Considering the ‘Multi‐layered’ theory of Denonvilliers’ fascia: how to approach for neurovascular bundle preservation on performing rectal mobilization (cadaveric study)

Abstract

Denonvilliers’ fascia, an important and yet, controversial structure, was first noted by a French Surgeon, Charles-Pierre Denonvilliers after a series of anatomical dissections of the perineum in 1936 1, 2. This structure is vital for colorectal surgeons as the understanding of it would significantly improve the oncological and functional outcomes after rectal cancer surgery. In the classical description of the total mesorectal excision (TME), Professor Heald advocated that the dissection plane should be in front of the Denonvilliers’ fascia during anterior mobilisation of the low rectum 3. Professor Bokey, amongst others, suggested this layer should be left intact, unless when dealing with locally advanced, anteriorly located tumours 4. A pragmatic approach was proposed by Professor Mortensen’s group in Oxford when performing anterior mobilisation of the low rectum 5. In this issue, Ghareeb et al. 6, on reviewing their videos of low anterior resection, noted the presence of multiple fascial layers in the pre-rectal space, went on to study 18 newly fixed male and female cadavers, with a binocular loupe for a more detailed dissection. They have confirmed the multi-layered theory of Denonvilliers’ fascia, as opposed to ‘fusion’ or ‘condensation’ of embryonic connective tissues. The authors proposed their technique to initiate the anterior rectal mobilisation by making an incision a few millimetres posterior to the peritoneal reflection to minimise the injuries to the neurovascular bundles. The study also provided insight into the mysteries of the Denonvilliers’ fascia in females. This cadaveric study has added further evidence and understanding of this important anatomical structure. With the advancement of surgical equipment, including ever-improving higher resolution imaging with a magnified view; we are in a better position and equipped to provide a more precise surgical dissection.