Background: The oncological outcome of surgery for the treatment of pelvic malignancies can be improved by performing pelvic lymphonodectomy. However, the extent and regions of lymph node harvest are debated and require profound knowledge of anatomy in order to avoid collateral damage. Methods: The embryological development and topographic anatomy of pelvic compartments in relation to pelvic lymphonodectomy for rectal, uterine, and prostate cancer are reviewed. Based on pre-dissected anatomical specimens, lymph node regions and drainage routes of the posterior and urogenital pelvic compartments are described in both genders. Anatomical landmarks are highlighted to identify structures at risk of injury during pelvic lymphonodectomy. Results: The ontogenesis of urogenital and anorectal compartments and their lymphatic supply are key factors for adequate lymphonodectomy, and have led to compartment-based surgical resection strategies. However, pelvic lymphonodectomy bears the risk of injury to somatic and autonomic nerves, vessels, and organs, depending on the regions and extent of surgery. Conclusion: Embryologically defined, compartment-based resection of pelvic malignancies and their lymphatic drainage routes are based on clearly delineated anatomical landmarks, which permit template-oriented pelvic lymphonodectomy. Comprehensive knowledge of pelvic anatomy, the exchange of surgical concepts between specialties, and minimally invasive techniques will optimize pelvic lymphonodectomy and reduce complications.

BackgroundThe incidence of Cholangiocellular Carcinoma (CCA) is increasing in the western world. The tumour has a high proportion of desmoplastic stroma and is correlated with a worse prognosis when cancer associated myofibroblasts (CAFs) are present. Recent studies showed promising results after liver transplantation (LTx) in non-resectable early stage CCA. Mycophenolic acid (MPA) and the mTor inhibitor Everolimus are used to prevent organ rejection but recently were shown to exhibit an antiproliferative effect on CCA-cells. Little is known about the influence of immunosuppressive drugs on tumour cell proliferation and migration after paracrine stimulation by CAFs. Moreover, it is still unknown, which signaling pathways are activated following these specific cell-cell interactions.MethodsCCA cell lines HuCCT1 and TFK1 were utilized for the study. CAFs were derived from resected CCA cancer tissue. Cell viability was measured by the crystal violet assay and tumour cell invasion was quantified using a modified co-culture transmigration assay. Semiquantitative cytokine-expression was measured using a cytokine-array. Protein expression and phosphorylation of ERK, STAT3 and AKT was determined by Western-blot analysis.ResultsCCA cells treated with MPA exhibited a dose related decrease in cell viability in contrast to Cyclosporine A (CSA) treatment which had no effect on cell viability. Everolimus significantly inhibited proliferation at very low concentrations. The pro-invasive effect of CAFs in co-culture transmigration assay was significantly reduced by Everolimus at a concentration of 1nM (p = 0.047). In contrast, MPA and CSA showed no effect on tumour cell invasion. Treatment of CAFs with 1nM Everolimus showed a significant reduction in the expression of IL 8, IL 13, MCP1, MIF and Serpin E1. CCA-cells showed significant increases in phosphorylation of ERK, STAT3 and AKT under the influence of conditioned CAF-media. This effect was suppressed by Everolimus.ConclusionsThe secretion of proinflammatory cytokines by CAFs may lead to increased activation of JAK/STAT3-, ERK- and AKT-signaling and increased migration of CCA-cells. Everolimus abrogates this effect and inhibits proliferation of CCA-cells even at low concentrations.LTx for non-resectable early stage CCA is currently performed in several clinical studies. Consistent with a role for common immunosuppressants in inhibiting tumour cell-proliferation and -invasion, our study indicates that a combination of standard therapies with Everolimus and MPA is a promising therapy option to treat CCA following LTx.

