作者：陈仕才

单位：广州医科大学附属肿瘤医院 胃肠肿瘤外科，广东 广州 510095

Authors: Chen Shicai

Unit:  Department of Gastrointestinal Tumor Surgery, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510095, Guangdong, China

摘要：

Toldt 筋膜一直以来被认为是在肠系膜发育旋转过程中结肠系膜与后腹壁发生黏附时两者表面的内脏腹膜相互附着形成的融合筋膜。尽管关于胃肠道膜解剖的各种理念逐渐被越来越多的临床医生所熟知并应用于胃肠道手术中，但对于Toldt 筋膜能否被打开以及手术层面的选择仍有争议。我们在前期研究中提出了腹膜退缩理论，根据此理论我们认为腹膜外筋膜始终包绕着肠系膜，Toldt 筋膜并非腹膜融合筋膜，而是胚胎发育过程中、腹膜退缩后保留的腹膜外筋膜，并将上皮下结缔组织层、浆膜下层（肿瘤TNM 分期中的T₃ 层）、Toldt 筋膜层及分隔肠系膜脂肪细胞小叶的纤维间隔统一归为腹膜外筋膜层。本文将以Toldt 筋膜为例，说明肠系膜黏附区域的典型结构，同时指出全结肠系膜切除术的正确层面为系膜筋膜平面与筋膜后平面之间的Toldt 筋膜层。腹膜退缩理论大大简化了对腹部筋膜与层面的认识，有助于推动胃肠道膜解剖手术的开展。

关键词： 腹膜退缩理论；肠系膜；腹膜外筋膜；Toldt 筋膜

Abstract：

Toldt's fascia had always been described as a fusion fascia formed by two layers of visceral peritoneum when the mesentery rotated and attached to the posterior abdominal wall. Although several anatomic theories for mesenteric -based surgery had been recommended and widely applied in gastrointestinal surgery, there was still controversy over whether Toldt's fascia could be opened and the choice of surgical plane. We have proposed the peritoneum retreat theory in our preliminary research, stating that extraperitoneal fascia always surrounds the mesentery, and Toldt's fascia is not a fusion fascia of the peritoneum, but rather part of the extraperitoneal fascia preserved during embryonic development. We have unified the submesothelial connective tissue layer, subserosal layer (T₃ layer of TNM stage), Toldt's fascia and fibrous septations separating mesenteric adipocyte lobules into the extraperitoneal fascia. Taking Toldt's fascia as an example, this study aims to demonstrate the typical histological structures in the regions of posterior attachment and indicates that the correct plane for complete mesocolic excision is the Toldt's fascia layer between mesofascial plane and retrofascial plane. The peritoneum retreat theory can greatly simplify the understanding of the abdominal fasciae and layers, and help promote the development of mesenteric-based surgery.

Key Words:  Peritoneum retreat theory; Mesentery; Extraperitoneal fascia; Toldt's fascia

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