Rectal Fascia Research Articles

Correlation study of functional magnetic resonance index and clinicopathological features of rectal cancer.

To investigate the correlation between DCE-MRI, R2*, IVIM, and clinicopathological features of rectal cancer. This was a prospective study, enrolling 42 patients with rectal cancer, 20 of whom underwent rectal mesorectal excision. Dynamic contrast-enhanced magnetic resonance imaging scanning was performed preoperatively in all patients, and additional preoperative scanning of R2* imaging and intravoxel incoherent motion was performed in those who underwent surgery. Artificially delineate the ROI around the tumor. Functional magnetic resonance index parameters Ktrans, Ve, R2*, D, D*, and f were estimated by computer software to analyze postoperative pathological reports of patients undergoing total mesenteric resection. Correlation and significance analyses of imaging metrics and pathologic features were performed by GraphPad Prism 9 to assess statistical significance. DEC-MRI, R2*, and IVIM have certain application values in the distance from the lower margin of the tumor to the anorectal ring, imaging T stage and N stage, tumor markers CEA and CA199, immunohistochemical indexes Ki-76 and P53, lymph node cancer metastasis, and rectal fascia status (P < 0.05). DEC-MRI, R2*, and IVIM provide reliable quantitative parameters for preoperative clinicopathological evaluation of patients with rectal cancer.

Diagnosis and treatment of retrorectal cystic hamartoma: clinical case

Background. Retrorectal tumors are a rare group of tumors that can be benign or malignant in origin; in most cases, they are asymptomatic. They mainly arise in the presacral space, which is limited by Waldeyer’s fascia posteriorly, the rectal fascia proper anteriorly, the ureters and lateral ligaments of the rectum laterally, the levator ani muscles and coccyx inferiorly, and the transition of the pelvic peritoneum between the second and third sacral segments superiorly. Magnetic resonance imaging (MRI) is crucial for diagnosis and surgical planning. Most retrorectal tumors require surgical treatment without preoperative biopsy. Here, we present a case of a retrorectal cystic hamartoma that was treated with surgery.Clinical case. Patient N., 45 years old, presented with suspected pelvic malformation. The patient reported experiencing pain in the sacrum area since May 2023, with no history of trauma. She sought medical help at a local polyclinic, where an ultrasound of the pelvic organs revealed a pelvic mass. The patient was then referred to an oncologist at the Multidisciplinary Clinical Medical Center “Medical City”. Physical examination showed no specific features, except upon rectal examination, where a non-displaced tumor measuring up to 2 cm was palpated along the posterior rectal wall. MRI of the pelvic organs confirmed the presence of a mass behind the lower ampullary rectum. Surgical treatment was subsequently performed, and the diagnosis of teratoma was confirmed through morphological and immunohistochemical studies.Conclusion. Early comprehensive diagnostics and an experienced surgical team are key factors for successful treatment of patients with retrorectal tumors.

Laparoscopic Nerve-Sparing Sacropexy: Tips and Tricks for a Safe and Anatomical Surgical Procedure

