Technique of dissection in the pre-rectal space of laparoscopic total mesorectal excision

Abstract

The development of laparoscopic total mesorectal excision (TME) has been promoting the better understanding of the anatomy in pre-rectal space for surgeons. If the dissection in pre-rectal space was inappropriate and entered into wrong anatomic planes, it would be easier to cause the proper fascia of rectum incomplete and damage the neurovascular bundles, and reduce the radical surgery outcome and induce urinary and sexual dysfunction, finally, affect the prognosis in patients. For surgical approach in pre-rectal space, the author proposed: Based on the related literatures, transecting the Denonvilliers′ fascia (DVF) when it′s definitely thickened after cutting the peritoneum 0.5 cm anterior to peri-toneal reflection, entering and dissecting in the space between DVF and the proper fascia of rectum, and forming a typical Three-line feature , including the cutting line of peritoneal reflection, the proximal and distal cutting lines of DVF, which can serve as the mark line and mark plane of the entrance to pre-rectal space. Not only this approach can keep the proper completeness of rectal fascia, but also it maximally reserves the DVF. Here, this article discussed the embryonic origins and anatomic characters of DVF, the structures of neurovascular bundles, dissection in the pre-rectal space, surgical approach and clinical outcomes between DVF and laparoscopic TME. Key words: Rectal neoplasms; Total mesorectal excision; Surgical procedures, opera-tive; Denonvilliers′ fascia; Laparos-copy