Deep Pelvic Anatomy Revisited for a Description of Crucial Steps in Extralevator Abdominoperineal Excision for Rectal Cancer

Stelzner, Sigmar; Holm, Torbjörn; Moran, Brendan; Heald, R. J.; Witzigmann, Helmut; Zorenkov, Dimitri; Wedel, Thilo

doi:10.1097/dcr.0b013e31821c4bac

Cited by 91 publications

(51 citation statements)

References 37 publications

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“…11 Many researchers have studied the perirectal fascia through macroscopic dissection. 10,[22][23][24][25][26][27] This causes problems as cadaveric or surgical dissections of an area rich in dense connective tissue may easily lead to the creation of artefacts. Radiologic imaging might be useful to study topographical relations, but fail to show enough detail due to limited resolution.…”

Section: Discussionmentioning

confidence: 99%

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?

Kraima¹,

West²,

Treanor³

et al. 2015

European Journal of Surgical Oncology (EJSO)

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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

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Section: Discussionmentioning

confidence: 99%

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?

Kraima¹,

West²,

Treanor³

et al. 2015

European Journal of Surgical Oncology (EJSO)

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“…Others shared their experience with TaTME in patients with narrow male pelvis and bulky pelvic musculature. This constellation is liable to elongate membranous urethra, resulting in a higher risk of injury [15]. Further risks include anterior quadrant involvement of distal rectal cancer and distorted tissue planes due to radiotherapy or variations of the normal anatomy, e. g., benign prostatic hyperplasia, and previous urologic treatment, e. g., transurethral resection of the prostate.…”

Section: Discussionmentioning

confidence: 99%

Urethral injury in body donor TaTME training

et al. 2017

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“…To overcome these shortcomings, the development of a continuous intraoperative neuromonitoring is desirable. In pelvic surgery, the complexity of topography, functional neuroanatomy [13][14][15], and standardized oncologic procedures placed high demands on a methodological setup for continuous intraoperative neuromonitoring. After the development of a suitable electrode design [16], the aim of this experimental study was to realize a continuous intraoperative monitoring of pelvic autonomic nerves under electromyography of the internal anal sphincter.…”

Section: Introductionmentioning

confidence: 99%

Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery

Kauff

Kempski

Koch

et al. 2012

Langenbecks Arch Surg

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Purpose: The aim of this study was to develop a methodological setup for continuous intraoperative neuromonitoring with intent to improve nerve-sparing pelvic surgery. Methods: Fourteen pigs underwent low anterior rectal resection. Continuous stimulation of pelvic autonomic nerves was carried out with a newly developed tripolar surface electrode during lateral, anterolateral, and anterior mesorectal dissection. Neuromonitoring was performed under electromyography of the autonomic innervated internal anal sphincter. Results: Continuous neuromonitoring resulted in significantly increased electromyographic amplitudes of the internal anal sphincter, confirming intact innervation throughout the whole dissection in each animal (median 0.9 V, interquartile range 0.5; 1.5 vs. median 3.4 V, interquartile range 2.1; 4.7) (p < 0.001). The median dissection time in each animal was 10 min within a median number of ten (range 8-13) tripolar electric stimulations. Conclusion: The pres ent study is the first to demonstrate that continuous intraoperative monitoring of pelvic autonomic nerves during low anterior rectal resection is feasible

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Deep Pelvic Anatomy Revisited for a Description of Crucial Steps in Extralevator Abdominoperineal Excision for Rectal Cancer

Abstract: The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.

Cited by 91 publications

References 37 publications

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?

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?

Urethral injury in body donor TaTME training

Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery

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