley and Anson (’46), Uhlenhuth, Wolfe, Smith and Middleton (’48) and of Wilson (’67). The pelvic splanchnics, including those fibers supplying the bladder, we find to be embedded in the presacral fascia for a considerable part of their course as noted previously by one of us (Roberts, Habenicht and Krishingner, ’64; Roberts, Hunt and Henken, ’68). Differences in methods of dissection could explain the discrepancy. The incidence of vesical dysfunction following abdorninoperineal resection of the rectum, and due to unilateral or bilateral paralysis of the bladder musculature, was at one time surprisingly high, as shown by Hill, Barnes and Courville (’38). Mallik (’61) at the time of his study stated that Received May 26, ’63. Accepted Sept. 24, ’69. 207 208 W. H. ROBERTS AND W. HOLMES TAYLOR FINDINGS the incidence was low for such surgery but still high in certain gynecological operIn the intact specimen i t is quite easy ations. Goligher ('67) believes that the to differentiate between the fibrous sheath branches to the bladder are injured in rec- of the rectum and the presacral fascia. The tal surgery, not so much by stripping the presacral fascia ensheaths the internal iliac presacral fascia off the sacrum as by cut- artery and its parietal branches, including ting the nerves too near their base. Bal- the umbilical artery, and also the ureters. lantyne and Smith ('68) are of the opin- The latter, however, tend to withdraw from ion that the nerves are damaged in the this fascia1 layer since they are anterior to Wertheim type of radical hysterectomy the vessels. The presacral fascia attaches either at the root of the broad ligament or laterally to the arcus tendineus of the pelwhere they lie in the vesicovaginal septum, vic fascia, at which level it is reflected onto in the process of resecting the upper va- the pelvic viscera. The rectum and posterior urethra, and the vagina in the female, gina. paralleling as they do the pelvic axis, cross MATERIALS AND METHODS the line of the arcus tendineus at more or In this particular study ten human pel- less right angles. The peripheral attachves were dissected, five male and five fe- ment of the presacral fascia to the arcus male, both from above and below. tendineus provides the viscera with, as Fig. 1 Posterior view, body prone. The ischiorectal fossa has been cleared of its fat and the inferior rectal nerve and vessels exposed. The anococcygeal body has been excised and a window made i n the inferior fascia of the pelvic diaphragm to expose the levator ani and the anococcygeal raphe. PELVIC FASCIA AND PELVIC SPLANCHNICS Close (’47) puts it, “efficient guy-ropes” and at the same time adequately supports the nervous elements embedded in it. Figures 1-4 show the stages of dissection in an approach from below and behind and which is meant to display the relation of the pelvic splanchnic nerves to the presacral fascia. Before doing this it is best to develop the fascial cleft between the presacral fascia and the fascial sheath of the rectum from above as far as it is convenient to do so, which is almost to the level of the pelvic floor. The presacral fascia, as seen in figure 4 has two leavss, an anterior and a posterior. The anterior leaf is reflected back onto the rectum 2-3 cm above the anorectal junction and fuses with the fascia propria at this level. The posterior leaf, which is more firmly attached to the mid-sacrum, joins the converging fibers of the levator ani and its 209 fasciae to insert between the internal and external anal sphincters. The presacral fascia is seen to form a significant part of the conjoined fasciae. While the nerve to the levator ani is outside the presacral fascia the pelvic splanchnics are invested by it and lie between the anterior and posterior leaves of the fascia. One or the other of these leaves must be broken through to expose them, depending on whether the approach is from above or below. The branches of the pelvic splanchnic nn. to the rectum, cervix and vagina and bladder peel off at appropriate levels as they pass from behind forwards within the fascia. Those to the rectum traverse the so-called “lateral ligaments of the rectum” along with the middle rectal vessels when these are present (fig. 5). It would be essential that the main body of the presacral fascia be left intact if the branches of the Fig. 2 The coccyx has been excised. Incisions to be made in the levator ani, as the dissection proceeds, are indicated. A