Extrafascial excision of the rectum for cancer: A technique for the avoidance of the complications of rectal mobilization

Abstract

Serious complications can occur following mobilization of the rectum for cancer including: ureteric injury, rectal perforation, hemorrhage, autonomic nerve damage, and local recurrence of the tumor in the pelvis. Each of these complications can be minimized by careful dissection in correct tissue planes in the pelvis. The rectum and mesorectum are surrounded by the fascia propria, a thin fascial envelope. This envelope offers a surface for dissection that leads the surgeon to a safe plane lying inside the autonomic nerves, the ureter, and the presacral vessels, and lying outside of the mesorectum and its associated vessels and lymphatics. The surgical anatomy of the pelvis is presented, with emphasis on the rectal fascia propria, as a basis for a detailed description of the technique of extrafascial excision of the rectum. Semin. Surg. Oncol. 18:207–215, 2000. © 2000 Wiley‐Liss, Inc.

Whole mount microscopic sections reveal that Denonvilliers' fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision?

“…Some believe the rectosacral fascia is a pre-existing structure, 9, 10, 30 whereas others argue it is a surgical artefact. 8,21,26 In our cadaveric specimens, the increased amount of loose collagen located just cranially to the anococcygeal ligament could correspond to the rectosacral fascia. The nomenclature of the fasciae related to the rectum varies as Waldeyer's fascia may refer to the rectosacral fascia, presacral fascia or all fascia posterior to the rectum.…”

“…Besides, in line with previous reports, 8,21 we confirm that the upper third of the rectum is enveloped by multiple fascial layers. Extra collagenous laminae are present that merge and disconnect between the mesorectal and parietal fascia, but a constant extra layer of fascia forming a surgical plane could neither be identified in the cadaveric specimens nor in the UMCU pelvic dataset.…”

“…This variability is more pronounced at the anterolateral mesorectum. Bissett et al 21 have previously reported a variable thickness in the mesorectal fascia. The surgical plane might easily be lost resulting in either damaging the nerves or ending up dissecting into the lobules of the mesorectal fat.…”

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

“…Some believe the rectosacral fascia is a pre-existing structure, 9, 10, 30 whereas others argue it is a surgical artefact. 8,21,26 In our cadaveric specimens, the increased amount of collagen located just cranially to the anococcygeal ligament could correspond to the rectosacral fascia. The nomenclature of the fasciae related to the rectum varies as Waldeyer's fascia may refer to the rectosacral fascia, presacral fascia or all fascia posterior to the rectum.…”

Operating Behind Denonvilliers' Fascia for Reliable Preservation of Urogenital Autonomic Nerves in Total Mesorectal Excision: A Histologic Study Using Cadaveric Specimens, Including a Surgical Experiment Using Fresh Cadaveric Models

“…After evaluation of surgically removed specimens, these same authors recently recommended, and most often chose, the mesorectal plane when tumors were nonanterior. 2 According to previous studies, [3][4][5][6][7] nerves that should be preserved (i.e., hypogastric nerve, pelvic plexus, and urogenital neurovascular bundle, including the cavernous nerve) are located anterolateral to the mesorectum, where DVF has no definable lateral edge. Recent discussions 1,2,8 on anterior dissection of TME have concentrated on whether DVF is attached to the resected side but not on which nerves of the urogenital viscera are liable to be injured along the fascia.…”