Skip to main content

Advertisement

SpringerLink
Log in

Laparoscopic-assisted low anterior resection of the rectum—a review of the fascial composition in the pelvic space

  • Review
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Introduction

Outcomes of rectal cancer treatment depend on the operative technique, and complication rates vary. Complications can occur during mobilization of the rectum, with damage to the ureter, autonomic nerves, and the rectum itself. Frequencies of these complications can be reduced by careful dissection of the correct tissue plane in the pelvic space.

Methodology

This paper reviews the fascial composition of the rectum for low anterior resection of the rectum. To date, fascial composition of the pelvic space has been considered based on clinical anatomy and histological examination of cadaveric specimens. However, clarification of fascial composition is clearly limited, to a certain extent, in histological examinations compared with clinical anatomy.

Conclusions

First, some degree of dissociation must exist between the histological examination and clinical anatomy. Second, surgeons should not consider fascia encountered intraoperatively as an artifact. To address these difficult issues, consideration should be made purely from the perspective of clinical anatomy. Originally, the trunk was embryologically regarded as a multi-layered structure (like an onion). Understanding the fascial composition of the abdomen is comparatively easy when approached from this perspective. If this theory is adapted to the pelvic space in order to avoid antilogy, an understanding of the fascial composition of the pelvic space should also be possible. We review previous papers based on this theory.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

References

  1. Porter GA, Soskolne CL, Yakimets WW, Newman SC (1998) Surgeon-related factors and outcome in rectal cancer. Ann Surg 227:157–167

    Article  PubMed  CAS  Google Scholar 

  2. Bokey EL, Chapuis PH, Dent OF, Newland RC, Koorey SG, Zelas PJ, Stewart PJ (1997) Factors affecting survival after excision of the rectum for cancer: a multivariate analysis. Dis Colon Rectum 40:3–10

    Article  PubMed  CAS  Google Scholar 

  3. Church JM, Raudkivi PJ, Hill GL (1987) The surgical anatomy of the rectum: a review with particular relevance to the hazards of rectal mobilization. Int J Colorectal Dis 2:158–166

    Article  PubMed  CAS  Google Scholar 

  4. Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

    Article  PubMed  CAS  Google Scholar 

  5. Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK (1998) Rectal cancer. The Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899

    Article  PubMed  CAS  Google Scholar 

  6. Asoglu O, Matlim T, Karanlik H, Atar M, Muslumanoglu M, Kapran Y, Igci A, Ozmen V, Kecer M, Parlak M (2009) Impact of laparoscopic surgery on bladder and sexual function after total mesorectal excision for rectal cancer. Surg Endosc 23:296–303

    Article  PubMed  Google Scholar 

  7. Hasegawa S, Nagayama S, Nomura A, Kawamura J, Sakai Y (2008) Autonomic nerve-preserving total mesorectal excision in the laparoscopic era. Dis Colon Rectum 51:1279–1282

    Article  PubMed  Google Scholar 

  8. Fernandez-Represa JA, Mayol JM, Garcia-Aguilara J (2004) Total mesorectal excision for rectal cancer: the truth lies underneath. World J Surg 28:113–116

    Article  PubMed  Google Scholar 

  9. Heald RJ, Moran BJ (1998) Embryology and anatomy of the rectum. Semi Surg Oncol 15:66–71

    Article  CAS  Google Scholar 

  10. Kinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94:620–626

    Article  PubMed  CAS  Google Scholar 

  11. Chapuis P, Bokey L, Fahrer M, Comm GSM, Bogduk N (2002) Mobilization of the rectum. Anatomic concepts and the bookshelf revisited. Dis Colon Rectmum 45:1–8

    Article  Google Scholar 

  12. Bisset IP, Chau KY, Hill GL (2000) Extrafascial excision of the rectum: surgical anatomy of the fascia propria. Dis Colon Rectum 43:903–910

    Article  PubMed  CAS  Google Scholar 

  13. Havenga K, DeRuiter MC, Enker WE, Welvaart K (1996) Anatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer. Br J Surg 83:384–388

    Article  PubMed  CAS  Google Scholar 

  14. Wigley C, Healy JC, Brooks RF (2008) Integrating cells into tissues. In: Standring S (ed) Gray’s anatomy, 40th edn. Churchill Libingstone, New York, p 39

