Anatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer

Abstract

Total mesorectal excision with autonomic nerve preservation for rectal cancer is based on the anatomy of the mesorectum and of the pelvic autonomic nerves. Cadaver dissections were performed to describe the relationship between these structures. Between the rectum and the sacrum a retrorectal space can be developed, lined anteriorly by the visceral leaf and posteriorly by the parietal leaf of the pelvic fascia. The hypogastric nerve runs anterior to the visceral fascia, from the sacral promontory in a laterocaudad direction. The splanchnic sacral nerves originate from the sacral foramina, posterior to the parietal fascia, and run caudad, laterally and anteriorly. After piercing the parietal layer of the pelvic fascia, approximately 4 cm from the midline, the sacral nerves run between a double layer of the visceral part of the pelvic fascia. The relationship between the hypogastric nerves, the splanchnic nerves and the pelvic fascia was comparable in all six specimens examined.

Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves

“…Hence, the present work tends to reject previous concepts of an extra constant fascial layer along which dissection is said to facilitate complete mesorectal excision and preserve the nerves. [8][9][10] The only constant extra layer of fascia is the lamina extending from the parietal fascia enclosing the IHP at the anterolateral mesorectum, which has been reported by Kinugasa et al 8 Future anatomical studies involving more specimens may want to focus on relation of gender, age and body mass index to the variable multi-layered appearance of the perirectal fascia.…”

“…At some points, there is actually an extra fascia [8][9][10] ; autonomic nerves do truly run either anteriorly 9 or posteriorly 8 to this fascia; and it seems that the nerves are located within the fascia. 11 Many researchers have studied the perirectal fascia through macroscopic dissection.…”

History of robotic surgery and its place in modern coloproctology: literature review

“…Хирургиче-ская техника при операциях на прямой киш-ке является наиболее сложной по сравнению с другими вмешательствами, что обусловлено ограниченностью пространства полости мало-го таза и наличием большого количества важ-ных анатомических структур в этой области. При раке прямой кишки техника выполнения тотальной мезоректумэктомии (TEM) является ключевой в обеспечении радикальности опе-ративного пособия [34][35][36]. Принцип TEM за-ключается в фасциально-футлярном удалении прямой кишки с мезоректальной клетчаткой, при этом плоскость диссекции должна про-ходить в слое между пресакральной фасцией и собственной фасцией прямой кишки.…”

Robotic Assisted Colorectal Surgery

“…The three dimensional HD image may help with precise dissection. Total mesorectal excision (TME) has been the golden standard of rectal cancer surgery (Heald et al, (1982), Enker et al, (1995), Havenga et al, (1996)). The exact recognition of the fascia structure around the rectum is mandatory to perform successful TME.…”

“…The important issue for better oncologic outcomes in colorectal cancer is a curative resection which means proper lymph node dissection. In rectal cancer surgery, the golden standard procedure is total mesorectal excision (TME) (Heald et al, 1982, Enker et al, 1995, Havenga et al, 1996. A complete TME procedure requires a precise dissection of loose avascular areola tissue between the fascia propria of the rectum and the presacral fascia without any injury to the fascia propria of the rectum.…”