Anatomic Basis of Sharp Pelvic Dissection for Total Mesorectal Excision with Pelvic Autonomic Nerve Preservation for Rectal Cancer

Kim, Nam Kyu

Abstract

Optimal goals of rectal cancer surgical treatment should include appropriate local control, higher survival rates, scrupulous operation procedures and good quality of life with maintained sexual and voiding function through the conservation of anal sphincter. Complete surgical removal of rectal cancer mass and adjacent lymph nodes in en-bloc package decreases the risk of local recurrence. Furthermore heightened awareness of better surgical techniques has created much interest in the anatomy involved in total mesorectal excision (TME), with particular focus on the fascial planes, nerve plexuses and their relationship to the surgical planes of excision. Total mesorectal excision focuses on several technical components and the quality of operated specimen. Sharp anatomic pelvic dissection along the visceral pelvic fascia must avoid any breach from the mesorectum haboring metastatic tumor deposits and lymph nodes. Also any coning down or blunt dissection should not be allowed. The rectal cancer mass and its surrounding mesorectum must be removed as one complete unit. Circumferential and distal resection margin must be also adequately obtained. Such sharp pelvic dissection instead of blunt dissection requires precised knowledge of the pelvic anatomy. Studying the hemisected cadevaric pelvis shows a clear relationship between the fascia and rectum. Also pelvic autonomic nerves can be saved to preserve the patient's sexual and voiding functions. Therefore the clincial importances of anatomical structures must be emphasized at each step of surgery. Upon such understanding of techniques, TME was performed in rectal cancer patients routinely and was able to obtain fair oncologic results and improved quality of life regarding sexual and voiding functions.