BACKGROUND: The architecture of perirectal fasciae is complex as mirrored by different anatomical concepts. OBJECTIVE: This study aimed to perform a comprehensive visualization of perirectal fasciae to facilitate strategies of rectal surgery such as total mesorectal excision, intersphincteric resection, and transanal total mesorectal excision. DESIGN: Macroscopic dissection and histologic studies of perirectal fasciae and autonomic pelvic nerves were performed. SETTINGS: This study was conducted in a university laboratory of macroscopic and microscopic anatomy. PATIENTS: Thirteen (5 female) pelvic specimens were obtained from body donors (67–92 years of age). MAIN OUTCOME MEASURES: The primary outcomes measured were the photodocumentation of perirectal fasciae, spaces and fusion zones, and histologic and immunohistochemical analysis of key structures. RESULTS: The retrorectal space is a mesofascial interface between the mesorectal fascia and the parietal pelvic fascia. The parietal pelvic fascia is composed of 2 lamellae ensheathing the autonomic pelvic nerves. The outer lamella of the parietal pelvic fascia and the presacral fascia confine the presacral space. The presacral fascia covers the median sacral blood vessels. Approximately at the fourth sacral vertebra, all fascial layers fuse in the midline and are densely connected to the posterior rectal wall via the rectosacral ligament. The parietal pelvic fascia fuses with the pubococcygeal and longitudinal rectal muscles at the anorectal junction. Anterolaterally, the neurovascular bundles are closely related to this fascial fusion zone and the rectogenital septum. LIMITATIONS: Because of the increased age of the body donors, the findings may be subjected to age-related degenerative processes. CONCLUSIONS: The 2 lamellae of the parietal pelvic fascia and the fascial fusion zones are key structures of perirectal anatomy. For autonomic nerve preservation, the recognition of the inner lamella of the parietal pelvic fascia is crucial. To avoid inadvertent rectal perforation or accidental presacral dissection, the rectosacral ligament must be identified and transected for complete rectal mobilization. See Video Abstract at http://links.lww.com/DCR/B389. ANATOMÍA FASCIAL PERIRRECTAL: NUEVOS CONCEPTOS SOBRE UN ANTIGUO PROBLEMA ANTECEDENTES: La arquitectura de las fascias perirrectales es compleja, reflejada por distintos conceptos anatómicos. OBJETIVO: Integración de conceptos sobre las fascias perirrectales para facilitar las estrategias de cirugía rectal, como la escisión mesorrectal total, la resección interesfintérica y la escisión mesorrectal total transanal. DISEÑO: Disección macroscópica y estudios histológicos de fascias perirrectales y nervios pélvicos autonómicos. AJUSTES: Laboratorio universitario de anatomía macroscópica y microscópica. PACIENTES: Trece (5 mujeres) muestras pélvicas obtenidas de donantes de cuerpo (67-92 años). PRINCIPALES MEDIDAS DE RESULTADO: Foto documentación de fascias perirrectales, espacios y zonas de fusión, análisis histológico e inmunohistoquímico de estructuras claves. RESULTADOS: El espacio retrorectal es una interfaz mesofascial entre la fascia mesorrectal y la fascia pélvica parietal. Este último se compone de dos láminas que envuelven los nervios pélvicos autonómicos. La lámina externa de la fascia pélvica parietal y la fascia presacra definen el espacio presacro. La fascia presacra cubre los vasos sanguíneos sacros medianos. Aproximadamente en la cuarta vértebra sacra, todas las capas fasciales se unen en la línea media y están densamente conectadas a la pared rectal posterior a través del ligamento rectosacro. La fascia pélvica parietal se une con los músculos rectal pubococcígeo y longitudinal en la unión anorrectal. Anterolateralmente, los haces neurovasculares están estrechamente relacionados con esta zona de fusión fascial y el tabique rectogenital. LIMITACIONES: Debido al aumento de la edad de los donantes de cuerpos, los hallazgos pueden estar sujetos a procesos degenerativos relacionados con la edad. CONCLUSIONES: Las dos láminas de la fascia pélvica parietal y las zonas de fusión fascial son estructuras claves de la anatomía perirrectal. Para la preservación del nervio autónomo de nervios pélvicos autonómicos, el reconocimiento de la lámina interna de la fascia pélvica parietal es importante. Para evitar la perforación rectal inadvertida o la disección presacra accidental, el ligamento rectosacro debe ser identificado y seccionado para una movilización rectal completa. Consulte Video Resumen en http://links.lww.com/DCR/B389.

