Reconsideration of the Anterior Surgical Plane of Total Mesorectal Excision for Rectal Cancer.

INTRODUCTION: Previous studies on total mesorectal excision suggested dissection anterior to Denonvilliers' fascia, which might lead to intraoperative pelvic autonomic nerves injury and a high incidence of urogenital dysfunction. TECHNIQUE: We dissected 4 cases of cadavers, mainly focusing on anatomy of Denonvilliers' fascia, to study the relationship between Denonvilliers' fascia and rectum. In practice, instead of dissection 1 cm above peritoneal reflection, dissection of the peritoneum was performed at the lowest level of peritoneal reflection during laparoscopic resection for mid-low rectal cancer.
RESULTS: The cadaveric study revealed that there were loose tissues between Denonvilliers' fascia and rectal specimen, thus a surgical plane posterior to Denonvilliers' fascia did exist. During laparoscopic resection for mid-low rectal cancer, some loose reticulate structures between Denonvilliers' fascia and proper fascia of rectum would present after dissection of peritoneum at the lowest level of peritoneal reflection. Then dissection within the surgical plane posterior to Denonvilliers' fascia became easy and feasible. In this plane, both the pelvic nerves and postoperative urogenital function could be well protected by Denonvilliers' fascia.
CONCLUSIONS: The anterior surgical plane for total mesorectal excision should be reconsidered, and dissection posterior to Denonvilliers' fascia is feasible and practicable for patients without risk of positive anterior circumferential resection margin.