Advertisement

Will the Extra Levator Approach for Low Rectal Cancer Become the New Gold Standard?

Pitfalls of a New Technique from the Anatomical Perspective
  • A. C. Kraima
  • P. Quirke
  • M. C. DeRuiter
  • C. J. H. van de Velde
  • H. J. Rutten
Chapter

Abstract

Total mesorectal excision (TME) involves radical en bloc excision of the rectum and mesorectum with an intact mesorectal fascia [1]. The object of TME is to achieve a tumour-free circumferential resection margin (CRM) to reduce the risk of local recurrent disease [2, 3]. Worldwide, low rectal cancer is a complex and challenging disease. Patients, in whom the bowel continuity cannot be restored because of a very low-lying rectal tumour or tumour invasion in the anal sphincter complex, are classically treated with an abdominoperineal excision (APE). This operation is associated with higher rates of tumour involvement of the CRM and intraoperative tumour perforations, resulting in a poorer oncological outcome when compared with a (low) anterior resection for more superiorly located rectal tumours [4, 5]. Due to the natural tapering of the mesorectum, the specimen is at great risk to distal coning, which often leads to a nonradical resection. One of the most difficult steps in APE is dissection of the perineal body.

References

  1. 1.
    Heald RJ (1988) The ‘Holy Plane’ of rectal surgery. J R Soc Med 81(9):503–508CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2(8514):996–999CrossRefPubMedGoogle Scholar
  3. 3.
    Heald RJ, Moran BJ (1998) Embryology and anatomy of the rectum. Semin Surg Oncol 15(2):66–71CrossRefPubMedGoogle Scholar
  4. 4.
    den Dulk M, Putter H, Collette L et al (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer 45(7):1175–1183CrossRefGoogle Scholar
  5. 5.
    Marr R, Birbeck K, Garvican J et al (2005) The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 242(1):74–82CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Kraima AC, West NP, Treanor D et al (2015) The anatomy of the perineal body in relation to abdominoperineal excision for low rectal cancer. Color Dis 18:688–695CrossRefGoogle Scholar
  7. 7.
    Quirke P, Steele R, Monson J et al (2009) Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet 373(9666):821–828CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kraima AC, West NP, Treanor D et al (2015) Whole mount microscopic sections reveal that Denonvilliers’ fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision? Eur J Surg Oncol 41(6):738–745CrossRefPubMedGoogle Scholar
  9. 9.
    Church JM, Raudkivi PJ, Hill GL (1987) The surgical anatomy of the rectum--a review with particular relevance to the hazards of rectal mobilisation. Int J Color Dis 2(3):158–166CrossRefGoogle Scholar
  10. 10.
    Lindsey I, Guy RJ, Warren BF, Mortensen NJ (2000) Anatomy of Denonvilliers’ fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg 87(10):1288–1299CrossRefPubMedGoogle Scholar
  11. 11.
    Golligher JC (1980) Anterior resection. In: Golligher JC (ed) Operative surgery of the colon, rectum and anus, 3rd edn. Butterworths, London, pp 143–156Google Scholar
  12. 12.
    Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K (2006) 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 49(7):1024–1032CrossRefPubMedGoogle Scholar
  13. 13.
    Zhang C, Ding ZH, Li GX, Yu J, Wang YN, Hu YF (2010) Perirectal fascia and spaces: annular distribution pattern around the mesorectum. Dis Colon Rectum 53(9):1315–1322CrossRefPubMedGoogle Scholar
  14. 14.
    Bissett IP, Hill GL (2000) Extrafascial excision of the rectum for cancer: a technique for the avoidance of the complications of rectal mobilization. Semin Surg Oncol 18(3):207–215CrossRefPubMedGoogle Scholar
  15. 15.
    Clausen N, Wolloscheck T, Konerding MA (2008) How to optimize autonomic nerve preservation in total mesorectal excision: clinical topography and morphology of pelvic nerves and fasciae. World J Surg 32(8):1768–1775CrossRefPubMedGoogle Scholar
  16. 16.
    Baader B, Herrmann M (2003) Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat 16(2):119–130CrossRefPubMedGoogle Scholar
  17. 17.
    Mauroy B, Demondion X, Drizenko A et al (2003) The inferior hypogastric plexus (pelvic plexus): its importance in neural preservation techniques. Surg Radiol Anat 25(1):6–15CrossRefPubMedGoogle Scholar
  18. 18.
    Walsh PC, Schlegel PN (1988) Radical pelvic surgery with preservation of sexual function. Ann Surg 208(4):391–400CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Standring S (2008) Gray’s anatomy, 40th edn. Churchill Livingstone, LondonGoogle Scholar
  20. 20.
    Kinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94(5):620–626CrossRefPubMedGoogle Scholar
  21. 21.
    Nesbakken A, Nygaard K, Bull-Njaa T, Carlsen E, Eri LM (2000) Bladder and sexual dysfunction after mesorectal excision for rectal cancer. Br J Surg 87(2):206–210CrossRefPubMedGoogle Scholar
  22. 22.
    Kraima AC, West NP, Treanor D et al (2015) Understanding the surgical pitfalls in total mesorectal excision: investigating the histology of the perirectal fascia and the pelvic autonomic nerves. Eur J Surg Oncol 41:1621–1629CrossRefPubMedGoogle Scholar
  23. 23.
    Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M (1994) Intersphincteric resection for low rectal tumours. Br J Surg 81(9):1376–1378CrossRefPubMedGoogle Scholar
  24. 24.
    Cong JC, Chen CS, Ma MX, Xia ZX, Liu DS, Zhang FY (2014) Laparoscopic intersphincteric resection for low rectal cancer: comparison of stapled and manual coloanal anastomosis. Color Dis 16(5):353–358CrossRefGoogle Scholar
  25. 25.
    Martin-Perez B, Andrade-Ribeiro GD, Hunter L, Atallah S (2014) A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Tech Coloproctol 18(9):775–788CrossRefPubMedGoogle Scholar
  26. 26.
    Martin ST, Heneghan HM, Winter DC (2012) Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 99(5):603–612CrossRefPubMedGoogle Scholar
  27. 27.
    Schiessel R, Novi G, Holzer B et al (2005) Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum 48(10):1858–1865CrossRefPubMedGoogle Scholar
  28. 28.
    Koyama M, Murata A, Sakamoto Y et al (2014) Long-term clinical and functional results of intersphincteric resection for lower rectal cancer. Ann Surg Oncol 21(Suppl 3):S422–S428CrossRefPubMedGoogle Scholar
  29. 29.
    Weiser MR, Quah HM, Shia J et al (2009) Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg 249(2):236–242CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2018

Authors and Affiliations

  • A. C. Kraima
    • 1
  • P. Quirke
    • 2
  • M. C. DeRuiter
    • 1
  • C. J. H. van de Velde
    • 1
  • H. J. Rutten
    • 1
  1. 1.Department of Radiation Oncology, Largo A. Gemelli 8 00168Università Cattolica S CuoreRomeItaly
  2. 2.Pathology and Tumour Biology, Level 4 Wellcome Trust Brenner BuildingSt James University HospitalLeedsUK

Personalised recommendations