Study Objective to demonstrate a nerve-sparing technique during laparoscopic sacropexy (LSP) for treatment of multicompartment pelvic organ prolapse. Design A step-by-step demonstration of our surgical procedure of laparoscopic sacropexy (LSP). Setting Sacropexy is the 'gold standard' procedure for apical prolapse. This procedure is characterized by a complete dissection of the avascular spaces and is nerve sparing technique saving superior and inferior hypogastric plexus and the hypogastric nerves. Patients or Participants Patients with POP-Q Stage III and IV/prolapse of uterine Interventions Our surgical nerve-sparing LSP technique proceeds in 10 steps: Step 1: Suspension of the sigma to the abdominal wall. Step 2: Opening the peritoneum and exposure of sacral promontory and of the longitudinal anterior vertebral ligament. Step 3: Dissection of the right medial pararectal space (Okabayashi's Space), respecting the integrity of the presacral fascia and of the rHN contained within it. Step 4: Dissection of the rectovaginal space with a latero-medial approach expecting the integrity of the rectal fascia. The lateral limits were defined by the uterosacral and rectovaginal ligaments, and the base was represented by the perineal body and levator ani muscle. Step 5: Dissection of the vesicovaginal space through the creation of an avascular space with the apex at the dorsal end of the bladder trigone and laterally limited by the vesicouterine ligaments. Step 6: Subtotal hysterectomy. Step 7: A first synthetic mesh (posterior) fixed with a total of five no. 3–0 non-absorbable sutures. Step 8: A second synthetic mesh (anterior) fixed with five no. 3–0 non-absorbable sutures. Step 9: Mesh fixation on the cervical stump and ligamentum longitudinale. Step 10: Mesh peritonealization. Measurements and Main Results LSP combines the high efficacy of reconstructive surgery using non-absorbable mesh with the fast recovery and low complication rate resulting from minimal tissue trauma and laparoscopicalprocedure precision. Conclusion A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps. to demonstrate a nerve-sparing technique during laparoscopic sacropexy (LSP) for treatment of multicompartment pelvic organ prolapse. A step-by-step demonstration of our surgical procedure of laparoscopic sacropexy (LSP). Sacropexy is the 'gold standard' procedure for apical prolapse. This procedure is characterized by a complete dissection of the avascular spaces and is nerve sparing technique saving superior and inferior hypogastric plexus and the hypogastric nerves. Patients with POP-Q Stage III and IV/prolapse of uterine Our surgical nerve-sparing LSP technique proceeds in 10 steps: Step 1: Suspension of the sigma to the abdominal wall. Step 2: Opening the peritoneum and exposure of sacral promontory and of the longitudinal anterior vertebral ligament. Step 3: Dissection of the right medial pararectal space (Okabayashi's Space), respecting the integrity of the presacral fascia and of the rHN contained within it. Step 4: Dissection of the rectovaginal space with a latero-medial approach expecting the integrity of the rectal fascia. The lateral limits were defined by the uterosacral and rectovaginal ligaments, and the base was represented by the perineal body and levator ani muscle. Step 5: Dissection of the vesicovaginal space through the creation of an avascular space with the apex at the dorsal end of the bladder trigone and laterally limited by the vesicouterine ligaments. Step 6: Subtotal hysterectomy. Step 7: A first synthetic mesh (posterior) fixed with a total of five no. 3–0 non-absorbable sutures. Step 8: A second synthetic mesh (anterior) fixed with five no. 3–0 non-absorbable sutures. Step 9: Mesh fixation on the cervical stump and ligamentum longitudinale. Step 10: Mesh peritonealization. LSP combines the high efficacy of reconstructive surgery using non-absorbable mesh with the fast recovery and low complication rate resulting from minimal tissue trauma and laparoscopicalprocedure precision. A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps.

Anatomical observation of the left parietal peritoneum and its clinical significance in left retro-mesocolic space dissection

Objective: To investigate the anatomic characteristics of the left parietal peritoneum and its surgical implementation while dissecting in left retro-mesocolic space. Methods: A descriptive case series research methods was used. (1) surgical videos of 35 patients who underwent laparoscopic radical resection (complete mobilization of splenic flexure) of colorectal cancer in Union Hospital of Fujian Medical University between January 2018 and December 2018 were reviewed; (2) four specimens after radical resection of rectal cancer performing in June 2020 were prospectively enrolled and reviewed; (3) five specimens of left parietal peritoneum from 5 cadaveric abdomen (3 males and 2 females) were enrolled and reviewed as well; Tissues of 3 unseparated regions, namely the root of the inferior mesenteric artery (IMA), the medial region and the lateral region (including kidney tissue), from above the 5 cadaveric abdominal specimens were selected to perform Masson staining and histopathological examination. Results: (1) Surgical video observation: "Staggered layer phenomenon" and typical left parietal peritoneum was found in 77.1% (27/35) of patients when the left retro-mesocolic space was separated from the lateral and central approaches. The left parietal peritoneum presented as a rigid fascia barrier between the lateral and central approaches, which was a translucent dense connective tissue fascia. After the splenic flexure were completely mobilized, the left parietal peritoneum stump continued to the cephalic side. (2) Observation of 4 surgical specimens: The dorsal side of the left mesocolon specimen was studied, and the left parietal peritoneum stump edge was identified. The outside of the stump edge was the left hemicolon dorsal layer, which was continuously downward to the rectal fascia propria. (3) Cadaveric abdominal specimens: The left retro-mesocolic space was separated through lateral and central approaches, and the rigid fascia barrier, essentially the left parietal peritoneum and Gerota fascia, was encountered. Cross-section view showed that the left parietal peritoneum could be further detached from the dorsal layer of the left mesocolon from the outside, but could not be further detached from the inside out. (4) Histological examination: There was no obvious fascia structure in the IMA root region, while outside the IMA root region, the left bundle of inferior mesenteric plexus penetrating Gerota fascia was observed. There were 4 layers of fascias in the medial region, including the ventral layer of the left mesocolon, the dorsal layer of the left mesocolon, left parietal peritoneum and Gerota fascia. Small vessels were observed between the dorsal layer of the left mesocolon and the left parietal peritoneum. In lateral region, renal tissue and renal fascia were observed. Three layers of fascia structures were observed clearly under high power field, including the dorsal layer of the left mesocolon, left parietal peritoneum, and Gerota fascia. Conclusions: The left parietal peritoneum is the anatomical basis of the "staggered layer phenomenon" from the lateral or central approaches during the separation of left retro-mesocolic space. The small vessels in the dissection plane are the anatomical basis of intraoperative microbleeding, which need pre-coagulation. The central part of Gerota fascia is penetrated by the branches of the inferior mesenteric plexus, which results in a relatively dense surgical plane. Thus, during the dissection through the central approach, it is easy to involve in wrong surgical plane by deeper dissection.

