Important points for protection of the autonomic nerves during total mesorectal excision.

BACKGROUND

One of the most important aspects for patients undergoing rectal cancer surgery is quality of life, which is closely related to postoperative sexual, urinary, and bowel functions. To preserve these functions, surgeons need to pay special attention to the fascial planes and autonomic nerve plexuses.

OBJECTIVE

The aim of this study is to describe the locations of autonomic nerves in critical areas and to demonstrate the correct surgical planes for protecting these nerves during total mesorectal excision.

DESIGN AND SETTINGS: Macroscopic and microscopic surgical dissections were performed in the anatomy laboratory. The dissections were recorded as video clips.

METHODS

Dissections were performed in accordance with the total mesorectal excision technique down to the pelvic floor on 2 female and 7 male cadavers. Autonomic nerves and related fascias were shown.

RESULTS

Autonomic nerves can be damaged during total mesorectal excision in 4 crucial areas: around the origin of the inferior mesenteric artery, in front of the promontory, the side walls of the pelvis, and the posterolateral corners of the prostate close to the anterior rectal wall. Fibers extending in front of the aorta and fibers coming from the sympathetic trunks combine to form the inferior mesenteric plexus around the origin of the inferior mesenteric artery. Most of the fibers that form the superior hypogastric plexus were fibers going downward from the inferior mesenteric plexus. The erigent nerves merge with the pelvic plexuses through the fascia of piriformis, which is part of the pelvic parietal fascia.

LIMITATIONS: The number of cadavers should be increased, especially the number of female cadavers.

CONCLUSIONS

The autonomic nerves must be protected during rectal cancer surgery to maintain the patient's quality of life. Therefore, knowledge of autonomic nerve positions and their relationship with surgical planes are very important for rectal surgeons.