Abstract
Fascial structures are the natural embryonic dissection plane for the precise surgery of rectal cancer. This chapter characterized the fascial structures implicated in the rectal cancer surgery, which include Toldt fascia, Denonvilliers’ fascia, proper fascia of the rectum, endopelvic fascia (parietal layer of pelvic fascia), presacral fascia, rectosacral fascia, and Waldeyer’s fascia. Toldt fascia is the extension of Gerota fascia and constitutes the natural dissection plane for the mobilization of left colon. The whole mesorectum was enclosed circumferentially by the thin layer of proper fascia of the rectum; the pelvic sacral bone was covered with the endopelvic fascia (parietal layer of pelvic fascia). Endopelvic fascia and proper fascia of the rectum fused at the level of sacral promontory, and the presacral space is entered after the fascial junction is incised.
Rectosacral fascia usually originated in the S4 level, and the retrorectal space is entered when this fascia is sharply incised. Waldeyer’s fascia constitutes the fascia layer covering levator ani muscle. Denonvilliers’ fascia is situated in front of proper fascia of the rectum. Usually, the anterior dissection for mobilization of the rectum is in front of Denonvilliers’ fascia to ensure oncological efficacy; however, to enhance the preservation of sexual function, some surgeons suggest the dissection plane be back to the Denonvilliers’ fascia. Full respect of the fascia structures is the basic principle for the precise implementation of total mesorectal excision for rectal cancer.
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References
Coffey JC, O’Leary DP. The mesentery: structure, function, and role in disease. Lancet Gastroenterol Hepatol. 2016;1:238–47.
Coffey JC, Dillon M, Sehgal R, et al. Mesenteric-based surgery exploits gastrointestinal, peritoneal, mesenteric and fascial continuity from duodenojejunal flexure to the anorectal junction—a review. Dig Surg. 2015;32:291–300.
Culligan K, Coffey JC, Kiran RP, et al. The mesocolon: a prospective observational study. Color Dis. 2012;14:421–8.
Culligan K, Walsh S, Dunne C, et al. The mesocolon: a histological and electron microscopic characterization of the mesenteric attachment of the colon prior to and after surgical mobilization. Ann Surg. 2014;260:1048–56.
Liang JT, Cheng KW. Laparoscopic dissection of Denonvilliers’ fascia implicated for total mesorectal excision for treatment of rectal cancer. Surg Endosc. 2011;25:935–40.
Liang JT, Cheng JC, Huang KC, Sun CT. Comparison of tumor recurrence between laparoscopic total mesorectal excision with sphincter preservation and laparoscopic abdominoperineal resection for low rectal cancer. Surg Endosc. 2013;27:3452–64.
Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New York: Informa Healthcare USA; 2007. p. 8–9.
Corman ML. Corman’s colon and rectal surgery. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2013. p. 6.
Crapp AR, Cuthbertson AM. William Waldeyer and the rectosacral fascia. Surg Gynecol Obstet. 1974;138(2):252–6.
Goligher J. Surgery of the anus rectum and colon. 5th ed. London: Bailliere Tindall; 1984. p. 5.
Skandalakis JE. Surgical anatomy: the embryologic and anatomic basis of modern surgery, vol. 2. Athens: PMP; 2004. p. 902–6.
Lindsey I, Guy RJ, Warren BF, Mortensen NJ. Anatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg. 2000;87:1288–99.
Lindsey I, Warren B, Mortensen N. Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers’ fascia. Br J Surg. 2004;91:121–3.
Lindsey I, Warren BF, Mortensen NJ. Denonvilliers’ fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum. 2005;48:37–42.
Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K. Operating behind Denonvilliers’ fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis Colon Rectum. 2006;49:1024–32.
Heald RJ, Moran BJ, Brown G, Daniels IR. Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers’ fascia. Br J Surg. 2004;91:121–3.
Liang JT, Chang KJ, Wang SM. Lateral ligaments contain important nerves. Br J Surg. 1998;85:1162.
Kinugasa Y, Murakami G, Suzuki D, Sugihara K. Histological identification of fascial structures posterolateral to the rectum. Br J Surg. 2007;94:620–6.
Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol. 1993;36:976–83.
Farrell SA, Dempsey T, Geldenhuys L. Histologic examination of ‘fascia’ used in colporrhaphy. Obstet Gynecol. 2001;98:794–8.
Nichols DH, Milley PS. Surgical significance of the rectovaginal septum. Am J Obstet Gynecol. 1970;108:215–20.
Crile G. Thoughts while watching a resident operate. N Engl J Med. 1972;287:826.
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Liang, JT. (2018). Anatomical Basis of Rectal Cancer Surgery Focused on Pelvic Fascia. In: Kim, N., Sugihara, K., Liang, JT. (eds) Surgical Treatment of Colorectal Cancer. Springer, Singapore. https://doi.org/10.1007/978-981-10-5143-2_4
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DOI: https://doi.org/10.1007/978-981-10-5143-2_4
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