Study on the Application of 1.5T Magnetic Resonance Imaging Image Fusion in the Staging of Rectal Cancer

Rectal cancer is a common gastric testicular malignancy, and surgical resection is the most effective treatment. The depth of local tumour filtration, lymph node metastasis and distant metastasis are all factors that influence the prognosis of rectal cancer surgery. MRI has the advantages of high-resolution, multidirectional, multi-angle, multiparameter imaging and zero radiation in soft tissue, so you can estimate the depth of tumour filtration and lymph node metastasis more accurately than ultrasound or CT. Today, it is a standard method for pre-operative imaging of rectal cancer. In this study, patients with rectal cancer have been studied from May 2020 to May 2021. 75 Patients were scanned at an arrow-shaped position and cross-sectional images, which are strictly vertical to the rectal wall, were designed after improvement at tumour level. The position of the coronal image is strictly vertical to the horizontal position. In this way, partial volume effects can be avoided and the depth of tumour filtration accurately evaluated. This helps surgeons determine the horizontal position of the tumor based on MRI images. To avoid the volume effect, the cross-section line must be vertical to the tumour axis. This study shows that in T3 tumours it is particularly important to measure the minimum level between the tumour and the rectal mesioma phase. The histology of the resected samples showed that if the distance between the tumor and the rectal mestrincular fascia exceeds 1 mm, the frequency of local recurrence is greatly reduced. If the distance between the tumor and the rectal mesiole fascia is less than 1 mm, the risk of local recurrence is greatly increased. Therefore, tumours with a straight mesosis of 1 mm or less margin-positive are called.

Reappraisal of the lateral rectal ligament: an anatomical study of total mesorectal excision with autonomic nerve preservation.

The term "lateral rectal ligament" in surgery for rectal cancer has caused confusion regarding its true existence and contents. In previous studies, investigators claimed the existence of the ligament and described its topographical features as neurovascular structures and their surrounding connective tissues located at the anterolateral aspect of the distal rectum or the posterolateral aspect of the middle rectum. The purpose of this study is to evaluate the structure of the so-called "lateral rectal ligament" in cadaver dissections. Dissection was performed in nine cadavers (eight males and one female, aged 73 to 94years) in accordance with typical total mesorectal excision techniques. During dissection, structures related to "the ligament" were examined and images recorded. At the anterolateral aspect of the distal rectum, the middle rectal artery was noted to be crossing the fusion of Denonvilliers' fascia and the proper rectal fascia. At the posterolateral aspect of the middle rectum, there was a structure which consisted of the rectal nerves running through the fusion of the pelvic fasciae. Although called "ligaments," neither structure contained discrete strong connective tissue fixing the rectum to the pelvic wall. The proper rectal fascia and surrounding pelvic fasciae fuse firmly anterolaterally and posterolaterally where neurovascular structures course toward the rectum. During a total mesorectal excision, the surgical dissection plane coincides with the fused part of the fasciae, which had long been considered the "lateral rectal ligament."

