A C Kraima1, N P West2, D Treanor2, D R Magee2, R L A W Bleys3, H J T Rutten4, C J H van de Velde5, P Quirke2, M C DeRuiter6. 1. Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands; Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK. 2. Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK. 3. Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands. 4. Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands. 5. Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. 6. Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands. Electronic address: m.c.de_ruiter@lumc.nl.
Abstract
AIM: Excellent understanding of fasciae and nerves surrounding the rectum is necessary for total mesorectal excision (TME). However, fasciae anterolateral to the rectum and surrounding the low rectum are still poorly understood. We studied the perirectal fascia enfolding the extraperitoneally located part of the rectum in en-bloc cadaveric specimens and the University Medical Center Utrecht (UMCU) pelvic dataset, and describe implications for TME. METHODS: Four 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 μm 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. RESULTS: The mid and lower rectum were surrounded by a multi-layered perirectal fascia, of which the mesorectal fascia (MRF) and parietal fascia bordered the 'holy plane'. There was no extra constant fascia forming a potential surgical plane. Nerves ran laterally to the MRF. More caudally, the mesorectal fat strongly reduced and the MRF approached the rectal muscularis propria. The MRF had a variable appearance in terms of thickness and completeness, most prominently at the anterolateral lower rectum. CONCLUSION: Dissection onto the MRF allows nerve preservation in TME. Rectal surgeons are challenged in doing so as the MRF varies in thickness and shows gaps, most prominently at the anterolateral lower rectum. At this site, the risk of entering the mesorectum is great and may result in an incomplete specimen.
AIM: Excellent understanding of fasciae and nerves surrounding the rectum is necessary for total mesorectal excision (TME). However, fasciae anterolateral to the rectum and surrounding the low rectum are still poorly understood. We studied the perirectal fascia enfolding the extraperitoneally located part of the rectum in en-bloc cadaveric specimens and the University Medical Center Utrecht (UMCU) pelvic dataset, and describe implications for TME. METHODS: Four 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 μm 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. RESULTS: The mid and lower rectum were surrounded by a multi-layered perirectal fascia, of which the mesorectal fascia (MRF) and parietal fascia bordered the 'holy plane'. There was no extra constant fascia forming a potential surgical plane. Nerves ran laterally to the MRF. More caudally, the mesorectal fat strongly reduced and the MRF approached the rectal muscularis propria. The MRF had a variable appearance in terms of thickness and completeness, most prominently at the anterolateral lower rectum. CONCLUSION: Dissection onto the MRF allows nerve preservation in TME. Rectal surgeons are challenged in doing so as the MRF varies in thickness and shows gaps, most prominently at the anterolateral lower rectum. At this site, the risk of entering the mesorectum is great and may result in an incomplete specimen.
Authors: Valerie Aurore; Raphael Röthlisberger; Nane Boemke; Ruslan Hlushchuk; Hannes Bangerter; Mathias Bergmann; Sara Imboden; Michael D Mueller; Elisabeth Eppler; Valentin Djonov Journal: J Anat Date: 2020-05-19 Impact factor: 2.921
Authors: María García-Gausí; Juan García-Armengol; Gianluca Pellino; Claudia Mulas; José V Roig; Alvaro García-Granero; David Moro; Alfonso Valverde Journal: Updates Surg Date: 2022-03-14