Anatomic Basis of Tumor Surgery

Modern biological understanding is the basis for a multimodality treatment of a tumor. 'Anatomic Basis of Tumor Surgery' is the only book that provides an.
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These observations are one of the findings we often encounter during retrorectal space dissection. The inferior hypogastric nerve continues parallel to the ureter and internal artery in a caudal and lateral direction, reaching the pelvic autonomic nerve plexus at the lateral pelvic sidewall. The inferior hypogastric nerve forms the pelvic nerve plexus at the lateral pelvic wall by encountering the parasympathetic sacral nerve originating from the 2 nd , 3 rd and 4 th sacral cavities.

Small numerous neurovascular bundles running from the pelvic nerve plexus to the genitalia cross the seminal vesicle in the 10 o'clock and 2 o'clock directions. We observe a mesh-like structure on the lateral pelvic wall and it descends to the genital organ at the lateral tip of the seminal vesicle. Therefore, dissection should be done carefully around these areas. Walsh and Donker 32 also reported that a useful marker for pelvic plexus midpoints is the tip of seminal vesicle in males.

Anatomic Basis of Tumor Surgery

At the level of the seminal vesicle, the running neurovascular bundle along the seminal vesicle should be considered, and one must pay attention to the pelvic plexus arising from sacral foramen during rectal mobilization. In a hemisectioned pelvis, the T-shape nerve can be easily observed Fig. By closer observation with magnification, the parasympathetic nerve can be observed crossing the piriformis muscle, penetrating the pelvic fascia in the sidewall and the parasympathetic nerve originated from 2 nd , 3 rd and 4 th sacrum, encountering the inferior hypogastric nerve and forming the pelvic plexus in the pelvic lateral wall.

From the pelvic plexus, numerous nervous branches run to the urogenital organ Fig. Cadaveric dissection on hemisectioned pelvis show the inferior hypogastric nerve descend into the pelvic cavity and meet sacral parasympathetic nerve arising from S2 th , 3 th , 4 th foramen nearby the piriformis muscle. The inferior hypogastric nerve form the pelvic plexus at the lateral pelvic wall after merging the sacral parasympathetic nerves.

Nerve bundles from pelvic plexus go to the genitourinary organ along the seminal vesicle in male. Regarding injury of the pelvic plexus, the areas that should be handled carefully during mobilization of the rectum are the lateral wall of the rectum and the area where the pelvic plexus is attached. After successive dissection of this area, the rectum is delivered from the pelvic cavity. An actual quadrangular mesh-like structure pelvic nerve plexus is adhered to the rectal proper fascia surrounding the mesorectum.

The parasympathetic nerve arises from the ventral roots of S and a rhomboid-shaped plaque of nervous tissue at the pelvic sidewall. The pelvic plexus is sometimes revealed as a matted rhomboid structure with dimensions of 4 cm by 2. The neurovascular bundle, described by Walsh and Schlegel, runs in front of the rectogenital fascia in the parametrium in females and in the space occupied by the seminal vesicles and the prostate in males. I would like to reemphasize the avoidance of damage to the pelvic plexus and the neurovascular bundle to the genitalia during dissection.

It is important to incise the rectosacral fascia first; the dissection must then go down to the coccyx and lateral wall of the rectum separated from the pelvic plexus. Around this area, proper traction of the rectum is important in preventing avulsion injury of pelvic plexus.

Anatomic Basis of Tumor Surgery | JAMA | JAMA Network

Meticulous dissection should be performed on the fascia surrounding the mesorectum and the pelvic plexus must be separated carefully Fig. During dissection of this area, the middle rectal artery is sometimes encountered. It should be identified, divided, and ligated with a surgical clip. It is important to avoid mass ligation in this area to avoid significant bleeding for nerve preservation. Too much traction of the rectum may cause avulsion injury to the running the 3 rd sacral nerve, which might result in male sexual function such as erectile dysfunction. Usually, cutting the rectosacral fascia and opening the retrorectal space laterally reveals the nervi erigentes, with the S3 component usually being the largest.