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

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

Laparoscopic Nerve-Preserving Sacropexy

Study ObjectiveTo demonstrate our developed nerve-preserving technique during laparoscopic sacropexy (LSP) for multicompartment pelvic organ prolapse. DesignA step-by-step demonstration of our surgical procedure on video (Canadian Task Force classification II-2). Informed consent was obtained from the subject, and the applicable Institutional Review Board provided approval. SettingAlthough sacropexy does remain the ‘gold standard’ procedure for apical prolapse [1], the subjective outcome of the procedure has been reported to be not so satisfactory as its anatomic outcome [2]. New onset bowel symptoms have been observed with voiding and sexual dysfunctions [3]. Published data revealed a correlation between iatrogenic denervation during LSP and postoperative dysfunctions [4-6]. We adopted a nerve-preserving approach with the aim of reducing the iatrogenic morbidity. InterventionsOur surgical nerve-preserving LSP technique from the promontory down to the right uterosacral ligament and the rectovaginal space proceeds in 3 steps:Step 1: Opening the peritoneum. The peritoneum is opened just medial to the right common iliac artery, approximately 20 to 30 mm above the sacral promontory, allowing a safe approach in an area far from nerves and vascular structures. Peritoneal incision is extended toward the promontory. The underlying presacral fascia containing the right hypogastric nerve (rHN) is identified and incised longitudinally. The presacral fascia and the rHN are then pushed medially to expose the longitudinal anterior vertebral ligament; the finding of the middle sacral veins represents the limit of any further medial dissection. Opening and displacement of the prevertebral fascia are not mandatory.Step 2: Opening the peritoneum of the right pelvic sidewall, respecting the integrity of the presacral fascia and of the rHN contained within it. An inverted L-shaped peritoneal incision extending from the sacral promontory up to the left uterosacral ligament is completed, with care taken to preserve the rHN identified previously. In proximity to the uterus, the dissection line crosses the upper edge of the right uterosacral ligament at its proximal third and extends medially. The rectovaginal space is opened and joined to the peritoneal tunnel with a section of the superficial layer of the right uterosacral ligament, preserving its deep nervous portion.Step 3: Dissection of the rectovaginal space, respecting the integrity of the rectal fascia. The rectovaginal space is fully dissected, and at its caudal edge the dissection is carried out laterally to the rectum upward to identify the pelvic parietal fascia covering the levator ani muscle, in the middle to the cranial edge of the perineal body. Preservation of the rectal fascia prevents possible injury to the middle rectal vessels and the rectal branches of the inferior hypogastric plexus, which runs close to the pelvic floor.The complete dissection of the rectovaginal space appears in an inverted V-shaped space covering approximately two-thirds of the posterior vaginal wall, with the apex at the convergence of the uterosacral ligaments. The procedure is completed with dissection of the vesicovaginal space through the creation of an avascular triangular-shaped space with the apex at the dorsal end of the bladder trigone and laterally limited by the superficial vascular layer of the vesicouterine ligaments. The bladder branches of the inferior hypogastric plexus run far from the surgical field in the deep portion of the vesicouterine ligaments. ConclusionA nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps, which allow the surgeon to visualize all of the nerve pathways and potentially dangerous anatomic structures.

Anatomy of the middle rectal artery: a review of the historical literature.

The middle rectal artery is a very important anatomical structure in rectal cancer surgery. It is the only vessel that penetrates through the proper rectal fascia into the pelvic cavity, and therefore threatens the integrity of total mesorectal excision. Moreover, it is very closely related to the lateral lymphatic drainage root. The definition of the middle rectal artery is ambiguous, and different frequencies, origins, and trajectories have been reported in various papers. The frequency of the middle rectal artery is reported to range from 12 to 97%. Traditionally, the middle rectal artery is described as an artery that penetrates the pelvic plexus from the lateral side along with the lateral ligament; the frequency of this lateral type of middle rectal artery ranges from 20 to 30%. However, the reports that describe higher frequency values also consider another type of middle rectal artery, which penetrates the neuro-vascular bundle from the antero-lateral direction; this antero-lateral type of middle rectal artery tends to be a small vessel, and frequently forms a common trunk with the prostatic artery. With advancements in endoscopic surgery, the knowledge of the precise anatomy of this structure is becoming more crucial for optimal rectal cancer surgery.