    Google Scholar 

  15. Sato T (1995) Local anatomy of the visceral fascia. Basis of layer structure and generation in each part. J Jpn Surg Assoc 56:2253–2272, in Japanese

    Google Scholar 

  16. Tobin CE, Benjamin JA, Wells JC (1946) Continuity of the fascia lining the abdomen, pelvis, and spermatic cord. Surg Gynecol Obstet 83:575–596

    PubMed  CAS  Google Scholar 

  17. Sato T (1980) Fundamental plan of the fascial strata of the body wall. Igakunoayumi 114:C168–C175, in Japanese

    Google Scholar 

  18. Sato T, Hashimoto M (1984) Morphological analysis of the fascial lamination of the trunk. Bull Tokyo Med Dent Univ 31:21–32

    PubMed  CAS  Google Scholar 

  19. Tobin CE (1944) The renal fascia and its relation to the transversalis fascia. Anat Rec 89:295–311

    Article  Google Scholar 

  20. Woodburne RT, Burkel WE (1994) The peritoneum. In: Woodburne RT, Burkel WE (eds) Essentials of human anatomy, 9th edn. Oxford Unibversity Press, New York, pp p436–p446

    Google Scholar 

  21. Perlemuter L, Waligora J (1971) Sigmoid colon. In: Cahiers D’Anatomie. Abdomen (II), Perlemuter L, Waligora J (eds) Tokyo: Chuou Tosho: p62-68. (translated book, Japanese)

  22. Toldt C (1893) Bauchfell und Gekrose. Erg Anat Entw Gesch 3:263–273

    Google Scholar 

  23. Toldt C (1893) Uber die Geschichte der Mesenterien. Ber Anat Ges 7:12–43

    Google Scholar 

  24. Takahashi T (2005) Fascial composition in the dorsal side of the rectum. Waldeyer’s fascia. Shoukakigeka 28:115–122, in Japanese

    Google Scholar 

  25. Takahashi T (2005) Fascial composition in the dorsal side of the rectum. Waldeyer’s fascia. Shoukakigeka 28:221–227, in Japanese

    Google Scholar 

  26. Jones OM, Smeulders N, Wiseman O, Miller R (1999) Lateral ligaments of the rectum: an anatomical study. Br J Surg 86:487–489

    Article  PubMed  CAS  Google Scholar 

  27. Pak-art R, Tansait T, Mingmalairaks C, Pattana-arun J, Tansatit M, Vajrabukka T (2005) The location and contents of the lateral ligaments of the rectum: a study in human soft cadavers. Dis Colon Rectum 48:1941–1944

    Article  PubMed  Google Scholar 

  28. 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 18:207–215

    Article  PubMed  CAS  Google Scholar 

  29. Nano M, Dal Coprso HM, Lanfranco G, Ferronato M, Hornung JP (2000) Contribution to the surgical anatomy of the ligaments of the rectum. Dis Colon Rectum 43:1592–1598

    Article  PubMed  CAS  Google Scholar 

  30. Nano M, Levin AC, Borghi F, Bellora P, Bogliatto F, Garbossa D, Bronda M, Lanfranco G, Moffa F, Dorfl J (1998) Observations on surgical anatomy for rectal cancer surgery. Hepatogastroenterology 45:717–726

    PubMed  CAS  Google Scholar 

  31. Fritsch H, Hotzinger H (1995) Tomographical anatomy of the pelvis, visceral pelvic connective tissue, and its compartments. Clin Anat 8:17–24

    Article  PubMed  CAS  Google Scholar 

  32. Fritsch H, Liemann A, Brenner E, Ludwikowski B (2004) Clinical anatomy of the pelvic floor. Adv Anat Embryol Cell Biol 175:1–64

    Article  Google Scholar 

  33. Heald RJ (1999) Recatal cancer—the tumour where surgical technique is re-writing the anatomy of the pelvis. A “personal view” article to introduce Japanese surgeons to the European concept—TME. Geka 61:969–982

    Google Scholar 

  34. Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ (2001) Consensus statement of definitions for anorectal physiology and rectal cancer. Colorectal Dis 3:272–275

