Surgical anatomy of the pelvis for total pelvic exenteration with distal sacrectomy: a cadaveric study



Intraoperative bleeding from the pelvic venous structures is one of the most serious complications of total pelvic exenteration with distal sacrectomy. The purpose of this study was to investigate the topographic anatomy of these veins and the potential source of the bleeding in cadaver dissections.


We dissected seven cadavers, focusing on the veins in the surgical resection line for total pelvic exenteration with distal sacrectomy.


The presacral venous plexus and the dorsal vein complex are thin-walled, plexiform, and situated on the line of resection. The internal iliac vein receives blood from the pelvic viscera and the perineal and the gluteal regions and then crosses the line of resection as a high-flow venous system. It has abundant communications with the presacral venous plexus and the dorsal vein complex.


The anatomical features of the presacral venous plexus, the dorsal vein complex, and the internal iliac vein make them highly potential sources of bleeding. Surgical management strategies must consider the anatomy and hemodynamics of these veins carefully to perform this procedure safely.

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  1. 1.

    Palmer G, Martling A, Cedermark B, Holm T. A population-based study on the management and outcome in patients with locally recurrent rectal cancer. Ann Surg Oncol. 2007;14:447–54.

    CAS  Article  Google Scholar 

  2. 2.

    Milne T, Solomon MJ, Lee P, Young JM, Stalley P, Harrison JD, et al. Sacral resection with pelvic exenteration for advanced primary and recurrent pelvic cancer: a single-institution experience of 100 sacrectomies. Dis Colon Rectum. 2014;57:1153–61.

    Article  Google Scholar 

  3. 3.

    Georgiou PA, Bhangu A, Brown G, Rasheed S, Nicholls RJ, Tekkis PP. Learning curve for the management of recurrent and locally advanced primary rectal cancer: a single team’s experience. Colorectal Dis. 2015;17:57–655.

    CAS  Article  Google Scholar 

  4. 4.

    Milne T, Solomon MJ, Lee P, Young JM, Stalley P, Harrison JD. Assessing the impact of a sacral resection on morbidity and survival after extended radical surgery for locally recurrent rectal cancer. Ann Surg. 2013;258:1007–133.

    Article  Google Scholar 

  5. 5.

    Moriya Y, Akasu T, Fujita S, Yamamoto S. Total pelvic exenteration with distal sacrectomy for fixed recurrent rectal cancer in the pelvis. Dis Colon Rectum. 2004;47:2047–53.

    Article  Google Scholar 

  6. 6.

    Pelv Ex Collaborative. Factors affecting outcomes following pelvic exenteration for locally recurrent rectal cancer. Br J Surg. 2018;105:650–7.

    Article  Google Scholar 

  7. 7.

    Baqué P, Karimdjee B, Iannelli A, Benizri E, Rahili A, Benchimol D, et al. Anatomy of the presacral venous plexus: implications for rectal surgery. Surg Radiol Anat. 2004;26:355–8.

    Article  Google Scholar 

  8. 8.

    Wanebo HJ, Koness RJ, Vezeridis MP, Cohen SI, Wrobleski DE. Pelvic resection of recurrent rectal cancer. Ann Surg. 1994;220:586–95.

    CAS  Article  Google Scholar 

  9. 9.

    Wang QY, Shi WJ, Zhao YR, Zhou WQ, He ZR. New concepts in severe presacral hemorrhage during proctectomy. Arch Surg. 1985;120:1013–20.

    CAS  Article  Google Scholar 

  10. 10.

    Celentano V, Ausobsky JR, Vowden P. Surgical management of presacral bleeding. Ann R Coll Surg Engl. 2014;96:261–5.

    CAS  Article  Google Scholar 

  11. 11.

    Flynn MK, Romero AA, Amundsen CL, Weidner AC. Vascular anatomy of the presacral space: a fresh tissue cadaver dissection. Am J Obstet Gynecol. 2005;192:1501–5.

    Article  Google Scholar 

  12. 12.

    LePage PA, Villavicencio JL, Gomez ER, Sheridan MN, Rich NM. The valvular anatomy of the iliac venous system and its clinical implications. J Vasc Surg. 1991;14:678–83.

    CAS  Article  Google Scholar 

  13. 13.

    Lotz PR, Seeger JF. Normal variations in iliac venous anatomy. AJR Am J Roentgenol. 1982;138:735–8.

    CAS  Article  Google Scholar 

  14. 14.

    Kachlik D, Pechacek V, Musil V, Baca V. The venous system of the pelvis: new nomenclature. Phlebology. 2010;25:162–73.

    CAS  Article  Google Scholar 

  15. 15.

    Caggiati A, Bergan J, Gloviczki P, Eklof B, Allegra C, Partsch A. Nomenclature of the veins of the lower limb: extensions, refinements, and clinical application. J Vasc Surg. 2005;41:719–24.

    Article  Google Scholar 

  16. 16.

    Beneventi FA, Noback GJ. Distribution of the blood vessels of the prostate gland and urinary bladder; application retropubic prostatectomy. J Urol. 1949;62:663–71.

    CAS  Article  Google Scholar 

  17. 17.

    Reiner WG, Walsh PC. An anatomical approach to the surgical management of the dorsal vein and Santorini’s plexus during radical retropubic surgery. J Urol. 1979;121:198–200.

    CAS  Article  Google Scholar 

  18. 18.

    Solomon MJ, Austin KK, Masuya L, Lee P. Pubic bone excision and perineal urethrectomy for radical anterior compartment excision during pelvic exenteration. Dis Colon Rectum. 2015;58:1114–9.

    Article  Google Scholar 

  19. 19.

    Miller JI, Larson TR. Simplified technique for improving exposure of the apical prostate during radical retropubic prostatectomy. Urology. 1993;44:117–8.

    Article  Google Scholar 

  20. 20.

    Chong GO, Lee YH, Hong DG, Cho YL, Lee YS. Anatomical variations of the internal iliac veins in the presacral area: clinical implications during sacral colpopepxy or extended pelvic lymphadenectomy. Clin Anat. 2014;28:661–4.

    Article  Google Scholar 

  21. 21.

    Morita S, Saito N, Mitsuhashi N. Variations in internal iliac veins detected using multidetector computed tomography. Acta Radiol. 2007;48:1082–5.

    CAS  Article  Google Scholar 

  22. 22.

    Kanjanasilp P, Ng JL, Kajohnwongsatit K, Thiptanakit C, Limvorapitak T, Sahakitrungruang C. Anatomical variations of iliac vein tributaries and their clinical implications during complex pelvic surgeries. Dis Colon Rectum. 2019;62:809–14.

    Article  Google Scholar 

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Correspondence to Masayuki Ishii.

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Ishii, M., Shimizu, A., Lefor, A.K. et al. Surgical anatomy of the pelvis for total pelvic exenteration with distal sacrectomy: a cadaveric study. Surg Today (2020).

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  • Pelvic exenteration
  • Sacrum
  • Iliac vein
  • Hemodynamics
  • Cadaver