腹腔镜内括约肌切除术的一些难点问题及思考

Reflections on the technical challenges and strategies in laparoscopic intersphincteric resection

摘要:

腹腔镜内括约肌切除术（ISR）是实现超低位直肠癌极限保肛的重要术式。本文基于团队400例手术经验，围绕手术一些关键难点提出系统优化策略。针对括约肌间隙游离困难，采用“折刀位经肛优先”策略，改善盆底暴露并降低环周切缘阳性风险；为预防降低吻合口漏的发生，探索ISR联合改良Bacon（Turnbull-Cutait）延期吻合方案，实现“安全免造口”；对吻合口大范围裂开，建立造口治疗师参与的全程管理体系，并开展经肛“U”形修补以促进吻合口快速愈合；在功能重建方面，尝试经腹肛提肌成形术以增强盆底支撑、改善控便功能。初步实践表明，这一系列策略有助于在ISR术中实现肿瘤根治与功能保护的平衡，为超低位直肠癌保肛治疗的规范化与个体化提供了新的思路，但仍需要更多高质量临床研究进一步证实。

Abstract:

Laparoscopic intersphincteric resection (ISR) represents a key technique for achieving maximal sphincter preservation in ultra-low rectal cancer. Based on 400 cases of surgical experience, this study proposes a series of systematic strategies addressing some major technical challenges of ISR. To facilitate precise dissection of the intersphincteric space, a "knife-edge position transanal-priority" approach was adopted, improving exposure and reducing the risk of circumferential margin positivity. To prevent and reduce anastomotic leakage, ISR combined with the modified Bacon (Turnbull-Cutait) delayed anastomosis was introduced as a "stoma-free but safe" alternative. For large anastomotic disruptions, a stoma-therapist-involved management protocol with transanal "U-shaped" repair was implemented to promote healing. Furthermore, a transabdominal levatorplasty was explored to enhance pelvic floor support and improve postoperative continence. Our initial experience suggests that, these strategies contribute to optimizing the balance between oncological radicality and functional preservation, offering a practical and individualized pathway for sphincter-saving surgery in ultra-low rectal cancer.