    Article  PubMed  CAS  Google Scholar 

  35. Diop M, Parratte B, Tatu L, Vuillier F, Brunelle S, Monnier G (2003) ‘Mesorectum’: the surgical value of an anatomical approach. Surg Radiol Anat 25:290–304

    Article  PubMed  CAS  Google Scholar 

  36. Muntean V (1999) The surgical anatomy of the fasciae and the fascial spaces related to the rectum. Surg Radiol Anat 21:319–324

    Article  PubMed  CAS  Google Scholar 

  37. Sato K, Sato T (1991) The vascular and neuronal composition of the lateral ligament of the rectum and the rectosacral fascia. Surg Radiol Anat 13:17–22

    Article  PubMed  CAS  Google Scholar 

  38. Crapp AR, Cuthbertson AM (1974) William Waldeyer and the rectosacral fascia. Surg Gynecol Obstet 138:252–256

    PubMed  CAS  Google Scholar 

  39. Tobin CE, Benjamin JA (1945) Anatomical and surgical restudy of Denonvilliers’ fascia. Surg Gynecol Obstet 80:373–388

    Google Scholar 

  40. Uhlenhuth E, Wolfe WM, Smith EM, Middleton EB (1948) The rectogenital septum. Surg Gynecol Obstet 86:148–163

    PubMed  CAS  Google Scholar 

  41. Uhlenhuth E, Day EC, Smith RD, Middleton EB (1948) The visceral endopelvic fascia and the hypogastric sheath. Surg Gynecol Obstet 86:9–28

    PubMed  CAS  Google Scholar 

  42. Aigner F, Zbar AP, Ludwikowski B, Kreczy A, Kovacs P, Fritsch H (2004) The rectogenital septum: morphology, function, and clinical relevance. Dis Colon Rectum 47:131–140

    Article  PubMed  Google Scholar 

  43. Wesson MB (1922) The development and surgical importance of the rectourethralis muscle and Denonvilliers’ fascia. J Urol 8:339–359

    Google Scholar 

  44. Van Ophoven A, Roth S (1997) The anatomy and embryological origins of the fascia of Denonvilliers: a medico-historical debate. J Urol 157:3–9

    Article  PubMed  Google Scholar 

  45. Richardson AC (1993) The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 36:976–983

    Article  PubMed  CAS  Google Scholar 

  46. Milley PS, Nichols DH (1969) A correlative investigation of the human rectovaginal septum. Anat Rec 163:443–451

    Article  PubMed  CAS  Google Scholar 

  47. 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 49:1024–1032

    Article  PubMed  Google Scholar 

  48. Heald RJ, Moran BJ, Brown G, Daniels IR (2004) Optimal total mesorectal excision for rectal cancer is by dissection in front of Denonvilliers’ fascia. Br J Surg 91:121–123

    Article  PubMed  CAS  Google Scholar 

  49. Clausen N, Wolloscheck T, Konerding MK (2008) How to optimize autonomic nerve preservation in total mesorectal excision: clinical topography and morphology of pelvic nerves and fasciae. World J Surg 32:1768–1775

    Article  PubMed  Google Scholar 

  50. Lindsey I, Warren BF, Mortensen NJ (2005) Denonvilliers’ fascia lies anterior to the fascia propria and rectal dissection plane in total mesorectal excision. Dis Colon Rectum 48:37–42

    Article  PubMed  Google Scholar 

  51. Heald RJ (1988) The ‘Holy Plane’ of rectal surgery. J R Soc Med 81:503–508

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Kameda Medical Center, 929 Higashicho, Kamogawa, Chibaken, 298-8602, Japan

    Makio Mike & Nobuyasu Kano

Authors
  1. Makio Mike
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nobuyasu Kano
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Makio Mike.

Additional information

This paper is not based on a previous communication to a society or meeting.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mike, M., Kano, N. Laparoscopic-assisted low anterior resection of the rectum—a review of the fascial composition in the pelvic space. Int J Colorectal Dis 26, 405–414 (2011). https://doi.org/10.1007/s00384-010-1107-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-010-1107-2

Keywords

Search

Navigation