The nerve to the levator ani may also be seen, arising from S3 and S4 with the nerve eirgentes.


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The deep narrow cavity often makes the surgeon excessively retract the rectum posteriorly and laterally; pelvic plexus injury can then easily occur. On operative field, bifurcation of the superior hypogastric nerve was noted at the aortic bifurcation. The inferior hypogastric nerve descends along the pelvic side wall. The pelvic plexus forms after merging with the sacral parasympathetic nerve. A sharp dissection around these areas may be necessary.

Therefore, preservation of the sacral parasympathetic nerve does not seem to be feasible in patients with a narrow and deep pelvis. Sometimes, urologists help colorectal surgeons to learn surgical anatomical knowledge regarding nerve-sparing surgery. Based on Walsh's report 35 on nerve-sparing radical prostatectomy, the seminal vesicle can be used as a landmark intraoperatively to identify the pelvic plexus, which is imbedded in thick fascia and perforated by branches of inferior vesical artery and vein.

The running neurovascular bundle is located at the extreme lateral part of the seminal vesicle, which is a continuation of the pelvic plexus at the lateral pelvic wall.

Anatomic Basis of Tumor Surgery

He pointed out several anatomical regions where injury to nerves important for sexual function may occur during rectal surgery. Injury to the hypogastric nerves in the retroperitoneal space along the peritoneal reflection of the sigmoid mesentery may result in ejaculatory dysfunction. Excessive traction on the rectum with anterior displacement of the rectum secondary to mobilization posterior to the rectum may result in neuropraxia or avulsion of sacral roots 2, 3, and 4.

During APR, injury to the cavernous nerves during perineal dissection may result in erectile dysfunction, as well. Division of the rectourethralis muscle and blunt dissection or excessive electrocauterization of the neurovascular bundle at the anterolateral part of the rectum may also contribute to sexual dysfunction.

Abdominoperineal resection can be considered to consist of total mesorectal excision during abdominal phase and sharp anatomical perineal dissection. The concept of TME is to perform precise anatomical pelvic dissection along the rectal proper fascia surrounding the mesorectum; the mesorectum disappears cm above the levator ani muscle.

In most cases, the rectal wall is attached lightly to the thin levator ani muscle; hence, the levator ani muscle can be seen only after the dissection finished. If the tumor were located in its vicinity, dissection around this area should be avoided. Concerning the practicality of operative techniques, abdominal phase techniques are the same as TME techniques.

Sharp pelvic dissection must be carried out along the visceral fascia enveloping the mesorectum to the levator ani muscle with preservation of pelvic autonomic nerve.

Anatomic Basis of Tumor Surgery

Perineal phase dissection is a key process in APR. During perineal dissection, an inadequate resection margin and blunt dissection along the nonanatomical plane encourage implantation of a malignant cell and local recurrence. Moreover, nonanatomical dissection can lead to serious complications, such as prostatic urethral injury, vaginal wall perforation, perineal sinus, and fistula.

Massive bleeding from pelvic side wall major vessel injury might occur, especially in males with a narrow pelvis. In patients with a narrow, deep pelvic cavity, it is nearly impossible to reach the levator ani muscle, resulting in the performance of perineal dissection at excessively high levels. For colorectal surgeons with insufficient experience, it is difficult to dissect the rectum from the perineum to the seminal vesicle level. In the classic pattern, anterior and lateral dissection from the prostate or vagina occurs after completion of posterior dissection. The dissected proximal colon is delivered outward through the perineal wound and, with traction of the delivered portion of the colon, anterior dissection is performed.

However, in patients with a narrow pelvis, such delivery of the proximal colon through the perineal wound can result in a fractured tumor and local recurrence due to limited operation field. Therefore, it is mandatory that the specimen be delivered in situ after posterior, anterior, and lateral dissection. In lateral dissection, the levator ani muscle must be divided near the bony insertion.