n unusually well-defined puborectalis component of the levator was present in this case. Fig. 3 Reflection of the levator a n i and the superior fascia of the pelvic diaphragm brings the presacral fascia into view. It is noted that the nerve to the levator ani supplies the muscle on its superior surface. The incision to be made in the presacral fascia, and just above the level at which it fuses with the fascia1 sheath of the rectum, is indicated. Fig. 4 Sagittal section as viewed from the medial side and from behind. The posterior leaf of the presacral fascia has been incised so as to develop the plane of cleavage between the rectum and the posterior wall of the vagina. It is observed that the pelvic splanchnic nn. to the rectum, also those to vagina and bladder are between the two leaves of the fascia, and anterior and a posterior. PELVIC FASCIA A N D PELVIC SPLANCHNICS 211 Fig. 5 Posterior view of a second specimen showing rectum freed up and relation of presacral fascia to it. “Lateral ligament of the rectum” or mesorectum containing branches of pelvic splanchnics to the rectum, and middle rectal vessels is shown. pelvic splanchnics to the bladder and viscera other than the rectum are to be preserved. DISCUSSION In a specimen where the body has be1.n horizontally transected near the lumbosacId junction one is more likely in the process of dissection to reflect both the presacral fascia and the fascia propria of t.he rectum as one. This is probably why earlier anatomists did not distinguish between them. Further if one concentrates on EXposing the pelvic splanchnics from below it is often easy to inadvertently pull them out of the Dresacral fascia in which they are embeddkd. In specimens in which the presacral fascia is well developed it is qujte apparent that the nerves lie within it. While only illustrations of the findings in the female have been shown the relationships are essentially the same in the male. CONCLUSIONS Both the main sympathetic supply to the pelvic viscera and the pelvic splanchnics are embedded in the presacral fascia. A correct understanding of this relationship would aid in reducing to the minimum the incidence of bladder dysfunction due to a unilateral or bilateral paralysis of the bladder wall musculature and resulting from their injury. ACKNOWLSDGMENT The fine art work of Mrs. Lucille Innes is much appreciated. 212 W. H. ROBERTS A N D W. HOLMES TAYLOR LITERATURE CITED Anson, B. J. 1963 A n Atlas of Human Anatomy. W. B. Saunders Co., Philadelphia, p. 507. Ashley, F. L., and F. J. Anson 1946 The pelvic autonomic nerves in the male. Surg. Gynec. and Obstet., 82: 598-602. Ballantyne, B., and P. H. Smith 1968 Surgical anatomy of the extrinsic innervation of the human female urinary bladder. J. Anat., 103: 199. Bruce, J., R. Walmsley and J. A. Ross 1964 Manual of Surgical Anatomy. Williams and Wilkins, Baltimore, p. 431. Close, W. J. 1947 The pelvic fascia, its significance to the surgeon. Med. J. Australia, 1: 490-494. Goligher, J. C. 1967 Surgery of the Anus, Rectum and Colon, 2nd Ed. Bailliere, Tindall and Cassell, London, pp. 7-8, 15-16, 34-35. Hill, M. R., R. W. Barnes and C. B. CourviIle 1937 Vesical dysfunction following abdominoperineal resection for carcinoma of the rectum. J. A. M. A., 109: 1184-1188. Mallik, M. K. B. 1961 A study of the urinary bladder following Wertheim hysterectomy with special reference to the incompetence of the urethral and ureteric orifices. J. Obstet. Gynaec. Br. Commonw., 68: 945-951. Paitre, F., D. Giraud and S. Dupret 1935 Pratique Anatomo-Chirurigicale Illustrke, Abdomen. Fasc. 11. G. Goin et Cie, Paris, pp. 379, 393, 412, 427. Pernkopf, E. 1964 Atlas of Topographic and Applied Human Anatomy. H. Ferner, ed., H. Monsen, tr. W. B. Saunders Co., Philadelphia, vol. 11, p. 292. Roberts, W. H., J . Habenicht and G. Wishingner 1964 The pelvic and perineal fasciae and their neural and vascular relationships. Anat. Rec., 149: 707-720. Roberts, W. H., G. M. Hunt and H. W. Henken 1968 Some anatomic factors having to do with urinary continence. Anat. Rec., 162: 341-347. Uhlsnhuth, E., W. M. Wolfe, E. M. Smith and E. B. Middleton 1948 The rectogenital septum. Surg. Gynec. and Obstet., 86: 148-163. Waldeyer, W., and G. Joessel 1899 Lehrbuch der Topographisch-Chirurgischen Anatomie Des Becken. Zweiter Theil. F. Cohen, Bonn. pp. 552-555, 633, 733, 905. Wilson, P. M. 1967 Anchoring mechanisms of the ano-rectal region. 11. S. Afr. Med. J., 41' 1138-1143.