Efficacy of high-resolution MRI in the prediction of tumor complete response after neoadjuvant chemora-diation therapy for T3 rectal cancer

Objective To explore the efficacy of high-resolution MRI in the prediction of tumor complete response after neoadjuvant chemoradiation therapy for T3 rectal cancer. Methods The clinical data of 108 patients with T3 rectal cancer who were admitted to Shanghai Cancer Center of Fudan University from 2010 to 2012 were retrospectively analyzed. The TNM stage of tumor, extramural depth of tumor invasion (mrT3 stage) , involvement of mesorectum and rectal fascia, tumor diameter and distance from anal edge to lower edge of tumor were the main items of evaluation using the high-resolution MRI. A total of 108 patients underwent surgical resection of tumor after neoadjuvant chemoradiation therapy. The tumor complete response after neoadjuvant chemoradiation therapy was evaluated by tumor node metastasis (TNM) stage and tumor regression grade (TRG) . The categorical data and multivariate analysis were done by the single factor analysis of variance (ANOVA) and Logistic regression analysis. Results The positive response rate of the T3a, T3b and T3c in the patients were 61. 5% (16/26) , 36. 9% (24/65) and 11.8% (2/17) after neoadjuvant chemoradiation therapy, respectively. The mrT3, mrN and tumor diameter were the potential factors affecting response of neoadjuvant chemoradiation therapy by the univariate analysis of pathological restaging (χ2 =50. 474, 30. 985 , 8. 318 , P 0.05) . Conclusion The mrT3 in patients undergoing high-resolution MRI before neoadjuvant chemoradiation therapy could predict the tumor complete response after neoadjuvant chemoradiation therapy for T3 rectal cancer. Key words: Rectal neoplasms, T3 staging; Neoadjuvant chemoradiation therapy; Magnetic resonance imaging; Prediction

Total mesorectal excision with water‐jet dissection in patients with rectal cancer: surgical and morphological aspects

This publication will describe our own experience of using the ERBEJET2(®) water-jet dissector during surgical interventions for rectal cancer. We utilized the water-jet dissection technique to obtain tissue specimens in 10 patients with rectal cancer. All patients thus underwent nerve-sparing low anterior resection of the rectum along with para-aortic lymphadenectomy. No intraoperative complications were registered. The postoperative period went uncomplicated in all patients. No dysuria was observed. Obtained tissue specimens were examined morphologically. Macroscopic examination included assessments of the preservation of the rectal fascia propria and the amount of cellular tissue along the anterior, posterior, and lateral surfaces of the rectum. We performed microscopy of the circumferential resection margin to characterize the surgical clearance and the intensity and depth of damage to the mesorectal tissue. On morphological examination, the quality of mesorectal excision was found to be good (Grade 3) in all 10 patients. As the results of our study demonstrate, the depth of lateral tissue damage is minimal with the water-jet dissector. Water-jet dissectors have their own place in the long list of armamentarium used in surgical interventions performed for rectal cancer and contribute to improving oncological and functional outcomes of surgical treatment in this patient population.

Rupture of a giant abdominal aortic aneurysm

We admitted a 76-year old male person with a ruptured abdominal aortic aneurysm. He was immediately brought to the emergency room (ER). The blood pressure was 80/40 mmHg, HTC less than 0.17. We decided to perform an emergent CT angiography wich verified referral diagnosis. The ruptured AAA was 12 cm in diameter. An emergent life saving operation had to be done so the patient was brought to the operation theatre (OT). The approach to the abdomen was a classic median laparotomy. After we had opened the abdomen, we found a huge retroperitoneal haematoma that pushed beside the intra-abdominal organs rising almost to the edge of the rectal fascia. The blood pressure suddenly dropped down to 45/25 mm Hg for the next several minutes. A continuous infusion of norepinephrine was administered (60 mcg/min) and we also administered several doses of pure adrenalin (3 mg) and pure norepinephrine (1 mg). We pulled out the intestines from the abdominal cavity and clamped the aorta just under the renal arteries. The blood pressure immediately rose to 80 mm Hg. Both common iliac arteries were clamped, too. During the surgery the patient was anuric. Autologous blood transfusion helped by cell saver was administered and additionally he got several doses of blood, blood derivates (fresh frozen plasma, cryoprecipitate, platelets) and other intravenous solutions at the amount of approximately eight litres. We replaced the ruptured AAA using 20 mm PTFE vascular graft. After surgery the patient was transferred to the intensive care unit (ICU) where the blood pressure rose and diuresis was established. First postoperative day the patient was woken up without neurological deficits. Second postoperative day the patient was able to expel the stool and he was transferred to the department of cardiovascular surgery. Tenth day after surgery he was discharged home. Six weeks after surgery we performed a control CT angiography that showed normal founding on the abdominal iliac and leg vessels.

Treatment of the rectal cancer in casuistic clinic for abdominal surgery, Clinical centre of the University of Sarajevo (2006-2010.)