During anterior dissection, the seminal vesicle and prostate gland must be exposed and the neurovascular bundle observed in the 10 o'clock and 2 o'clock directions. The so-called sharp anatomical perineal dissection empowered by 3D concept based on pelvic MRI is important in preventing local recurrence. Interestingly, important anatomical structures can be seen by pelvic MRI. On a coronal view, the anal sphincter and levator ani muscle are clearly seen. Therefore, we can get information on whether the anal sphincter is involved by MRI and digital examination.

If the cancer invaded the sphincter muscle preoperatively, APR should be performed without hesitation. On a MRI coronal view, the cancer is located close to the obturator muscle and a natural waist is formed between the ischiorectal fat and the mesorectum which terminates directly above the levator ani muscle. Shown in the figure of the vicinity of the imaginary dissection line, metastatic lymph nodes can be observed.

Possible metastatic lymph nodes are present in the mesorectum and located only mm away from the dissection plane in deep pelvis Fig. Therefore, a metastatic lymph node can be injured readily; hence, tumor cell seeding could also occur readily. At the time of perineal dissection, metastatic lymph nodes are also located close to the planned dissection line. An inadequate dissection plane or shorter resection margin could facilitate tumor cell seeding or residual cancer cells, similar to an inappropriate total mesorectal excision. Recently Marr et al. Based on this data, during APR, a wider resection margin should be obtained based on the MR anatomical plane.

In the perineum, important landmarks are the superficial and deep perineal muscle in the perineal body anteriorly and the anococcygeal ligament posteriorly. A couple of vessels encountered during perineal dissection are branches from the internal pudendal artery and vein. The levator ani muscle must be cut at the level of bone insertion and should be done with a wide resection margin Practically, we can get information about the relationship between the tumor and the levator ani muscle and anal sphincter muscle on an axial and coronal view of pelvic MRI and can avoid dissection around the tumor level.

Recently published data showed acceptable functional and oncologic outcomes of intersphincteric resection for low rectal cancer, and recommended it as a valuable procedure for sphincter-saving rectal surgery. We must exclude patients who have external sphincter invasion, puborectalis, or levator ani muscle invasion. Furthermore, Brown et al. They beautifully described not only depth of tumor invasion of the rectal wall, but also the mesorectal fascia and pelvic autonomic nerve. We can get much information of importance in the staging of the tumor, resectability, planning the extent of lymph node dissection, and selecting patients who need neoadjuvant chemoradiation therapy.

Many young surgeons participated in discussion and observed live surgery of TSME of rectal cancer. In a national Norwegian audit involving 3, new patients, the technique of TME was compared with conventional surgery. Sharp pelvic dissection under direct vision based on anatomical knowledge has become essential in the field of rectal cancer surgery. Cadaveric dissection enables surgeons to perform sharp pelvic dissection based on the surgical anatomy of rectal cancer surgery.

Sharp pelvic dissection and sharp perineal dissection based on an anatomical and 3D MR image-based concept is important for the curative resection of rectal cancer. Also, a safe operation and good quality of life after surgery can be provided to patients with rectal cancer. Sharp anatomical pelvic dissection is the key to producing good functional and oncologic outcomes.

Macroscopic assessment of gross specimen after the tumor is resected is essential for colorectal surgeons because any kind of defect on the mesorectum or tumor close to the resection margin, narrow and shorter margin around the waist of APR specimen should be avoided. Pre or post adjuvant modality approaches can achieve optimal goals for treatment. Functional consideration should be considered at the time of surgery planning. National Center for Biotechnology Information , U.

Journal List Yonsei Med J v. Published online Dec Find articles by Nam Kyu Kim. Author information Article notes Copyright and License information Disclaimer. Received Dec 2. This article has been cited by other articles in PMC. Abstract The optimal goals in the surgical treatment of rectal cancer are curative resection, anal sphincter preservation, and preservation of sexual and voiding functions. Rectal cancer, sharp pelvic dissection, rectal proper fascia, mesorectum, pelvic autonomic nervous system.

Open in a separate window. Adjuvant therapy for patients with colon and rectal cancer. Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery. Please enter the message. Please verify that you are not a robot.

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