Background Education of clinical anatomy and training of surgical skills are essential prerequisites for any surgical intervention in patients. Here, we evaluated a structured training program for advanced gynecologic laparoscopy based on human body donors and its impact on clinical practice. Methods The three-step training course included: (1) anatomical and surgical lectures, (2) demonstration and hands-on study of pre-dissected anatomical specimens, and (3) surgical training of a broad spectrum of gynecological laparoscopic procedures on human body donors embalmed by ethanol-glycerin-lysoformin. Two standardized questionnaires (after the course and 6 months later) evaluated the effectiveness of each of the training modules and the benefits to surgical practice. Results Eighty participants took part in 6 training courses using a total number of 24 body donors (3 trainees/body donor). Based on a 91.3% (73/80) response rate, participants rated high or very high the tissue and organ properties of the body donors (n = 72, 98.6%), the technical feasibility to perform laparoscopic surgery (n = 70, 95.9%), and the overall learning success (n = 72, 98.6%). Based on a 67.5% (54/80) response rate at 6 months, participants rated the benefit of the course to their daily routine as very high (mean 80.94 ± 24.61%, n = 53), and this correlated strongly with the use of body donors (r = 0.74) and the ability to train laparoscopic dissections (r = 0.77). Conclusions This study demonstrates the technical feasibility and didactic effectiveness of laparoscopic training courses in a professional and true-to-life setting by using ethanol-glycerol-lysoformin embalmed body donors. This cost-efficient fixation method offers the option to integrate advanced surgical training courses into structured postgraduate educational curricula to meet both the technical demands of minimal invasive surgery and the ethical concerns regarding patients´ safety.

BACKGROUND: Although the middle rectal artery is a relevant anatomical landmark for rectal resection and lateral lymph node dissection, descriptions of this entity are highly divergent. OBJECTIVE: Dissection, visualization, morphometry, and 3-dimensional reconstruction of the middle rectal artery to facilitate its management in surgery. DESIGN: Macroscopic dissection, histologic study, morphometric measurements, and virtual modeling. SETTING: University laboratory of applied surgical anatomy. PATIENTS: This study includes formalin-fixed hemipelvis specimens (n=37) obtained from body donors (age, 67–97 y). MAIN OUTCOME MEASURES: The main outcome measures are photo documentation of origin, trajectory, diameter, and branching pattern; immunolabeling of lymphatics; and 3-dimensional reconstruction of the middle rectal artery. RESULTS: The middle rectal artery was present in 71.4% of body donors (21.4% bilateral, 50% unilateral), originated from the anterior division of the internal iliac artery, and branched either from the internal pudendal artery (45.5%), the inferior gluteal artery (22.7%), the gluteal-pudendal trunk (22.7%), or a trifurcation (9.1%). One to 3 branches of varying diameters (0.5–3.5 mm) entered the mesorectum from the ventrolateral (35.7%), lateral (42.9%), or dorsolateral (21.4%) aspect. The middle rectal artery was accompanied by podoplanin-immunoreactive lymphatic vessels and gave off additional branches (81.8%) to the urogenital pelvic organs. Three-dimensional reconstruction revealed the complex course of the middle rectal artery from the pelvic sidewall through the pelvic nerve plexus and parietal pelvic fascia into the mesorectum. LIMITATIONS: Findings retrieved from body donors may be prone to age- and fixation-related processes. CONCLUSIONS: The investigation disclosed the rather high prevalence of the middle rectal artery, its 3-dimensional topographic anatomy, and its proximity to the autonomic pelvic nerves. These features play a role in the surgical management of this blood vessel. The data provide the anatomical rationale for the lateral lymphatic spread of rectal cancer and an anatomical basis for nerve-preserving lateral lymph node dissection.