Malignant disease of the colon and rectum is the most often human neoplasm which comprises about 30% of all digestive tumours. Thereat, cancer of the lower end the colon (rectum) comprises 45 to 48% of all CRC (colorectal cancers). According to "American Society Cancer", only lung and prostate cancer in men and breast and cervix cancer in women are more frequent than CRC. The incidence of colorectal cancer is 20 to 30/100.000 citizens. Rectal cancer is the result of interection of disturbed genetic factors with external factors. The first surgical treatments began with Faget, who did the first rectal extraperitoneal excision (1739). It was improved by Ernest Milles in 1908, and in 1923, Hartman did the resection without anamnesis. In the middle of 20th century, Dixon defined the resective interventions and in Litre did a colostomy. The aim of this study is point out the necessity of early diagnosis and protocolar chirurgical end oncological approach to the treatment of this malignant disease which must be done before choosing any operative procedure in order to prevent postoperative morbidity. On the material of the Clinic for Abdominal Surgery at the Clinical centre University of Sarajevo, during the four-year period (from 2006 to 2010), out of the 406 patients with CRC, 261 of them (64.3%) had cancer of the final part of the colon and rectum. In this case, all the time of the treatment, protocol was strictly applied. Primary surgery was performed on the early stages of the disease. Radiochemotherapy (RCT) followed by operation after 6 to 8 week is applied in the progressive state of the disease with the penetration of the meso rectal fascia with positive lymph-gland assessment (NMR-nuclear magnete resonance). Out of 261 operated patients, 5 of them (1.9%) underwent transanal resections where the tumour was up to 2 cm; 104 patients (39.8%) underwent rectal resection with TME (II and III tumour states of recto-sigma); 24 (9.2%) patients uderwent amputation; 156 (22.4%) underwent left chemicolectomy with rectal resection and 29 (11%) underwent intersphincteric colo-trans-versal-anal anastomosis. The operation by Hartman was performed on 44 (16.8%) patients and colostomy on 10 (3.8%) patients in emergency service. In the tumours with low localisation we do low colo-transversal-rectal or ultra-low intersphincer colo-anal anastomosis. Total meso rectal excision and lymhadenectomy is our priority. We fully respect the oncologic approach, i.e. complete removement of the affected organ with the lymphovascular arcade. Operative lethality up to 30 days was 2.5% (comorbidity, thromboembolism). Owing to combined protocolar approach of surgical and radiochemotherapy, extirpational interventions are not so frequent any more compared with resections with low and ultra-low anastomosis. Team work and close cooperation of oncologic team of physicians (surgeons, gastroenterologists, pathologists, oncologists, radiotherapeutists) as well as respect for the protocol of the treatment are the most important factors of a successful oncologic surgery.

Anatomic observation of annular distribution of perirectal fascia and space around the mesorectum

To explore the regional anatomy of the rectum including the perirectal fasciae and spaces. Twenty-one cadavers (15 males and 6 females) were embalmed and their vessels were visualized by injection with color dye. From the cadavers, 30 hemipelvis and 6 three-quarter pelvis were harvested. The perirectal fasciae and spaces and the pelvic autonomic nerves were dissected and examined. Three tissue layers were dissected from the inside to the periphery including the proper rectal fascia enveloping the mesorectum, the presacral fascia, and the piriformis fascia fused with the sacral periosteum. The mesorectum comprised 2 parts with the classical posterolateral fat covered by the proper rectal fascia posteriorly and the anterior fat covered by the posterior layer of Denonvilliers fascia anteriorly. Extending anteriorly to the anterior layer of Denonvilliers fascia, the presacral fascia bisected the space between the mesorectum and the piriformis fascia into the retrorectal space and the presacral space. The retrorectal space extended cranially to the left retrocolic space, anterior to the space between the 2 layers of Denonvilliers fascia(prerectal space). From the inside to the periphery, the proper rectal fascia, the presacral fascia, and the muscular fascia are distributed in an annular pattern around the mesorectum. The presacral fascia divides the perirectal space into 2 annular parts, the central retrorectal space and the peripheral presacral space. The retrorectal space is the ideal surgical plane for total mesorectal excision.

