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?

Abstract

ReuseUnless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. TakedownIf you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. Abstract AimExcellent understanding of the arrangement of fasciae and nerves surrounding the rectum is necessary for total mesorectal excision (TME). However, the fasciae anterolateral to the mesorectum and surrounding the low-rectum are still poorly understood. We studied the perirectal fascia along the complete length of the rectum in en-bloc cadaveric specimens and the University Medical Center of Utrecht (UMCU) pelvic dataset, and describe implications for TME. MethodsFour donated human adult cadaveric specimens (two males, two females) were obtained through the Leeds GIFT Research Tissue Programme. Paraffin-embedded blocks were produced and serially sectioned at 50 and 250 m intervals. Whole mount sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, the UMCU pelvic dataset including digitalised cryosections of a female pelvis in three axes, was studied. ResultsMultiple fascial layers surrounded the upper rectum. In the 'holy plane' of TME, laminae merged with the mesorectal and parietal fascia. Nerves ran directly laterally to the mesorectal fascia. More caudally, the mesorectal fascia approached the longitudinal layer of the rectal muscularis propria 3 with the neurovascular bundles situated anterolaterally. The mesorectal fascia had a variable appearance in terms of thickness and completeness, which was most prominent anterolaterally. ConclusionOptimal TME requires dissection on the mesorectal fascia to preserve the nerves. Rectal surgeons are challenged in doing so as the mesorectal fascia varies in thickness and is often absent in some areas. More caudally, a wider excision may be needed to avoid incomplete specimens.4

Architectural differences in the anterior and middle compartments of the pelvic floor of young‐adult and postmenopausal females

“…The architecture of the levator and sphincter ani complexes, the urethral sphincter, and the perineal body and its extensions have been topics of contention for over a century and still attract attention (Dickinson, 1889;Oelrich, 1983;DeLancey, 1986;Woodman & Graney, 2002;Kearney et al 2004;Yucel & Baskin, 2004;Wallner et al 2009), implying that their anatomy is still incompletely understood. The connections of these entities with neighboring structures in particular remain topics of contention (Uhlenhuth & Day, 1948;Milley & Nichols, 1969;DeLancey & Starr, 1990;DeLancey, 1992;Fritsch et al 2004;Kraima et al 2015). These disagreements probably originate in the deep position and, hence, limited accessibility of the pelvic floor within the bony pelvis.…”

Total mesorectal excision with Denonvilliers' fascia in anterior rectal tumours using taTME technique – a video vignette

“…It was suggested that TME should be carried out in front of the fascia to ensure radical resection particularly in anterior rectal tumours [6]. Also, this part of TME is particularly difficult due to limited access created by pelvic angles and the prostate anteriorly in men.…”

The development of the cloaca in the human embryo

“…In agreement, pelvic surgeons occasionally report peritoneal troughs that extend to the pelvic floor in neonates (Uhlenhuth et al 1948) or coelomic remnants on the pelvic floor in adults (Heald & Moran, 1998). The fascia as such develops only after birth (Kraima et al 2015).…”