Technical Points Regarding New Enterostomy Formation for Incarcerated Stomal Prolapse in Loop Enterostomy

Aim: Incarcerated stomal prolapse is a rare complication of enterostomy. Numerous procedures have been described, such as additional laparotomy to fix the intraabdominal intestine in place, enterostomy revision, or correction of the prolapse following stoma creation. The authors report successful managements by stomal reconstruction and discuss several clinical points, including the techniques of surgical revision for incarcerated stomal prolapse in loop enterostomy. Patients: Case 1) A female infant weighing 2755 g was delivered at 34 weeks of gestation. On the first day after birth, a right supra-abdominal transverse incision of 10 cm in diameter was used for transverse loop colostomy in a cloacal malformation. Two centimeters of the stomal loop was approximated with sutures to prevent evisceration of the small intestine between the 2 limbs of the loop. Interrupted sutures of 5-0 absorbable monofilament secured the seromuscle of the colon to the peritoneum and fascia, and also to the skin. The distal limb of the colostomy prolapsed 11 months after birth. The physical findings revealed that 10 cm of the distal limb was intussuscepted. Case 2) A female infant weighing 2550 g was delivered at 39 weeks of gestation. A radiological examination by contrast enema showed no spastic rectum and colon, as in Hirschsprung’s disease. Under the laparotomy of a right supra-abdominal transverse incision of 5 cm in diameter, loop ileostomy was performed at 30cm on the proximal side of the cecum such as Case 1. Subsequently, the proximal limb of the ileostomy prolapsed 2 days after operation. The physical findings revealed that 10 cm of the proximal limb was intussuscepted. New enterostomy formation: Divided enterostomy was performed with 3-cm stitching of each limb. The stomal site was moved to the inside from the previous stomal site to oversew and fix by the rectal fascia. The children have been well without trouble since undergoing the new eneterostomy formation. Conclusions: Operation to repair the prolapse of a stoma is advised if it causes problems. We found that simple mobilization of the bowel and excision of the redundant bowel provided a satisfactory result in the present cases.

Perirectal Fascia and Spaces: Annular Distribution Pattern Around the Mesorectum

In view of debate on the optimal surgical planes for total mesorectal excision, this study was designed to explore the regional anatomy of the perirectal fascia and spaces. Twenty-one cadavers (15 male and 6 female) were embalmed and their vessels visualized by injection with color dye. From the cadavers, 30 hemipelves and 6 three-quarter pelves were harvested. The perirectal fascia and spaces and the pelvic autonomic nerves were dissected and examined. Three tissue layers were dissected from the inside to the periphery: the proper rectal fascia enveloping the mesorectum, the presacral fascia, and the piriformis fascia fused with the sacral periosteum. The mesorectum comprised 2 parts: posterior, with the classical posterolateral fat covered by the proper rectal fascia; and anterior, with the anterior fat covered by the posterior layer of Denonvilliers fascia. Extending anteriorly to the anterior layer of Denonvilliers fascia, the presacral fascia bisected the space between the mesorectum and the piriformis fascia into the retrorectal space and the presacral space. The retrorectal space extended cranially to the left Toldt's space, anterior to the space between the 2 layers of Denonvilliers fascia. From the inside to the periphery, the proper rectal fascia, the presacral fascia, and the muscular fascia are distributed in an annular pattern around the mesorectum. The presacral fascia divides the perirectal space into 2 annular parts: the central retrorectal space and the peripheral presacral space. The retrorectal space is the ideal surgical plane for the total mesorectal excision.

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

The fascial structures of the rectum and the “so-called mesorectum”: an anatomical or a terminological controversy?

Since the introduction of Total Mesorectal Excision (TME), the term mesorectum has been largely used by surgeons to indicate the perirectal adipose tissue contained within the rectal fascia [3]. From a scientiWcally correct anatomical point of view the use of the term mesorectum should be discouraged. It is a misnomer which has caused lack of clarity and misleading in literature since numerous authors frequently reported the concept that the rectum presents a proper mesorectum. The preWx meso- indicates a peritoneal fold linking a segment of the digestive tube to the wall and containing vessels and nerves; according to this deWnition, the rectum does not have a true “meso”. The rectum is a retroperitoneal organ covered by peritoneum on two-thirds of its anterolateral surfaces. Posteriorly, the rectum lacks any peritoneal folds. Moreover, its walls are encircled by fat tissue

Management of the posterior compartment

A rectocele is a herniation of the rectum through the recto vaginal septum causing a protrusion of the posterior vaginal wall. The prevalence of rectocele ranges from 20% to 80% of the general population. Hendrix et al. performed a cross-sectional analysis of women who enrolled in the women’s health initiative of a hormone replacement therapy clinical trial. The total populationwas 27,342women. At baseline pelvic examination the prevalence of rectocele was approximately 18%, whether or not the women had undergone a prior hysterectomy. African/American women in this particular study demonstrated the lowest predisposition for prolapse. Parity and obesity were strongly associated with the increased risk for rectocele. However, whether or not black women are protected from prolapse remains a contentious issue as a Nigerian study has shown rectocele may be present in up to 11.4% of women over the age of 40. The natural history of prolapse has been very poorly studied, Handa et al. performed annual pelvic examinations on women over a 2–8-year period. The annual incidence of rectocele was 5.7 cases per 100 women years. While the progression rate for stage 1 rectocele was 13.5 per 100 women years there was a regression rate of 22 per 100 women years. This shows spontaneous regression is common in stage 1 prolapse. It is therefore very important that stage 1 prolapse be managed conservatively in the first instance as many will resolve. Rectocele was once thought to be a condition affecting only multiparous females and resulting from obstetric damage or increased tissue laxity with ageing and menopausal atrophy. However, rectocele has been observed in asymptomatic volunteers during defaecography. Obstetric events are usually the major predisposing factor. Traumatic delivery and damage to nerve, muscle and connective tissue will result in altered function and anatomical position of the pelvic tissues. The rectal fascia may separate from the perineal body causing a low transverse defect, although higher isolated defects in various parts of the recto vaginal tissue are also described. Chronic constipation and straining may also cause damage to the recto-vaginal septum over time and result in a rectocele. Finally, posterior vaginal prolapse is extremely common after colposuspension, which is likely to change the vaginal axis and cause a strain on the posterior vaginal wall detaching it from its fascial attachments. Table 1 shows aetiological factors in the development of a rectocele.

Clinical anatomy of the pelvic floor.

The study presented here comparing cross-sectional anatomy of the fetal and the adult pelvic connective tissue with the results of modern imaging techniques and actual surgical techniques shows that the classical concepts concerning the subdivision of the pelvic connective tissue and muscles need to be revised. According to clinical requirements, the subdivision of the pelvic cavity into anterior, posterior, and middle compartments is feasible. Predominating connecting tissue structures within the different compartments are: Paravisceral fat pad within the anterior compartment (Fig. 17, I), rectal adventitia or perirectal tissue within the posterior compartment (Fig. 17, II), and uterosacral ligaments within the middle compartment. The nerve-vessel guiding plate can be found in all of these compartments; it starts within the posterior compartment and it ends within the anterior one. It constitutes the morphological border between the anterior and posterior compartments in the male. This border is supplied by the uterosacral ligaments in the female. Whereas in gross anatomy no further border is discernable between anterior and posterior or middle compartment, the rectal fascia (hardly visible in embalmed cadavers) demarcates the rectal adventitia and is one of the most important pelvic structures for the surgeon. In principle, the outlined subdivision of the pelvic connective tissue is identical in the male and in the female; facts that become clear from early human life and that are already established during this period (Fig. 18). The uterus is interposed between the bladder and rectum and subdivides the pelvic peritoneum into two pouches thus establishing the only real difference between male and female pelvic cavity. The preferential direction of the pelvic connective tissue fibers is not changed by the interposition of the uterovaginal complex. The pelvic floor muscles are composed of the portions of the levator ani muscle, the muscles of the cavernous organs and the deep transverse perineal muscle in the male. The latter does not exist in the female. We have clearly shown that the different muscles can already be found in early human life and that they are never intermingled with the muscular walls of the pelvic organs. The levator ani muscle of the female, however, is intermingled with connective tissue long before the female sexual hormones exert influence. We have also shown that the distinct sexual differences within the pelvic floor muscles as well as within the sphincter muscles can already be found in early human life. Both the external urethral and the external anal sphincter muscles are not completely circular. The external anal sphincter is intimately connected with the internal sphincter as well as with the longitudinal muscle. Whereas the innervation and function of the urethral sphincter muscles are mostly clear, cloacal development, innervation, and function of all parts of anal sphincter complex are not completely clarified. As to the support of the pelvic viscera, we believe that intact pelvic floor muscles, an undisturbed topography of the pelvic organs, and an undisturbed perineum are of more importance than the so-called pelvic ligaments. Our hypothesis points to the fact that the support of pelvic viscera is multistructural. Thus in pelvic surgery, a lot of techniques have to be revised with the aim to preserve or to reconstruct all the structures mentioned. This is a multidisciplinary task that can only be solved by cooperation of morphologists, urologists, gynecologists, and coloproctologic surgeons or by creating a multidisciplinary pelvic floor specialist.